Integrative Approaches for Pelvic Pain in Trauma Recovery

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Conceptualising Pain

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

"An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." (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)

Pain can be described as a complex interplay between physical and emotional responses triggered by actual or potential tissue damage. In simpler terms, pain is often likened to a warning signal, similar to 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 actual tissue damage. Similarly, briefly touching a hot surface induces pain as a protective signal, although there might be no lasting harm to the skin. This analogy helps people understand that pain is not solely a result of physical injury but also involves the brain processing signals to indicate potential threats to the body.

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. (Loeser JD, Treede RD. The Kyoto protocol of IASP Basic Pain Terminology. Pain. 2008; 137(3): 473–7. doi:10.1016/j.pain.2008.04.025. PMID 18583048) 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. (Treede RD. 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 reports. 2018 Mar;3(2)) For instance, in conditions like 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. (Catley MJ, O'Connell NE, Berryman C, Ayhan FF, Moseley GL. Is tactile acuity altered in people with chronic pain? A systematic review and meta-analysis. The Journal of Pain. 2014 Oct 1;15(10):985-1000.) 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.

Pelvic Pain In Trauma Survivors

"pelvic and abdominal pains in women were strongly associated with rape and sexual assault" "Whether from anal rape or genital assault, causes of pain may be local, such as scar tissue or peripheral nerve damage, or may be maintained by altered central pain mechanisms, including centrally maintained muscle hyperalgesia and sensory dysesthesias, which frequently result from intense pain. We should emphasize that rape in this sample was unlikely to be a single event but rather a systematic part of domination and destruction of individuals and their families.25, 26, 27, 28 Accounts were of brutal multiple rapes over weeks or months, with significant untreated injuries. Poor nutrition, hygiene, and lack of health care are endemic in the settings where much torture took place."

Mindful Movement

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, qigong, or simple stretching routines.

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 not only to alleviate pain but also to unlock pleasure by reconnecting individuals with their bodies.

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.

Mindfulness

Mindfulness is a 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. Studies exploring mindfulness have showcased its profound impact on pain perception. By incorporating mindfulness practices, individuals can 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. This heightened awareness often leads to a better understanding of pain triggers, reduced pain sensitivity, and an overall improvement in coping mechanisms for managing pelvic pain.

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. 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.

Physiological Responses

Delving into the realm of physiological responses, studies have ventured into exploring how our body reacts to different stimuli. The pelvic floor exhibited the earliest signs of tightening, prompting reflections on the body's primal defense mechanism during fight or flight responses when shown non-sexual, scary and threatening images.

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 (HIIT) with slow, mindful stretching, the latter emerged victorious in alleviating pain, emphasising the significance of mindful movement coupled with awareness.  

Mindfulness practices were found to be effective in reducing pain perception and anxiety scores. through an "increase neuronal activity in areas of interoceptive awareness and allows for reappraisal of sensory information." that can lead to a reduction in pain perception. reducing pain ratings and anxiety scores when compared with baseline testing and other cognitive manipulations. The brief meditation training was also effective at increasing mindfulness skills.

Practical Application

Breathing Techniques

Engaging in a practical exercise begins with a self-check-in followed by gentle, slow movements and breath control activities:

• Gentle movements on a ball and observation of breath patterns set the stage.
• Explorations into rib breathing and belly breathing unravel the potential for deep breaths to counteract the shallow, stress-induced apical breathing.
• Directing attention to the pelvic floor, participants learn to observe and control its movements in correlation with breath and posture alterations.
• Experimenting with breathing techniques tailored to joyful or fearful moments unravels the ability to modulate physical responses using breath awareness.
• The exercise encourages the exploration of diverse breathing techniques - from visualisations like sniffing coffee or blowing out candles to structured methods like box breathing.
• Alternate nostril breathing with the aim of harnessing breath as a potent tool to calm the nervous system.

Window of Tolerance

The concept of the "Window of Tolerance" plays a crucial role in exposure therapy by providing a framework to understand and manage 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. The Window of Tolerance, a concept introduced by psychiatrist Dan Siegel (Siegel, D.J. (1999). The developing mind: How relationships and the brain interact to shape who we are. New York; Guilford Press), defines an optimal state of arousal where an individual can effectively process emotions and information. When working within this window, exposure therapy allows for a balanced exploration of fears without triggering extreme reactions. (Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy (Norton Series on Interpersonal Neurobiology). WW Norton & Company) 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 optimize the therapeutic process, enhancing the individual's ability to face and overcome their fears while avoiding overwhelming reactions.

Resources

• Breathing Techniques You Can Practise at Home!