DIM SIMs of Prostatits and CPPS
I want to start this article off with a little task for you to complete, it is very simple and will only take a few seconds. All I want you to do is tell me which of these 2 words you find most threatening.
Chronic or Persistent?
Which one makes you feel less comfortable and which one is a little easier on the palate?
According to the Collins English Dictionary (other dictionaries are of course available, but I would advise you if I can against using the ‘Urban Dictionary’) the meaning of each is as follows:
- Chronic – “continuing for a long time; constantly recurring” and “developing slowly, or of long duration”
- Persistent – “showing persistence” and “incessantly repeated; unrelenting”
For me (as a sufferer of chronic and/or persistent pain) the word Chronic has darker connotations. It means something more sinister. It is foreboding. Whereas the word Persistent sounds a little more friendly. The kind of word you might strike up a conversation with, albeit a short one. I love the English language for its intricacies, ‘onomatopoeia’ is when a word’s pronunciation imitates its sound. Some clear examples are – buzz, boom, crackle, hiss, plop, squeal. Chronic sounds creaky, it sounds like the cogs in a clock that don’t quite match up. Persistent has a more sing song sound. It could be the call of a small bird, or a wheel that rubs.
The point is that both words mean the same thing. In fact if you reread the meaning above the word persistent sounds more catastrophic! Context is key and when it comes to pain this is so important to understand. The language we use when describing pain has long lasting consequences. As a person who has experienced pelvic pain for longer than 3 months would you rather your pain be called Persistent or Chronic? They both mean the same thing, but their context suggests something quite different. Here is a great article from Michael Vlagg from “Body in Mind” on how our words have far reaching consequences when talking about pain.
So, for a person who has had pelvic pain for 2 months and 27/28/29/30 days (depending on the length of said month) they are only classified as having acute pelvic pain, yet as soon as the clock strikes midnight they become chronic pelvic pain sufferers. I find that tough to stomach. How about we just use the term Male Pelvic Pain with a duration of ….. months/years? Does the prefix ‘Chronic’ or ‘Persistent’ really matter? Will I.P Freely never hesitate or dribble before and after urination? Will Ivor Biggen always live up to his namesake? Language is a funny affliction, one that we are often bound to, something that we are born into. But this doesn’t mean we can’t change and adapt, it doesn’t mean we have to remain fixed to the ways of old. Lets look at pain through modern lenses, with a patient centric approach, focused on bespoke pain management and symptom alleviation
What are DIM SIMs?
DIMs and SIMs are an acronym of “Danger (signals) In Me” and “Safety (signals) In Me”. They are the offspring, if you like, of David Butler and Lorimer Moseley (authors of The Explain Pain Handbook and world experts in the field of pain). All of us experience Danger signals and Safety signals in a totally unique fashion, bespoke to ourselves and made up of a plethora of previous experiences, education, societal interactions and the media to name but a few of their influences. Safety signals are vital to us and we cannot have too many Safety signals. The jar named SIMs is bottomless and will therefore never overflow. The jar labelled DIMs however, is limited and there are only so many Danger signals we can contain before there are consequences. Moseley and Butler (2015) state that too many DIMs will start to construct a pain experience, to the point where one small DIM could be the tipping point between no pain and pain (here)
I have found the DIMs and SIMs model a highly valuable tool when managing and reducing my CPPS/Prostatitis patient pain levels whilst increasing their quality of life. Used in combination with manual therapy, self-care, graded movement and exercise exposure, relaxation and mindfulness (which this is a form of) and pain education patients are able to take control of their lives again.
I set up a simple task with my patients to identify their own DIMs and SIMs. Each patient’s answers are unique and offer me a brief insight into their beliefs around their pain. I will then task them with creating their own list to identify what they consider Safety or Danger signs in their life. So, cast your eyes over the list below and ask yourself what you consider to be a DIM or a SIM.
