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[Physio Discussed] Understanding pelvic pain: drivers, treatment & research with Dr Sandy Hilton and Bill Taylor

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In this episode, we discuss some of the clinical challenges of pelvic pain. We explore: 

  • What is the driver to pelvic pain
  • How do we connect pelvic health with whole body function? 
  • Landscape of pelvic pain research
  • Can pelvic pain be resolved? 
  • What strategies can be most effective in treating pelvic pain? 

Want to learn more about pelvic pain? Dr Sandy Hilton has done a brilliant Masterclass with us called “Pelvic Pain: A Clinical Course from Pain to Pleasure” where she goes into further depth on this topic. 

👉🏻 You can watch her class now with our 7-day free trial -https://physio.network/podcast-hiltontaylor

Dr. Sandy Hilton is a Doctor of Physical Therapy and co-founder of Entropy Physiotherapy in Chicago, where she specializes in treating complex pelvic pain and provides education and mentorship to healthcare professionals. With a strong focus on chronic pain and pain science, she teaches internationally and has co-authored the book Why Pelvic Pain Hurts. Sandy has held leadership roles within the American Physical Therapy Association and currently serves on the Abdominal and Pelvic Pain SIG of the International Association for the Study of Pain. She also co-hosts the podcast Pain Science and Sensibility, translating research into clinical practice.

Bill Taylor is a highly experienced Physiotherapist with nearly 40 years in the field and over 25 years specializing in pelvic dysfunction, particularly male pelvic floor issues. He is internationally recognized for his expertise and has contributed to leading textbooks on chronic pelvic pain and pelvic girdle assessment. Bill has a strong background in manual and exercise therapy, teaches extensively across Europe, and mentors students while lecturing at several UK universities. He also serves as a Clinical Director in Edinburgh, continues to work with dancers, and holds leadership roles on professional and charitable boards related to pelvic health.

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Our host is @James_Armstrong_Physio from Physio Network

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UNKNOWN:

Thank you.

SPEAKER_01:

Welcome back to Physio Discuss, the podcast where clinical insight meets real-world impact. In this episode, we're tackling a topic that is often misunderstood, under-discussed and deeply impactful. That is pelvic pain. And we've brought two absolute legends in to guide us through it. Sandy Hilton, a powerhouse in pelvic health physiotherapy. Sandy is known globally for her compassionate, evidence-informed approach to persistent pain. And she blends neuroscience, humour and clinical wisdom to make pelvic pain a reality. pelvic health accessible and human. Bill Taylor, a clinical researcher and educator with decades of experience bridging the gap between musculoskeletal and pelvic health. Bill's work challenges the silos in our profession and brings big picture thinking to complex problems. Today, we together explore what really drives pelvic pain? How do we connect pelvic health with whole body function? What's the current landscape of pelvic pain research? Clinically speaking, can pelvic pain and actually be resolved what practical strategies make the biggest difference and what's one thing every person with pelvic pain deserves to know plus we talk about the common missteps clinicians still make and how we can all do better so whether you're a musculoskeletal physio curious about pelvic pain a pelvic health specialist deep in the trenches or somewhere in between this episode is packed with clinical insights fresh perspectives and practical strategies you can bring into your next session. So let's dive in. I'm James Armstrong and this is Physio Discussed. Bill and Sandy, welcome to the Physio Discussed. podcast. It's great to have you on. We're going to be talking about pelvic pain today, which is a big subject, but it's great to have you on. I certainly think it's going to be interesting and I'm sure the listeners are keen to gather some thoughts of yours and also really helping improve their treatment and understanding. And we're going to kick straight off in a minute about how do we understand the drivers of pelvic pain and something that we need to think about what's driving this pain and how well do we understand that? Bill, should we get started with yourself on that

SPEAKER_00:

one there? I'm not sure we understand it hugely well. We got some ideas around it for sure again the science is sparse I would say but I think if you want to kind of put it into some broad headlines or broad titles you're looking at maybe muscle dysfunction in some way you're looking at nerve irritation sensitization and you're looking at biomechanics and lifestyle factors which includes obviously it's a big biopsychosocial arena as a condition it's difficult to diagnose it's difficult to get a diagnosis it's then difficult to get someone that maybe understands what physically can be done to the pelvic floor to help change the symptoms and I think both Sandy and I are coming from a kind of a background of a very holistic centred background of looking at all the different components that play into it and I think it's very different for different people it can be it can depend on are you an anxious person do you have a propensity for that are you able to relax do you live a life that's full on with the job and her family and lots and lots of demands placed on you and you're trying to cope with pelvic pain amongst all of that. But I think that from a what can we do about it point of view, it's definitely muscle, nerve, and then lifestyle and psychological factors.

