5.1 Biopsychosocial Treatment: Education

At the end of the evaluation, the clinician should have a series of findings, where a pattern of segmental involvement can be determined. If so, then treatment involving a posterior-to-anterior mobilization can be introduced at that level in an attempt to assess theoretical accuracy. If the symptoms are altered, the clinician will have a strong indication of neurological involvement.

Utilizing the hierarchy noted here, all treatments are to begin with education aimed initially at attaining and maintaining appropriate neutral spinal alignment as outlined by McKenzie. ⁵ This will serve many purposes: (1) it will minimize the strain throughout the dural structures, (2) it will serve as a means for the clinician to assess the patient’s willingness to participate in her own health care, and (3), it will empower the patient to self-correct, and decrease the hyperkyphotic alignment that reflects a state of hypervigilance while decreasing the secondary muscle tenderness associated with this posture. This format has been shown to be effective at facilitating the healing process for all pelvic pain patients, regardless of central involvement. The assumption is that change of locus of control from passive recipient of pain to active participant in healing will lead to a more positive outcome. ³ , ⁴ , ⁶ , ⁷

Up to 85% of patients suffering with a chronic pelvic pain will have musculoskeletal dysfunction and postural changes including scoliosis and pelvic rotation. Abnormal postures have been found to increase muscular tension and spasms with subsequent muscle shortening that further aggravates the patient’s pain, resulting in persistent, perpetuated pain cycles. ⁸ , ⁹

A significant portion of the treatment regimen for the pelvic pain patient may be to optimize patient’s postures during common activities of daily living. Doing so will assist in her overall healing process. ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ Postural training is imperative for efficiently healing the individual with spine-facilitated pain. Stresses and strains associated with postures, especially flexion, will increase the production of glial and plial scar formation and concomitant fluid-filled cavities. ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ Due to the arrangement of the spinal anatomy, deformation of the spinal canal will lead to deformation of the internal structures of the canal. As an example, it was found that the S2 nerve root was tensioned, or strained 16% during a combination of cervical and lumbar flexion: the slouched position. ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ The correction of a patient’s posture will have a twofold benefit: (1) it will minimize the aforementioned neuromechanical strains and (2) it will afford the patient the opportunity to be an active participant in their healing process, thereby empowering themselves to heal.

Intervertebral disk pressures are directly related to the alignment of the spine to the thigh and the angle of the hip and knees. ³ , ⁴ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ Less than optimal spinal alignment will increase focal stresses, restrict spinal capsular capacious qualities, and impede imbibition (the means to which the spinal structures receive nourishment). Imbibition dictates the need for movement, and this was noted by Harrison and colleagues by the overwhelming preference for “adjustable” chairs to meet this need. ¹⁰ , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ Harrison and co-workers further reported the reduction of lower back pain, and the reduction of paraspinal muscle activity and forward inclination of the head, when a lumbar support was utilized in conjunction with firm foam as the material on which one sits, along with the use of armrests. ¹¹ , ¹⁶ , ¹⁸ A correction of prolonged, static positions will further limit the detrimental compressive forces to which the intervertebral disks are subject. This will reduce the likelihood a primary disk lesion, and if the patient’s symptoms are either directly or indirectly related to neural irritation, then the simple practice of attaining and maintaining appropriate, erect postures will assist in the long-term healing process.

Postural dysfunctions, as they relate to the pelvic pain patient, may be due to:

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  Childhood injuries

  
  
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  Structural malformation: scoliosis, short-leg syndrome, hemipelvis

  
  
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  Poor ergonomics

  
  
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  Recreations activities

  
  
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  Frequent wearing of high heels

  
  
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  Sedentary lifestyle

  
  
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  Constant sitting in poorly designed chairs and sofas

  
  
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  Pregnancy

  
  
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  Breast feeding positions

  
  
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  Trauma: motor vehicle accident, sport, etc.

  
  
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  Poor breathing patterns

  
  
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  Illness or disorders: emphysema, asthma, chronic fatigue syndrome

  
  
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  Surgical adhesions

  
  
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  Pelvic laxity

As the patient is progressing through the rehabilitation program, it is appropriate that the clinician be immediately present to offer gentle words of encouragement, and postural corrections as necessary. Often the patient will require verbal assurance that the malaise of exercise is appropriate and necessary, and is to be considered as distinct from the pain she has been suffering. All too often, the patient suffering will associate any local pain as a regression of their status regardless of origin, exercise induced or otherwise. Determining the factors that motivate the individual will assist in their desire to participate in the re-conditioning program. Discuss with the patient what their goals are, and attempt to introduce movements, exercises, and activities that meet those goals.

