Research Review By Dr. Ceara Higgins©


Download MP3

Date Posted:

April 2017

Study Title:

Musculoskeletal Dysfunctions in Patients with Chronic Pelvic Pain: A Preliminary Descriptive Survey


Mieritz RM, Thorhauge K, Forman A, et al.

Author's Affiliations:

University of Southern Denmark, Odense, Denmark; Odense University Hospital, Odense Denmark; Private Practice, Randers, Denmark; Aarhus University Hospital, Aarhus, Denmark; Nordic Institute of Chiropractic and Clinical Biomechanics, Aarhus, Denmark.

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2016; 39: 616-622.

Background Information:

Chronic pelvic pain (CPP) is characterized by episodic or constant pain in the pelvic region lasting more than 6 months (1). The condition in generally nonspecific, but is estimated to affect 25% of fertile women (2) and 10-16% of men (3). Causes of CPP include pregnancy (4), gastrointestinal, urinary, gynaecological, neurologic, and musculoskeletal (MSK) conditions. No effective treatments have been found and the role of the musculoskeletal system in CPP is poorly understood.

We do know that pain from MSK dysfunction can be very similar to gynaecological pain (5) and it has been hypothesized that manual therapy targeting MSK dysfunction can be helpful for patients with CPP (7). Theories regarding this observed efficacy of manual therapy include the effect of MSK dysfunction on the autonomic nerves supplying the pelvic viscera and the blood flow in the area (9), as well as the possibility that referred pain from the muscles, hips, pelvis, or lumbar spinal joints may be responsible for the symptoms of CPP (7). The purpose of this study was to determine the prevalence of MSK dysfunction in patients with CPP based on a standardized clinical examination.

Pertinent Results:

94 patients completed the study. 48 patients (51% of the sample) were classified as having MSK dysfunctions in the lumbar/pelvic region. Both groups showed similar demographics with the only significant difference being noted in self-rated health status, with only 27% of the group with MSK dysfunction rating themselves as excellent or very good compared to 50% of the non-MSK dysfunction group. In addition, it was noted that patients in the MSK dysfunction group tended to report more pain in the anterior and posterior lower limbs. It is possible that referred pain from the muscles, hips, pelvis, or lumbar spinal joints may be responsible for these symptoms (8).

Significant differences between groups were seen in most of the clinical tests. No differences were observed for the Gaenslen’s test, the modified Schober 15 index, and lumbar rotation both left and right. The authors conclude that this allows us to potentially identify a subgroup of patients with MSK dysfunction that may comprise as much as half of all patients with CPP. This could help to explain why some patients have continued pain even when no endometriosis is found on subsequent laparoscopy (12), or why some patients show recurrent pain after surgical treatment for endometriosis (13). As a result, manual therapy targeting MSK dysfunction in patients with CPP should be further investigated. SI joint dysfunction was particularly high in the MSK dysfunction group, so may be a relevant area of focus for treatment, especially as SI joint dysfunction is often recognized as causing pain in the posterior pelvis with radiating pain into the lower limbs (6).

Similar patterns of pain were seen between the two groups with respect to pain levels changing along with the stage of the menstrual cycle. This indicates that MSK problems may be a comorbidity or secondary to hormonal or gynaecological disorders. If the MSK dysfunctions were the main pain generators, we would expect to see more stable pain levels in the MSK dysfunction group throughout their menstrual cycles, however, this does not mean that these patients wouldn’t still benefit from treatment aimed at their MSK dysfunction (11).

Clinical Application & Conclusions:

51% of studied patients with CPP were classified as having MSK dysfunction and these patients tended to report more pain in the anterior and posterior lower limbs. This could allow for the identification of a subgroup of CPP patients who would benefit from treatment aimed toward MSK dysfunction, opening the door for manual therapists, including chiropractors, physiotherapists, registered massage therapists, etc. to play a significant role in the treatment of CPP. As there is currently no known effective treatment for CPP as a whole, this could be of vital importance to this patient group.

Study Methods:

Participants were recruited from the endometriosis referral center at the Department of Gynecology at the Aarhus University Hospital in Skejby, Denmark between January, 2007 and January, 2010 based on the following inclusion criteria:
  • Women aged 18 to 50.
  • Referred to the Aarhus University Hospital for lapraroscopic investigation on suspicion of endometriosis.
  • Able to speak, read, and understand Danish.
Exclusion Criteria:
  • Known diagnosis of endometriosis, cancer, diabetes, cardiovascular disease, inflammatory joint diseases, obvious joint abnormalities, or other spine or MSK disorders.
Participants completed a questionnaire designed to collect information on age, height, weight, education, work, self-reported health, self-reported pain during menstruation, from menstruation to ovulation, and during ovulation, and a 30-minute clinical examination with a chiropractor with 4 years of experience and a special interest in pelvic pain. Conversation was kept to a minimum during the examination and participants were blinded to the health care personnel.

