The Puzzle of Pelvic Pain: A Rehabilitation Framework for Balancing Tissue Dysfunction and Central Sensitization II: A Review of Treatment Considerations

Om pelvic pain, en tilstand som mange opplever men som er vanskelig å behandle når man mangler elementer fra smertefroståelse. Dette gjelder egentlig alle kroniske smertetilstander. Alt forklares i denne viktige studien. Nevner biomedicinalism, ny forståelse av smerte, sentral sensitering, body maps, graded motor imagery, mirror therapy, m.m. Behandlingskonseptet som nevnes ligner det vi har etablert på Verkstedet.
Physical therapists have been instrumental in guiding the medical system away from “end-organ” focus in the assessment and treatment of persistent pelvic pain. How- ever, for the most part physical therapists remain in a bio- medical model of treatment focusing on tissue dysfunction as a framework for the assessment and treatment of per- sistent pelvic pain. This article proposes a framework that integrates current understanding of local tissue dysfunc- tion with the wider context of sensitized protective mecha- nisms within the spinal cord and brain. Current concepts in pain science, particularly as it relates to the Neuromatrix and central sensitization, lead away from bio-medicalism towards a bio-psycho-social model of evaluation and treat- ment of persistent pelvic pain.

They proposed a framework for the treatment of pelvic floor dysfunction that moved away from the traditional strengthening approach of Kegel exercises. The idea that one cause of persistent pelvic pain and overactive bladder syndromes may be hypertonic muscles, instead of hypotonic muscles, has changed the treatment focus for some patient complaints of pelvic pain.

Physical therapists have made a compelling argument that many forms of persistent pelvic pain may have origins in myofascial dysfunction causing “end point” organ irritation, including swelling, redness, and pain in the bladder, prostate, testicles, or the vagina.4

Fitzgerald et al5 demonstrated in a multicenter feasibility study that physical therapy intervention of myofascial treatment applied to the perineum, abdominal wall, and pelvic floor demonstrated a 57% response rate compared with a 21% improvement rate with general massage therapy.

Butler7 describes biomedicalism as a “patho-anatomical search for a singular cause for chronic problems.” Waddel8 defines a biopsychosocial approach as an “individual-centered model that considers the person, their health problem and their social context.” The International Association for the Study of Pain describes pain as a “sensory and emotional experience”9 that encompasses both tissue nociception and the inter- pretation of the pain experience.

Globally, chronic pain and stress are at epidemic levels, as history shows, epidemics are best altered by education.7 The treatment of chronic pelvic pain has been well-recognized to have a mind (stress)- body (nociception) connection; however, education has not been widely used in this pain population to effectively link the 2 areas.

The summary of these conceptual changes is as follows:

  1. Pain is an output expression of the brain in response to a perception of threat.14,15 A therapeu- tic goal in persistent pain is to restore movement without triggering a protective pain response.
  2. Pelvic pain is complex. Psychosocial considerations include sexuality, cultural expectations, privacy, and religious issues.
  3. Chronic pain does not necessarily correlate with injury or disease, and nociception is neither neces- sary nor sufficient for a pain response.15,16
  4. The nervous system slides and glides as we move.16-18
  5. Neurophysiology-based pain education is an effec- tive adjunct to physical therapy intervention.12,13,19 Educating patients in the concepts of pain science, including neural plasticity, increases understanding and decreases the threat response.

Central sensitization encompasses “impaired functioning of brain-orchestrated descend- ing anti-nociceptive (inhibitory) mechanisms and (over) activation of descending and ascending pain facilitatory pathways.”21 The pain response operates within the entire system of nociceptive input, periph- eral neurogenic sensitization, and central sensitiza- tion.

Neurophysiology-based pain education forms the basis of treatment in central sensitization and refers to patient education about the role of central and peripheral processes in persistent pain.21 A patient who believes that local tissue dysfunction is the primary cause of a chronic pain state is likely to have thoughts and beliefs that limit normal mobility and function in the affected area.30

There are a mas- sive number of potential threats within the context of persistent pain.30 Using educational tools in the clinic to accurately explain pain helps give contextual meaning to the patient’s symptoms. Reduction of threat decreases the need for the engagement of active coping systems such as the sympathetic, immune, endocrine, and motor systems and the need for pro- tective pain states.16,38 Threats can be identified in a biopsychosocial framework (Table 1).

