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Autonomic Features of Chronic Pelvic Pain

In Pelvic Floor Physical Therapy by Elizabeth Akincilar5 Comments

 

By Elizabeth Akincilar

 

Understanding and effectively treating chronic pain continues to challenge the medical community. Now more than ever, there is a sense of urgency to treat this disease. With the astounding reports of opiate addiction and opiate related deaths in this country, we now know that throwing drugs at chronic pain is not the answer. So what is the answer? Thankfully there is a lot of ongoing research trying to figure that out. At the 3rd World Congress of Abdominal and Pelvic Pain in October 2017, some exciting research about chronic pelvic pain was presented which we will share here in the 3rd post of our blog series covering the conference.

 

Dr. Thomas Chelimsky, a neurologist from the Medical College of Wisconsin, presented his research about the autonomic features of chronic pelvic pain.

 

To effectively treat pelvic pain, we first must better understand pelvic pain itself. People suffering with pelvic pain often have comorbidities, which are other chronic diseases or conditions that are simultaneously present. Dr. Chelimsky examined some of the comorbidities that are often present with chronic pelvic pain. He presented research suggesting that many of the psychological comorbidities that we see with chronic pelvic pain, such as depression and anxiety, seem to be driven by the pain disorder, not the psychological disorder. Additionally, he suggested that certain comorbidities seemed to coincide with particular types of pelvic pain syndromes. I found these bits of research particularly interesting:

 

  • Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) was more associated with dyspepsia and chronic idiopathic nausea
  • Myofascial pelvic pain (MPP) was more associated with dysmenorrhea, migraine, Post-Traumatic Stress Disorder (PTSD), and Chronic Regional Pain Syndrome (CRPS)
  • Having both MPP and IC/BPS resulted in an increased chance of also having fibromyalgia and panic disorder
  • Having two pelvic pain disorders and PTSD was associated with having more comorbidities
  • Age of onset of comorbidities was earlier for PTSD, dysmenorrhea, migraine, depression, and panic attacks and later for fibromyalgia and chronic fatigue syndrome

 

He posed the question, does this information tell us something about the role our autonomic nervous system (ANS) plays in chronic pain?

 

To review, the autonomic nervous system is the part of the nervous system that acts largely unconsciously and regulates bodily functions such as heart rate, digestion, urination, and sexual arousal. It is the primary mechanism in control of the fight-or-flight response. There are two parts that make up the ANS, the sympathetic and the parasympathetic nervous system. The sympathetic nervous system is often considered the “fight or flight” system, whereas the parasympathetic nervous system is considered the “rest and digest” or “feed and breed” system.

 

Dr. Chelimsky presented one study that found a difference in the sweat response between MPP and IC/PBS. Sweat response is controlled by the sympathetic nervous system. This study found an increase in sweat response in the group with MPP versus the IC/PBS group, suggesting that the sympathetic nervous system may be more involved with MPP versus IC/PBS. Additionally, the parasympathetic nervous system was more affected in the IC/PBS group versus the MPP group.

 

How does this information help us treat pelvic pain? Here’s a summary of the New Pelvic Pain Model he suggested.

 

IC/PBS seems to cause visceral hypersensitivity via an autonomic mechanism that impairs vagal functioning. The vagus nerve is the 10th cranial nerve and works with the parasympathetic nervous system. Therefore, a proposed treatment strategy for people with IC/PBS could be to stimulate the vagal system.

 

MPP seems to cause vascular hypersensitivity via sympathetic autonomic neuropathy. Therefore, a proposed treatment strategy would involve improving vascular flow via manipulation or reducing sympathetic outflow.

 

For people suffering from both MPP and IC/PBS, the proposed treatment strategy would be to combine both treatments for MPP and IC/PBS.

 

Interestingly, this may partially explain why physical therapy is particularly helpful for patients with MPP. Much of manual therapy is focused on improving vascular flow.

 

This is suggesting that the brain may be the driver in chronic pain; therefore, management needs to be directed at the brain rather than the end organ.

 

The periaqueductal gray (PAG) is a part of our midbrain that may play a pivotal role in treating chronic pain. The major functions of the PAG include control of pain and analgesia, fear and anxiety, vocalization, lordosis and cardiovascular control.

 

The PAG is a dynamic structure. In order for the PAG to do its job, which in part is to control pain, it has to grow. Research has found that in people with chronic pain, it doesn’t grow. One study showed that in patients with endometriosis and no pelvic pain the PAG was larger than in patients with endometriosis and pelvic pain. Jandra wrote more about this last week in the second post of our #WCAPP17 blog series, Endometriosis: Beyond the Lesions.

 

So, how do we stimulate the PAG so it can grow and reduce pain? Dr. Chelimsky suggests that we improve vagal function. He suggests three methods to improve vagal function:

 

  • Cognitive Behavioral Therapy (CBT)
  • Direct stimulation of the vagus nerve with auricular stimulation
  • Interval exercise training

 

We still have much to learn about chronic pelvic pain, but it is research such as this that is bringing us one step closer to more effective treatments.

 

We thank Dr. Chelimsky for a fantastic presentation! The entire lecture is available here, starting on page 100.

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.

Comments

  1. Thank God you guys did a fabulous job to save my soul…Iam in Australia and not diagnosed yet but all the symptoms is there , my physiotherapist with Dysfunction of the Vavus Nerve but doctor here dont listen to physiotherapist…thanks again …years ago when I was 26 had a hysterectomy because of endometriosis and pain and prolapse of everything after my last pregnancy. What about my daughters both have endometriosis? – e-mail address is [email protected] -t

    1. Author Liz Akincilar says:

      Hi Ersa,

      I’m glad that you found the post helpful. If both of your daughters have endometriosis, I would recommend talking to their gynecologist about the most effective treatments strategies for them, as there are very effective and safe treatment strategies available.

      Best,

      Liz

  2. Thank for all information, so interesting!
    When you are talking about vascular hypersensitivity, do you mean intrauterine pain?
    I am a patient of pudendal neuralgia and I deal ok with the pain. But 2 years ago, I started suffering pain with pressure and temperature changes. Also I have like alergic reaction due to contact with semen or another vaginal gel or liquid. My physiotherapist thinks that it is congestion syndrome pelvic, but my veins are fine, even I have a retroflexive uterus. Can I suffer vascular hypersensitivity?
    Thank you from Spain!

    Lucia

    1. Author Liz Akincilar says:

      Hi Lucia,

      Thank you for your question. From your description, it does not sound like you have pelvic congestion syndrome, but I can not be certain, of course. It also does not sound like vascular hypersensitivity. Maybe your central nervous system is hypersensitized since you’ve had pain for a long time? Without knowing your full history and doing an evaluation it is impossible for me to say.

      I wish you the best of luck.

      Liz

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