• I have just been diagnosed with Prostatitis
• We are at war with ISIS
• Light exercise
• A supportive boss who allows me time off for my appointments
• Noisy neighbours
• Interest rates going up
• A hospital stay
• Learning about my CPPS/Prostatitis
• Hearing “you’ll just have to live with this”
• Staying at home all the time
• A nagging partner
• A holiday abroad
• Hearing “your test results are all clear”
• Finding a specialist who treats CPPS/Prostatitis
• Having my own techniques to reduce my CPPS/Prostatitis symptoms
• Knowing someone else who has CPPS/Prostatitis
• Reading posts on a CPPS/Prostatitis forum
• Being prescribed antidepressants
• Crying with laughter
So, how did you get on? Did you find that a number of those listed above traversed both DIM SIMs categories? This is down to context and how your perception of that statement affects you. Let’s dissect “light exercise” using a skype consultation I had with a client recently – My question to him was how does the thought of returning to light exercise make him feel. His response was common stating that the very thought of going to the gym set off alarm bells for him. He associated the pulling and pushing of resistance machinery as a DIM that a session in the gym had resulted in a recent flare up. I replied that light, graded, relevant exercise was important to his recovery and that we should find an activity that he felt safe with. He said that he had started skateboarding… I will be honest with you and say this was not what I expected to hear from a male in his mid 30’swho had suffered with Chronic/Persistent pain (delete as appropriate) for nigh on 19 years… It is all about context. He found the skating to be fun, exciting and a release. He wasn’t hitting the half pipes, but he was out doing light exercise. He had even purchased a wobble board so he could practice his balance in his living room – a total SIM. Do you see how our perception of events can change our reaction to them? How one form of light exercise is deemed threatening, yet another a release.
The aim of the DIM SIMs exercise is to outweigh your Danger signs with Safety signs, simple right? Butler and Moseley devised the “Protectometer,” a gauge that indicates the level of safety or danger signals in you. The gauge moves up and down depending on how much danger or safety you feel. The more DIMs you identify then the higher your indicator moves and the more pain you are likely to feel and vice versa. The “Protectometer” changes every day, from minute to minute as we find ourselves in differing circumstances, mind sets and stresses. SIMs can be found in all scenarios but locating them is key and not always apparent at first glance, look at the “light exercise” example above. If “a holiday abroad” is deemed a DIM, how might you make it a SIM? Could you drive instead of fly? Could you go for a shorter holiday in length or distance? How about not going abroad, why not try somewhere more local to you? I urge you to create your own list, to look into your beliefs and weigh up their foundations. To see if, with a different perspective, you too can locate those sometimes hard to find SIMs. The DIM SIMs approach is well documented and a highly recognised and successful model of managing and reducing pain. It will take some soul searching, but in my opinion this is a great investment and a path towards your recovery.
Back to the original question – Chronic or Persistent? For me, based on my beliefs I would rather be labelled with persistent pelvic pain than chronic. For me this is a SIM, I feel safer with this label (I would rather not have a label if I am honest but that is another conversation). Chronic is a DIM and something I would not like to be associated with. It reminds me of an old gnarly tool shed that should have been pulled down years ago! Right I think you have seen enough of the inner workings of my imagination today. Consider listing your own personal DIMs and SIMs. Search for them, look inside (and outside) and weigh up what really makes you feel safe. I am confident it will make you look at your CPPS/Prostatitis differently.
To watch David Butler in action talking about DIMs and SIMs click here. The whole You Tube clip is well worth the investment, but if you prefer to go straight to the action watch from 23.50.
Please feel free to email us with your comments, feedback and suggestions, we would love to hear from you – firstname.lastname@example.org
The Pelvic Pain Clinic
Karl is a sports and advanced clinical massage therapist with the qualifications, experience and knowledge in the treatment of male pelvic pain and in particular Prostatitis and Chronic Pelvic Pain Syndrome (CPPS). He has worked in men’s health since 2006 and has succesfully been treating male pelvic pain since 2009. He is the owner of The Pelvic Pain Clinic, London.