This afternoon, while my rambunctious little toddler was attempting (and ultimately failing!) a nap, I had the fantastic opportunity to chat with Shelly Prosko, a physiotherapist and yoga therapist in Alberta, Canada who specializes in working with individuals experiencing chronic pain (including pelvic pain!). Shelly is an all-around incredible human, knowledgeable clinician, and dynamic educator. I hope you all enjoy this interview as much as I enjoyed it!
As many of you know, I recently took a huge step in my career and moved to Atlanta with my husband, accepting a job as a pelvic health physical therapist for a newly opening private practice with One-on-One Physical Therapy. Leaving my patients behind was one of the hardest parts of moving (if you’re reading this prior patient, I miss you!). One of the things I realized when working to find colleagues to treat my current patients was that I treat quite a number of people with chronic pain. And I love it. When I left Greenville, I would estimate that close to 50% or more of my caseload were men and women who had been experiencing pelvic pain for 6 months or more (and many of them, much longer than that!). Often times, people experiencing chronic pain feel trapped in an inactive state—fearing movement, exercise and even social activities as they correlate increased activity with increasing pain. The sad truth about this is that reality and current research tends to show the complete opposite:
Movement is medicine for chronic pain.
Now, let’s take a step back…
What is chronic pain and what isn’t it?
I promise this blog post is going to stay on track. Honestly, there are so many people much smarter than I am who have written amazing books, articles, and blog posts on understanding chronic pain. So, I will be succinct here, but give you some good resources at the end if it leaves you thirsty for more.
In short, all pain is produced by the brain. (Your pain is real, not all in your head, but the brain is always really involved!) Pain is an alarm system used by the brain when it perceives damage or even sees a threat of damage to the body. Pain is there to motivate the body to action—basically to help you eliminate the source of “threat.” Example: I step on a tack. I feel “pain.” I move my foot off of the tack.
This alarm system works really well for situations like the one above. There is a threat. We remove the threat. We feel better. But it is important to recognize that the amount of pain does not always correlate with the amount of damage. Example: A man walks into the emergency room with a knife sticking out of his leg, but isn’t experiencing “pain.” A papercut can be felt as VERY painful.
The point is, the brain takes information in about our current situation, past experiences, emotions, etc. to create an experience of pain that it perceives as useful to us for the time being. This experience is influenced by situation (i.e. needing to get to the emergency room so the knife doesn’t “hurt”) emotion (i.e. No one knows what is wrong with me, so it must be really really bad!), fears (i.e. I am never going to be able to run again!), and life stressors (i.e. going through a divorce when the pain initially began).
So, how does this relate to movement?
For many people experiencing pain, movement often becomes a “threat” to the brain. For example, if a person is experiencing pelvic pain and the brain believes that walking will worsen the pain, then often walking will be a pain producing activity—to protect you from the “threat” of walking! Over time, the threshold for pain can change and people can become more sensitive to movements or activities—basically, the brain becomes very good at playing the pain “tune.” Lorimer Moseley uses the example of an orchestra in his book Explain Pain. If an orchestra plays the same song again and again, they become very very good at playing that song. Our brain works in the same way.
With that being said, we have learned that if we can help a person to move in a way that his or her brain is not protecting or guarding by pain, we can actually reduce the sensitivity to those movements and help a person get back to an active lifestyle with less pain. This is as true for a person experiencing chronic pelvic pain as it is for a person with chronic low back pain or neck pain or ankle pain.
Does it actually work?
The awesome part is that research has shown that movement and exercise are extremely helpful in pain reduction! A meta-analysis in 2014 published by the American Journal of Physical Medicine and Rehabilitation found that regular aerobic exercise improved pain, disability and depression/anxiety scores in people with low back pain. Another meta-analysis and systematic review published in 2014 by the Archives of Physical Medicine and Rehabilitation found that walking exercise helped to reduce pain levels in men and women experiencing chronic musculoskeletal pain. Even pregnant women with low back and pelvic girdle pain see benefits of exercise in pain reduction as noted in this 2012 review by the Journal of the Section on Women’s Health.
To see even more benefits of exercise, check out this awesome video by Dr. Mike Evans:
So, how do you get started if you hurt?
The key piece here is that we want to start moving at low pain levels in a way that will be therapeutic for your body—not in a way that will cause your body to guard and produce increased pain. When I treat patients with chronic pain, I start recommending movement at the first or second visit (of course, depending on the specific patient). Here is where I typically start:
- Begin with small, manageable movement goals: If you have spent the last 5 years moving from bed to the couch, it is probably not the best thing for you to begin a running program. For these people who have been very sedentary, I recommend starting small by aiming to walk around the house once every hour and perhaps adding in a small series of shallow squats at their kitchen counter along with a few other easy exercises. On the other hand, if you are fairly active, but have avoided regular exercise, try to slowly build up to a routine again. I generally recommend starting at 10-15 minutes and building up to 30-60 minutes depending on the person.
- Explore new and different exercise options: I have seen time after time that a person may be frustrated that she cannot do an exercise she enjoyed (i.e. running) so will stop exercising all together. Often times, I find that although one exercise may aggravate symptoms, another will be much more tolerated! I recently worked with a wonderful patient experiencing chronic pubic joint and pelvic pain—she loved walking for exercise, but found that walking was aggravating her pubic joint. We tried exercise in the pool, and she LOVED it! Not only could she begin moving again, but her pain seemed to stay at a low level while she exercised! So explore other options—walking, swimming, yoga, pilates, etc. Be open!
- Try not to be afraid of pain: Remember to see pain for what it really is! I often tell my patients that if an activity keeps their pain low or improves their pain, it is likely a good, safe exercise for them to be doing. That being said, sometimes patients will try an exercise and it will severely worsen their symptoms—and that is part of the learning process. Generally, we find if we hold off on that activity for a short time while finding another activity that is more tolerable, we can often return to the other activity at a later date with much lower levels of discomfort.
- Work with a team: I always recommend that my patients work closely with myself or another health care provider while they are getting back to movement. Sometimes, it is a little of trial and error learning what movement strategies are the most optimal to start with. Be patient, share your experiences, and be open to suggestion for different things to try!
So, good luck! Get started, and let me know if you have any questions! Thankfully, I am not by any means the only person who has written on this topic, so check out these excellent resources from my colleagues working with people with pain.
On Pain & the Brain:
- 5-minute video on Chronic Pain
- AWESOME Pain Science Education Workbook for Patients and Therapists by Greg Lehman
- Everything on the NOIGroup.com site by David Butler & Lorimer Moseley
- The Pain Toolkit, by Pete Moore
- Explain Pain & Painful Yarns books by Lorimer Moseley and David Butler
- Why Pelvic Pain Hurts book by Adriaan Louw and Sandy Hilton
On Exercise for Pelvic Pain:
- Pelvic Pain and Exercise: What Exercises Can Help Treat My Pelvic Pain by Stephanie Prendergast at PHRC
- Pelvic Pain and Exercise: General Fitness Tips by Stephanie Prendergast at PHRC
- Yoga for Pelvic Pain by Dustienne Miller
Do you have any other resources you love? What has worked for you in the past? PTs, what are your favorite suggestions to give patients? Let’s share and learn together in the comments below!