Exploring pelvic pain – summary of a presentation given by Dr Ruth Jones
Accumulate 10 points for pain for PGP
Accumulate 10 points for pain; some factors that appear to influence the accumulation of a pain experience (reproduced with permission from Lovegrove Jones, R., 2003).
Multiple factors somehow contribute to the pain experience. With this belief system in mind, a ‘10 points for pain™’ model is one concept that a number of patients and clinicians have found useful (Lovegrove Jones, R., 2003). It is an easy way to demonstrate that pain can develop for many different reasons and works on the premise that pain is rarely the result of one single incident, but normally stems from a range of different issues or a whole lifestyle that contribute to the 10 points and painful state.
In this way, the patient and therapist can move away from the solely structural pathological model, to one that considers for example, the brain in pain, the person’s beliefs about their pain, nutritional issues, in addition to any pathology or motor control issues. For example, there is evidence that understanding pain reduces the threat of it, altering patients’ attitudes and beliefs, increasing pain thresholds, and when combined with physiotherapy, reduces pain and disability. The 10 points for pain is not an exhaustive list, and the patient is encouraged to fill out their own chart, adding in any factor that they believe may contribute to their pain. Furthermore, it is important to emphasise that this is not an absolute scoring system that says that diagnosed pathology is 4 points, having negative beliefs and attitudes is 2 points, having poor motor control is 3 points, being angry or fearful is 2 points.
Some patients will accumulate more points in one area than another, or those same factors will have a higher (or lower) weighting in different patients. The task of the therapist and patient is to start piecing the different parts of the puzzle together in order to understand the unique accumulation of factors that tip the patient over the threshold from a pain-free (below 10 points) to a painful (above 10 points) state.
Over time the patient then can reduce their points by choosing to change the areas in their life that they believe are contributing to their pain experience and let go of the things that they cannot change. The therapist assists by reducing the patient’s accumulated pain points in areas amenable to the therapist’s particular discipline.
The following article is reproduced from an article written in 2010 and it is a record of Ruth’s presentation rather than being provided directly by Ruth.
Ruth explained that she has been fascinated by an ‘outstanding’ book which has been written by two Australian physiotherapists and looks at chronic pain – it is called Explain Pain by David S Butler and G Lorimer Moseley and costs about £40.00 (back in 2010). Ruth suggested that it is well worth buying and was written for people without any medical training who had chronic pain where the feeling of discomfort had not completely subsided despite the benefits of time, healing or treatment.
How chronic pain can differ from acute pain
Ruth explained that the book is useful on a number of levels but not least because it shows that chronic (persistent) pain doesn’t seem to present like ‘normal’ or ‘acute’ pain which often has a specific role in our survival. The authors of Explain pain recognise that even where there is no disease or structural breakdown, long-term pain can occur, which can make life a misery. They suggest that if readers understand more about how the body works and how we perceive pain, we can use this knowledge to our advantage. Often our lack of understanding can mean we inadvertently make the pain worse and by learning to manage it better, we can reduce it (even though we can’t always make it go away completely). Ruth said that in her work as a physiotherapist and treating women with PGP, she tries to look at the body as a whole and not just the mechanical aspects of a woman’s pelvis. She says that she may examine the spinal column, the bony pelvis and whether or not the joints are working properly, but she needs to keep in mind how the whole system works. This is because a problem with one of the systems within the body can have implications for others. So, for example, if the joint system is not working well, the muscles compensate for stability loss and this can introduce additional stresses and problems. Ruth finds that it is often easy for physios to pick up on a dysfunction of some kind but it is much harder to relate this to the patient’s presenting condition. Ruth explained that although she and her colleagues may be very experienced in using their eyes to see dysfunctions, it is difficult to be objective. As a result, Ruth has been looking for objective measurements to help her assess patients. Her recent PhD included work to identify a tool that could be used to help assess patients objectively. She explained that it can be used in conjunction with visual and tactile skills. This measurement tool includes a ’points system’ as a way of analysing pain and provides a useful index to finding out what aspects affecting a patient can add on points (and increase pain) or diminish points (which can decrease the pain). A trigger which increases points (and therefore pain) in one individual may not be a problem at all for someone else. Ruth explained that if you have accumulated ten points this will mean that you experience a significant amount of pain. You may be experiencing a number of aspects or factors which are contributing to this high degree of pain (such as long hours of discomfort in the car for a long commute or having to walk up three flights of stairs to your flat). So the aim is to find relevant factors and then ways to reduce them so that you can decrease the number of points associated with them to a more manageable level, i.e. below ten. This tool can be used with any experiences of pain in any part of the body but has proved to be useful for Ruth when used to help her patients with PGP.
