Download Sacral Base L + R

OMT for Common
Gynecologic Disorders
Rebecca Alsip, DO
November 15, 2012
Lecture Objectives
1. Review Sympathetic and Parasympathetic innervations
pertinent to the female GU system
2. Review and discuss common structural findings and
treatment of somatic dysfunction(s) associated with
pelvic disorders such as:
1. Premenstrual Syndrome
2. Endometriosis
3. Dysmenorrhea
3. Recognize and explain MFTrP (Myofascial Trigger Points)
for the pelvic floor
Female GU Anatomy
Sympathetic innervation from
Lesser Splanchnics
Parasympathetic innervation from
Pelvic Splanchnic Nerves
Sympathetic Innervation
Visceral Organ
Spinal Cord
Level
Corresponding
Ganglion
Kidneys
T10-T11
Superior
Mesenteric
Adrenal Medulla
T10
Superior
Mesenteric
Upper Ureters
T10-T11
Superior
Mesenteric
Lower Ureters
T12-L1
Inferior Mesenteric
Bladder
T11-L2
Inferior Mesenteric
Ovaries
T10-T11
Superior
Mesenteric
Uterus/cervix
T10-L2
Inferior
Mesenteric
Erectile tissue of
clitorus
T11-L2
Inferior Mesenteric
Fallopian tubes
T10-L2
Inferior Mesenteric
Parasympathetic Innervation
Visceral Organ
Nerves
Kidney/upper
ureter
CN X (vagus)
Ovaries
CN X (vagus)
Lower
ureter/bladder
S2-4 (pelvic
splanchnics)
Uterus and
genitalia
S2-4 (pelvic
splanchnics)
Common Gynecologic Disorders
 Dysmenorrhea
 Endometriosis
 Premenstrual Syndrome
 Pelvic floor dysfunction
Dysmenorrhea
 Defined as painful menstruation
 Consists of recurrent, crampy lower abdominal pain that
occurs just before or during menses
 Due to prostaglandin release during endometrial
sloughing that causes nonrhythmic uterine contractions
 No specific physical findings related to the dysmenorrhea
itself, but may find pelvic/sacral somatic dysfunctions
 Treatment includes NSAIDs, OCPs, acupuncture and OMT
 Chapman’s points along IT band, pubic bone, or sacrum,
addressing sympathetics as well as parasympathetics
 Pelvic Diaphragm to relieve edema and increase drainage
Endometriosis
 Defined as the presence of implanted endometrial glands
and stroma in extrauterine locations
 Often leads to pelvic pain, dysmenorrhea, dyspareunia and
infertility
 Physical exam findings including tenderness and palpable
nodules in posterior cul-de-sac and/or uterosacral
ligaments, tender adnexal masses and pain with uterine
movement
 Confirmatory diagnosis made by direct observation of
endometrial implants
 Treatment includes pain control, hormone treatments,
surgical intervention, as well as OMT
 Sacral rocking for normalizing parasympathetic tone
 Treatment of any dysfunction at T10-L2 (uterus)
 Mobility of pelvic diaphragm to relieve pelvic congestion
Premenstrual Syndrome
 Presence of both physical and behavioral symptoms that
occur repetitively with the menstrual cycle and interfere
with a woman’s daily functioning
 Physical symptoms include abdominal bloating, fatigue,
headaches, and breast tenderness
 Behavioral symptoms include labile mood, irritability,
difficulty concentrating and depressed mood
 Treatment is focused at specific symptoms
 Headache Tx includes NSAIDs, OCPs or OMT aimed at
suboccipital and cervical regions
 Abdominal bloating Tx includes collateral ganglion release,
mesenteric releases of small intestine, ascending and
descending colon and colonic milking, as well as associated
thoracic and lumbar dysfunctions
Pelvic Floor
Dysfunction
 Consist of urinary or fecal incontinence, as well as pelvic
organ prolapse
 Can be due to childbirth, pregnancy, nerve injury, or injury
to coccygeus or levator ani muscles
 These can lead to or stem from somatic dysfunction,
including TPs
 Treat with Kegel exercises, injections and OMT
 Myofascial release, counterstrain, reciprocal inhibition
Treatment of Pelvic Disorders
 Osteopathic Manipulation
 Lymphatic drainage
 Tx of thoracic/lumbars
 Tx of innominates
 Tx of pubic bone
