INTERVIEW 9 SM: Can you tell me a bit about the practice you work in?

P9: Its a group practice; because we have got specialists in different areas of practice we basically appeal to all patients, so Ive got colleagues who are specialists in sports care. My specialist area is paediatrics, and we have quite a big paediatric base in this practice. We are three partners and four associates and we usually have three or occasionally four osteopaths working at any one time. SM: And how long have you been practicing for? P9: Nine and a half years. SM: And which college did you graduate from? P9: 2003, BSO. SM: So, what is your understanding of the mechanism behind primary dysmenorrhea? P9: I dont see it as one condition so I think there are various different factors that can result in the same symptom that someone feels. So, sometimes I So for me, I want to know what the aetiology of the symptom is, and there are various groups of patients. Sometimes I think it relates to vascular congestion, other times I think its more muscular, spasmodic. And sometimes it relates to when were looking at vascular congestion - the ability of the organs to move within the pelvis, sometimes it relates to the ability of the pelvis to move and support the organs, sometimes it relates to actually how the pelvic organs relate to the gut organs. So for me, theres various different causes of it and when I see a patient with it its about working out what the cause is for that particular patient and how I can influence it. SM: So when you say vascular congestion, are you thinking more arterial, venous or P9: Or lymphatic, or a combination of all. So for me, I see a lot of patients I think fall into the vascular lymphatic congestion side. Arterial blood goes in under high pressure, so if somethings going to disrupt vasculature, quite often it is stasis affecting vascular and lymphatic drainage, affected before you affect arterial supply. But I do wonder sometimes whether the spasmodic cases are caused by poor arterial supply. SM: Do you think there is an age difference between these different types of patient? P9: I think I see more congestive, but a lot of the young girls I treat, who start theirI see a lot of teenagers around menarche, I think a lot of the younger ones I

treat are getting more spasmodic pain than congestive pain. And when I look at the groups I treat, I think a lot of the women begin to develop dysmenorrhea premenopause or after children, and a lot of those I think is congestive, but Ive also seen congestive in young as well. SM: But possibly the idea of the congestion, the gradual failing which makes thing gradually worse P9: And the various injuries that you acquire; I sometimes see women around the time their periods begin again after having a baby and various trauma has happened during the delivery, their whole structures changed, their whole postures changed and what they currently have post-delivery is something that doesnt work for drainage the pelvic floors different. The pelvis has been rearranged and the guts the organs have been rearranged, the uterus itself, stretched, cut, whatever it takes. SM: Is it possible to talk about a specific patient, their symptoms, what your approach was, how you treated them and how it went? P9: Yeah, Ill have to think now OkIve got a patient who I took on who was basically prepared to go for surgery, she was considering having a hysterectomy. So she got into her mid-forties, she hadnt had children, shed had a miscarriage two years prior to when she came to see me. Up until the miscarriage she had no problems at all with dysmenorrhea, so I consider it a case of primary. Im assuming that fits your definition? Basically, both her mother and her twin sister had had children and after theyd had their children they had developed the same symptoms of dysmenorrhea and theyd both had hysterectomies at a young age. So she was in her early to mid-forties, shed had a miscarriage, shed basically decided that she probably wasnt going to have children, and was in the mind-set that if she has to spend three days in bed every month, theres no point having periods so she was looking at having a hysterectomy. Her mum and her sister had had lots of treatment and nothing had helped; I treated I treat her husband and he mentioned that they had to cancel an event they were going to on the weekend because of it, and I dropped into the conversation that it might be worth a look before she went down the surgery route. So she came in basically saying, my mum and my sister couldnt get any help and I dont think youll help me but my husband says I should try. SM: Right, it wasnt you who treated the mother and sister? P9: No, they didnt have any osteopathy but they went down the route of all the medications that were possible. They tried implants to see if hormone treatment would make a difference and they both ended up with hysterectomies before the menopause. And when I took her history, she had no particularly interesting surgical history, the miscarriage itself had been fairly uncomplicated, she had a D and C after and I cant remember how longshe was about 12 or 13 weeks in when she miscarried. When I assessed her, it just felt like nothing moved. Her sacrum didnt move, her pelvis didnt move talking in terms of involuntary motion. Structurally there was definitely a real kind of hard barriers at the end

