View source for Integrative Approaches for Pelvic Pain in Trauma Recovery

 
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'''Original Editor '''- [[User:Naomi O'Reilly|Naomi O'Reilly]] based on the course by [[Diana Blaney|Diana Blaney]]

'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  &nbsp;   
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== Introduction ==
Our understanding of how trauma, emotional wellness, and sexual health intersect has increased in recent years.<ref name=":4" /> There has been increasing recognition of, and interest in, the connection between the brain, trauma, and physical well-being.<ref name=":4">Darnell C. Tending to painful sex: applying the neuroscience of trauma and anxiety using mindfulness and somatic embodiment in working with genito-pelvic pain and penetration disorders. Sexual and Relationship Therapy. 2023 Jul 3;38(3):398-410.</ref> Having a good understanding of pain, nociception, and the impact of trauma on pain is beneficial when selecting interventions for clients with a history of trauma and pelvic pain. Certain integrative strategies can be used to help manage pain and fear in these individuals, including mindfulness, mindful movements, breathing techniques and graded exposure.

== Conceptualising Pain ==
The most widely accepted and current definition of [[Pain-Modulation|pain]], established by the International Association for the Study of Pain (IASP), is as follows:<blockquote>Pain is: "An unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage."<ref>Malik NA. [https://apicareonline.com/index.php/APIC/article/view/1352/2194 Revised definition of pain by ‘International Association for the Study of Pain’: Concepts, challenges and compromises.] Anaesthesia, Pain & Intensive Care. 2020 Jun 10;24(5):481-3.</ref></blockquote>Pain can be described as a complex interplay between '''physical''' and '''emotional''' responses triggered by actual or potential tissue damage. Pain is often likened to a warning signal (e.g. an alarm system), alerting us when our body perceives potential harm. For instance, sipping an icy drink might cause a momentary brain freeze - a sensation often interpreted as pain without tissue damage. Similarly, briefly touching a hot surface induces pain as a protective signal, although there might be no lasting harm to the skin.<ref name=":6">Blaney D. Integrative Approaches for Pelvic Pain in Trauma Recovery Course. Plus, 2024.</ref> These analogies can help people understand that pain does not simply occur because of physical injury but also involves the brain and body processing signals to indicate potential threats to the body.

=== Pain vs Nociception ===
[[Nociception]] is distinct from pain. "Nociception refers to the signal traveling in the nervous system while pain is the perception of the unpleasant experience."<ref name=":7">Marchand S. [https://www.frontiersin.org/articles/10.3389/fpain.2020.574370/full Mechanisms challenges of the pain phenomenon]. Front Pain Res (Lausanne). 2021 Feb 10;1:574370. </ref> Nociceptors detect "danger" or noxious stimuli, including extremes of temperature (high and low), strong mechanical forces and noxious chemicals. These messages are sent to the spinal cord, and then the brain.<ref>Armstrong SA, Herr MJ. Physiology, Nociception. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551562/</ref> Nociceptive signals are modulated at a number of levels of the central nervous system, so "pain is not the mere reflection of nociception. Genetic, environmental, societal, physiological, and psychological factors will influence the perception of pain."<ref name=":7" />