 Tx of sacrum
 Chapman’s Points
 Smooth, firm palpable
nodules located in the
deep fascia
 Rotary stimulation for
20-60 seconds
 Travell’s Myofascial
Trigger Points
Lymphatics
 Helps improve vascular
congestion
 Enhances lymphatic
drainage
 Start with thoracic inlet
release, then move to
the thoracoabdominal
diaphragm release, then
to pelvic diaphragm
Pelvic innominates
 Can have anterior or
posterior innominates
due to hamstrings or
quadriceps muscles, as
well as other pelvic
somatic dysfunction
 Helpful for patients who
have pelvic pain
 Can treat these with
muscle energy
Pubic Bone Dysfunction
 Can be due to extreme
innominate rotation
 Can also be due to
trauma, such as
childbirth, or pelvic floor
muscle tightness
 Can treat with muscle
energy
Sacral dysfunction
 Any kind of dysfunction
can lead to altered
parasympathetic tone
 Caused from other
somatic dysfunctions,
trauma, childbirth or
pelvic floor muscle
dysfunction
 Can treat with
articulatory or muscle
energy
Anterior Chapman’s Points
Posterior Chapman’s Points
Travell’s Myofascial
Trigger Points
 Trigger point (TP): hypersensitive focus
within taut band of muscle, may or may
not follow an injury
 Direct stimuli initiates trigger points by
causing abnormal, continuous input from
the muscle spindle, leading to reflex
tension in the associated muscle
 Somatic dysfunction and TPs are closely
related and potentiate each other
 Ex. Emotional stress may be associated
with clenching of the teeth and may
produce TPs in the masseter and pterygoid
muscles
EMBRYOLOGY OF MYOTOMAL PAIN
Myotome – the dorsal part of each somite
in a vertebrate embryo, giving rise to the
skeletal musculature
19 Days
Dermatome – the lateral wall of each
somite in a vertebrate embryo, giving rise to
the connective tissue of the skin, an area of
the skin supplied by
nerves from a single
spinal root.
19 Days
Embryology of Myotomal Pain
Myotomal Distribution Patterns of Trigger Points
Myotomal referral patterns are
associated with cramps,
weakness, and myofascial
trigger points related to muscles
that are innervated from the
same nerve root.
Pelvic Floor Muscle Trigger Points
 TPs in lower abdomen may
cause urinary frequency,
urgency, sphincter spasm,
or bladder discomfort
 Dysfunction of muscles of
the pelvic floor can cause
innominate rotations, pubic
shears
 Can also cause somatic
dysfunction leading to
pelvic pain, dysmenorrhea
or urinary problems
 Treatment
 Muscle Energy
 Myofascial release
 Reciprocal inhibition
 Injection with local
anesthetics
 Spraying with
vapocoolant spray
Trigger Point vs. Tender Point
Trigger Points
Tender Points
Characteristic pain pattern
No typical pain patter
Located in muscle tissue
Located in muscle, tendons
and ligaments
Radiating pain pattern
No radiating pain pattern
Locally tender
Locally tender
Taut band of tissue
Taut band not present
• Trigger points mapped all over body in the belly of muscles
• Exam reveals taut band within the muscle with local
tenderness, as well as tenderness radiating to an area of the
body specific for that muscle
• Referred pain is reproducible
Sclerotomal Pain:
• The part of each somite in a
vertebrate embryo giving rise
to bone or other skeletal
tissue
• Referral pattern follows a
ligament, bone or joint that
shares innervation from the
same nerve root
• deep, achy, toothache quality
EX: Iliolumbar ligament
QUESTIONS??
THANK YOU!
REVIEW:
SACRAL DIAGNOSIS
Sacral Base Anterior
Name: Sacral Base Anterior, Bilateral Sacral Flexion
Lateralization: Does NOT matter.
Spring test: Negative
Landmarks:
Sacral Base:
Sacral Sulcus:
ILA:
STL:
Bilaterally (B/L) Anterior
B/L Deep
B/L Posterior
B/L Tight
Ant +
Deep
Ant+
Deep
Motion:
Sacral Base:
ILA:
B/L +
B/L –
Post - Post-
Sacral Base Posterior
Name: Sacral Base Posterior, Bilateral Sacral
EXTENSION
Lateralization: Does NOT matter.
