Integrative Approaches for Pelvic Pain in Trauma Recovery: Difference between revisions

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== Introduction ==
== Introduction ==
Our understanding of how trauma, emotional wellness, and sexual health intersect has greatly advanced in recent years.<ref name=":4" /> Moreover, 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> A good understanding of the brain and nervous system function is necessary when selecting approaches that may help clients experiencing pelvic pain in trauma recovery. Mindful movement, breathing techniques, and graded exposure can help create new pathways for experience within the body and brain.<ref name=":4" /> This article explores mindfulness, somatic embodiment practices, and cognitive behavioural therapy as pain management tools.
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 ==
== 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>"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, like 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. These analogies can help people understand that pain is not solely a result of physical injury but also involves the brain and body processing signals to indicate potential threats to the body.
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.
 
The following video provides a basic overview of the concept of brain smudging, which can occur with persistent pain.
 
{{#ev:youtube|v=3QVAY5stO3U|300}}<ref>Neuro Orthopaedic Institute. Explaining Brain Smudging. Available from: https://www.youtube.com/watch?v=3QVAY5stO3U[last accessed 10/4/2024]</ref>


=== Pain vs Nociception ===
=== Pain vs Nociception ===
[[Nociception]] is important for the "fight or flight response" of the body and protects us from harm in our surrounding environment. Distinct from pain, nociception refers to the brain's encoding and processing of noxious stimuli signalling actual tissue damage.<ref>Loeser JD, Treede RD. The Kyoto Protocol of IASP Basic Pain Terminology. Pain. 2008 Jul 31;137(3):473-477.</ref> Unlike pain, which encompasses both physical and emotional responses, nociception is a more specific process wherein the brain detects and interprets signals indicating bodily injury.<ref>Treede RD. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5902252/pdf/painreports-3-e643.pdf The International Association for the Study of Pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes.] Pain Rep. 2018 Mar 5;3(2):e643. </ref> For instance, in conditions like [[Complex Regional Pain Syndrome (CRPS)|Complex Regional Pain Syndrome]] (CRPS), chronic low back pain, or arthritis, studies have shown decreased tactile acuity, highlighting altered responses to tactile stimuli without necessarily reflecting heightened pain levels.<ref>Catley MJ, O'Connell NE, Berryman C, Ayhan FF, Moseley GL. [https://www.jpain.org/action/showPdf?pii=S1526-5900%2814%2900792-5 Is tactile acuity altered in people with chronic pain? a systematic review and meta-analysis.] J Pain. 2014 Oct;15(10):985-1000.</ref> This distinction between nociception and pain is crucial in understanding how the brain processes sensory information, supporting healthcare professionals in tailoring treatments for various pain conditions.
[[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 Trauma Survivors ==
Chronic pelvic pain with unclear aetiology has been associated with a history of trauma among women that included reports of physical or sexual abuse.<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>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> This type of abuse includes multiple rapes with significant untreated injuries and sexual assault and is characterised by a "systematic part of domination and destruction of individuals and their families." <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 a review 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 the 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 pain include the following:


* [[Scar Management|scar tissue]] or peripheral nerve damage leading to localised pain
== Pelvic Pain in Survivors of Trauma ==
* altered central pain mechanisms, including muscle [[hyperalgesia]] and sensory dysesthesia
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>
== Physiological Responses ==
Delving into the realm of physiological responses, studies have ventured into exploring how our body reacts to different stimuli. The [[Pelvic Floor|pelvic floor]] exhibited the earliest signs of tightening, prompting reflections on the body's primal defence mechanism during fight or flight responses when shown non-sexual, scary and threatening images.<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>  


