Many patients find that managing chronic pelvic pain conditions can sometimes be difficult. Oftentimes there is no one “thing” or pathology that symptoms can be tied to which, understandingly, can be frustrating or overwhelming. More accurately, chronic pelvic pain is a complex interaction of both physiological and psychosocial components. It is not only the body but the mind and the environment that can contribute to a pain experience.
In her presentation at the 3rd World Congress of Abdominal and Pelvic Pain Conference this past October, Dr. Afton Hassett addressed the impact of psychosocial factors on chronic pain. Dr. Afton Hassett is a licensed clinical psychologist and an Associate Research Scientist in the Department of Anesthesiology at the University of Michigan Medical School. Her research efforts at the Chronic Pain and Fatigue Research Center and those presented at the conference focus on how resilience factors such as positive emotions impact functional and neurological outcomes in individuals with chronic pain. Her lecture, Revisiting the Importance of Resilience in Pain, is summarized below:
To understand how to effectively treat chronic pain and how to promote and incorporate resilience as an intervention, we have to understand the nature of pain. It is important to note that pain is processed by many areas of the brain and that these areas of the brain are interconnected. That is, areas of the brain that are involved in pain processing are also responsible for functions such as attention and emotions. In a study completed by Frey et al., investigators looked at the relationship between pain and attention. Researchers took a group of women who chose to have a medication-free delivery and had them use virtual reality goggles as a way to distract them from the pain. The women that utilized the virtual reality goggles reported a 40% decrease in pain during their first stage of labor compared to the control group.3 Similarly, Dunbar et al., reported that patients participating in Duchenne laughter a.k.a. from your gut laughter, had increased pain thresholds.1 *There is a such thing as laughter therapy! From these studies and many following, Dr. Hassett and colleagues suggest that thoughts, emotions and pain are processed by many of the same areas of the brain and therefore, thoughts and emotions can influence the experience of pain.
So how exactly might your thoughts or emotions affect your pain? Depends on if they are positive or negative. The literature consistently links negative affect to key factors in chronic pain such as high clinical pain intensity, greater use of pain medication and poor quality of life. On the other hand, many experimental studies have associated positive affect to lower overall pain ratings, decreased use of pain medications and decreased induced pain tolerance. This means that managing depression, anxiety and anger whilst promoting happiness, enthusiasm and gratitude could positively alter the pain experience. The leading theory behind this impact of positive affect on behavior is Broaden and Build Theory proposed by Dr. Barbara Fredrickson which asserts that positive emotions: (1) broaden our thoughts and actions, (2) undo effects of negative emotions, and (3) build resiliency.2
In a collection of other studies researchers determined that positive emotions are diminished in individuals with chronic pain conditions such as fibromyalgia, chronic low back pain and chronic pelvic pain.4,5 Another study by Verbrugge et al., found, and that is often echoed by my patients with chronic pelvic pain, is that those with chronic pain often give up the things they love or value to do the things that they must do.9 This can disrupt one’s ability to seek joy and may negatively feed into the pain experience. But if positive emotions can alter the pain experience then can’t I or you or your patients do something to promote positive affect? Yes! – With “Positive Activity” interventions. And the greatest thing about positive activity interventions? They can be inexpensive, are easily accessible and effective. Doing things such as savoring a beautiful day, performing acts of kindness or participating in loving kindness meditation can help enhance resilience. Muller et. al reported that in a randomized control trial of 96 participants with pain, those that participated in eight weeks of tailored positive activity interventions reported improvements in pain intensity, pain control, life satisfaction, positive affect and depression. Even more encouraging, about 74% of these participants continued incorporating positive activities at two and a half months follow-up.7 In a randomized control trial nearly three times as large, Peter et al., identified improvements in happiness and depression that remained at six months follow-up in patients with chronic musculoskeletal pain that participated in either cognitive behavioral therapy or positive activity interventions.8
In her lecture at the conference, Dr. Hassett presented preliminary findings of her PRISM, Promoting Resilience with Innovative Self-Management, study. PRISM is a randomized control trial of 300 participants with back pain and comorbid fibromyalgia that participate in eight weeks of online self-management programs of either cognitive behavioral therapy (eCBT), resilience-enhanced cognitive behavioral therapy (PRISM) or usual care. The key differences in intervention between the eCBT and PRISM groups is that those in the PRISM group also participate in four positive activity interventions: signature strengths, savoring, acts of kindness and positive piggy bank.6 Signature strengths involves identifying your strengths and using them in a new way (check out your strengths here, it’s free and kind of fun!); savoring involves two to three minutes of mindful appreciation of a positive experience; and acts of kindness involves doing something kind for others and yourself. Of the four, the positive piggy bank might be my favorite. It requires you to write down something that made you happy that day for 30 days. At the end of the 30 days, you read through each memory and recall details of that event that made you happy.6 I did an abbreviated, week-long version of the positivity piggy bank and let me tell you, with all the crazy in the world, it was refreshing to slow down and reflect on something positive!
So, what does all of this mean for physical therapists or other clinicians that treat patients with chronic pain? With education we can help promote and enhance positive affect in our patients in a reliable and scalable manner! And what does all of this mean for patients with chronic pain? Partaking in positive activity interventions, whether that’s mindfulness or doing something kind for another, CAN help build resilience and mitigate the pain experience. Providers and patients, check out these other free, helpful resources that provide positive interactive activities for patients: FibroGuide and Happify.
We thank Dr. Hassett for a fantastic presentation! The entire lecture is available here, starting on page 220. You can also follow her on Twitter @AftonHassett.
References:
- Dunbar et al. Proc R Sco B 2011;1373
- Fredrickson. AM Psychol 2001;56:218-226
- Frey, Hassett, Bell, Housey, Low & Bauer. New data for the Society of Obstetric Anesthesiology and Perinatology, 2017.
- Hassett et al. Arthritis Care Res 2008;59:833-40
- Hassett et al. Clin J Pain 2016;32:907-14
- Hassett & Williams R01 NRO17096 NIH-NINR
- Mueller et al. Clin J Pain 2016;32-44.
- Peters et al. Clin J Pain 2017 Apr 4 Epub ahead of print
- Verbrugge et al. Rheum Disease Clin North Am 1990;16:741-61
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.