Spring test: Positive
Landmarks:
Sacral Base:
Sacral Sulcus:
ILA:
STL:
Bilaterally (B/L) Posterior
B/L Shallow
B/L Anterior
B/L Loose
Post Shallow
Post Shallow
Motion:
Sacral Base:
ILA:
B/L –
B/L +
Ant + Ant +
29
Vertical Axis Diagnosis: less
common
Name: Left Sacral Margin Posterior
Lateralization: Matters NOT. Always call on
Posterior side.
Shallow
For Left Sacral Margin Posterior:
P–
A+
Landmarks: data recorded on lateralized side
Sacral Base:
Sacral Sulcus:
ILA:
STL:
L Posterior
L Shallow
L Posterior
L Tight
Motion:
Sacral Base:
ILA:
L–
L–
R+
R+
P-
How could we treat this?
A+
Deep
Findings for Unilateral Sacral Flexion
(Sacral Shear)
Anterior
 The sacral base on the side of the
significantly inferior ILA will generally
be anterior: FLEXED
 The ILA will be significantly inferior
(& posterior!)
 {Sacrotuberous ligament will be
pliable and under less tension than
the contralateral side.}
Right unilateral sacral flexion
Posterior
Markedly
Inferior
Motion Testing for Unilateral Sacral Flexion
(Sacral Shear)
 There will be no motion at the
inferior ILA - it is locked down
- or
+/-
+/-
A
 The base on the same side is
likely to have adequate motion
 There is generally good motion at
any of the other locations but the
motion is not likely to “add up”
+/-
P/
I
(we can’t use our paper model for this one!)
(No Axis.)
-
Unilateral Sacral Extensions
 Findings:
Rare
L Base P
P-
L sulcus shallow
L ILA ant/markedly superior
STL loose
+/-
A/S
Spring: may be +
Motion:
 Sacral Base: L  ILA:
L +/-
R +/R +/-
Left Neutral Sacral Oblique Axis
Somatic Dysfunction
Name: L on LOA, RL on LOA,
L Forward Torsion
Landmarks: if calling findings on L side
Sacral Sulcus:
Sacral Base:
ILA:
STL:
L Shallow
L Posterior
L Post./ Inf.
L Tight
A+
P-
Motion Testing:
Spring:
Sphinx:
L5:
Sacral Base
ILA:
- (It springs!)
- (improves with extension)
NSLRR
LR+
L +/R +/-
P+/-
+/A
note: Seated Flexion test may be + on R with this dysfunction (confirmatory)
Left
Right
Midline
Right Neutral Sacral Oblique Axis
Somatic Dysfunction
Name: R on ROA, RR on ROA,
R Forward Torsion
Landmarks: if recording findings on R side
Sacral Sulcus:
Sacral Base:
ILA:
STL:
R Shallow
R Posterior
R Post./ Inf.
R Tight
A+
Motion Testing:
Spring:
Sphinx:
L5:
Sacral Base
ILA:
NSRRL
L+
L +/-
P+/-
RR +/-
Note: Seated flexion test may be + on L with this dysfunction (confirmatory)
Left
Midline
Right
Left Non-Neutral Sacral Oblique Axis
Somatic Dysfunction
Name:
R on LOA, RR on LOA,
L Backward Torsion
Landmarks: if recording findings on the L side in this example
Sacral Sulcus:
Sacral Base:
ILA:
STL:
L Deep
L Anterior
L Ant./Sup.
L Loose
P+/-
Motion Testing:
Spring: + (It does not spring!)
Sphinx: + (findings worsen with extension)
L5: confirmatory
FRLSL
Sacral Base
L - R +/ILA:
L + R +/-
A+
note: Seated flexion may be + on R with this dysfunction (confirmatory)
Left
Right
Midline
Right Non-Neutral Sacral Oblique Axis
Somatic Dysfunction
Name:
L on ROA, RL on ROA,
R Backward Torsion
Landmarks: if recording findings on R side in this example
Sacral Sulcus:
Sacral Base:
ILA:
STL:
R Deep
R Anterior
R Ant./ Sup.
R Loose
P+/-
Motion Testing:
Spring: +
Sphinx +
L5:
Sacral Base
ILA:
FRRSR
L +/- R L +/- R +
A+
note: seated flexion may be + on L with this dysfunction(confirmatory)
Left
Right
Midline