SPEAKER_02:

Just everything. Yes, exactly.

SPEAKER_01:

I was thinking the same thing, Sandy. Any additions to that? Well, you can't addition to that, but anything else you want to add to that, Sandy?

SPEAKER_02:

What Bill said about not just lifestyle factors, but how you go about in your life. Totally unscientific But I think the people that I have treated over the years that have persistent pelvic pain are just smart people. Is there a correlation to how overthinking? It's like we play to our strengths and we're people that are really good. I had a patient once that when I first was doing biofeedback ages ago, I did the test on her and she was like, hey, I scored really well. And I'm like, technically, if you're walking around with really tight muscles all the time, that's not good. Yeah. like walking around with your fist clenched but she's like can I take this to my office because we talk about happened to be a lawyer that the more tight assed you were the better you were and she goes I think I should get a raise and I've thought about her periodically as like a very intelligent person was trying all the things she knew to help herself but it was getting worse with the effort and I think that's something that in how we go about our lifestyles is do we remember to let go and the can you relax maybe but maybe you just don't and you forgot what that feels like. Not to oversimplify, but what happens if the nerves just are squeezed all the time and you learn how to stop

SPEAKER_00:

doing that? We don't have much awareness or connection of our pelvic floor. And so the idea that it might be tight is kind of almost a new idea to people. The number of times I see patients that after I've seen them a couple of times, they went, I really get this idea that I'm walking around all the time, really tense in my pelvic floor. And that strategy taught me to let go. I'm just blown away by the release in my pelvic floor because there's also kind of an idea that your pelvic floor should stay tight all the time so wee yourself or so you don't poo yourself or so you walk around with the whole thing tense whereas in actual fact we don't need that much tension in the muscles to stop a leakage or a leakage of urinary feces. I always say to my patients that especially the guys because guys are often told that they don't have a pelvic floor it's kind of astounding really and they have no connection with it and everything that happens in their pelvic floor is is a gift from the gods it's bestowed on them from on high it arrives it works you use it it leaves when it goes away you don't consider it until you need it again so if you have to start consciously trying to connect with it there's a lot of perplexity there's a lot of looks on faces like you want me to do what so definitely the very very first thing you do with patients is education is try to say to them look you have this pelvic floor it's there that thing you said about walking around with your fist clenched is such a good method to understand because I'll say, if they say, well, I still don't understand why is my pelvic floor doing this? I said, well, if you walked around all day with your fist clenched, I said, do it now for two minutes and I squeezed them as hard as you possibly can. Now sit there and talk to me and tell me how you feel after two minutes. You're going to want to let go. You're not going to want to have those muscles so tight. And so they kind of think, oh, okay. So if you see this kind of realization during the first session that, oh, okay, maybe there's something here. Maybe I can do something about this. Maybe I can connect to this. Because they're often, probably you're exactly in the same boat as me, Sandy. You're kind of like a tertiary referrer. So often the people that come to you have tried lots of different things. Frequently, the very last thing they've been told is that there's nothing that can be done for them and they're going to have to learn to live with it. And if you're quite young, that's quite a challenging thing to hear, to think that this really, really disabling, painful condition is something that is not going to be treatable. And the doctor or whoever you've seen, the clinicians has not given you something tangible that can change it.

SPEAKER_02:

Learn to cope with it and you're an 18 year old guy who's like this is my life now.

SPEAKER_00:

And you know if they're told that they don't want to live with that and that's the huge big sequelae of this is that there's a lot of people it can really affect them psychologically and that's where the psychological component comes in.

SPEAKER_02:

None of us can do this by ourselves. It is a team effort. I think pain in general but pelvic health in particular for the previous part of treating in my professional career are very much a tertiary, like they've tried everyone before they've come to see me and I just hope not to be one more failed attempt. But I have the absolute luxury of working with acute care providers. So I'm seeing people that have horrible pelvic pain and you ask how long it started and they say last Tuesday. And I'm just like, this is such a valuable opportunity to what if we can really treat it in acute populations and have it not get persistent.

SPEAKER_00:

That's think that is possible the longer I've been in practice which especially in pelvic pain 40 years in physio 20 odd years in pelvic pain people come see me sooner and absolutely treating them sooner is better they improve quicker they do better they're able to take their own management strategies on and really work hard at them and really turn the control around so that their condition isn't controlling them and they're controlling it

SPEAKER_02:

so important because then the self-efficacy gets high

SPEAKER_00:

instead of washed I think it's interesting talking about pay because I often say to my patients I can't treat your pain I said because it's too hard pain's too hard a thing to treat but actually I can definitely help you feel less hopeless and I can help you feel less miserable and if we can reduce your misery and reduce your hopelessness your self-efficacy your self-worth your whole sense of who you are really improves recently I had a physiotherapist come to see me who had pelvic pain we had a big long chat and at the very end of the interview he said something really interesting to me and it kind of harks back a little bit to what you were saying about pelvic pain and how it's different to other pains, Sandra. He said to me that his pelvic pain somehow had got to the essence of who he was, the essence of his being, and the very soul of him. He said he's had sore shoulders, sore knees, sore backs. He's had the whole lot. But his pelvic pain had really, absolutely, really taken him down, like really, really knocked him off his perch. And I think that is the thing about pelvic pain that's so different to other pain conditions.