== Pelvic Pain in Survivors of Trauma ==
A history of trauma, including physical and sexual abuse, is a recognised risk factor for chronic pelvic pain.<ref>Garza-Leal JG, Sosa-Bravo FJ, Garza-Marichalar JG, Soto-Quintero G, Castillo-Saenz L, Fernández-Zambrano S. Sexual abuse and chronic pelvic pain in a gynecology outpatient clinic. A pilot study. Int Urogynecol J. 2021 May;32(5):1285-91. </ref><ref>Panisch LS, Tam LM. The Role of Trauma and Mental Health in the Treatment of Chronic Pelvic Pain: A Systematic Review of the Intervention Literature. Trauma Violence Abuse. 2020 Dec;21(5):1029-1043. </ref> <ref name=":3">Chandler HK, Ciccone DS, Raphael KG. [https://academic.oup.com/painmedicine/article/7/4/344/1937879 Localization of Pain and Self-Reported Rape in a Female Community Sample.] Pain Medicine 2006, 7(4):344–352.</ref><ref name=":2">Williams AC, Peña CR, Rice AS. [https://www.jpsmjournal.com/article/S0885-3924(10)00461-6/fulltext Persistent pain in survivors of torture: a cohort study.] J Pain Symptom Manage. 2010 Nov;40(5):715-22. </ref> The relationship between sexual assault and pelvic pain has been reported in reviews of the general population,<ref>Leserman J. Sexual abuse history: prevalence, health effects, mediators, and psychological treatment. Psychosom Med. 2005 Nov-Dec;67(6):906-15. </ref> as well as in studies researching the effect of sexual assault in the torture of women and men.<ref>Moisander PA, Edston E. Torture and its sequel--a comparison between victims from six countries. Forensic Sci Int. 2003 Nov 26;137(2-3):133-40. </ref>

Causes of chronic pelvic pain in survivors of torture may include the following:<ref name=":2" />

* [[Scar Management|scar tissue]] or peripheral nerve injury leading to localised pain
* altered central pain mechanisms, including muscle [[hyperalgesia]] and sensory dysaesthesia (abnormal sensation)
== Pelvic Floor Muscle Activation Patterns and Awareness in Response to Threat ==
Van der Velde and Everaerd<ref name=":1" /> explored the connection between involuntary activity in the pelvic floor muscles, awareness of muscle activity and threat experienced by women both with and without [[vaginismus]]. In this study, participants' pelvic floor muscles activated in response to threatening and sexually-threatening videos. This could be considered as part of a general defence mechanism.<ref name=":1">Van der Velde J, Everaerd W. The relationship between involuntary pelvic floor muscle activity, muscle awareness and experienced threat in women with and without vaginismus. Behav Res Ther. 2001 Apr;39(4):395-408.</ref> Women with vaginismus also had decreased muscle awareness in their pelvic floor area.<ref name=":6" /> Similarly, survivors of sexual violence have been found to have decreased awareness of their pelvic floor anatomy and decreased pelvic floor perception (i.e. brain smudging).<ref name=":6" />

Please watch the video below if you would like to learn more about brain smudging. 

{{#ev:youtube|3QVAY5stO3U|300}}<ref>Neuro Orthopaedic Institute. Explaining Brain Smudging. Available from: https://www.youtube.com/watch?v=3QVAY5stO3U [last accessed 16/04/2024]</ref>

== Mindfulness and Mindful Movement ==
'''[[An Introduction to Mindfulness|Mindfulness]]''' is a [[Stress and Health|stress]]-reducing strategy where an individual develops an awareness "through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment."<ref>Kabat‐Zinn J. [https://onlinelibrary.wiley.com/doi/pdf/10.1093/clipsy.bpg016 Mindfulness‐based interventions in context: past, present, and future]. Clinical psychology: Science and practice. 2003 Jun;10(2):144-56. </ref> An individual attempts to control the focus and direction of their attention without rejecting or suppressing thoughts.<ref>Kabat-Zinn J. Full catastrophe living. New York: Bantam Books Trade Paperbacks; 2013.</ref> A number of studies have highlighted the significant impact of mindfulness on pain perception. Brotto et al.<ref name=":0" /> found that mindfulness is as effective as cognitive behavioural therapy (CBT) for "most pain- and sexuality-related endpoints in the treatment of PVD [provoked vestibulodynia]."<ref name=":0" /> Mindfulness can help individuals:<ref>Rosenbaum TY. An integrated mindfulness-based approach to the treatment of women with sexual pain and anxiety: promoting autonomy and mind/body connection. Sexual and Relationship Therapy 2013; 28(1–2):20–28. </ref>
* develop a heightened awareness of their body's signals
* better understand pain triggers
* reduce sensitivity to pain
* reduce pain perception and anxiety scores<ref>Zeidan F, Gordon NS, Merchant J, Goolkasian P. [https://www.jpain.org/action/showPdf?pii=S1526-5900%2809%2900691-9 The effects of brief mindfulness meditation training on experimentally induced pain]. J Pain. 2010 Mar;11(3):199-209.</ref>
* improve coping mechanisms for managing pelvic pain