5.2 Biopsychosocial Treatment: Cognitive Behavioral Therapy

Clinicians must be aware that depression and anxiety commonly accompany patients who suffer from pelvic pain. It is often quite difficult to determine what the cause is, and what the effect is. It is further known that patients with pelvic pain will demonstrate “health care seeking behavior”; however, a direct link to psychological and physical disease has yet to be found. ¹⁹ Williams et al compared women with chronic pelvic pain with healthy women, analyzing their depression, anxiety, and sexual dysfunction using the following scales: Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Spielberger Trait Anxiety Inventory (STAI), and the Golombok Rust Inventory of Sexual Satisfaction (GRISS). ¹⁹ The findings concluded that those with chronic pelvic pain had significantly higher BDI and BAI scores when compared with the normal population, and the GRISS score was also found to be significantly higher in those with chronic pelvic pain. Those suffering from chronic pelvic pain also were found to have greater difficulty communicating with loved ones. They often demonstrate avoidance behaviors and they state that they have a decreased sense of sensuality and sexuality. There was no difference found in reported relative to anorgasmia, ²⁰ indicating appropriate physiological function and absence of dysfunction.

Behavioral modification is imperative in the treatment of those with chronic pelvic pain. The neurological systems, both central and peripheral, must be desensitized through a progressive introduction of movement activities that do not provoke pain. This, in part, can be accomplished by reducing joint restrictions with joint-specific mobilizations and allowing the patients to partake in movement and activity. Somatization is the propensity to experience and report somatic symptoms that have no pathophysiological explanation, and to misattribute them to disease and then seek medical attention. ²¹ , ²² Patients with a catastrophic perspective have a greater rated disability index, greater rated disability, and greater health care utilization as compared with those who are unaffected. Anxiety toward activity, intimate or otherwise, produces a state of hypervigilance, which in turn facilitates greater muscle tension and pain, and perpetuates the cycle of activity avoidance and pain behaviors. ²³ “Nonanatomic” pelvic pain syndromes do not respond well to biomedicine, but they do respond better with psychosomatic treatments. ²⁴

Continual passive movement and movement in general have been shown to facilitate healing of synovial joints, and the regeneration of hyaline cartilage, in addition to the maintenance of appropriate joint characteristics necessary for normal function. This is explained by: (1) improved fluid dynamics, (2) stimulation of mechanoreceptors to obtund pain, (3) prevention/lessoning of restrictive/painful adhesions, and (4), possibly, the promotion of the formation of a pseudodisk. ²⁵

Cognitive behavioral psychological pain management techniques, as outlined by Howard, ⁸ are detailed in Table 5.1.

5.3 Neurological and Joint Treatments: Manipulations and Mobilizations

Manipulation is an ancient art of healing dating back to the time of Hippocrates, and it has been used intermittently by the medical community in the treatment of pain, swelling, and spasms. ²⁶ Ancient Chinese, Egyptian, and Greek medical accounts note the change in respiration rate, arterial pulse, and reduction of muscle tone with the application of mobilizations to the bony pelvis. ²⁷ , ²⁸ Manipulation and mobilizations have been found to be equally effective in the eradication of pain and restoration of function. ²⁹ , ³⁰ Research performed on sheep has demonstrated that short and fast thrusts have been found to produce larger adjacent segmental motion, and research that utilized longer pulse durations actually caused greater local motion at the segmental contact point. ³¹ Therefore, we will be discussing the use of manipulations and mobilizations throughout this textbook.

Utilizing spinal mobilizations or manipulations in the treatment of pelvic pain is not a unique concept. According to Jamison et al, 11% of the chiropractic profession of Australia has utilized spinal adjustments to manage their patients with pelvic pain. ³² Browning found spinal manipulation to be an underused treatment modality in the treatment of pelvic pain. ³³ According to Weiss, a common cause of persistent pain after neural decompression surgery revolves around the sensitized nerve, connective tissue, muscles, and ligaments that had initially predisposed the nerve to injury and then remained the dominant problem following surgery. ³⁴ What is unique, however, is the application of spinal mobilizations as directed by embryological derivation, and the concurrent treatments that will assist in the overall management of the patient with pelvic pain. By mapping the patient’s pain and symptomology, physical presentation, and positive clinical testing maneuvers, and then tracing back the viscus in question, the clinician will know where along the spine each treatment is to be applied. Take the following into consideration as a common presentation:

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  Patient A reports pain deep within the rectum.