Table 1. Identifying Threats in a Biopsychosocial Frameworka

Worried x-rays showing “arthritis” Worried x-rays showing disc bulges Lack of specific diagnosis
Multiple medications ineffective Doing too much without pacing

Fear of pain
Fear of not recovering
Fear of serious injury
Fear of reinjury Sadness/depression Hopelessness about recovery Attitude toward sexuality

Withdrawn from family/joy Withdrawn from hobbies/sports Legal battle stress
Family stress/anger
Financial stress/worries
Work stress/anger

When sensitized neural states have been identified, the use of neurophysiology of pain education then flows into gentle guided exercises to normalize input into the sensory-motor cortex. Within the neuroma- trix, there are sensory maps, motor maps, and maps for smell, vision, and peripersonal space to name a few.39 The smudging of these body maps refers to a loss of normally distinctive localization and has been demonstrated in phantom limb pain,40,41 complex regional pain syndrome (CRPS),42 and chronic pain.43 Smudging in the sensory-motor cortex often occurs in the painful area and can also occur in the body part adjacent to the affected area on the homunculus.41,43

Patients with pelvic pain may report symptoms that could be indicative of smudging including the sensa- tion that their pelvic anatomy is altered or missing, or they may report foot pain that began after their pelvic pain. Since the feet lie next to the genitals on the homunculus, it is postulated that this may be the result of homuncular smudging.

Gentle guided movements such as pelvic tilts, move- ment of the ischial tuberosities, and guided sensory training in various sitting, standing, and lying postures may be useful for increasing sensory awareness.47,48

Body map training may be used to address the neuromatrix by modifying fear con- ditioning, teaching neutral alignment, reorganizing the sensorimotor cortex, and changing awareness of body parts.39,40,51

There are approximately 200 inhibitory neurons descending from the brain that help downregulate the sensitive nervous system for every one nocicep- tive or danger neuron traveling up to the brain.16

The activity in descending pathways is not constant and can be modulated.52 Decreasing levels of vigilance, attention, and stress are some techniques that may enhance the activity in the descending pathways.12,21 Decreasing a stress response may also help to decrease the sympathetic nervous system response.

Treatment options may include the following:
• Connective tissue mobilization: Mobilization of the soft tissue is used to have a direct effect on tis- sue dysfunction, given the basic need of muscles, fascia, and neural tissue to move in order to be healthy.3,53 Connective tissue mobilization may also directly impact the state of the autonomic nervous system, specifically by interrupting the viscera-somatic reflex arc, which is an autonomic reflex.54 Therefore, connective tissue mobilization may affect both tissue dysfunction and sensitiza- tion through modulation of the nervous system. Clinically, treatment of the connective tissue has been shown to be an important component of tissue dysfunction-based treatment in urologically based pelvic pain.5 It is proposed that this treat- ment may have an important effect not only on local tissue dysfunction but also on the sensitized nervous system.
• Deep breathing: Oxygen is vital for every organ in our body. People with persistent pain tend to have maladaptive breathing patterns, including shallow apical breathing.55 Retraining deep breathing, with both lateral costal and diaphragmatic techniques, is believed to downregulate the sensitive ner- vous system, particularly the sympathetic nervous system.55

• Relaxation training: There are many different styles of relaxation training, including paradoxical relaxation,24 progressive muscle relaxation, auto- genic training, mindfulness training, and medita- tion.56 Research shows that people who meditate have more gray matter in regions of the brain that are important for attention, emotional regu- lation, and mental flexibility.55 Meditation may also decrease anxiety and improve self-esteem.57 Mindfulness training is the skill of maintaining focus on something by choice while allowing thoughts, emotions, and sensations to come in and out of awareness, and at the same time, aware- ness without judgement.56 Patients will respond to different relaxation strategies and a variety of relaxation strategies should be tried to find the best fit. Clinically, patients will gravitate to one form or another, often from personal preference. Allowing a patient to choose her or his preference may help improve compliance.58
• Cardiovascular exercise: There is evidence that aerobic exercise lowers a person’s stress response and assists in mood and anxiety relief.59,60 The American College of Sports Medicine recommends performing moderately intense cardiovascular exercise for 30 minutes per day on at least 5 days per week, or vigorously intense cardiovascular exercise for 20 minutes per day on at least 3 days a week. In addition, the recommendation is that an individual perform 8 to 12 repetitions of 8 to 10 strength training exercises at least twice per week.61
• Guided imagery: Guided imagery allows for individual exploration into belief patterns and movement patterns that may not be helpful in the goal of returning to normal movement and function. These thoughts, beliefs, and move- ments are often outside of conscious awareness and largely outside of one’s control.62 Imagery engages the power of the mind to reduce anxiety, depression, and stress. Carrico et al62 conducted a pilot study, using a guided imagery CD spe- cifically recorded and scripted for women with interstitial cystitis and pelvic pain. The study found that approximately 45% of the treat- ment group participants responded to guided imagery therapy, noting a moderate or marked improvement on the global response assessment. Pain scores and episodes of urgency significantly decreased in the treatment group.

