Download File - CEP 756: Sexual Issues

Chronic Pelvic Pain and
Mindfulness Based Interventions
JENNI LIMOGES, PT, DPT
What is pain
 Explain pain video: David Butler, PT and Dr.
Lorimer Moseley
Chronic Pelvic Pain
 Pain of at least 6 months duration that occurs in the
lower abdomen or below the umbilicus and has
resulted in functional or psychological disability.
 Dyspareunia: pain with intercourse
 Vulvar vestibulitis syndrome (VVS) is the leading
cause of painful intercourse in fertile women

Severe pain and tenderness with attempted vaginal
penetration or touch


Burning, stinging, or rawness
Physical findings such as redness and swelling
Chronic Pelvic Pain
 Progresses from a sexual pain disorder due to
provoked pain to a pure pain disorder in spite of the
avoidance of vaginal penetration or touch
 In the literature, CPP is described as a multisystemic
and multifactorial disease

Its etiology is complex involving neurological, psychological,
and muscular factors
 Studies show the prevalance of CPP among women
to be anywhere from 4% to 40%
Etiologies of Pelvic Pain












Painful menstruation
Endometriosis
Adenomyosis
Interstitial cystitis
Pudendal nerve entrapment
Ovarian cysts
Vaginisimus
Depression
Physical/sexual abuse
Irritable bowel syndrome
Inflammatory bowel disease
Chronic constipation
Pelvic anatomy
Pelvic anatomy
Muscular component of CPP
 Trigger points: knots or taut bands in muscles that
refer pain either at the site of the trigger point or to a
site remote from the actual trigger point.
Muscular component of CPP
 Fascial restrictions
Physical therapy treatment
 A study of women with vulvar pain who received
physical therapy



71% reported a 50% reduction in pain
62% reported improvement in their sex life
50% reported improvement in their quality of life overall.
Treatment techniques
Treatment techniques
Biopsychosocial component of CPP
 Studies have shown correlation between prevalence
and type of certain psychological factors and chronic
pelvic pain

higher prevalence of social withdrawal and negative effect, fear
avoidance and phobic anxiety to vaginal touch, need for
control, impulsivity or “sensation” seeking, fear of loss of
approval from others
 Other studies have shown that trigger points in the
pelvic floor are strongly affected by slight degrees of
stress, anxiety, and nervous arousal.
Biopsychosocial component of CPP
 Those suffering from pelvic pain often report an
increase in symptoms with stress and a decrease of
symptoms with the reduction of stress and anxiety
 Individuals with pelvic pain are rarely aware of the
impact of the relationship between stress and their
symptoms
Biopsychosocial component of CPP
 Neurobiological research shows the link between
emotion and pain
 Greater pain is related to emotional stress and
limited emotional awareness, expression, and
processing
 Research shows the potential importance of
emotional communication, empathy, attachment,
and rejection
 Emotions are integral to the conceptualization,
assessment, and treatment of persistent pain
Pain-Tension-Anxiety cycle
Mindfulness Based Interventions

Paradigm shift of treatment for chronic pelvic pain: changing
the tendency to stay in chronic states of anxiety, fear, dread,
sorrow, resentment, or anger must be done for any real
resolution of pelvic pain

The tendency to chronically tighten pelvic floor muscles under
stress can be modified with training in calming down a
chronically vigilant nervous system.
Mindfulness Based Interventions
 Mindfulness means maintaining a moment-by-
moment awareness of our thoughts, feelings, bodily
sensations, and surrounding environment.
 Historically, mindfulness has been called “the heart”
of Buddhist meditation
Mindfulness Based Interventions
 Mindfulness also involves acceptance, meaning that
we pay attention to our thoughts and feelings
without judging them—without believing, for
instance, that there’s a “right” or “wrong” way to
think or feel in a given moment
 When we practice mindfulness, our thoughts tune
into what we’re sensing in the present moment
rather than rehashing the past or imagining the
future
Mindfulness Based Interventions
 Boosts our immune system
 Increases positive emotions and decreases negative
emotions

May be as good as anti-depressents
 Increases gray matter in brain regions linked to
learning, memory, emotion regulation and empathy
 Enhances relationships
Mindfulness Based Interventions
 Study from the Department of Urology at Stanford
University School of Medicine

Combined physical therapy and paradoxical relaxation
training of chronic pelvic pain in men

138 men treated over a one month period
 72% of subjects reported moderate improvement with a 69% to
80% decrease in pain and urinary symptoms
Mindfulness Based Interventions
 Study from the departments of Psychology and
Obstetrics and Gynecology University of British
Columbia

Group mindfulness based psychoeducational program aimed
at women with sexual dysfunction
100 female subjects
 Improvements in self reported sexual desire, arousal, satisfaction,
and reduced levels of sexual distress and negative mood

Mindfulness Based Interventions
 Another study from the department of Obstetrics
and Gynecology University of British Columbia




Pilot study of 20 partnered women with sexual difficulty and
significant sexual distress and history of childhood sexual
abuse
Randomized into CBT or MBT
Significant effect of MBT on greater subjective sexual arousal
CBT and MBT groups experience significant decrease in sexual
distress
Mindfulness Based Interventions
 Recent Cochran review of treatment of CPP found
limited and promising evidence for the use of MBI
and strong evidence for the use of physical therapy
treatment
 The need for more research including RCT
Role of MFTs
 Collaboration with the medical community including
Mds, nurses, nurse practitioners, and PTs
 Recognizing patients potential need for referral to PT
or MD
 Asking questions about pelvic pain with patient
reports of sexual dysfunction and/or history of
sexual abuse
 Integrating knowledge of behavioral therapies with
mindfulness
References
 Anderson R, Wise D, Sawyer T, Chan C. Integration of Myofascial
trigger point release and paradoxical relaxation training treatment of
chronic pelvic pain in men. J Urol 174 (1): 155-60, 2005
 Brotto L, Seal B, Rellini A. Pilot study of a brief cognitive behavioral
versus mindfulness-based intervention for women with sexual distress
and a history of childhood sexual abuse. Journal of Sex & Marital
Therapy, 38, 1-27, 2012
 Brotto L, Klein C. Psychological factors involved in women’s sexual
dysfunctions. Expert Rev. Obstet Gynecol. 5 (1), 93-104, 2010
 Brotto L, Woo J. Mindfulness training and applications to female
sexuality. The female patient. 34, 2009
References
 Brotto L, Basson R, Gehring D. Psychological profiles among women
with vulvar vestibulitis syndrome: a chart review. J Psychosom Obstet
Gynecol, 24, 195-203, 2003
 Gevirtz, Richard. The muscle spindle trigger point model of chronic
pain. Biofeedback, Summer 2006
 Paiva S, Carneiro M. Complementary and alternative medicine in the
treatment of chronic pelvic pain in women: what is the evidence. ISRN
Pain, 2013
 Wise D, Anderson R. A Headache in the Pelvis: A new understanding
and treatment for chronic pelvic pain syndroms, 5th ed. Occidental,
California: National Center for Pelvic Pain Research, 167-214, 2008
Questions
 Contact info
Jenni Limoges, PT, DPT
Physical Therapy Partners
[email protected]
775-853-7475