SPEAKER_02:

I talk about Melissa Farm her a lot because I admire her greatly. She is a psychologist, researcher, does basic science. And she's the one that was the author of the mouse vulva study, where she actually went and irritated little mouse vulva to find out what happens to acute vulvar pain in mouse and mice and whether they'd still have sex. And it's a fabulous study, just conceptually and also, how do you do that? One thing that she did at a presentation, I think it was the first World Congress on abdominal and pelvic pain that has stuck with me since is talking about how in the hierarchy of needs, peeing, pooping, and sex are part of that base level and they're all supposed to be pleasurable. Like none of those are supposed to hurt. There should be a feeling of relief after a good poo where you finally get to empty your bladder and certainly sex should always be pleasurable. The loss of that has a multi-layer hit because you not only are now having a negative experience with functions that have to happen and all of the consequences that, that you have lost some pretty important pleasures that help to regulate us, that help to keep us healthy, and taken those and twisted them into something negative. And just the power of that. I sat there in the conference like, whoa, yeah, that would be that essence of who you are and the very basis of our needs gets disrupted. Everything above that is affected.

SPEAKER_00:

Yeah, I think that's true. And I think we're kind of predictive machines, you know, the way our minds work. if you look at Andy Clark's work looking at AI and on the boundaries of how our brains really predict pain and how pain the predictive model of pain really starts to really play in with you've got kind of things in your brain like neurotags and the neurotag for bladder the bladder can be really close to the neurotag in your brain or be part of that neurotag rather for peeing it's all tied in with urinary function your prediction that when you get this feeling that that's going to cause bladder symptoms it's going to make you want to pee you know there's a huge stigma around peeing yourself and leakage and that whole issue that I remember last year at ICS Toronto or the year before there was a guy who did a talk a fantastic talk with the idea that urinary incontinence was a social construct and that in fact if you lived in a country where you could just pee at will then you could never be incontinent because you could just go pee behind a lamppost and it would be absolutely acceptable and we have a little bit we have it close and we have it in France they have peace wires in the street you can see the legs and you can see the shoulder you just can't see the bit in the middle

SPEAKER_02:

Germany you just got to be careful walking by a bridge because there were an awful lot of people when I lived there that were just peeing off the bridge

SPEAKER_00:

yeah exactly exactly but it's kind of interesting how that whole thing ties in with shame and how people feel about themselves and there's a whole bunch of how you feel about your body and how you almost feel like your body lets you down and it's a big disappointment and also like you say if you're 18 and a lot of the patients I see are probably 25 and under so you young people they're dating they want to have sex they don't want to be peeing themselves they don't want to smell of pee they don't want to be in pain and pain gets rid of your libido doesn't make you feel you want to have sex makes you wonder especially if you've got complicated things like pain with erections or pain with ejaculation that can be a really off-putting thing when it comes to having sexual relations and it stops you dating it stops your whole life that's not what you should be doing when you're 18 you should be a people you should be exploring sex you should be doing all the things that 18 year olds want to do and that inability to do them I think really really really drags people down

SPEAKER_02:

and robs them of what should be fun and pleasure and

SPEAKER_01:

absolutely so I think we've really exposed how important this area is and Bill you sort of likened to the patient that you saw that said it's to get into the essence of their being and how important that is so in terms of the treatment that we have So the ability to help these people. Where would you say that the research is at the moment? And from a clinical point of view, how confident are we that we can relieve and eliminate the pain? I mean, we talked about that a bit already, but it improves the symptoms

SPEAKER_00:

for these people. I wanted to start with one paper from ICS Madrid, which was by, and I'm going to read it because I can never remember her name. Starzik Prosperio is her first name, and it's a paper entitled Effectiveness of Nonviolence. for conservative therapies for chronic pelvic pain in women. And it's a systematic view. Level 1A evidence, which is fantastic for us, because to be honest, we have level 1A evidence for the treatment of incontinence. So we know that physiotherapy, if you're leaking, is really good. It works well. But this paper was great because it basically looked at multimodal physiotherapy. So it looked at different things like hands-on therapy, exercise therapy, breathing. It looked at some psychological input And what it found was that it was really effective in women with CPP, chronic pelvic pain syndrome, with a high certainty of evidence. So the way they did the study, they were really rigorous in how they looked at the papers that chose to include. It came up to say that this should be a first-line approach when we are coming to treat conservative treatment options and not to go down a surgical route, perhaps tying with pharmacological route, but maybe that makes it a bit more effective. But this paper said that physiotherapy should be almost like a first stop. And I think that was the first really decent paper. There's some other work by Marden and I think that was a year before or 2022. And that looked at treatment recommendations and they were looking at kind of surgery and the whole medical kind of intervention and find that it wasn't very successful really. But this paper by Marjota is fantastic. And I think it really is the first time that we've got a basis to start from.

