Rethinking Pelvic Pain: How “Desensitization” Fits into PT

In Female Pelvic Pain, Male Pelvic Painby Stephanie Prendergast9 Comments

I am dedicating this blog post to the work of Lorimer Moseley. His presence and research is revolutionizing treatment approaches to pain. Here at PHRC we are strategically and diligently working as a team innovating our treatment approach to incorporate his research. Lorimer also happens to be one of the reasons the IPPS had its most successful meeting yet back in October of last year. We had our highest number of attendees ever, at 390, with the highest ratings and reviews for the individual presentations and overall conference content. Before launching into this post, I would like to share some of the backstory about how this year’s IPPS meeting came to be and how it coincides with an important initiative at PHRC.

Last year I had the honor of being the first PT Scientific Program Chair for the IPPS’s 20th Annual Scientific Program. Therefore, I wanted to use this opportunity to bring a PT in as a keynote speaker for the first time in the history of the society. I pondered my lists of PTs that have high-level, evidence-based approaches that would be meaningful for both the PTs and MDs in our audience that treat pain. My thinking was that the sophisticated audience of the IPPS is now expertly treating end-organ disease, myofascial dysfunction, and neuropathic pain and dysfunction in the tissues. Yet, we all have patients that are still suffering with pelvic pain despite our expert intervention. Who can help us figure out why?

Enter pain expert and neuroscience researcher, Lorimer Moseley. AND he happens to be a trained physiotherapist!

To quote Lorimer, I began “pestering” him in 2011 to become one of our keynote speakers and also to present the post-conference workshop. It is not often he comes to the U.S and many medical professionals treating pain have not been fortunate enough to hear him speak. After a few months of “pestering” and with some help from the Women’s Health Section of the APTA, contracts were signed and Lorimer was on his way to the U.S. from Australia.

Concurrently, the crew at PHRC has been discussing how to better help our chronic pain patients that seem “stuck”. The concept of pain physiology came up over and over again. We read books, had animated discussions, purchased various writings such as “Understand Pain, Live Well Again” by physiotherapist Neal Pearson, and we took a private course from a medical hypnotherapist who works on “changing the brain” to try to help us better serve our patients. Despite our efforts, we still felt like something was missing and we were spinning our wheels. We did not know how to integrate the information that we were learning into clinical practice and we were frustrated.

In August of 2012, the importance of the whys and hows of pain physiology education became much more clear. I was invited to give a lecture about pelvic floor physical therapy at the PUGO SIG of the International Association for the Study of Pain meeting in Milan, Italy. Lorimer and his amazing research team were present amongst 8,000 attendees from all over the world. The conference hall was filled with rows and rows of posters about the relevance of pain physiology education and the influence our behavior as medical professionals has on our patients. Everything began to click and it was impressed upon me that we NEED to change our practice. Even though this will be a challenge and very different than our standard manual treatments, if we do not change our practice we are simply not helping certain patients and we certainly will not be leaders in the field.

I returned from Milan and presented this info to the PHRC team. We all agreed this was a missing link in treatment, but remained confronted with “how do we actually DO this?”. We began having weekly meetings leading up to the IPPS conference about how to identify and properly educate and treat our chronic pain patients. We headed for Chicago armed with many questions that we were hoping Lorimer and practicing therapists in the U.S., such as Sandy Hilton, Carolyn Vandyken, and Daniel Kirages could answer.

And they did.

Rethinking pelvic pain. Reflections on two decades of Explaining Pain.

During his colorful and intelligent keynote presentation, Lorimer raised the question, is nociception sufficient or necessary for pain? Detailing high-level research, Lorimer showed us that visual experience, similar to the pain experience, is based upon the brain’s EVALUATION OF SENSORY INPUT. He went on to describe pain as an emergent conscious experience that serves to evoke a behavioral protective response that is modulated both by nociception AND “anything relevant to the need to protect body tissue, such as mood and meaning, context, and consequences.”

What does this mean?

It means our brains our capable of producing pain responses when there is, in fact, no damage to the tissues or actual threatening stimuli. An example of this could be patients who experience pain upon one second of sitting. Is sitting actually damaging their tissues or their pudendal nerve? No. But are our patients feeling pain? Yes.

Why?

The lecture continued on to describe neurotags and the role they have in pain perceptions. Individual neurotags are formed by beliefs, knowledge, logic, social context, anticipated consequences, family, media, culture, etc. Neurotags create pain OUTPUTS. Most of us think of pain as an INPUT of danger, and this is simply not true in cases of chronic pain (versus acute pain).

Under “normal” circumstances, nociceptive messages travel up the peripheral and central nervous system pathways and are processed precisely in the primary somatosensory cortex. Under “abnormal” circumstances, as in the processing mechanisms of patients suffering with chronic pelvic pain, input is interpreted by the brain imprecisely, resulting in faulty neurotagging and pain outputs in the absence of dangerous stimuli.

