By Jessica Newman, LMHC
Living with persistent pelvic pain is, by definition, painful physically. What can be hard to talk about (especially for folks with pelvic pain) is just how emotionally distressing the pain is. And because the mind and body are a functional whole (think: a Mobius strip) emotional distress can trigger or amplify physical pain and vice versa. The good news, however, is that you can learn to use the intimate feedback loop between body and mind to feel better both physically and emotionally.
Here are some ideas clients have found helpful in coping with their pelvic pain.
- Learn about the physiology of chronic pain
Pain can be a shape shifter-some days better, some days worse. This uncertainty contributes to feelings of anxiety and being out of control. When people have less of sense of control they tend to feel more stressed, which usually increases physical pain. Having accurate information about the physiology of pain can restore a sense of control. Even when the pain is worse, it makes sense why it’s there. This alone has been shown to reduce emotional suffering and increase people’s sense of their ability to cope. The work of David Butler and G. Lorimer Moseley is generally considered some of the best information about this topic. - Learn to elicit the relaxation response
Most folks have heard of the stress response of fight, flight, and freeze and know it can increase pain. Fewer people know that we all also have an inborn relaxation response- the natural counterbalance to the stress response.
You can learn to elicit the relaxation response through meditation, prayer, visualization, yoga, or t’ai chi, as well as more everyday activities like coloring, petting your pet, or repetitive physical tasks like knitting or chopping. Choose a few ways that work for you at different levels of distress. For example, many people find it very hard to use methods where you “go inside” with your attention when pain is intense (e.g. meditation). In these moments, eliciting the relaxation response by putting your attention outside of your sensations, or using distraction, is often helpful. - Identify your triggers and recognize that flares can occur because of “trigger stacking”This is the same idea as learning about pain physiology. Increasing a sense of predictability contributes to a sense of agency and control, which tends to help us feel more capable of dealing with difficult things. Triggers can be physical (exercise, sitting, sex) or emotional/cognitive (stress at work or home, the thought, “Uh-oh-here’s the pain again, I can’t handle this.”) It can help to keep a diary or log while you are still learning about your triggers. Be aware that it may not necessarily be that a particular event or activity always causes symptoms, but rather, “trigger stacking”-i.e. you would feel ok if you had a stressful day, or ok if you had sex, but if you had a stressful day, had sex, and were feeling particularly unsupported by your partner, then you might have greater symptoms. Knowing your triggers can help you predict how you’re going to feel, and return to you a sense of choice about which activities to do when. For example, if you know that sex and exercise can both be triggers, you might choose to do one on one day and one on the other, with some time in between, and/or increase your relaxation or other positive activities on a day when you know you’ll have multiple triggers.
- Get as much support as you can
In general, the more stress we are under, the more support we need to cope. This isn’t a reflection of personal strength or weakness, but rather a general truth about being a person. It can be especially helpful to get support from other people with chronic pain as they can, “get it” in ways that people who haven’t experienced chronic pain haven’t. - Don’t try to push against the waves
One of our first responses to pain, whether physical or emotional, is to tighten up against it, reject it, and try to ward it off. This is a natural response to unpleasant situations. And yet, this is like being at the beach and stiffening when we sense a big wave coming at us. Paradoxically, when we stiffen, the wave crashes into us very hard. Whereas when we roll with the energy of the wave it washes over us and we are less buffeted. Just like waves, our emotions and sensations are changing. If we can learn to move towards them with acceptance, even the ones we strongly dislike can become more tolerable. This is easy to write about, but hard to do in practice. Therapy can help, as can mindfulness practices such as this one. - Avoid avoidance
When we are in pain, we (unsurprisingly!) tend to stop doing activities that hurt. This is called the pain/avoidance cycle. It is imminently logical and can be part of a good short-term solution to a pain flare. As long-term solution it can turn into a double whammy: we’re in pain and not doing things we enjoy. This can lead to more negative emotions, which can then make pain feel even worse. Avoiding avoidance is not the same as “sucking it up” or ignoring your pain. Rather the idea is to practice tolerating (rather than rejecting) some pain and even some small acceptable increase in pain for the benefit of feeling more connected to things that are important to you in your life. This idea often feels overwhelming to people because of how scary pain can be. If this is true for you, you may wish to seek the support of a therapist who can help you make this feel more approachable by breaking things into smaller steps and pieces.
- Name your feelings with kindness
When you are having an especially hard time, it can be helpful to simply name and acknowledge your feelings-“I’m feeling really scared right now”; “I’m really angry that I have to work so hard to feel well.” Naming feelings tends to put a little healthy distance between us and emotions that might otherwise feel overwhelming. It can also help to think about how we would talk to a friend or a young child who was having the same experience-usually we are much kinder and gentler, which can really help when we’re hurting. - It’s the thought the thought that counts
Thoughts aren’t just abstract mental events. They have a real impact on our emotions, physiology, and our actions. For example, if I think, “I’ll never get better” it might make it hard for me to go to PT or to learn relaxation, which in turn would actually make it hard for me to feel better. Conversely, the thought, “I’m feeling hopeless right now, but I know that I feel a bit better if I even do 5 minutes of relaxation” can encourage me to do just that and feel a little better. Learn which thoughts tend to increase distress (e.g. “I can’t handle this”) and practice “reframing” them in ways that tend to help you feel more resilient. Partners and friends can help with this, as can therapists. - Increase positive activities and things that give you a sense of mastery
Whenever we’re coping with a strong negative situation, it helps to try to counterbalance this with positive activities. You can think of this like a bank account-if experiences of pain are making a lot of “debits” on your account, it’s important to try to make “deposits” of good experiences. - Set small goals and celebrate successes
Recovering from and coping with chronic pain is not a linear process. Taking time to highlight and celebrate your successes can help sustain you. This is particularly helpful to do during a flare when people often lose sight of their progress. If you can’t remember, which can sometimes happen, ask a partner, a friend, or even your physical therapist when you’re there, to remind you. Sometimes people also find it helpful to write down their progress so they can look at it when they’re feeling hopeless or having a setback.
I know that when you are in chronic pain it can seem like you’ve always felt this way and that you will always feel this way. In reality, chronic pain can get better, and, unbelievably, you can learn to feel better, even if pain stays part of your life. Just take it one small step at a time. If you think you’d like to work with a therapist about these issues, I welcome you to reach out to me at: [email protected].
About The Author
Jessica Newman, LMHC is a psychotherapist in private practice in Cambridge, MA. She received her Master’s in Counseling Psychology with a Holistic Specialization from Lesley University, where she is now an adjunct professor. Jessica’s approach to counseling blends a warm, supportive relationship with practical skill building to help people manage anxiety, depression, trauma, life stressors and transitions. You can read more about Jessica and her approach here.
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
Brilliant article, thank you for writing it! I’ve been practicing some of the above ideas for a while now and they definately help. I will keep the list somewhere handy for quick reference if I’m having a tough day.
Excellent Article!!! I love that I can put each one of these into practice and improve my outlook on pelvic pain. Thank you!!