SPEAKER_02:

Yes. I also like Katie Vincent's work on endometriosis and encouraging physical therapy as a first one treatment for endometrial pain as well. There is one of, and full disclaimer, it's a friend of mine, Lori Forner out of Australia just finished her PhD and she was looking at prolapse if you were lifting heavy for women, which isn't pain, but there's so many people that have that sense of fragility that I've been using her research around, look, you can lift heavy and it's not likely that it will increase or give you any prolapse. Whether you've had children or not, to encourage people that have pain, it's like you're not fragile. It's a really strong, really protective bit of you. Nothing will fall out or fall off. We know that's safe, despite all of the aunties that have told you, you know, you hurt, you should never run, or you hurt, don't sit, which is just daft. Like, how do you go through your life not sitting? Although there's some very not good information out there, we're starting to get some good evidence to say, here's a direction to go instead. Do it. we need more? Yes. Do we need the clinical practice deadline to get finished? Yes. Do we need Jilly Bond to finish her work on sensory integration and what we can do with that? Yes. But it's so much better than even five years ago.

SPEAKER_00:

You definitely were getting there. I think the loading thing is really interesting because from a kind of a layperson's point of view, if you've got pelvic pain and you go on to patient support groups, it often says don't lift weights, don't lift heavy, you know, don't go to the gym, don't exercise, don't squeeze your muscles because that's going to cause us all sorts of problems. I think the best example is our young mother goes to the doctor and with a prolapse is really interesting. It's not pain, but it's a dysfunction. And the doctor says, whatever you do, don't lift anything over four or five kilos. As she stands up and lifts up her 15 kilogram baby, her 20 kilogram bag of nappies and her buggy and says, okay, I'll do that. So we have kind of a lot of mythical support and information out there. And I find that I totally agree with Sandy in that there's a fear. They have fear avoidance. they come to the clinic they've stopped exercising I often say the treatment of these guys is all about one thing and it's all about movement and they've stopped I had a triathlete once who's a really good example of this who stopped cycling because of his pelvic pain and it didn't get any better so he stopped running because of his pelvic pain and it didn't get any better then he kept swimming but that didn't get any better and he was a high level he was a masters level triathlete so he then decided to have a standing desk at work because he didn't like sitting and it didn't get any better and he was doing different things but nothing really improved and by the time he saw me he'd stopped leaving the house he was lying on his couch to work and then by the time I think maybe after I saw him he wasn't even working so he'd gone from this guy he was training seven times a week to somebody that just was not moving and it was really interesting because you kind of think that's quite a complex scenario but actually my whole approach with that was how do I get him moving again well did I do to get him moving because he's so far away from moving in any way shape or form and it's about loading tissue and we're understanding more and more about tissue load and training load and how we can apply that to pelvic floor function and I think like Sandy says there's been some really interesting studies especially relating to the perinatal postnatal period looking at the effect of heavy lifting on women and babies there's no negative effects the effects are all really positive in fact they reduce all of the complications you would expect with pregnancies and deliveries and I think that it would be great to have some research looking at strength and conditioning and pelvic pain because Sally's laughing because she knows that's what I'm going to go and look at so I think that for me I love to get tissue loaded I think tissue like you know tissue becomes healthy when you load it that's what it's designed to do and the more we can load it and all of the other positives psychological effects of building resilience and strength and reducing the sense of fragility and guys especially think they're broken you know they think they're they think they're done and so we need to we need to give them that sense of confidence back Sandy said something at the beginning as well like walking the journey with them like we're side by side with them because we have to take them on out and they need the confidence to to go there and to do it

SPEAKER_02:

you know people stop doing things not because well sometimes because they're told to but also because of hurts this is like and i say do squats and they're like yeah it hurts and i'm like do squats anyway but we modify it so that that is a minimal amount you know it's like that i think completely made up rule of no don't increase your pain more than plus two like i've never been able to find a citation for that so if you know one bill let me know

