Anita Showalter, D.O., FACOOG (D)
Dean of Clinical Sciences,
College of Osteopathic Medicine
Associate Professor and Chair, Women’s Health
Pacific Northwest University of Health Sciences
Objectives
 Discuss osteopathic philosophy in patient care
 Discuss the osteopathic approach to pelvic pain
 Review of pelvic anatomy
 Case presentations
Osteopathic Philosophy
The body is a unit; the person is a unit of body, mind
and spirit.
II. The body is capable of self regulation, self-healing
and health maintenance.
III. Structure and function are reciprocally interrelated.
IV. Rational treatment is based upon an understanding
of the basic principles of body unity, self-regulation,
and the inter-relationship of structure and function.
I.
Foundations for Osteopathic Medicine
The Founder of Osteopathic
Medicine: A.T. Still
“The Osteopath should
find health. To find
health should be the
object of the doctor.
Anyone can find
disease.”
A.T. Still, Philosophy of
Osteopathy
Somatic Dysfunction
Definition:
Impaired or altered function of related components of
the somatic (body framework) system: Skeletal,
arthrodial, and myofascial structures, and related
vascular, lymphatic and neural elements. Somatic
dysfunction is treatable using osteopathic
manipulative treatment.

Atlas of Osteopathic Techniques, 2nd edition, page 4
Osteopathic Treatment
 Application of manual
techniques to somatic
dysfunction
 Myofascial-articular
 Visceral-autonomic
 Somato-visceral
 Viscero-somatic
 Techniques
 Articular
 Myofascial
Principles of Fascia
 At the time of early dissection, was thought to be an organ
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system
Preservatives changed the properties of fascia and its
importance was not realized
Fascia has properties of strength and resilience
Fascia can be influenced
Fascia has a memory that connects to traumatic incidents
Surgery can cause fascial strains if incisions are not
carefully reapproximated
Trauma can cause various fascial strain patterns
The Fascial Being
Patient History
 History of trauma
 MVA’s
 Falls
 Childbirth
 Rape
 Work
 Strain patterns
 Repetitive trauma
Gynecologic Exam
 Is the cervix in the usual position
 Pain with insertion of the speculum?
 Initial
 Deep
 Bimanual
 Uterus midline?
 Adnexal tension/laxity?
Osteopathic Examination
 Structural screening exam
 Look for areas of asymmetry
 Tissue texture changes
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Tension
Bogginess
Turgor
 Heat
 Red reflex
Treating the Patient
 Rule out any emergent or urgent conditions requiring
immediate medical or surgical intervention
 Do appropriate imaging studies
 Do a structural exam looking for somatic dysfunction
or possible visero-somatic or somato-visceral
conditions
 Explain rationale for OMT and treat patient on a trial
basis
Patient
Follow
Up
 Somatic dysfunction successfully treated may feel
worse for several hours to a week – warn the patient!
 Successful treatment will then show improvement.
Chronic conditions will recur over time.
 Each successful treatment will show increasing
improvement and last for a longer period of time.
 Dosing of treatments is aimed at having the patient
return at about the time symptoms recur and see
progressively longer intervals between treatments.
Problems of a Visceral Origin
 Viscero-somatic problems will respond initially but
will quickly return within hours.
 If the treatment is not improving the patient’s
symptoms, look for other causes.
 If imaging studies and laboratory are negative,
consider scheduling a diagnostic laparoscopy.
 Patients with significant somatic dysfunction that did
not get better with OMT will often improve for 3-4
months after diagnostic laparoscopy, then the
symptoms tend to recur.
Anatomy Review
Anatomy Take Home Points
 Midline organs should be midline
 Paired organs should be symmetric
 Restrictions in the surrounding tissues and fascia may
lead to tissue texture changes and pain
 There may be viscero-somatic and somato-visceral
reflexes at play in pain syndromes
Case #1 – History of Chief
Complaint
 42 year old with a 2 year history of intermitent vaginal
burning and pain
 Frequent dyspareunia
 Treated numerous times for vaginal yeast without
improvement
 Biopsy negative for pathologic changes
Case #1 – Structural Exam
 ASIS low on right
 Outflare of right ilium, inflare of left
 Pubic shear low on right
 Sacral torsion
 Lumbar rotation
 Tissue texture changes in the thorax
 Vulva visually red. Tender areas in the vagina along
the levators on the right.
Case #1 - Treatment
 External somatic findings treated.