range movement that I didnt, they were barriers too soon so she had less movement than I expected. When I felt involuntary motion in the various organs, I took a logical look around all the organs in the whole abdomino-pelvic space. It felt like her uterus was hard and immobile, and it felt pulled towards the right side; most of her symptoms were into the right side, they were down into She had them with every period so she was being investigated to find out whether it related to the ovary, but they felt not because it was every period and not every other, which they would have expected. So I felt down into the pelvic fossa I had a look at appendix, caecum to see what was around there that wasnt particularly mobile but it didnt feel like it was a cause or an aetiology, but the whole uterus felt like it was tethered towards the right side. When I palpate, I look at how it floats in space and it was a bit like when you make a tent and you pull the ropes too hard on one side. It had an immobility that didnt feel like it came from the structure, but from the tethering of the structure. Treatmentwise I worked mostly with involuntary motion initially; she had a history of low back pain as well and shed had mostly structural treatment and it had been recurring quite often. I thought, well, shes had a lot of structural treatment, lets just see if something else works. She was quite skeptical, she hadnt expected me to just not do anything, which is what she thought I was doing. I was quite shocked at how quickly she responded, so I treated her twice before her next period and she said, I had pain, but I didnt have to take painkillers. Her standard was, shed get pain and shed have a warm bath: if it subsided she wouldnt take painkillers, if it didnt shed take painkillers so the warm bath worked, basically. And then the next time she had her period Id seen hershe was also for some reason having her periods three weeks apart, that had changed after the miscarriage as wellit then went for four weeks and she had another one and she had no pain, so she was quite shocked. SM: You treated her in that interim? P9: In the interval, two or three times, I cant remember the details of it. I saw her this week and its probably about six months since Ive started treating her and she has only had one period in that time where shes had enough pain to take painkillers and she only took one dose. Shed not had any pain thats kept her in the house she was staying at home for two or three days every time. And now I dont think, now shes coming with a different problem and I just assess to see if theres anything else left to do, but now it feels like her uterus floats within her pelvis. She was under a private gynaecologist and theyve discharged her and written a referral recommending that she gets osteopathic treatment covered in her private healthcare. SM: Youve saved the insurance company a lot more money! Did you just use involuntary motion? P9: No, I did some quite direct work into the right iliac fossa, I also did quite a bit structurally to get her lumbar spine and thoracic spine moving because I felt that they werentwhen you watched her move, her whole trunk moved a bit like a block and I wanted her uterus to stay floating and moving and sliding in the

pelvis and I think that only really happens if your pelvis is moving and articulating it. SM: Yes, so thats manipulation and articulation? P9: Yes, and some soft tissue. But I would say predominantly I used involuntary motion to treat, I dont think I could have achieved what I achieved without it. SM: And some more visceral techniques as well? P9: Yesmy background, I havent had any official visceral training, but I palpate involuntary motion, I can put my hand on an abdomen and differentiate between different structures within there, so I palpated the involuntary motion of structures in the abdomen as well as some direct work on the ascending colon, which I felt was a bit of a monster. Once the uterus started floating, it felt like that was grabbing slightly. SM: Would that be your approach to other patients with this? P9: To be honest, you probably get this all the time: I dont have that kind of textbook approach for a condition; I know some osteopaths that work by a checklist. I tend to listen to the history, get some impression about whether I think theres pathology going on, assess to exclude, and then put my hands on and I say, well how does his body work, what moves, what doesnt. And I broadly speaking - treat to improve motion and improve vasculature; look at symmetry of function. And after that I make a hypothesis between that and the symptom. I treat what I find and then wait for the symptom to respond. And I said to her, I know I can feel various things going on, I dont think its helping your uterus, youve had this for a few years, pain killers havent touched it, the hormone treatment youve had hasnt touched it, Im not promising Im going to make any difference but give me three treatments, and then we can decide whether I have made a difference. SM: She must have been pleased. P9: Yeah, she was. I was too; I was actually shocked, because obviously, she responded. Because she came in with this doing, like no-one can help me, I dont think youre going to help me, Ive got surgery booked in three months and Ill have it, you cant help me. So yeah, no, I was quite SM: So do you mean you were thinking this was quite a congestive problem? P9: No, I think it was more than congestive. There was a congestive element to it, but I think her uterus, the quality of it wasnt just congested, it was hard. It felt to me like there was some kind of myofascial reaction to the tightness that had tightened the fascia that surrounds the uterus. So congestiveness might have caused the pain, but a just congested uterus feels different to how hers felt. So I think she was getting spasmodic pain, as in muscular spasm, in addition to vascular congestion.

SM: Something to do with the trauma of the miscarriage and the D and C? P9: I dont know. I dont have an idea about why it would be so one-sided, about why it would be so tethered down on that side. I dont know her history, whether she has had, that its possible there could have been somewords gonewhen you get ectopic uterine tissue SM: Endometriosis? P9: Yes. I dont know whether thats a possibility, and maybe the hormonal changes of pregnancy provoked areas of tissue to respond that werent responding before. I dont know whether that wasit was quite a strong tethering, it felt almost like scar tissue but there was nothing in her history indicating that there could be scar tissue in that area. If shed said, oh, I had my appendix out or I had a laparoscopy I would have understood where that had come from, but in my mind there wasnt a clear reason as to why it would be so tethered to that side. SM: You said you treat some young teenagers who are starting their periods and getting problems, is it the same kind of approach? P9: Yeah, I mean my basic approach is looking at the function of the organ involved, so thats the uterus, and then understanding that the uterus needs good vasculature support, needs good lymphatic and venous drainage, but it also needs to move within the pelvis, so its attached to various points. I look at the structures that are attached to it and whether they work, whether theyre in balance. If youve got one innominate thats rotated and higher than the other one, then its going to put the torsion through the ligamentous structures that are holding that uterus in place. Then I look at how the uterus relates to the other organs in the abdominal space, how the diaphragm and the pelvic floor work together to pump that patient I mentioned, I did quite a bit of work on motion of the pelvic floor and I felt that there really wasnt much movement in it. And its hard to know when someones had pain whether thats the cause of or a reaction to, because I think when it hurts you tend to hold. SM: Right. So is that an exercise-type treatment or? P9: No, I balance the pelvic floor using indirect techniques. So, the pelvic floor is attached to various places in the pelvis and you can feel motion in the pelvic floor by holding the innominates. You can work that way. I did quite a bit of work on her diaphragm as well actually, I forgot to mention that. So I basically look at the organ, the support of the organ from a neurological/vascular point of view. Lymphatics I include in vascular. And then itsI talk about the house that it lives in to patients, youve got to make sure that she surroundings supportive, and that the other people who live in the same space also support. SM: I dont know if you can think of another patient where maybe you werent able to help, didnt really make much difference?