• Yoga: The term yoga is derived from the Sanskrit verb yug, which means to bind or join. This refers to the overarching goal of yoga to unite the mind and body in a way that promotes health.63 Comprehensive protocols have been adapted for yoga in the management of chronic pain. Yoga specifically addresses body awareness through body map training, breathing techniques, and increased awareness of mental and physical states, which may help patients better understand their pain response. Several mechanisms could potential- ly explain the benefits of yoga for persistent pain conditions. Yoga can decrease sympathetic ner- vous system activity, reduce inflammatory mark- ers, reduce stress markers (cortisol), and increase flexibility, strength, circulation, and cardiorespi- ratory capacity.63 Yoga has also been shown to increase the frequency of positive emotions and could potentially undo the physiological effects of negative emotions, broaden cognitive processes, and build physical and psychological resources.63 Finally, it is possible that yoga can lead to improve- ments in self-efficacy for pain control.63
• Affirmations/positive thinking: Patients may be able to learn to control and change their thoughts, seeking mastery in the following areas: stress inoculation, assertiveness in dealing with their sit- uation, handling conflict that arises around their pain, and decreasing their resistance to get bet- ter.64 Thoughts are nerve impulses, and negative thinking alone may drive persistent pain states. Moseley et al65 demonstrated that the thought of movement alone was sufficient to increase pain and swelling in CRPS. The contribution to persis- tent pain states from thoughts and beliefs provides a significant possibility for therapeutic interven- tion. Clinicians can assist and encourage the use of positive affirmations and can demonstrate good modeling of these techniques.
• Joy/laughter: Ongoing stress, particularly in the absence of positive coping skills, lowers resistance, weakens the immune system, and increases suscep- tibility to health problems.66 Pain is reduced while undergoing functional magnetic resonance imag- ing by positive pictures, beautiful music, positive expectations, enticing smells, sweet tastes, social touch, and sexual behavior.67 Patient instruction may include choosing a positive environment for exercise, one that is interesting, novel, and fun.

• Addressing sleep dysfunction: A systematic review concluded that there is consistent evidence asso- ciating chronic low back pain with greater sleep disturbances and reduced sleep duration.68 Reid et al69 looked at the efficacy of aerobic physical activity with sleep hygiene education to improve sleep, mood, and quality of life in individuals with chronic insomnia. The study concluded that an aerobic physical exercise program (involving two 20-minute sessions 4 times per week or one 30-minute session 4 times per week) with sleep hygiene education can be very beneficial to patients with insomnia and depressive mood.69

In peripheral neurogenic pain, nerves are sensitized as a result of plastic changes that have occurred within the peripheral nervous system, including the development of abnormal impulse-gen- erating sites.16,17,71-73 Nerves may also be sensitized because of chemical processes from proinflammatory mediators including prostaglandins, serotonin, brady- kinin, cytokines, and macrophages.16,74

Decreasing the sensitivity of the peripheral nerves may be addressed mechanically through a variety of manual therapy techniques that propose to unload the nerve by increasing the space or fluid motion in the tis- sues around the nerve.2,17,18,24 With decreased tension of the soft tissues surrounding the nerves including muscles, connective tissue, scar tissue, and abnormal joint mechanics, the nerve has a better chance of moving well within the space surrounding it.

A neurodynamic assessment includes physical pal- pation of the nerve where possible, as well as passive and active neurodynamic tests.16,70 For the pelvis, this involves the pudendal, ilioinguinal, iliogastric, femoral, and obturator branches of the lumbosacral nerves.

The pudendal nerve can also be mobilized through various depths of squatting with modifying the neck position to load and unload the dura mater and the nervous system. (See Appendix A.)

Once tissue dysfunction, central sensitization, and neurodynamics have been addressed and are showing signs of improvement, patients need to establish short- and long-term goals to help reduce the threat of increased function. The patient may be asked to create a list of pain control strategies that they can use to pace activities.

Hebb93 described the neurologic basis of motor learning as “Neurons that fire together, wire together. Neurons that fire apart, stay apart.” This is the key concept in using graded motor imagery in retraining the sensitive nervous system. By practicing the skill first through imagery and then progressing to actual movement, there is a change in the representation of the movement and the involved body parts in the sen- sory and motor cortices.46,94 Notably, this can be done without triggering a protective pain response that will help restore normal sensitivity to the nervous system.

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