Most of us think pain is an input of danger, not an output of the brain, and this is simply physiologically inaccurate. Lorimer went on to demonstrate numerous studies showing that understanding pain physiology decreases patients’ actual pain perceptions without any peripheral treatment. Patients who received proper explanations about pain physiology had improved quality of life outcome measures compared to those who received either physical treatment and/or peripheral physiology education (i.e., body mechanics for patients with low back pain). This is not to say that there are not issues in the tissues, we know there are in many cases, but there are also issues in the brain that just happen to be less obvious. And they have largely been ignored over the course of medicine, rendering pain a nation-wide epidemic.

The therapeutic target for us as providers is to truly understand what pain is and help our patients do the same. The problem is that brain physiology is incredibly complicated. It is also crucial to make the distinction between “it’s all in your head” and “pain is produced in your head”. We are NOT implying our patients are making up their pain as they have unfortunately been told over the years, but rather, we recognize why pain occurs in the absence of actual threat. A good way to understand pain, identify and diffuse all “threats” or stimuli that trigger pain outputs, and normalize our cortical matrix is through education, graded motor imagery, and visualization.

The educational component can occur through useful books such as Lorimer’s Explain Pain and Painful Yarns.

We are now using these materials to educate our patients at PHRC. The harder part is the integration of graded motor imagery and visualization. We are currently working on strategies to do this. Stay tuned to our blog as we share how we are integrating this pain physiology education and central nervous system treatment into our overall approach. We can no longer ignore the role the central nervous system plays in chronic pain and it’s time to make a change.

All my best,

Stephanie

Comments

  1. This is very encouraging. I hope to order Lorimer’s books shortly. May I suggest, in talking with patients in these new ways, please don’t avoid the big S word. Suicide. Horrific chronic pain, regardless of the cause, after years of enduring it, makes suicide almost a Godly choice to simply stop the pain. If you are not afraid to talk about it, as patients, we will find the courage to talk about it. It doesn’t mean we want to commit suicide, we simply want to it to be okay to talk about what it feels like to escape the pain. Hoping this sounds as intended. Loved your blog article. Thank you!!!!

  2. Bravo, Stephanie, for continuing to push the envelope in the search for the treatment of chronic pelvic pain. The brain is indeed an important piece of the chronic pain puzzle. That’s why “brain” drugs like antidepressants are often effective in treating pain.

  3. Thank you for your wonderful posts. I always appreciate them!
    PTs always talk to me as though my chronic perineal pain were simply a learned response that could be unlearned by pushing my limits (i.e. sitting for longer and longer periods). But I am not convinced that my pain is not, in fact, delivering “true” information, that my pain is mechanically based. After all, my pain does reliably increase during the day with accumulated vertical pressure, or with twisting and bending. How does one know whether or not pain is merely “learned” or is really signaling a problem?

  4. Hi Stephanie,
    Thanks for posting this blog! I am eager to see your follow up blog with information about how your team continues to use this paradigm shift successfully. In my practice, I understand these concepts, but seem to struggle with really getting them into a working model.
    Thanks again!
    Shannon

  5. I am in the midst of trying to integrate Lorimar Mosley’s teaching/research with most of the patients I see for chronic pelvic pain, and one man I have worked with over the years w/ CRPS in his foot. We are using “Explain Pain” as a textbook for the pt w/ CRPS – and daily worksheets to gradually improve his ability to take weight through his L foot. We have done every other kind of CRPS intervention out there, and he has been to every specialist in the country – had some very odd interventions. This is the most notable and consistent success we have had, using pacing and graded exposure with the mountain analogies at the end of the book. I am having a more difficult time using the strategies for sitting pain and dyspareunia, but working on it. I was so excited to see this post, and look forward to the strategies you are discovering. Thanks so much this blog! I learn from each one!

    1. Author

      Thank YOU Natalie for sharing this info with us! From one PT to another, it helps so much to hear specifics on how you are incorporating LM’s teaching with your patients!

      Warmly,
      Stephanie

  6. Hi
    Thanks for writing a birlliant and informative blog..
    I have suffered for 7 years with urinary issues and later ,…sit bone issues that morphed into severe anal/rectal pain after a ‘nerve re-section’ surgery. i have tried MANY things but am still in agony. I know I have CNS issues after all this time, but also feel I have ’tissue issues’.. Something is making my anus hurt when touching any surface and my bladder feel that constant urge to pee, and hesitant urine stream.
    I am thrilled to see such a great understanding of PN and its effects on the nervous system.. It also gives me hope that I can get better!.Would love to speak with you guys
    Thanks again!
    Kathy

  7. Dear Stephanie,

    I have read some of your blog posts. I want to thank you from the bottom of my heart. Your and your teammates’ curiosity,willingness to help people, talent and hard work is reflected everywhere. I know this way you are able to help a lot of people living with pain like me, and I am sure taking this vital part into consideration in treating pain will take you and us all further ahead. Best wishes for you!

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