There is accumulating evidence for clinical focus on key muscular and fascial structures with the potential to influence pelvic pain and dysfunction.

Lee, Lee & McLaughlin (2008) have noted: "The abdominal canister is a functional and anatomical construct that synergistically work together [involving] the diaphragm, including its crura, and by extension the psoas muscle, whose fascia intimately blends with that of the pelvic floor and the obturator internus muscle, the deep abdominal wall including transversus abdominis, and its associated fascial connections, anteriorly and posteriorly, the deep fibres of multifidus, the intercostals, the thoracolumbar vertebral column (T6-12 and associated ribs, L1-L5) and osseus components of the pelvic girdle (innominates, sacrum and femora)."

The pelvic floor and the respiratory diaphragm are seen to be structurally and functionally bound together by fascial and muscular connections; and just as dysfunctional breathing patterns influence pelvic function, so the reverse is true. Rehabilitation of the functions of the thorax, pelvic girdle, and pelvic floor may be enhanced by more normal physiological breathing patterns, while improving these patterns is aided by pelvic functionality, whether achieved through exercise, breathing retraining, postural reeducation, manual therapy, or other means. (McLaughlin 2009, Chaitow 2007)

Within the patterns of overuse and misuse that characterise chronic and acute insults to the body in general, and the low back and pelvic regions in particular, the evolution of myofascial trigger points is a common feature within a background of hypertonicity, induration and fibrosis. (Travell & Simons 1999, Anderson 2009, Key 2008, Fitzgerald 2009)

In this same context Prather (2009), Cox (2005), Janda et al (2007), Fitzgerald (2009) and many others, have implicated dysfunction involving: psoas, iliacus, quadratus lumborum, piriformis, hip adductors, rectus abdominis, abdominal obliques, scalenes and intercostals.

A focus on these and other adaptive soft tissue (and inevitably joint) changes, without due regard to etiological features, would offer short-term benefit at most. However, it is suggested that postural or other functional rehabilitation, without attention to such soft-tissue changes, would offer equally short-term results. (Chaitow et al 2002, Fitzgerald 2009)

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.

Resources

1. Anderson R et al. Painful Myofascial Trigger Points and Pain Sites in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome. J of Urology 2009;182(12):2753-8.
2. Bialosky J et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain. Manual Therapy 2009;14:531-8.
3. Chaitow L. Chronic pelvic pain: Pelvic floor problems, sacroiliac dysfunction and the trigger point connections. JBMT 2007;11(4):327-39.
4. Chaitow L, Bradley D, Gilbert C. Multidisciplinary Approaches to Breathing Pattern Disorders. Churchill Livingstone, Edinburgh 2002.
5. Cox J. Possible generators of retrotrochanteric gluteal and thigh pain. JMPT 2005;28(7):534-7.
6. Degenhardt et al. Role of osteopathic manipulative treatment in altering pain biomarkers: a pilot study. J Am Osteopath Assoc 2007;107:387-400.
7. Fitzgerald M et al. Randomized feasibility trial of myofascial physical therapy for the treatment of urologic chronic pelvic pain syndromes. J of Urol 2009 Aug;(182):570-80.
8. Janda V, Frank C, Liebenson C. Evaluation of muscular imbalance. In: C. Liebenson, Editor, Rehabilitation of the Spine: A Practitioner's Manual (second ed.). Philadelphia: Lippincott Williams & Wilkins, 2007.
9. Lee D, Lee LJ, McLaughlin L. Stability, continence and breathing: The role of fascia following pregnancy and delivery. JBMT 2008;12:333-48.
10. McLaughlin L, Goldsmith CH. Altered respiration in a case series of low back / pelvic pain patients. 6th Interdisciplinary World Congress on Low Back & Pelvic Pain, Barcelona, November 2007.
11. McPartland JM et al. Cannabimimetic effects of osteopathic manipulative treatment. J Am Osteopath Assoc 2005;105:283-91.
12. Prather H, Dugan S, Fitzgerald C et al. Review of Anatomy, Evaluation, and Treatment of Musculoskeletal Pelvic Floor Pain in Women. Physical Medicine and Rehabilitation
13. Travell JG, Simons DG. Myofascial pain and dysfunction: The trigger point manual. The lower extremities, Vol 2. Baltimore: Williams & Wilkins 1999:186-214.