'''Mindful movement''' involves performing movements or exercises with awareness and attention. It combines the principles of mindfulness with various movement practices, such as [[yoga]], [[Tai Chi and the Older Person|tai chi]], [[Qigong for Health and Disease Management|qigong]], or simple stretching routines.<ref>Flehr A, Barton C, Coles J, Gibson SJ, Lambert GW, Lambert EA, Dhar AK, Dixon JB. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714085/pdf/12906_2019_Article_2642.pdf #MindinBody - feasibility of vigorous exercise (Bikram yoga versus high-intensity interval training) to improve persistent pain in women with a history of trauma: a pilot randomized control trial]. BMC Complement Altern Med. 2019 Aug 29;19(1):234. </ref> <ref name=":0">Brotto LA, Bergeron S, Zdaniuk B, Driscoll M, Grabovac A, Sadownik LA, Smith KB, Basson R. A Comparison of Mindfulness-Based Cognitive Therapy Vs Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia in a Hospital Clinic Setting. J Sex Med. 2019 Jun;16(6):909-923.</ref> Mindful movement requires individuals to slow down and be present in mind, body and spirit.

During mindful movement, individuals pay close attention to bodily sensations, breath, thoughts, and emotions as they perform each movement or posture. The emphasis is on tuning into the body's movements, observing sensations without judgment, and fostering a deep connection between the mind and body. This practice enhances body awareness, promotes relaxation, reduces stress, and cultivates a sense of calmness and clarity through increases in "neuronal activity in areas of interoceptive awareness".<ref name=":8">Clark Donat LE, Reynolds J, Bublitz MH, Flynn E, Friedman L, Fox SD. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8760341/pdf/main.pdf The effects of a brief mindfulness-based intervention on pain perceptions in patients with chronic pelvic pain: A case series.] Case Rep Womens Health. 2022 Jan 8;33:e00380.</ref> It also "allows for reappraisal of sensory information."<ref name=":8" />
== Graded Exposure ==
Graded exposure is designed to help individuals overcome specific fears, phobias, trauma or anxiety by gradually exposing them to a feared stimulus or situation in a controlled and systematic way.<ref>George SZ, Wittmer VT, Fillingim RB, Robinson ME. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5568573/pdf/nihms891184.pdf Comparison of graded exercise and graded exposure clinical outcomes for patients with chronic low back pain]. J Orthop Sports Phys Ther. 2010 Nov;40(11):694-704. </ref> This approach requires an individual to break down a fear-inducing stimulus or situation into smaller, more manageable steps. The individual is progressively exposed to these steps, starting with the step that will produce the least anxiety. Each step aims to help the individual build their confidence and tolerance, gradually desensitising them to the stimulus. Thus, they learn to cope with the situation without experiencing overwhelming fear or distress.<ref>Ariza-Mateos MJ, Cabrera-Martos I, Ortiz-Rubio A, Torres-Sánchez I, Rodríguez-Torres J, Valenza MC. Effects of a Patient-Centered Graded Exposure Intervention Added to Manual Therapy for Women With Chronic Pelvic Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2019 Jan;100(1):9-16. </ref>

{{#ev:youtube|v=HHfUdOM8QIQ|300}}<ref>Dr.Paul Stone. Graded Exposure. Available from: https://www.youtube.com/watch?v=HHfUdOM8QIQ[last accessed 10/4/2024]</ref>

