Integrative Approaches for Pelvic Pain in Trauma Recovery

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

Top Contributors - Ewa Jaraczewska, Jess Bell, Kim Jackson and Nupur Smit Shah  

Introduction[edit | edit source]

Our understanding of how trauma, emotional wellness, and sexual health intersect has greatly advanced in recent years.[1] Moreover, there has been increasing recognition of, and interest in, the connection between the brain, trauma, and physical well-being.[1] 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. Knowledge of integrative approaches is useful as these approaches may offer survivors relief. Mindful movement, breathing techniques, and graded exposure can help create new pathways for experience within the body and brain.[1] This article explores mindfulness, somatic embodiment practices, and cognitive behavioural therapy as pain management tools.

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:

"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, 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 following video provides a basic overview of the concept of brain smudging, which can occur with persistent pain.


Pain vs Nociception[edit | edit source]

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.[4] 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.[5] 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.[6] 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[edit | edit source]

Chronic pelvic pain with unclear aetiology has been associated with a history of trauma among women that included reports of physical or sexual abuse.[7][8] 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." [9] The relationship between sexual assault and pelvic pain has been reported in a review of the general population [10] as well as in the studies researching the effect of sexual assault in the torture of women and men. [11]

Causes of pain include the following:

  • scar tissue or peripheral nerve damage leading to localised pain
  • altered central pain mechanisms, including muscle hyperalgesia and sensory dysesthesia

Physiological Responses[edit | edit source]

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 defence mechanism during fight or flight responses when shown non-sexual, scary and threatening images.[12]

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. [12] [13]

Mindful Movement[edit | edit source]

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. [14] [15]

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.[15]

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."[16]

Mindfulness[edit | edit source]

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.[17] Studies exploring mindfulness have showcased its profound impact on pain perception. By incorporating mindfulness practices, individuals can:[18]

  • 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.
  • Better understanding of pain triggers
  • Reduce pain sensitivity
  • Reduce pain perception and anxiety scores[19]
  • Improve coping mechanisms for managing pelvic pain.

Graded Exposure[edit | edit source]

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.[20] 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.[21]


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

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.

The Window of Tolerance, introduced by psychiatrist Dan Siegel [23] defines an optimal state of arousal in which an individual can effectively process emotions and information.

Exposure therapy allows for a balanced exploration of fears without triggering extreme reactions when working within this window. [24] 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.

Practical Applications[edit | edit source]

Breathing Techniques[edit | edit source]

Engaging in practical exercises 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 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.
  • Encouraging 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.

Graded Exposure[edit | edit source]

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.[25] Graded exposure program should include the following:[25][26]

  • Assessment and Determining functional goals
  • Establishing an individual's hierarchy of the pain-related fear stimuli.
  • Patient education.
  • Choosing activity based on fear hierarchy.
  • Gradual exposure to challenging situations using a series of practice and preparation.
  • Repeated real-time exposure. [27]
  • Transferring activity into everyday life.
  • Reevaluation of the fear hierarchy.

Resources[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 1.2 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. Neuro Orthopaedic Institute. Explaining Brain Smudging. Available from:[last accessed 10/4/2024]
  4. Loeser JD, Treede RD. The Kyoto Protocol of IASP Basic Pain Terminology. Pain. 2008 Jul 31;137(3):473-477.
  5. 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 Rep. 2018 Mar 5;3(2):e643.
  6. 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. J Pain. 2014 Oct;15(10):985-1000.
  7. 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.
  8. 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.
  9. 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. Vandyken B, Keizer A, Vandyken C, Macedo LG, Kuspinar A, Dufour S. 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.
  14. 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.
  15. 15.0 15.1 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.
  16. 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.
  17. Kabat-Zinn J. Full catastrophe living. New York: Bantam Books Trade Paperbacks; 2013
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. Dr.Paul Stone. Graded Exposure. Available from:[last accessed 10/4/2024]
  23. Siegel DJ. (1999) The Developing Mind. How Relationships and the Brain Interact to Shape Who We Are, 1st Edition. Guilford Publications, New York.
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  26. 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.
  27. 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).