SPEAKER_00:

funnily enough i was talking to someone about this on the weekend about you know who decides like let two out of ten and actually real analog scale they can be useful for me but does the patient care about them no does the patient often get a little bit upset when you ask them to give them a score out of 10 because how can you take this really complicated experience that you're going through how can you take your nociceptive feeling and say it's 2 out of 10 it's 5 out of 10 it's really contextual isn't it I mean I remember having a rugby player who played for the national rugby team come to see me because he had hurt his leg during the game he'd played the whole match and I said look I need to send you for an x-ray I think he might have fractured your fibula no no I can't have it wasn't that sore so he went and had his x-ray and he had fractured his fibula but he played 90 minutes with a broken bone and then as soon as the x-ray came back he said oh yeah I'm on crutches now because I can't walk so you know contextual factors we understand have this massive role to play but I think your 2 out of 10 I kind of find it useful I like it to see if my treatments are working but that's about all I don't really like it to say to the patient look you know your 2 out of 10 might be my six out of ten you know and that's a lot with dancers and you know dancers my six out of ten they have no sense of pain their concept of pain they think they dance through pain and there's lots of scientific evidence out there that say dancers have a different pain perception completely to the whole of the population

SPEAKER_02:

what does the pain mean I just did an old person injury and hurt my ankle the other day at work showing people doing progressive box jumps because I missed my landing you know and I just like shrugged it off I was like, whatever, it's just pain. And a little warped, but moving through it because I know that the tissues will heal faster if I use them. That knowledge outweighs the, it hurts to do this because I don't think I'm hurting something. I think this is a healthy thing. And if it's a little aggravated, that's fine. I can calm it down and do it again. I'm safe. I'm good to go. But that is a knowledge that I have from years and PT school and research and classes. And I you look at relatives and friends that are like, oh, I heard I shouldn't do it. It'll make it worse. And you do have to know, like, when does pushing it make it worse? And when does pushing it make it better? That's true for ankles, which you can see and compare to your other side pretty easily. It's really also true for pelvic structures, but we can't see them. And even if we looked at them That's not visually meaningful information. So you're trying to change function that is normally unconscious by consciously paying attention to it, but not too much because that can increase the symptoms and you don't have a norm to base it on. So that's tricky.

SPEAKER_00:

Yeah, very tricky.

SPEAKER_02:

It is possible to go to the question, can it get better? Yes, pain gets better. Do we have a great way to know what the most efficient way to get someone from where they are to where they want to go? No, but we're better than we were. I wouldn't call it efficient yet. There's still a lot of trial and error. 100%.

SPEAKER_00:

I think with all of our pelvic pain patients, I mean, we all have our biases and we all regress to those because it's where you're comfortable, isn't it? I want to go to where I think I know how I'm going to help this patient. I always think every patient I have is, and I heard Ebony Rio from Australia say this, so she said it before me, but I've thought it and said it for a while. I don't feel I'm stealing it for her, but I remember her saying it and thinking, damn, I've not been able to say that before now. But I think every patient we have is like an equals one case study and we're collecting data and we collect the data and then we have to create a hypothesis and then we maybe even try to have to reject that hypothesis and if we can't we have to accept it and if we have to accept it then we know we've minimized our bias to a degree because we've followed some kind of scientific rationale or algorithm to get to where we are like you said I don't think there's always a straightforward answer every single patient is really unique there's kind of trends and things that we do but I think there's physiotherapy is one of those interesting well I think every single job every single vocation every single kind of profession has this but I used to always say that we're a bit like whatever's trendy like maybe non-relaxing pelvic floor muscle you write it's like primary seven kids playing soccer you write it on the ball and you kick it up the park and everybody runs after it and hey they pick up and they go hey it's non-relaxing pelvic floor this month and of course it's way more complex than that it's a little bit of this and a little bit of that and sometimes what happens when you get a patient that comes in with normal pelvic floor tone and they're in agony and you're thinking okay this is throwing me for a bit so you have to step back and you have to try to analyse the information you've got in front of you I think that thing about there's not always damaged tissue in these patients there's not always damage there's not always injury that whole concept that there could be no susceptive output which is causing a pain experience without there being actual damage or damage that perhaps maybe a that has been there because of trauma or infection has healed but the pain has stayed and then what do we do about that? You probably feel this I think Sandy as well because I think maybe we spoke about this is like pelvic floor patients have often been told this is all in their head and I think one of the things we know about modern science of pain is that if a patient says they're in pain they're in pain and that's their experience. We have to believe that because if you don't believe it you might as well send them to see someone else because if you're going to disbelieve them from the get-go and they often I often feel like they have been a bit disbelieved. When they don't leave with a bag of medication or a prescription for something from the last consultation they had, they feel really that they've been cast adrift. They feel that there's nowhere to go. And I think frequently if you treat pelvic pain patients, the thing that you hear after the first initial appointment is, I feel that you're the first person that's listened to me. And I feel it's the first time I've been heard. And I always try to do three different things with my patients. Especially because I see 95% men. We're really... we're simple beings we like it straightforward we don't like anything too complicated and I'll say to them look so what's going to happen today is we're going to try and find out what's wrong with you and give it a name that's the first thing the second thing is we're going to try and figure out what we're going to do to try and help you on your journey to recovery and then the third thing is we're going to try and figure out how long that's going to take and I'll say and I know that's putting my head on the slab I said but I like to do it because actually they leave thinking alright okay so this guy he listened to me he seemed to have some understanding of what I was going on about. He also has some kind of logical plan that I'm going to follow. And he's using my symptoms to measure whether or not that's going to be effective.

