This is a Really exciting time in pelvic health where our understanding of the brain, pain and how we can change someone’s experience are all evolving. By this I don’t just mean in the psychological way, but in a true “pain experience” sense as well as thinking about how we can change biological markers and antecedents to pain, such as inflammation, with our words and how we approach people with chronic pain.
Sandy Hilton is a Doctor of Physical Therapy based in Chicago, America. She has contributed to multiple book chapters, papers, and co-authored “Why Pelvic Pain Hurts” and is an international instructor and speaker on treating pelvic pain for professionals and for public education. She’s also a regular contributor on health related podcasts, and is co-host of the Pain Science and Sensibility Podcast with Cory Blickenstaff, which I can wholly recommend as both a source of evidence and a great lesson in how to unpick and understand it.
Sandy was the Director of Programming for the Section on Women’s Health of the American Physical Therapy Association from 2012 – 2017. She is now on the board of the Abdominal and Pelvic Pain special interest group, a part of the International Association for the Study of Pain. We sat down for a chat about what an evidenced, neurocentric approach to treating pelvic pain looks like in practice. Here are some notes and links that came out of our conversation. There were a few glitches in the beginning but it does get better by about 9mins! (a metaphor for life?) – skip to 9mins if you get frustrated. You’ll find the links I mention at the end of this.
The evidence for graded motor imagery, laterality and exposure in pelvic pain is in its infancy, relying heavily on the work completed in CRPS for the hand and foot. We’re currently choosing to make an educated assumption that different areas of the body may respond similarly and therefore the well evidenced and documented CRPS guidelines could apply to the pelvis. If you’re new to this approach click here for the Graded Motor Imagery website. It’s also invaluable to be familiar with pain physiology and pathology, and the seminal work of the NOI group over the last decade (ish). They regularly share useful blogs and evidence on their website evidence on their website and I’d thoroughly suggest reading and rereading Explain Pain Supercharged (available). It’s important to fully understand the physiology – to know what’s possible and what’s not (in a positive and negative way). Some minor elements have updated since publication, but the principles are sound. And wonderful. And complex ?
How can we approach chronic pelvic pain?
Start with the assumption that people Can get better and Do get better from chronic pain. Chronic pain can change. Believe it and your patients will. If You don’t think it can change where’s your programme going? You have to have the concept that pain changes nailed down to then be able to design a programme, monitor it, load it efficiently (and that includes ‘loading’ in a graded exposure sense as well as Actual Loading – the pelvic floor needs it! – not just weights but postural and pressurised loading) and adjust as needed.
Which patients can we use a more neurocentric approach with? (i.e. who do we do this time consuming weird stuff with…? I jest!)
All of them.
To some degree!
Clinical reasoning protocols don’t yet exist (though Sandy is involved in writing a pain treatment guideline) and so we can use some of the more obvious indicators of a sensitised system:
– Just thinking about doing something causes pain or refusal/discomfort (it’s real, they’re not making it up)
– Autonomic tells – sweating, flushing, goose bumps, feeling faint, and feeling nauseous are all autonomic threat responses.
– Body language – leaning away, avoiding eye contact or protecting themselves with closed arms or legs, foetal postures, getting up and running out…
– Them watching you do something and getting autonomic response
If talking hurts then touching first isn’t the way forward. Don’t feel you have to do a traditional pelvic floor and pelvis assessment immediately, or indeed at all – you can get objective data regarding their response to implied or actual tasks and sensory tolerance and use that to guide progressions with treatment. It’s thoroughly evidence-based. It’s within your scope. It’s not psychology – refer for that as it can really help! We’re talking about sensory integration and graded exposure to concepts and then to actual movement. It’s all physio.
Most people come to see you because they want to ‘feel better’. Define what ‘better’ means to the patient. Give them options, but make sure they’re not your goals, they have to be important to the patient.
Think about challenging their limitations in a way that respects them – are they real? Can they be tested in another way/another position/another situation?
Be slow enough in your approach to hear their goals, their fears and ask open questions and give them time to respond. I know this may seem difficult with time constraints, but I achieved it in my busy NHS clinic. Even 10 open minutes can give them the space to thrive.
Get an idea of how likely they are to want to change. Ask them! Are they Very fixed? We “nudge, not swamp” their system to begin making small changes – all from a top down approach that allows them to remain comfortable and in control whilst making progress.
PHODA cards (Photographs of Daily Activities)
Using these cards can start the conversation – how comfortable do you feel in your body doing things and what do you want to change? They’re especially good to use if people aren’t able to set their own goals. Symptom chronicity and the reality of living within the limitations of pain provocation, medical experiences of people telling them there’s nothing wrong or nothing they can do, can build a fixed image of what their body is and what its capable of. You can change that (within reason, and respectfully).
Ask the patient to flick through the deck, take the cards that are meaningful to them and their life, and then rank them from easiest to hardest. Ask them to tell you about each hard picture – the pictures all mean different things to different people. Use them as a tool to expand upon areas of their life they want to change to inform how you then plan their rehabilitation.