=== Window of Tolerance in Graded Exposure Therapy ===
The concept of the "window of tolerance" plays an important role in graded exposure therapy. It provides a framework for understanding and managing an individual's emotional and physiological arousal levels during the therapeutic process. <blockquote>The window of tolerance, introduced by psychiatrist Dan Siegel,<ref>Siegel DJ.The Developing Mind. How Relationships and the Brain Interact to Shape Who We Are, 1st Edition. New York: Guilford Publications, 1999.
</ref> defines an optimal state of arousal in which an individual can effectively process emotions and information. </blockquote> When working within a window of tolerance, individuals can explore their fears without triggering extreme reactions.<ref>Ogden P, Minton K, Pain C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. W. W. Norton & Company.</ref> However, if the individual moves outside of their window of tolerance, they may enter a state of hyper-arousal (characterised by panic or extreme anxiety) or hypo-arousal (marked by dissociation or numbness). Therefore, graded exposure must be carefully tailored to keep individuals within their window of tolerance. This ensures that anxiety and fear are kept at a manageable level, allowing for gradual adaptation and reduced distress over time. 
== Practical Applications ==

=== Breathing Techniques ===
Practical breathing exercises usually begin with a self-check-in followed by gentle, slow movements and breath control activities. The following exercises can be tried. Sitting on an exercise ball can be helpful for these techniques:<ref name=":6" /> 

* check in with your body, paying attention to areas of stiffness 
* start to move gently on the ball while observing breath patterns
* explore rib breathing and belly breathing rather than apical breathing, which tends to be shallow and associated with fight, flight or freeze mode
* direct attention to the pelvic floor
** find your iliac crests, pubic bone and coccyx
** tilt the pelvis forwards and backwards to feel for differences in the pelvic floor with these movements
** focus on changes in the pelvic floor with breath
* think of a joyful or fearful moment and be aware of what happens at the pelvic floor, experience how breath impacts these sensations
* try different breathing techniques, such as visualisations (e.g. imagine you are sniffing coffee or blowing out candles), box breathing or alternate nostril breathing

=== Graded Exposure ===
The central aim of graded exposure is to ''increase an individual's ability to participate in relevant activities '''despite''' pain or anxiety.'' A graded exposure programme should include the following:<ref name=":5">Vlaeyen JW, de Jong J, Leeuw M, Crombez G. Fear reduction in chronic pain: graded exposure in vivo with behavioural experiments. Understanding and treating fear of pain. 2004 Jul 29:313-43.</ref><ref>Leonhardt C, Kuss K, Becker A, Basler HD, de Jong J, Flatau B, Laekeman M, Mattenklodt P, Schuler M, Vlaeyen J, Quint S. [https://journals.lww.com/jgpt/FullText/2017/01000/Graded_Exposure_for_Chronic_Low_Back_Pain_in_Older.4.aspx Graded Exposure for Chronic Low Back Pain in Older Adults: A Pilot Study.] J Geriatr Phys Ther. 2017 Jan/Mar;40(1):51-59. </ref>

* assessment
* determine functional goals
* establish an individual's hierarchy of pain-related fear stimuli
* patient education
* choosing an activity based on this fear hierarchy
* gradual exposure to challenging situations through practice and preparation
* repeated real-time exposure<ref>Naachimuthu KP, Kalpana T. Graded Exposure and Use of Thiruppugazh for Stuttering: A Case Study. Indian Journal of Positive Psychology. 2022 Mar 1;13(1).</ref>
* transferring these activities into everyday life
* re-evaluation of the fear hierarchy

== Resources  ==
*[https://mag.foyht.org/breathing-techniques-you-can-practise-at-home/ Breathing Techniques You Can Practise at Home!]
*[https://www.talkplus.org.uk/wp-content/uploads/2023/12/Graded-Exposure.pdf Graded Exposure]
== References  ==

<references />
[[Category:Course Pages]]
[[Category:Trauma]]
[[Category:Pain]]
[[Category:ReLAB-HS Course Page]]