SPEAKER_02:

Well, you told them that you expect it to get better. The question isn't, can it get better? The question is, how long will it take to

SPEAKER_00:

get better? Yeah, 100%. I don't say, I say to them, look, I've been doing this for long enough. I've seen thousands of patients, right? You can get better from this. I know you can. And actually, if you go back to some of the early literature on pelvic pain, it was written about as a self-limiting condition. So it would often go away. And sometimes when you speak to guys who've had it maybe for 25 years, they say, oh, you know, I was okay for five years. Then it came back. Then I was okay for 10 years. Then it came back. We know that it can definitely go away. And I think with physio and movement and loading and maybe some specific work on tissue when it's required, then it can be a really effective thing that we do.

SPEAKER_02:

One of the things I love about our profession is that when we do our jobs right, we help people not need us anymore. And we're there for consultations, but it's not, you have to come see me once a week for the rest of your life kind of thing. Look, I'm here in your corner, but I'm going to give you the tools to take care of yourself when this flares and manage it.

SPEAKER_00:

It's funny, isn't it? When you treat people with pelvic pain and they clutch onto you and they don't want to let go. You're like a lifesaver. And I frequently say to them, I said, so I'm going to ask you to do something today. I want to do a little bit of visualization with you. I said, I want you to think about the yoke that you have on your shoulders your pelvic pain yoke I want you to take it off and I want you to leave it in the corner and I want you to leave without it today and I'll take care of it for you don't worry I'm not going to chuck it out I'm going to hold on to it because people identify with the whole experience they've had so I'm asking them to leave some of themselves behind with this idea that you deserve a little bit of support with this I almost encourage them to become a little bit resilient on me or reliant on me rather in the very first few sessions so that they feel super supportive So they can understand really, really quickly that they don't actually need me that much. I'm their check-in. They can come back and see me, but it's kind of like, I believe you. This is what you've got. It will get better. Let's see if we can figure out a plan for you, a journey for you to travel down to try and improve it.

SPEAKER_02:

And really pointing out that their recovery path is unlikely to be the same as the person recovery path they're reading online. Or if they read online that someone tried what they're currently doing and it didn't work, help them. That's actually normal too. And the reporting bias of the people who got better aren't usually online talking about it.

SPEAKER_00:

The number of times I'll say to guys, look, with this, once you're better, you don't want to be in a patient support group. You hightail it out of there. You run down the street and go back and have sex and live your life and go and do everything that you've not been able to do. And the last thing you want to do is talk about it. You want to just go and be, just go and live, just go and be yourself. So I totally agree with that for sure. I

SPEAKER_02:

like a little point on by Just because you're biased doesn't mean you're wrong. I love my biases. So the people who have noticed it can come in and do their little, yeah, my pain's a three, but my anxiety's up here at a nine. Or I've noticed that when my anxiety goes up, my pain goes up. Or if I'm not sleeping, my pain goes up. And you start to see the equalizer effect. So it's not really just the pain scale.

SPEAKER_00:

I'm going to jump in a little bit about anxiety because anxiety, I find it a little bit triggering because anxiety is one of those things where we can gaslight our patients, I think, because we can say, oh, you're just anxious. Positive. that anxiety is your thing therefore that's not my responsibility and actually your anxiety is stopping my very very fabulous treatment from working and actually it's really funny isn't it because if someone shouts to you relax what happens you clench your sphincter you don't relax your sphincter because it's like what's going on what's happening what's happening so never in the history of someone being told or shouted at to relax has that ever happened and I say to my guys anxiety is an interesting thing because again it's the social construct it's And it's maybe a medical construct. I said, but it's basically fight, flight or freeze. It's basically physiology. It's basically our autonomic nervous system making us feel. We're dumping adrenaline and cortisol into our system and we feel like shit. And that basically is anxiety. Now, that's really important because the reason for anxiety, the reason for fight, flight or freeze is so that you survive. So it can't be nuanced. It's either on or off. Because if you go, oh, is that a danger? Dead. Every time you stop and think about it, you're a goner so you have to respond in that way but obviously pelvic pain isn't going to kill you we hope and so the deal is I get my guys I've been doing it for a while now and I'll say to them do you know what what happens if somebody comes up to you and actually I stole this really from Jilly Bond and then expanded it a little bit it's brilliant really and I'll say so the first thing that happens if you're a zebra at the washing hole and a tiger comes to get you and I know that's wrong because they're not from the same continent but I like the analogy so I'm sticking to it so basically the tiger comes along and attacks you. The first thing you do if you're a zebra is you go back up on your hooves and you try to fight the tiger off. And you do that for, I don't know, 30 seconds, 40 seconds until you're exhausted. And then what do you do? Then you take off. And then if you run fast enough, so the other thing about pelvic floor function as well, which I'll say here, is if you're able to defecate quickly and urinate quickly, you can jettison 10 kilos of poo and pee. So you're 10 kilograms lighter than the guy beside you. who's still having to run with the 10 kilos in his hands. So you get to escape and hide behind the rock. And when you hide behind the rock, what do you do? You freeze and you breathe. And you try to breathe really slowly because you try to bring back your, you've burnt off your adrenaline cortisol and now you want to increase your parasympathetic activity to calm yourself down. So I get them to do things like, I say the first thing is you get into fight stance and start boxing for your life. Box as hard as you possibly can. Then once you've done that for 90 seconds and you're just absolutely exhausted, get running. Because now the fight didn't work, you've got to get out of the way. Then once you've done that, go and hide behind a rock and breathe. So work on that physiology of the anxiety to bring it down a bit. It works for all sorts of pain, but it works especially well for pelvic girdle pain patients and pelvic floor pain patients. I would say to them, take some of those things, take some of the part of your journey that you really didn't like. which are the little triggers that give you anxiety and put them in front of you and punch them out of the way punch them as hard as you can run away from them as hard as you can and then hide from them as hard as you can and actually a lot of the guys it's just one of the little strategies that I really like for my pelvic pain patients to use when we're talking about anxiety and to say to them you know what anxiety is not this thing that you can't manage or control and I mean there's lots of psychological things to do but as a physio I want to be moving my patients so of course I go and try and find something that's about exercise loading and move so anyway

SPEAKER_02:

well because we don't do like if you get a cramp in your foot you stand on it you move you don't lie down stick it on the back of the sofa and wait for it to go away but people get a cramp in their ass and they're like oh don't sit here's your little cushion you

SPEAKER_00:

can't you jump out of bed don't you and if it's in the middle of the night you don't stay under the curtain I think I have some cramp I will breathe through that no you scream jump out of bed and your partner's going what are you doing what's going on

SPEAKER_02:

yeah and we gotta do the same thing with the pelvic floor is load it like for real load it

SPEAKER_00:

I

SPEAKER_02:

love that. I put people in virtual reality. I have not, I'm going to totally steal that from you and Julie about, okay, here we go. I have rocks outside the clinic. We can do this. You were talking, I'm like, oh yeah, I can use that. But I put them in VR. Beat Saber is a fabulous thing. Put that on a level higher than you think you can do for 10 minutes and they're moving in ways they've been protecting and all kinds of stuff's going on where they just don't, they're not thinking about it anymore because they're trying to smash the those boxes that are coming at their face really fast. And that none of what we have talked about has been people lying on the table breathing and doing pelvic muscle relaxation exercises.

SPEAKER_00:

There's a big spectrum, isn't there? Someone maybe might have a real fear about moving, so you have to grade it for them. But if I'm giving them, I will say to them, I like nasal breathing, I'll get them to use nasal clips to open up their airways so they can breathe better. I'll get them to do breathing and take the breathing into their workplace, get them to do the breathing exercises sitting up at work if you can reduce your sympathetic nervous activity by nasal slow vagal breathing that can be a really positive thing and then it comes back into just about getting control it's about being in control and feeling that you can manage and you have a bunch of strategies to apply to your symptoms that you can control a bit

SPEAKER_02:

buffet of options because the one that worked yesterday won't necessarily work today and that's normal too 100%

SPEAKER_00:

and that's thing you used to say about I love your little thing about exercise snacks and pleasure snacks and go and like go out for a walk at lunch go and have that coffee that you really really enjoy there's lots of kind of don't eat this don't eat that don't drink that don't do that but actually there's not that much evidence regarding nutrition and irritation and food now for some people that's the thing but for a lot of people it isn't

SPEAKER_02:

right and the blanket don'ts then you end up having stolen everything that makes

SPEAKER_00:

a person's life enjoyable. Yeah, 100%. Everything you used to enjoy is gone. You limit yourself. It's like going on a diet. You just take all the pleasure. And that's

SPEAKER_02:

just rude. So you have to find things that people can do that feel good for the kindness, the compassion and practicality of it, but also for the treatment aspect of it because doing things that bring you pleasure, decrease the cortisol levels, increase dopamine, serotonin, oxytocin, get you in a less contracted state. state it just changes the whole chemical output so if we can tap into that for two to three minutes periodically through the day total bonus.