 Vaginal tender points treated with counterstrain
(positioning for tissue changes)
 Redness dissipated while treating!
 PT for individualized exercises
 Continue treatments every 4 weeks
 Patient is symptom free most of the time
Case #2 – History of Chief
Complaint
 44 year old female with a four year history of
progressively severe pelvic pain
 Was treated with a TAH for endometriosis 4 years
earlier
 When pain did not resolve, one ovary was removed.
Later the other was as well. The pain persisted. No
hormones were given because of the endometriosis.
 First patient visit, patient was sobbing in the fetal
position unable to talk normally
Case #2- Surgical Treatment
 The patient was so acute that despite negative
ultrasound, I decided to do a diagnostic laparoscopy.
She would barely let me touch her on the first visit, so
OMT was held off.
 Massive adhesions of the small bowel to the anterior
abdominal wall were left alone.
 Other adhesions were from the bowel to the vaginal
cuff and bladder and were taken down. No active
endometriosis was seen.
Case #2 – Osteopathic Examination
 The patient’s pain was somewhat relieved by the
surgery. She allowed manipulation after.
 The patient was noted to have a vertical AND an
anterior/posterior shear (unusual finding).
 There was tenderness in the suprapubic fascia
 Sacral torsion noted
 Lumbar rotation noted
Osteopathic Treatment
 Correction of the pubic shear brought the most pain
relief, especially the AP component.
 Myofascial release of the suprapubic tissues and deep
traction to prevent adhesion reformation were taught
to the patient to do at home.
 Patient was seen weekly for treatment and managed
with narcotics for pain.
 Patient was sent for prolotherapy on the pubic
symphysis and sacroiliacs bilaterally. Had significant
pain with the first treatment, and significant
improvement with the second.
Conclusions
 Pain management may often require a multiple
disciplinary approach for successful treatment.
 Sometimes, symptoms of somatic dysfunction mimic
other medical conditions prolonging successful
diagnosis and treatment.
 Being aware of the possibility of somatic dysfunction
in pain syndromes will lead to quicker diagnoses and
prevent unnecessary intervention and diagnostic
studies.
ashowalter@pnwu.org
References
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Interactive Pelvis and Perineum
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Primal Pictures, Inc.
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www.primalpictures.com
An Osteopathic Approach to Diagnosis and Treatment, Eileen L Di Giovanna, Stanley
Schiowitz, 1991. J.B.Lippincott
Progressive inhibition of neuromuscular structures (PINS) technique, DJ Dowling ,J
Am Osteopath Assoc, May 2000; 100: 285 - 298.
An Osteopathic Approach to Treating Women With Chronic Pelvic Pain, Melicien A.
Tettambel, J Am Osteopath Assoc, Sep 2005; 105: S20 - S22.
Protocols for Osteopathic Manipulative Treatment (OMT).Revised July 1998.
http://www.txosteo.org/Documents/OMT_protocols.pdf
Maigne JY, Chatellier G, Faou ML, et al. The treatment of chronic coccydynia with
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References (cont)
 Osteopathic Considerations in Systemic Dysfunction, Second Edition, Michael &
William Kuchera
 Efficacy of high-velocity low-amplitude manipulative technique in subjects with low
back pain during menstrual cramping. David Boesler, DO. JAOA Vol 93 No2 February
1993 203
 Manipulation for Dysmenorrhea. Mary Elizabeth Hitchcock, D.O. JAOA Vol. 75, June
1976
 Tettambel, M. Gynecology. In Ward, RC, ed. FOUNDATIONS FOR OSTEOPATHIC
MEDICINE, 2nd ed. Philadelphia, PA. Lippincott, Williams & Wilkins;2003;409-419.
 Tettambel, M. Obstetrics. In Ward, RC,ed. FOUNDATIONS FOR OSTEOPATHIC
MEDICINE, 2nd ed. Philadelphia, PA. Lippincott, Williams & Wilkins; 2003; 450-461.
Hodges SD, Eck JC, Humphreys SC. A treatment and outcomes analysis of patients with
coccydynia. Spine J. Mar-Apr 2004;4(2):138-40. [Medline].
 Maigne R. Diagnosis and treatment of pain of vertebral origin: a manual medicine
approach. Baltimore: Williams & Wilkins, 1996:339–40.
 Mennell JB. The science and Art of Joint Manipulation. London: Churchill, 1952.
 http://www.sofmmoo.com/english_section/7_coccyx/coccyxmv.pdf