Pelvic Pain Q&A Series
In this edition of the Pelvic Pain Q&A series I am delighted to bring you Sandy Hilton. Sandy is the co-owner of Entropy Physiotherapy in Chicago. She is a Doctor of Physical Therapy and the co-author of ‘Why Pelvic Pain Hurts‘. And, Sandy is on the board of the International Association for the Study of Pain (IASP) specialist interest group – Abdominal and Pelvic Pain. I have had the pleasure of being taught by Sandy. Now I am very excited to bring you her views on pelvic pain, successful treatment and trigger points to name a few of the topics we discuss.
Muscles have often been blamed as the primary cause of chronic pelvic pain, with stretching and trigger points central to many recovery plans. What are your thoughts on this and can we do better than just focusing on muscles for successful recovery from pelvic pain?
Pain is influenced by much more than the areas that hurt and a continued focus on any one type of tissue is missing the larger picture and reducing the opportunities of effective interaction. Trigger points in particular have been over exaggerated in the cause and treatment of pain. The original work by Travell and Simmons was “extrapolated” from clinical experience and never tested. We have daily normal experiences that people have sore spots, and that those spots do not turn into permanent entities in muscle. Normal soreness and stiffness need to not be pathologized (ie “latent” trigger points that only the provider can feel, and that are described as proof of a problem that will need continued care by that provider).
The trends in education, particularly in pelvic health, have focused on a problem in the tissue as the cause of pain. There is simply too much evidence against this approach to continue to use in the clinic or to promote it in courses and conferences.
Instead, we can focus on multi-model approaches that include touch and movement to reintegrate an upregulated sensory system, to work on progressive return to activity, and to make these approaches fit within the patient’s individual preference and needs. There are more options for this than can fit in this response! Any movement or sensory input that the individuals likes and enjoys is fair game as an intervention to change pain.
The pelvis is a powerhouse and able to withstand huge forces yet pelvic pain patients are often told to avoid activity in recovery – sex, cycling, squatting etc. Is this model helpful in the long term recovery from pelvic pain?
The pelvic region is indeed a powerhouse and has a normal capacity for force absorption. It is reasonable for people to move differently:
- When they are in pain (acute or chronic)
- Have concerns about incontinence
- Have been told that normal activity is going to make them worse or cause harm
Our job in pelvic health is to help people gradually increase the capacity of the tissues to absorb force again and restore the confidence for activity so that it is comfortable (and fun) again.
Squatting is normal, it helps maintain hip range, strength, balance, and is fabulous for neural gliding for all of the pelvic nerves. Sitting is also normal, does not damage tissues under normal sitting times (2 – 3 hours should be well tolerated!), and is a natural position of rest and relaxation. Cycling (including motorbikes) does not cause damage to structures. The fit of the bike is critical to comfort, as is a gradual training program to restore normal capacity.
When health and fitness professionals demonize or belittle an activity they are actively doing harm by putting a barrier between people and the movements that keep them healthy. An example is those who say that squatting is dangerous to the pelvic muscles and the pudendal nerve in particular. If that were true, the generations of humans who squat easily on a regular basis would have had continence and pain issues disproportionate to those who culturally do not squat. This is not what happens. Squatting is safe, normal, and something to be preserved! Those same myths are marketed about sitting, riding bikes and horses, jumping, having sex, climbing stairs, pretty much every normal human movement. This kind of activity shaming is anti-helpful for health care and needs to stop.
How do you find ‘safe’ movements/activities/exercise for patients to engage with? Swimming has been deemed a good place to begin, should we just prescribe the same exercise for all pelvic pain patients?
My first question to patients about movement/activity/exercise is “what do you enjoy?” and then we go from there to design a meaningful and relevant program. Walking tends to be in all my programs due to the necessity to be comfortable walking. Exercise is best if it is something the person likes, has consistent access to, and has the skills to do it with good form. After a baseline level of function is determined, the program becomes a standard strength and conditioning program based on the patients choice of preferred activity. By encouraging patient choice we can increase the likelihood of a positive outcome as it will be more often done, more often enjoyed, and provide an inherent motivation to be consistent enough to see progress. In order to meet these principles, individualized programs are a necessity.
Moving away from relying on the therapist for recovery. Why is self empowerment so important for successful treatment and recovery from pelvic pain?
In order to reach beyond our comfort and confidence we need to know that we will be able to recover from the effort and that we are not putting ourselves in unreasonable danger, A predictable and meaningful recovery is the support ground needed in order to put enough challenge and repetition into the system for a change to occur.
- Not enough load? Nothing is going to change.
- Not enough capacity to tolerate the increased load? Nothing is going to change.
We need to keep basic strength and conditioning principles in mind when designing programs. And we need to teach patients the skill of adapting their program in order for them to continue to increase their program despite travel or equipment availability. This adaptability and independence is the foundational skill needed to have confidence about their treatment programs and to persist through the work of a gradual progression to where there is no need for therapy beyond consulting/problem solving.
What is the role of the IASP specialist group Abdominal and pelvic pain in the future of pelvic health?
The International Association for the Study of Pain promotes and supports education and the sharing of best evidence around pain across the world. The Abdominal and Pelvic Pain Special Interest Group is actively promoting research and sharing evidence on best practice specifically to the treatment of pelvic and abdominal pain conditions. The SIG is aiming to have active representation from researchers and clinicians around the world. Together we can shorten the time between the onset of a problem and the resolution of the problem. As our colleagues from Convergence EBP said at the 4th World Congress on Abdominal and Pelvic Pain in 2019 – we need to work towards prediction and prevention. The more people who are actively involved the better! All health professionals and patients/patient advocates interested in abdominal and pelvic health have a place within the SIG!
Do you have any take homes for patients suffering with pelvic pain – what they should or shouldn’t do in recovery?
There are some “non-negotiables” about health and these apply to people suffering with pelvic pain too!
Sleep: The best evidence says 7 – 8 hours of sleep per night is crucial. It’s hard when you hurt to sleep well, so this may not be not an easy thing. It is a critical thing to sort out though, do the best you can and use all the ways to make it more likely:
- A cool, dark, and quiet room is best.
- Stop drinking fluid 2 hours before you plan on being asleep. This allows the bladder to be better emptied on that last trip before bed. People under 65 years should not be getting up to use the bathroom at night. And those over 65 should only need once. Get help from your local pelvic health physio if this is a problem for you!
- As much as possible, keep the same schedule going to sleep and waking up.
Movement: Equally necessary for health is sufficient movement and exercise. 150 minutes per week of movement sufficient to get your heart rate up and strength training 2 – 3 times per week is the minimum.
Your program only needs to be hard enough for you. The type of exercise that is right for you is the one that you like (and will do consistently). Start where you are and get going. This is good science.
Food: You need all the basic building blocks for health. How you get them is going to depend on your unique biology and preference.
Laughter and doing fun things with fun people. Seek out positive experiences!
You can get help along the path from a wide variety of professionals. Don’t give up hope. And do keep moving!
Thank you so much for your insight and expertise here Sandy. I know many readers will fund this information hugely beneficial – patients and therapists alike.