SPEAKER_00:

And I think as well sex is an activity of daily living isn't it and we come away from it we stop doing it and so what tends to happen with when you stop having sex is that you stop having intimacy and when you stop having intimacy that makes you feel really alone and sad and low mood and so I encourage my patients to say you know go back to your partner say to them this is where I get a foot rub get a hand rub get a head rub have a cuddle take 10 minutes every day and say okay I need my pleasure snack now we're going to cuddle together guys especially often don't look for intimacy when they're not looking for sex because they're slightly worried that if they go towards the intimacy that might lead to sex and they're not sure if it's going to be possible and they're not sure if it's going to not be sore so therefore they kind of stand back a bit and then the whole issue with how your partner how the there's a gap between you and oftentimes the thing about pelvic pain patients is they actually look or they can look quite well you know they don't have a cast on their leg they don't have a brace on there's no face validity that there's anything wrong with you because it's hidden it's embedded in your pelvis and so sometimes people are looking say oh you look okay why what's wrong with you you look you're young you're healthy and also they put on a brave face because they don't want people to know it and that's exhausting that can be really really exhausting

SPEAKER_02:

and I think leads to more tension and more loss of the things that make you feel good. So just the wrong road entirely. And you get further and further away the things that can help you recover. And as health providers, we need to not be adding to that. Helping people keep options and know that pain is weird. Even pelvic pain has that extra level, but also just pain in general. And you can't rest it better after, you know, maybe that first initial bit where you're making sure that bones aren't actually broken. And I'm structurally sound so I can load this that that part needs to happen and then you need to grade that exposure but that's where pelvic stuff becomes really interesting so yes intimacy but it's like diving off a board at some point you can't just practice you're going to have to do it and that's where it's like I've worked with gentlemen especially of look okay you're structurally sound you're fit for purpose for all these different pieces go have sex but go have sex the weekend before your appointment so that if you end up with a spasm or something doesn't go the way you want it to I'm here for you I can help you calm everything back down and don't send pictures

SPEAKER_00:

I had a patient recently he wanted to come see me I hadn't seen him for a long time he was doing really well but he hadn't gone back to being sexually active because of the pain and he phoned and said I think I need to come and see you and he was being quite specific about what his issues were and I said mate I think you just need to go out and find someone and have sex I think you need to go date I think you need to go find some people go and live your life I said go do that and then come back and tell me how it goes so I didn't hear from him for a bit and I thought I wonder if I've given them the wrong advice so I sent a text message going just checking in how are you doing oh great I have a girlfriend we're having sex it's working well I said do you think you need to come and see me no I don't need to come and see you and it's a bit like that jumping off the cliff it's not even about giving it's about being validated about that decision is okay because the last thing they want to do is do something that makes them worse because they've tried super hard and I still I think I used to say to patients I still do actually the only thing that's worse than the pain that you have on the first day that you come to see me is if you have a flare during treatment and you suddenly think you've absolutely gone back to square one I said but you haven't I said you absolutely haven't all your benefits all the things that you've gained on the path are still there you haven't lost them it's that idea about bridging the gap between pelvic health and whole body function you know like the pelvis is not this area separate from the rest of the body the penis is not this organ that is disconnected and doesn't connect to everything else the vagina is not this thing it's not an island separate from everything everything goes together works together and it's part of this larger system that's absolutely tied in with everything that we do for sure

SPEAKER_02:

that was a fabulous

SPEAKER_01:

summary very good we've literally got less than a minute probably to go both of you it's been brilliant listening from my point of view so I bet the listeners have been enjoying it as well I'm going to get the listeners to be left with one thing now and that is one thing that you individually yourselves would want someone with pelvic pain to know

SPEAKER_02:

always pain can and does change and there is help be courageous and seek help and we can help you find people

SPEAKER_00:

brilliant Bill I would absolutely echo that I think that pelvic pain you're not stuck with it there are things that you can do yourself there are things that physical therapists can do physiotherapists can do to get you in the right direction it's not a life sentence and have hope stay the course reach out find someone that can help you I'm sure you'll get there

SPEAKER_01:

brilliant Sandeep Bill, thank you so, so much for your time. It's been a real honour to have you both on the podcast and thank you for giving up your time, morning and evening. Take care, both of you. Thank you again. Thank you.