Studies focusing on [[vaginismus]] shed light on reduced muscle awareness in the pelvic floor, demonstrating a link between mind-body awareness and physical conditions. Equally compelling was a meta-analysis highlighting the positive impact of mindful movement on individuals grappling with fibromyalgia. Comparing the efficacy of [[High Intensity Interval Training|High-Intensity Interval Training]] (HIIT) with slow, mindful stretching, the latter emerged victorious in alleviating pain, emphasising the significance of mindful movement coupled with awareness. <ref name=":1" /> <ref>Vandyken B, Keizer A, Vandyken C, Macedo LG, Kuspinar A, Dufour S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8134766/pdf/main.pdf Pelvic floor muscle tenderness on digital palpation among women: convergent validity with central sensitization.] Braz J Phys Ther. 2021 May-Jun;25(3):256-261. </ref>
Causes of chronic pelvic pain in survivors of torture may include the following:<ref name=":2" />


== Mindful Movement ==
* [[Scar Management|scar tissue]] or peripheral nerve injury leading to localised pain
Mindful movement involves performing physical activities or exercises with a deliberate focus on awareness, attention, and being present in the moment. 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>
* 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" />


Defined as the art of slowing down to be present in mind, body, and spirit, it facilitates introspection into thoughts, feelings, and physical sensations. Lori Brotto's impactful research underscores [[mindfulness]] as a tool to alleviate pain and unlock pleasure by reconnecting individuals with their bodies.<ref name=":0" />
Please watch the video below if you would like to learn more about brain smudging.  


During mindful movement, individuals pay close attention to bodily sensations, breath, thoughts, and emotions as they engage in 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 an"increased neuronal activity in areas of interoceptive awareness and allows for reappraisal of sensory information."<ref>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>  
{{#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 ===
== Mindfulness and Mindful Movement ==
Mindfulness is a [[/www.physio-pedia.com/Stress and Health|stress]]-reducing strategy where an individual develops an awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally and accepting them as they are. 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> Studies exploring mindfulness have showcased its profound impact on pain perception. By incorporating mindfulness practices, individuals can:<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>
'''[[An Introduction to Mindfulness|Mindfulness]]''' is a [[/www.physio-pedia.com/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


* Develop a heightened awareness of their body's signals, enabling them to discern pain sensations more accurately and respond to them in a more adaptive manner.
'''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.
* Better understanding of pain triggers
* Reduce pain sensitivity
* 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.  


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 ==
Graded exposure is a therapeutic technique used in psychology and healthcare to help individuals overcome fear, phobias, anxiety, or trauma by gradually exposing them to the 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 involves breaking down the fear-inducing stimulus or situation into smaller, manageable steps or levels. The individual is then exposed to these steps sequentially, starting with the least anxiety-provoking level and gradually progressing towards the more anxiety-inducing aspects as they build confidence and tolerance. The aim of graded exposure is to desensitize individuals to the feared stimulus, helping them to relearn or reinterpret the situation, reducing their anxiety response, and eventually allowing them to cope effectively 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>
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>
{{#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 ===
=== Window of Tolerance in Graded Exposure Therapy ===
The concept of the "Window of Tolerance" plays a crucial role in exposure therapy by providing a framework for understanding and managing an individual's emotional and physiological arousal levels during the therapeutic process. In graded exposure, individuals are gradually exposed to feared stimuli or situations to alleviate their anxiety or distress. <blockquote>The Window of Tolerance, introduced by psychiatrist Dan Siegel <ref>Siegel DJ. (1999) The Developing Mind. How Relationships and the Brain Interact to Shape Who We Are, 1st Edition. Guilford Publications, New York.
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> Exposure therapy allows for a balanced exploration of fears without triggering extreme reactions when working within this window. <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 exceeds their window, they may enter a state of hyper-arousal (characterized 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, ensuring a manageable level of anxiety or fear, which allows for gradual adaptation and reduced distress over time. By respecting an individual's Window of Tolerance during graded exposure, clinicians can optimise the therapeutic process, enhancing the individual's ability to face and overcome their fears while avoiding overwhelming reactions.
</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 ==
== Practical Applications ==


