By Malina Kelly and Alison Wroth, Physiotherapists, Guildford
Pain is an integral part of human experience and serves the purpose of a vital protective function. Persistent pain may be thought of as overprotection – pain can be experienced in the body, with no real threat of damage or disease.
Health professionals sit with patients daily, listening to their experience of persistent pain. Many patients have faced difficulty accessing sustainable and effective management for persistent pain, while some have unhelpful beliefs about the generators of their pain and feel helpless in their own management.
Modern pain neuroscience offers a current evidence-based model of pain, utilising a biopsychosocial approach.
Current scientific understanding views pain as an emergent and dynamic process influenced by many factors, including individual beliefs, emotions, life stressors, trauma, nutrition, sleep, inflammation, movement and social connection. Thus, pain is an output from the central nervous system.
Pain is always real; it is felt in the body tissues. Pain occurs due to a complex interplay of multiple systems, including musculoskeletal, neuroimmune and endocrine systems.
When explained to patients effectively via this updated model, individuals can understand their pain through a more accurate, holistic lens.
Being complex and multifactorial means there are many ways that pain can be changed. Changing any contributing system, can change the experience of pain.
Persistent pelvic pain
Persistent pelvic pain affects one in four women and one in 12 men in Australia. Common treatments, including medication, surgery and hormonal intervention, are often unsuccessful.
While modern pain science teaches that persistent pelvic pain results from multiple interacting systems, including psychological and social factors, biomedical treatments continue as the mainstay.
Biomedical-focused treatments reinforce the patient’s belief that there must be something wrong, and that they require pharmacological and/or surgical treatments to fix whatever is wrong.
The pelvic floor muscles (PFM) are found in men and women, at the base of the pelvis. PFM have an important role to play in bladder and bowel continence. PFM contract to allow control of continence and relax to allow effective bladder and bowel emptying.
PFM provide support to the organs of the pelvis; they are important for sexual function in men and women.
What is less commonly known about PFM is that these small muscles are responsive to emotions. PFM are often the first muscles in the body to tighten in response to high energy emotions such as anxiety, fear, excitement and anger. PFM often tighten when humans are in pain or feeling unsafe.
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In persisting pelvic pain conditions in both men and women, PFM are often tense and overactive. PFM tension contributes to symptoms such as sexual pain, cyclical pelvic pain in women, bladder pain, urinary urgency, urinary incontinence, pain with defaecation, anal fissures, bowel urgency, constipation and genital pain.
Often overlooked in a biomedical approach to pain, the role of the PFM may not be identified as a contributing factor to a patient’s symptoms.
Key messages
- Pain is an emergent and dynamic process, with many contributing factors
- The pelvic floor muscles often tighten in response to pain and high energy emotions
- Modern pain science and a biopsychosocial approach offers hope for patients with persisting pain conditions.
The role of physiotherapists
Pelvic health physiotherapists provide individual PFM assessment and training using a range of biofeedback techniques. In patients with persistent pelvic pain, PFM training typically involves a ‘downtraining’ approach.
This begins with providing feedback for individuals to feel their muscles, move them, and finally to learn to relax them – unwinding tension in the pelvis over the longer term.
This becomes a vital tool in changing their pain experience. As patients learn to feel their tension, they are empowered with the ability to change tension, and ultimately their pain experience.
A biopsychosocial approach forms the foundation of pelvic health physiotherapy. Patients are often surprised by the comprehensive nature of assessment and the time taken to investigate the multiple potential contributing systems to their pain.
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Postgraduate training incorporates updated pain science as such pelvic health physiotherapists are well placed to help patients better understand and explore their pain.
As part of holistic management, pelvic health physiotherapists address PFM dysfunction, physical activity, hydration, nutrition, sleep, emotional health and social factors – referring on to more suitable practitioners as required.
Modern pain science teaches that pain is a changeable experience. Many factors contribute to pain and there are many ways to connect to pain and promote recovery. Current pain science is very hopeful, it is now up to practitioners to integrate this hope into our practice.
Author competing interests – nil
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