  
  
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  Active motions of the spine demonstrate local hypomobility of T10 to L3.

  
  
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  Segmental, arthrokinematic, testing confirms local hypomobility of T10 to L3.

  
  
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  Prone knee flexion test is positive; fasciculations are noted.

  
  
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  The clinician can cross-reference the patient’s history, with the tests shown in Table 5.2, and determine that treatment via mobilizations can be initiated at T12 to L2.

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Table 5.2 Embryological origin of selected organs and joints

  	C3	C4	T6	T7	T8	T9	T10	T11	T12	L1	L2	L3	L4	L5	S1	S2	S3	S4	S5	Co1	Co2
  Organ/Joint
  SCJ	X	X
  Pancreas				X	X
  Liver						X
  Gall Bladder			X	X	X	X	X
  Stomach/duodenum				X	X	X	X
  Small intestine						X	X
  Epididymis							X
  Colon: ascending							X	X	X	X
  Kidney							X	X	X	X
  Appendix							X	X	X	X
  Ureter								X	X	X
  Bladder fundus								X	X	X
  Uterine fundus								X	X	X
  Bladder Neck								X	X	X
  Vagina								X	X	X
  Suprarenal gland								X	X	X
  Ovary/testes								X	X	X
  Colon; flexure										X	X	X
  Colon; sigmoid																	X	X	X
  Prostate																X	X	X	X
  Urethra																X	X	X	X
  Rectum																	X	X	X

Spinal mobilizations have been shown to be effective in the treatment of acute and subacute lower back pain. Biomechanically, mobilizations/manipulations facilitate the restoration of segmental mobility and the restoration of function ³⁴ , ³⁵ through the repeated loading of the spinal connective tissues. Decreased resistance to segmental, arthrokinematic movement is due to creep deformation and microfailure of tight connective tissue. ³⁵ , ³⁶ This has been achieved after 9 minutes of end-range posterior-anterior mobilizations in asymptomatic subjects. Single-treatment sessions involving two minutes of central posterior to anterior spinal mobilizations demonstrate minimal osteokinematic improvements of motion. It is only via continued treatments and the postural/lifestyle education that actual improvements in spinal osteokinematic motions can be appreciated. ³⁵ , ³⁶

Beneficial physiological responses to spinal mobilizations and manipulations include the transient decrease of motor-neuronal activity. As reported by Dishman, the facilitation of motor-evoked potentials in the gastronomies was noted after a spinal mobilization/manipulation; it was not noted in those who had assumed a nonmanipulative side-lying position. ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ It was further found that group Ia, Ib, II, and IV afferents responded in a graded fashion to the velocity, magnitude, and direction of a vertebral loading. Stimulation of group Ib, III, and IV muscle afferents actually exerted an inhibitory effect on alpha motor neurons. Thoracic and lumbar spinal mobilizations and manipulations have been shown to be safe and effective in treating a variety of pain conditions. The risks involved with performing a thoracolumbar manipulation have been studied and the rate of injury has been found to be 1 in 3.7 million. ⁴² Considering these findings, the mobilizations that will be discussed here are the CPA variety as outlined by Maitland, Cyriax et al. ³ , ⁴³ Other mobilization techniques have shown to be effective as well; however, covering all the various techniques is beyond the scope of the textbook.

In the provision of mobilizations/manipulations, the clinician need not be concerned with producing an audible “click.” It has been shown that cavitation is not an essential component of a manipulation or mobilization. ⁴⁴ As long as the contraindications are respected, the provision of a mobilization/manipulation is a viable treatment choice. Rationale for the provision of a mobilization/manipulation is the presence of a localized muscle spasm, or a restriction of movement at a joint and or the presence of pain. ⁴⁵ Improvements of range of motion and reduction of muscle spasms after the provision of a mobilization/manipulation have been noted regardless of symptom duration, and those suffering will often experience the greatest improvements. ⁴⁶ , ⁴⁷ , ⁴⁸ When performing a mobilization or manipulation, the clinician must take care to determine the effected side, as a compressive event, further joint loading, will occur on the contralateral side to that being treated. ⁴⁹