=== Breathing Techniques ===
=== Breathing Techniques ===
Engaging in practical exercises begins with a self-check-in followed by gentle, slow movements and breath control activities:  
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" />


* Gentle movements on a ball and observation of breath patterns set the stage.
* check in with your body, paying attention to areas of stiffness
* Explorations into rib breathing and belly breathing unravel the potential for deep breaths to counteract shallow, stress-induced apical breathing.
* start to move gently on the ball while observing breath patterns
* Directing attention to the pelvic floor, participants learn to observe and control its movements in correlation with breath and posture alterations.
* explore rib breathing and belly breathing rather than apical breathing, which tends to be shallow and associated with fight, flight or freeze mode
* Experimenting with breathing techniques tailored to joyful or fearful moments unravels the ability to modulate physical responses using breath awareness.
* direct attention to the pelvic floor
* Encouraging the exploration of diverse breathing techniques - from visualisations like sniffing coffee or blowing out candles to structured methods like box breathing.
** find your iliac crests, pubic bone and coccyx
* Alternate nostril breathing with the aim of harnessing breath as a potent tool to calm the nervous system.
** 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 ===
=== Graded Exposure ===
The goal of exercises in graded exposure technique is to ''increase activity level '''despite''' of pain.'' The goal is NOT to '''''reduce''' pain-related fear.''<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> Graded exposure program should include the following:<ref name=":5" /><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>
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 and Determining functional goals
* assessment
* Establishing an individual's hierarchy of the pain-related fear stimuli.
* determine functional goals
* Patient education.
* establish an individual's hierarchy of pain-related fear stimuli
* Choosing activity based on fear hierarchy.
* patient education
* Gradual exposure to challenging situations using a series of practice and preparation.
* choosing an activity based on this fear hierarchy
* 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>
* gradual exposure to challenging situations through practice and preparation
* Transferring activity into everyday life.
* 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>
* Reevaluation of the fear hierarchy.
* transferring these activities into everyday life
* re-evaluation of the fear hierarchy


== Resources  ==
== Resources  ==

Latest revision as of 11:55, 17 April 2024

Original Editor - Naomi O'Reilly based on the course by Diana Blaney

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction[edit | edit source]

Our understanding of how trauma, emotional wellness, and sexual health intersect has increased in recent years.[1] There has been increasing recognition of, and interest in, the connection between the brain, trauma, and physical well-being.[1] 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[edit | edit source]

The most widely accepted and current definition of pain, established by the International Association for the Study of Pain (IASP), is as follows:

Pain is: "An unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage."[2]

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.[3] 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[edit | edit source]

Nociception is distinct from pain. "Nociception refers to the signal traveling in the nervous system while pain is the perception of the unpleasant experience."[4] 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.[5] 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."[4]

Pelvic Pain in Survivors of Trauma[edit | edit source]

A history of trauma, including physical and sexual abuse, is a recognised risk factor for chronic pelvic pain.[6][7] [8][9] The relationship between sexual assault and pelvic pain has been reported in reviews of the general population,[10] as well as in studies researching the effect of sexual assault in the torture of women and men.[11]

Causes of chronic pelvic pain in survivors of torture may include the following:[9]

  • 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[edit | edit source]

Van der Velde and Everaerd[12] 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.[12] Women with vaginismus also had decreased muscle awareness in their pelvic floor area.[3] 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).[3]

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

[13]

Mindfulness and Mindful Movement[edit | edit source]

Mindfulness is a 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."[14] An individual attempts to control the focus and direction of their attention without rejecting or suppressing thoughts.[15] A number of studies have highlighted the significant impact of mindfulness on pain perception. Brotto et al.[16] 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]."[16] Mindfulness can help individuals:[17]

  • develop a heightened awareness of their body's signals
  • better understand pain triggers
  • reduce sensitivity to pain
  • reduce pain perception and anxiety scores[18]
  • 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, qigong, or simple stretching routines.[19] [16] 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".[20] It also "allows for reappraisal of sensory information."[20]

Graded Exposure[edit | edit source]

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.[21] 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.[22]

[23]

Window of Tolerance in Graded Exposure Therapy[edit | edit source]

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.