Take a photo of the cards and put it in their chart. Reassess whether things have changed. This is useful data.
These can be especially useful for sex and when considering sexual practises which are not in your vocabulary – understanding the biomechanics and some of the potential sensory loading issues and how that can translate.
This is the starting point of the CRPS/GMI protocol. It rests on the principle that in order to recognise left from right in an image your brain has to use the pre-motor cortex to imagine your body in that position and then check whether that’s right or not. There’s evidence showing delays in this ability in people who have CRPS hand and foot. Honestly, go read the GMI handbook it’s superb.
So one way to approach changing the consistent pain experience of your patient is to tap into the way their brain manipulates the idea or concept of their pelvis. Starting with laterality can give the brain a way to manipulate their pelvis but without actual movement (or the neurotags associated with it) which will potentially cause a threat response/pain. It’s just a flash of the idea of the pelvis, or more specifically the activation of a sequence of neurones that means the pelvis, without doing anything with it. It’s about being able to think of the body part without triggering symptoms. You can use it to start activity in pre/motor/sensory coretex in a way that’s less threatening than doing or touching or talking.
One way to do it is to run through the NOI Group Recognise App and use hand or foot measurements to see how well they do, or potentially have a baseline. The app allows you to input your own images. I have some images I’ve inputted and use for baseline testing. I also use powerpoint presentations of more complex images of people in different postures and get people to decide whether it’s the person’s front/back/left/right of the pelvis they’re looking at.
When do you need to use it?
Some evidence shows it’s good for everyone to do first, improving the speed of progression through GMI. I’d say it’s hard in the pelvis. Jury’s out at the moment. Certainly those I’ve spoken to so far (Sandy, Jessica Reale and Katie Kelly – check out the other GMI chats int eh vlog if you haven’t seen them) use them sometimes but not always, and when proprioception and awareness is particularly poor. Even if they’ve already done a PFM assessment.
Definitely think about using it in patients who have very poor proprioceptive awareness and can’t organise or integrate their sensory input.
There is no protocol. Yet. (Give us time!) As Sandy often says “Principles NOT protocols”.
Progressing from Laterality there’s some evidence for implicit and explicit imagery (please refer to the GMI Handbook).
Sandy talks about getting patients to Think like an athlete – imagine yourself doing it. It activates the premotor coretex without actually moving/activating the area physiologically. It can get your body used to the movement (being non-threatening) before you then do it for real. Provide the brain with enough experiences (real, imagined or visualised) and the basal ganglia has a large range of options to choose from when you then go to move that area and make the decision regarding whether this will be threatening or Is threatening. Practise makes perfect. I’ve talked more about visualisation and guided imagery in other vlogs – especially the one about sensory integration. Have a look at that one if you’re lost.
Then get them moving/functioning/doing
De-threaten it – in a way that’s true, provable, reproducible and demonstrable. Put them into a process – if we can turn it up we can turn it down. Work out how to make this change dependable in a way that makes sense to them.
“If you get a cramp in your foot you stand on it. But if you get a cramp in your pelvic floor we’re told to rest and walk with crutches. You also don’t start hopping on your foot – there is a middle ground.”
“You’re not going to damage anything by putting pressure on it.”
Treatments should always be Sub Threat. Give patients the tools to achieve, progress and regress but allow them to guide the process. Aim for consistent improvements – even 30 seconds/1 rep increase per day. Gently increase the baseline, don’t stay. Don’t fear flares, drop down a couple of levels and go back up. It should be super easy. It’s like a running programme – you need to keep at it and you’ll improve. It’s strength and conditioning for the pelvis – calm it down and build it back up. This applies to everything. Treatment shouldn’t create a top down protective response.
Find your way into their system – be non-threatening, relaxed, patient-led. Desensitisation will trickle down into all sorts of their ADLs.
Make sure they know their hurt is not harming them.
Shelly Prosko – does fabulous Yoga for pelvic health. You can find her online course here. She also makes the world a better place. Have a watch of some of her WOW chats with some famous physio (and other) faces.
Sandy’s Entropy Physiotherapy webshop has the PHODA cards for sale here.. You can obviously make your own – these are quite handy and easy to tuck away in a clinic drawer.
Get some great cues of how to improve your body language from Mark Bowden and his fab TED talk.
World Congress on Abdominal and Pelvic Pain (WCAPP) Registration is live! Click here if you’re interested.
My ‘YOU CAN CHANGE YOU!’ absolute motivation video – The Amazing transformation of Army veteran doing Yoga. (I just watched this again, it is ridiculously inspiring. It makes me want to do Yoga RIGHT NOW.)
Keen to know more about how to put all this together? Come and join me on a Happy Bladder Course – dates are up for 2019 in the UK and Ireland. And for my #BladderHeroes (previous participants of the course) there’ll be a few dedicated #BrainPhysio courses in April. Keep your eyes peeled in the Facebook group!