She said that this approach is helpful with her patients because it is possible to work out which aspects are affecting their everyday lives adversely and to see which can be reduced to minimise the number of points and the associated pain. Ruth has been helping patients to see whether they can reduce the points to as few as just three and to keep them there even if they cannot attain even fewer points. (Please note, the points system isn’t used instead of manual therapy, it is a tool for helping to make the treatment more effective and to last between sessions and, possibly, avoid needing further treatment sessions). Ruth encouraged the audience who have pain with PGP, to look at aspects which might increase or decrease the amount of points associated with the pain. For example, there may be various activities or environments that add points and others that can take them away (e.g. you might love tennis and because you do, the actions don’t inflame your pelvis the way that standing to use an iron does if you hate this job). Ruth explained that this approach can be very personal to you; hormone levels may play a role; emotions can contribute; your immediate environment could affect you (e.g. having to use steep stairs in your house every day); whether what you do every day is enjoyable, boring or very upsetting, can all contribute. Nutrition may come into this for you or a direct trauma (e.g.”I was fine until I got pregnant” or “I didn’t have this pain until I fell over”). Sometimes our previous experiences can increase or decrease points; for example, we may find that we are reminded of pain more when around certain stressful people or ones who also have pain and tend to be negative so they drain our energy. Ruth suggested that individuals can use this system to their advantage and find ways of reducing points and keeping them to an amount where pain is under control and manageable. Of course, not all factors are controllable – but the knack is to find areas of life that are, so that you can minimise them. So, if you always put your pelvis out when you lift the shopping, find ways to do the shopping where you don’t need to lift – get your partner to do the shopping or get the groceries delivered, etc.
How we perceive and experience pain
Some of the fascinating aspects of Ruth’s presentation included how our brains work in registering pain and how pain can have a very different role in different situations. We can find a small graze or tiny paper cut very painful but as we don’t see the injury as life threatening, we aren’t given messages to ignore the pain and run away. By contrast, where we are in a life-threatening situation, our bodies rarely register pain so intensely in order to help in our survival. In a combat zone, for example, a soldier may have a very significant wound but not feel his injuries at all when he is trying to escape from the danger of further attack. If he stopped moving because the pain was so bad, it might hinder his escape. Once he is safe and in hospital, he may find that the level of pain rises considerably because he is no longer in imminent danger. It seems that once you focus on a painful area, your brain can send out more signals to keep it monitored and the number of receptors in the area start to increase and to send even more messages back. The overall effect of this is that the more you concentrate on the pain, the more receptors work to tell you about it. So it really can be the case that focusing solely on how painful your pelvis is, the worse the pain can appear and that can be without you doing anything physically demanding at all (so you could just be sitting instead of bending down or carrying a heavy object!). We believe that it is very important that women with the symptoms of PGP first take steps to find a manual therapist who is experienced in techniques to overcome stiffness or ‘stuck’ joints in the pelvis. However, many of us find that while we have treatment to realign an asymmetrical pelvis, we may still experience a lesser degree of pain afterwards which continues. So this is where the points system can be particularly useful – use it to help you identify aspects of your life that can increase or decrease your own particular pain and this can act as an effective supplement to the benefits of manual therapy. As Ruth drew her presentation to a close, she pointed out that it isn’t just physical factors that you need to watch, attitudes and beliefs can have an effect too which can be just as powerful. So if you understand more about how the body experiences pain and about your pain in particular, you stand more chance of adapting your response to it and making it less severe.
Again, many thanks from the Pelvic Partnership committee to Ruth for giving us permission to reproduce the original summary of her presentation here and the addition of the diagram she has sent with permission for us to use the material in this article. We really appreciate these additions, which enhance the original summary.