The window of tolerance, introduced by psychiatrist Dan Siegel,[24] defines an optimal state of arousal in which an individual can effectively process emotions and information.

When working within a window of tolerance, individuals can explore their fears without triggering extreme reactions.[25] 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[edit | edit source]

Breathing Techniques[edit | edit source]

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:[3]

  • 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[edit | edit source]

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:[26][27]

  • 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[28]
  • transferring these activities into everyday life
  • re-evaluation of the fear hierarchy

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 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.
  2. ↑ Malik NA. 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.
  3. ↑ 3.0 3.1 3.2 3.3 Blaney D. Integrative Approaches for Pelvic Pain in Trauma Recovery Course. Plus, 2024.
  4. ↑ 4.0 4.1 Marchand S. Mechanisms challenges of the pain phenomenon. Front Pain Res (Lausanne). 2021 Feb 10;1:574370.
  5. ↑ 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/
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ Chandler HK, Ciccone DS, Raphael KG. Localization of Pain and Self-Reported Rape in a Female Community Sample. Pain Medicine 2006, 7(4):344–352.
  9. ↑ 9.0 9.1 Williams AC, Peña CR, Rice AS. Persistent pain in survivors of torture: a cohort study. J Pain Symptom Manage. 2010 Nov;40(5):715-22.
  10. ↑ Leserman J. Sexual abuse history: prevalence, health effects, mediators, and psychological treatment. Psychosom Med. 2005 Nov-Dec;67(6):906-15.
  11. ↑ 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.
  12. ↑ 12.0 12.1 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.
  13. ↑ Neuro Orthopaedic Institute. Explaining Brain Smudging. Available from: https://www.youtube.com/watch?v=3QVAY5stO3U [last accessed 16/04/2024]
  14. ↑ Kabat‐Zinn J. Mindfulness‐based interventions in context: past, present, and future. Clinical psychology: Science and practice. 2003 Jun;10(2):144-56.
  15. ↑ Kabat-Zinn J. Full catastrophe living. New York: Bantam Books Trade Paperbacks; 2013.
  16. ↑ 16.0 16.1 16.2 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.
  17. ↑ 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.
  18. ↑ Zeidan F, Gordon NS, Merchant J, Goolkasian P. The effects of brief mindfulness meditation training on experimentally induced pain. J Pain. 2010 Mar;11(3):199-209.
  19. ↑ Flehr A, Barton C, Coles J, Gibson SJ, Lambert GW, Lambert EA, Dhar AK, Dixon JB. #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.
  20. ↑ 20.0 20.1 Clark Donat LE, Reynolds J, Bublitz MH, Flynn E, Friedman L, Fox SD. 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.
  21. ↑ George SZ, Wittmer VT, Fillingim RB, Robinson ME. 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.
  22. ↑ 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.
  23. ↑ Dr.Paul Stone. Graded Exposure. Available from: https://www.youtube.com/watch?v=HHfUdOM8QIQ[last accessed 10/4/2024]
  24. ↑ Siegel DJ.The Developing Mind. How Relationships and the Brain Interact to Shape Who We Are, 1st Edition. New York: Guilford Publications, 1999.
  25. ↑ Ogden P, Minton K, Pain C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. W. W. Norton & Company.
  26. ↑ 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.
  27. ↑ Leonhardt C, Kuss K, Becker A, Basler HD, de Jong J, Flatau B, Laekeman M, Mattenklodt P, Schuler M, Vlaeyen J, Quint S. Graded Exposure for Chronic Low Back Pain in Older Adults: A Pilot Study. J Geriatr Phys Ther. 2017 Jan/Mar;40(1):51-59.
  28. ↑ 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).
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