The physical examination included:
  • Active range of motion of the lumbar spine with the patient standing. Painful movement in at least one direction was considered indicative of a mechanical MSK disorder.
  • Identification of myofascial trigger points in the quadratus lumborum, gluteus medius, gluteus maximus, piriformis, and psoas muscles through digital palpation.
  • Springing tests and segmental palpation from T9-L5 and sacroiliac joints (SIJ) were performed with the patient lying prone. Pain reproduced with posterior to anterior pressure was considered indicative of a mechanical MSK dysfunction.
  • Pelvic girdle pain tests including the posterior pelvic pain provocation test; flexion, abduction, external rotation, and extension of the hip test; and Gaenslen’s test (10). The posterior pelvic pain provocation test was considered indicative of mechanical MSK dysfunction if axial pressure reproduced pain. When the flexion, abduction, external rotation, and extension of the hip test reproduced pain on the contralateral side around the SIJ, it was considered to indicate SIJ dysfunction and when it provoked pain on the ipsilateral side anteriorly it was considered to indicate a hip joint disorder. Gaenslen’s test was considered positive for a mechanical MSK disorder if it reproduced pain.
  • Palpation for pain over the sacrotuberous ligament was conducted through the rectum and was considered positive when pain was reproduced.
Based on the physical examination findings the patient was classified as having MSK dysfunction or not having MSK dysfunction. The full procedure was repeated at 3 months post physical examination to check for errors.

Study Strengths / Weaknesses:

  • The sample size was small, limiting their ability to statistically distinguish between the two groups.
  • Only one clinician performed the examinations and there is no current gold standard for the tests included in the examination.
  • A few questionnaires which were included were returned with incomplete information on weight and pain levels.

Additional References:

  1. Fall M, Baranowski AP, Elneil S, et al. EAU guideline on chronic pelvic pain. Eur Urol 2010; 57(1): 35-48.
  2. Zondervan KT, Yudkin PL, Vessey MP, et al. The community prevalence of chronic pelvic pain in women and associated illness behaviour. Gen Pract 2001; 50(468): 541-547
  3. Schaeffer AJ. Epidemiology and evaluation of chronic pelvic pain syndrome in men. Antimicrob Agents 2008; 31 (Suppl 1): S108-S111.
  4. Malmqvist S, Kjaermann I, Anderson K, et al. Prevalence of low back and pelvic pain during pregnancy in a Norwegian population. J Manip Physiol Ther 2012; 35(4): 272-278.
  5. Moore J, Kennedy S. Causes of chronic pelvic pain. Ballieres Best Pract Res Clin Obstet Gynaecol 2000; 14(3): 389-402.
  6. Jarrell JF, Vilos GA, Allaire C, et al. Consensus guidelines for the management of chronic pelvic pain. J Obstet Gynaecol Can 2005; 27(8): 781-826.
  7. Browning JE. The mechanically induced pelvic pain and organic dysfunction syndrome: an often overlooked cause of bladder, bowel, gynecologic, and sexual dysfunction. Neuromusculoskelet Syst 1996; 4(2): 52-66
  8. Proctor ML, Hing W, Johnson TC, et al. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2006; 19(3): CD002119.
  9. Jamison JR, McEwen AP, Thomas SJ. Chiropractic adjustment in the management of visceral conditions: a critical appraisal. J Manip Physiol Ther 1992; 15(3): 171-180.
  10. Vleeming A, Albert HB, Ostgaard HC, et al. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J 2008; 17(6):794-819.
  11. Montenegro ML, Mateus-Vasconcelos EC, Rosa ESJC, et al. Postural changes in women with chronic pelvic pain: a case control study. BMC Musculoskelet Disord 2009; 10: 82.
  12. Sutton CJ, Ewen SP, Whitelaw N, et al. Prospective randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril 1994; 62(4): 696-700.
  13. Vercellini P, Crosignani PG, Abbiati A, et al. The effect of surgery for symptomatic endometriosis: the other side of the story. Hum Reprod Update 2009; 15(2): 177-188.