P9: With dysmenorrhea? SM: Other osteopaths Ive spoken to at this point often talk about patients who had other issues going on, and hadnt necessarily bought into the treatment, or P9: Yeahthe only one I could think of didnt see out the course of treatment, so I didntI made some progress, Id say, over a couple of months. She had ME, or chronic fatigue as well. So in terms of technique and treatment I was limited to how much I could do at any one time. I had a conversation with her at the start that basically said, yes I probably can help, but I think it will take quite a lot of treatment because of the way Im going to have to treat you. Im going to have to leave gaps between treatments that are longer than I would choose to normally and Im going to not do so much as I normally would. And progress was really slow. And she had something like two slightly better ones but still had a lot of pain, and then one really bad one and decided not to continue. SO Im not sure, because I couldnt follow upbut that was about three or four years ago so Im wracking my brains as to what we did. But hers was mostly congestive, but she was soshe didnt do much exercise because of her chronic fatigue. It was quite hard once I got things moving for her to keep it moving. SM: Did she suffer from a mood as well? P9: Yes. Massive mood changes with her actually thats what changed first, she reported that her mood was different before her period, her other half had noticed. That changed the first months, which she liked almost more than the pain change. But she didntI did say to her, I like being up-front with patients, I would say dont expect a quick fix. Youve got to have the time and resources too, and I think time was a factor for her. She traveled quite a distance too, shed got my name from somebody and decided to travel for it, so she might have gone to see someone more local, I dont know. But I think her ME was a significant factor in the ability of her body to change, basically. And I was quite keen not to overload her. Maybe I could have treated more vigorously, but Im slightly wary of making people react. SM: When youre treating patients for this, do you give them any advice on exercise, diet or anything else to do outside of treatment? P9: Sometimes. It very much depends on what I feel, particularly teenagers. I meet a lot that I think are really dehydrated, and I think that makes a huge difference on the ability of tissues to cope with things. On the feel of tissues and response to treatment. So I will advise in that situation. I dont have many supplements I recommend; Im cautious of recommending supplements because I feel like its not an area of expertise, so sometimes I point people in the direction of other people who can talk to them about supplements. I mean it depends what Im doing, I mean if Im dealing with a post-partum mum whos got some quite nasty pelvic floor damage and some of her symptoms relate to recovery from birth, then Ill give pelvic floor exercises and Ill for others, for the lady that I talked about, I got her doing more exercise. I said to her I dont

care what you do, I just want you to do more that makes your pelvis move. Shes got a gym at home so she worked out, shes been doing a lot more lower body work. And I said, you know, its not about weights or resistance, its about moving. Up until about a month ago she had a dog that she used to walk quite regularly. SM: Do you think an osteopath who doesnt have visceral or IMS training can help women with this condition? P9: Yes, definitely. It depends onits not really the technique, its the philosophy. I use a lot of visceral or IVM-type work because its what Ive had training in, its what I teach, its my expertise. But I know some very good classical osteopaths whove perfected their structural technique, to probably a similar level that Im working at perfecting my IVM work, and theyre equally good at getting structures moving, improving the blood supply, drainage. Theres many ways to do it; its the philosophy that makes a difference, not the actual technique. SM: Is there anything else youd like to add or any advice you have for young or newly qualified osteopaths interested in treating this? P9: I guess, for me, I get most of my approach from the anatomy, and I think you need a really high level of anatomy to apply osteopathy to a subject like dysmenorrhea. So, to the organs involved. Personally, I didnt have that level of anatomy when I qualified and it wasnt going on courses and learning a technique that was useful, it was actually learning anatomy behind the technique because once you know the anatomy, you can apply a technique to it. So yeah, I think my advice is, learning whats there and what supports it. Where does the vascular supply come from? How does the uterus get its vascular supply? How does it drain? Where are the ligaments attaching? What do they attach to? And that gives you the links between the structures, which is what were good at treating. But if you havent got it in your mind-set, then you cant do it.