Joint dysfunction is often the result of adhesions and muscle contractures, and poor stabilization capacities of the ligaments and muscles. The application of a mobilization and manipulation improves local osteokinematic properties of a joint and is essential for rapid absorption of scar tissue, and affords better structural organization of the healing tissues. ⁵⁰ , ⁵¹ Mobilization-induced hypoalgesia has been demonstrated in numerous studies on humans, indicating that mobilizing an area of injury and the area proximal to injury reduces hyperalgesia. ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁶ , ⁵⁷ Stimulation of the central nervous system (CNS) will induce a release of endogenous chemicals from cells in pain control circuits via the stimulation of periventricular gray matter (PVG), periaqueductal gray (PAG), or the nucleus raphe magnus with the resultant release of enkephalin or monoamines producing analgesia. ⁵⁸ Furthermore, mobilizations effectively lead to a bilateral activation of descending inhibitory pathways that result in a reduction of hyperalgesia, and sympathoexcitatory effects of the treatment were noted in changes of skin conductance and cutaneous blood flux. ⁵⁹ The reduction of hyperalgesia by joint mobilization and manipulation involves the release of 5-hydroxytryptamine (5-HT) serotoninergic and alpha-2 noradrenergic receptors in the spinal cord. 5-HT receptors are for neurotransmitter and peripheral signal mediator serotonin. 5-HT receptors are located on the cell membrane of nerve cells and other cell types including smooth muscles in animals, and they mediate the effects of serotonin as the endogenous ligand. 5-HT receptors also affect the release of other neurotransmitters including glutamate, dopamine, and gamma-amino butyric acid (GABA). Data from research indicate that it is the activation of nonopioid pathways that are involved with descending inhibition through serotonin and noradrenaline that produce the analgesia. ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁵⁴ , ⁵⁵ , ⁵⁶ , ⁶⁰

Joint mobilization and manipulation also activate muscle spindle and golgi tendon organ primary afferent fibers, which may inhibit the alpha-motor neuron and reduce muscle spasms and hyperalgesia. Pain is initiated in the Type IV receptor system, and it is carried to the brain via the anterolateral spinal tracts. These tracts can be modulated by all peripheral and/or articular mechanoreceptors. Activation of the peripheral mechanoreceptors by joint or soft-tissue manipulation will reduce the presynaptic inhibition of nociceptive afferent activity and lead to pain suppression. The alleviation of muscle spasms is likely due to the stimulation of Type I and II mechanoreceptors within the spinal joints themselves. The result is the modulation of activity involving the fusimotor muscle spindle loop system. ²⁶

There is growing evidence as to the efficacy of spinal mobilization and manipulation therapy in the treatment of pain regarding long-term potentiation (LTP) and long-term depression (LTD). Spinal mobilization/manipulative therapy are thought to address the LTP, which is known to be reversible, within a sensitized pain-signaling segment of the spine. ⁶¹ LTD has been noted to occur in the dorsal horn neurons after low-frequency stimulation of A-delta afferent fibers and has further been shown to reverse the LTP established by C-fiber activation of those same dorsal horn neurons. The LTD has been observed to last for days, and the improved biomechanics through spinal mobilization/manipulative therapy may allow for the restoration of normal activities, which will facilitate central de-sensitization. ⁶² The phenomenon of neuroplasticity ⁶³ has been noted to occur as a response to a variety of internal and external demands made on the nervous system inclusive of mobilizations/manipulations. Spinal mobilization/manipulation therapy appears to be effective through the stimulation of A-beta, A-delta, and C-fibers and less for the mechanical “breaking of adhesions.” It is under this premise that the utilization of a mobilization or manipulation of the spine is found be effective in treating those patients who are suffering from pain due to a facilitated segment, central sensitization. Effects of mobilization/manipulation on local dorsal horn-mediated inhibition of A-delta and C-fibers have been noted as a potential hypoalgesic mechanism and have been found to have both local and peripheral effects in the lumbar spine; A-delta has also been found to be mediated with stationary bicycle riding and lumbar extension exercises. ⁵² This has been noted as a result of local antiinflammatory ⁵⁷ and decreased electromyography (EMG) activity. ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁶⁴

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