Soft Tissue Manipulation and Pelvic Pain

Soft Tissue Manipulation and Pelvic Pain By Leon Chaitow, ND, DO

Bialowsky (2009) reports that the effects of soft-tissue-focused manual therapies includes:

• Changes of blood levels of b-endorphin serotonin (Degenhardt et al 2007)
• Endogenous cannabinoids (McPartland et al 2005)
• Improved circulation and drainage
• Decreased muscle spasm
• Relaxation
• Re-alignment of soft tissues
• Breaking of adhesions
• Increased range of motion
• Removal of cellular exudates

Manual Therapy Approaches

The listing below of a selection of currently utilised manual therapy approaches that address fascial and myofascial dysfunction takes for granted that there would be simultaneous or subsequent focus on etiological features. Also, the seven modalities listed should not be regarded as definitive, as there are many other variations. However, those listed (and briefly discussed) represent a variety of validated biomechanical approaches, some of them novel and others well established.

1. Connective tissue manipulation (ctm), as practised in relation to chronic pelvic pain, is a variation on the work of Dicke (1953) and Ebner (1975). Known in Germany where it was developed as "Bindegewebsmassage", it involves direct manual strokes, or forms of vigorous skin rolling, focused on connective tissue. Connective tissue is treated/mobilized until there is: improvement in mobility, decrease in sensitivity, and increase in warmth. Goals include: improved circulation; improved tissue integrity; decreased ischemia; reduced nocigenic chemicals in restricted connective tissue; decrease or elimination of visceral pain or dysfunction---possibly involving reflex effects; decrease in adverse neural tension on peripheral nerve branches.
   


2. Fascial manipulation (FM). The key premise of FM is that fascia presents a specific organization and relationship with the underlying muscles. In particular, the fascia is seen as: coordinating element for motor units (grouped together in myofascial units); uniting element between unidirectional myofascial units (myofascial sequences); connecting element between body joints via myofascial expansions and retinacula (myofascial spirals). This model is supported by in-depth studies of fascial anatomy and physiology. Numerous dissections of unembalmed human cadavers have evidenced: muscular fibre insertions directly onto deep fascia (Stecco et al 2007); fibre distribution according to precise motor directions (Stecco et al 2008, 2009); myotendinous expansions that link adjacent segments (Stecco et al 2009). Extensive histological analysis of deep muscular fascia has also provided evidence for hypotheses concerning fascia's role in proprioception and tensional force distribution within the fascial system. (Stecco et al 2006, 2007)
   


3. Muscle Energy Technique defined as "a form of osteopathic manipulative diagnosis and treatment in which the patient's muscles are actively used on request, from a precisely controlled position, in a specific direction, and against a distinctly executed physician counterforce". (ECOP 2009) Various studies have demonstrated that muscle energy techniques increase muscle extensibility (Ballantyne et al 2003) and range of motion (Burns & Wells 2006) including thoracic rotation. (Lenehan et al 2003)
   


4. Myofascial release. King (2010) notes that myofascial release (MFR) is "a system of diagnosis and treatment first described by AT Still, and his early students, which involves continual palpatory feedback to achieve release of myofascial tissues."
   
   Direct MFR: A myofascial tissue restrictive barrier is engaged for the myofascial tissues and the tissue is loaded with constant force, until tissue release occurs.
   
   Indirect MFR: The dysfunctional tissues are guided along the path of least resistance, until free movement is achieved. (ECOP 2009)
   


5. Scar tissue release. Kobesova et al (2007) suggest that scars may develop adhesive properties that compromise tissue tensioning, altering proprioceptive input, behaving in much the same way as active myofascial trigger points. It is suggested that faulty afferent input can result in disturbed efferent output leading to (for example): protective postural patterns, increased neurovascular activity, and pain syndromes. The term active scar is designated to describe the ongoing additional neural activity associated with adhesive scar formations.
   


6. Straincounterstrain (SCS). Osteopathic system of diagnosis and indirect treatment, in which the patient's somatic dysfunction is treated, using passive positioning, resulting in spontaneous tissue release. (ECOP 2009) SCS technique involves shortening myofascial structures to reduce the nociceptive experience arising from firm palpation of a tenderpoint in the dysfunctional tissues.
   


7. Trigger point deactivation methods. Montenegro et al (2009) insist that myofascial pain syndrome should always be considered as part of the differential diagnosis of chronic pelvic pain. Systematic reviews have investigated the effectiveness of soft tissue manual intervention for inactivating trigger points (TrPs) (Fernandez-de-las-Penas et al 2005, Rickards 2006, Vernon & Schneider 2009). Anderson et al (2009) have identified the most common location of TrPs related to pelvic pain: pubococcygeus (90%), external oblique (80%), rectus abdominis (75%), hip adductors (19%), gluteus medius (18%).

These themes are explored further on my blog http://chaitowschat-leon.blogspot.com/ and Web site www.leonchaitow.com/index.htm.