In my 25 years as a pelvic physical therapist, I witnessed more women patients with chronic pelvic pain achieve their goals with minimal, manageable, or no pain in a shorter time frame in the last half of my career compared to the first half. The game changer is targeting the central nervous system as a driver for chronic pelvic pain (CPP) through pain neuroscience education, mind exercises, and evidence-based self-care skills that patients implement concurrently with medical care.
Unfortunately, most women with CPP cannot easily access or afford treatments with pain-science-informed pelvic physical therapists or experience long wait times for in-person or virtual care. In 2021, we launched a digital self-care solution containing information and skills for women of all socioeconomic backgrounds to learn and practice in the comfort and privacy of home.
Chronic pelvic pain CPP) is defined as 3-6+ months of pain (1) and accompanying pelvic floor dysfunction of one or more bladder, bowel, sexual, or core stabilization functions. One out of seven women (1)—an estimated 27 million—in the United States suffers from symptoms such as pain with sitting, pain with vulvovaginal provocation (tampon insertion, penetrative sex), bladder pain, urgency and frequency, constipation, abdominal pain, and bloating.
The gap between clinical symptoms and pathological signs is a constant feature of CPP. The patient’s description of pain may appear excessive due to the limited findings on physical examination, complementary investigations and anatomical changes which, on their own, cannot explain the patient’s pain (2). Chronic pain is heavily influenced by the central nervous system (CNS), which alters the person’s experience of pain over time3.
Women with CPP experience significant struggles in their psychological well-being and relationships in addition to simultaneous pelvic dysfunction(s) that negatively affects their quality of life (3). Research shows that depression and anxiety (which co-occurs with CPP in 66% and 63% of women, respectively), as well as a person’s ability to cope with, fear of pain, and the extent to which they catastrophize their pain, affects their individual experience of pain (4).
Prolonged pain can be the result of increased sensitivity of the nervous and immune systems, shifts in how the CNS processes the incoming actual or perceived threat messages, and a decrease in the brain’s ability to send inhibitory signals to incoming threat messages. The dysfunctional pattern of hypervigilance, overprotection, pain amplification, and maintenance, is termed “central sensitization” (5).
A preponderance of women with CPP likely have central sensitization-driven pain (6,7), so a more “central” approach targeting brain and top-down mechanisms may warrant treatment for central sensitization-driven pain. In addition, a program that is accessible digitally and affordably would solve barriers to receiving care for CPP.
PelvicSense™ is a low-cost digital self-care program centered on a biopsychosocial approach to CPP treatment and includes three main pillars or modules:
1. Pain neuroscience and evidence-based strategy education help women understand the root cause of their condition, shift pain beliefs, learn coping strategies, and prevent pain catastrophizing.
2. Mindfulness exercises elicit relaxation, improve mood, implement self-soothing skills, and increase pain tolerance by reducing nervous system sensitivity.
3. Body movements reduce pelvic floor and accessory muscle guarding, improve ease of movement, and reduce fear of pelvic functions.
Preliminary results from our current pilot study assessing the efficacy of the PelvicSense™ program on pain, sexual function, and quality of life in 60 women diagnosed with CPP are encouraging. Among the first 10 participants, the average completion after three months is 74%, with 40% completing the entire program. Although the program is doable within three months, its individualized nature (e.g., participants can complete content relevant to them and can revisit valuable components) naturally involves a wide range of time to complete. As such, completing 74% in three months is considered excellent. Preliminary results of the perceived effectiveness of the program are in Table 1.
Table 1. Perceived Effectiveness of PelvicSense Modules | ||||
Module | Range | Mean | Median | % Agree |
Pain Neuroscience & Strategy Education | 8 - 10 | 9.3 | 10 | 100.0% |
Mindfulness Exercises | 7 - 10 | 8.4 | 8.5 | 100.0% |
Body Movements | 3 - 10 | 7.8 | 8.5 | 90.0% |
Note. N = 10. All reports of perceived efficacy were rated on a scale of 0 (not at all) to 10 (extremely). Percent agreement was indicated by the % who responded ≥ 5. |
Instead of progressing with central sensitization, pelvic anxiety, and increasingly worsening symptoms, under a current system where such resources are difficult to access in much of the country, women can readily obtain an affordable, online, easy-to-follow, available 24/7, science-based self-management program, that does not require additional scheduling with ancillary health coaches or providers, to enhance pelvic healing in the comfort and privacy of home concurrently with usual care.
References:
1.Dydyk, A. M., & Gupta, N. (2023). Chronic pelvic pain. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK554585/
2. Levesque, A. et al. Clinical Criteria of Central Sensitization in Chronic Pelvic and Perineal Pain (Convergences PP Criteria): Elaboration of a Clinical Evaluation Tool Based on Formal Expert Consensus. Pain Med. 2018 Oct; 19(10): 2009–2015. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372934/
3.Till et al. Psychology of Chronic Pelvic Pain: Prevalence, Neurobiological Vulnerabilities, and Treatment. Clin Obstet Gynecol. 2019 Mar; 62(1): 22–36. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340718/
4.Lopez M. et al. Psychological Profile in Women with Chronic Pelvic Pain. J Clin Med. 2022 Nov; 11(21): 6345. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9658626/
5. Shallcross, R. et al. Women’s Experiences of Vulvodynia: An Interpretative Phenomenological Analysis of the Journey Toward Diagnosis. Archives of Sexual Behavior. Volume 48, pages 961–974,(2019) https://link.springer.com/article/10.1007/s10508-018-1246-z
6. Siquera-Campos, V. et al. Current Challenges in the Management of Chronic Pelvic Pain in Women: From Bench to Bedside. Int J Womens Health. 2022; 14: 225–244.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8863341/
7. Woolf, C. Central sensitization: implications for the diagnosis and treatment of pain. PAIN. 2011 Mar;152(3 Suppl):S2-S15. doi: 10.1016/j.pain.2010.09.030. https://pubmed.ncbi.nlm.nih.gov/20961685/
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