PGP, pain and manual therapy
by Lucy Walmsley, Physiotherapist
Whilst delighted to be asked to write this article, I am slightly daunted as pain is an enormous subject. Very clever people have devoted their whole lives to understanding how pain works, and I am neither very clever, nor able to devote much time to the subject because I devote most time to tidying up after small children, but I will have a go!
My main aim in this article is to clear up a few myths and help people to understand what they should expect from treatment and, in particular, explain some of the principles of good pain management.
The first important point is that pain is not normal. Pain exists in its first and basic form to tell us that something is wrong and to prompt us to do something about it. So pain should not be ignored. It is not ‘normal’ to experience pain during pregnancy, and if you are, then you are very sensible to seek help and you are not making a fuss by asking for treatment. The main reason people get pelvic pain is because of a mechanical dysfunction at the pelvis, where one or more of the pelvic joints becomes stiff and so makes the mobility asymmetrical. This explains why the pain does not just get better on its own, if something is ‘stuck’ and causing an imbalance in how your pelvis works, then however much you rest or wait, it will not get better until the imbalance is addressed.
However, somewhat confusingly, the level of pain that you experience does not always equate to the amount of damage or stiffness in an area; hurt does not equal harm. Pain is a multifaceted process and many things can determine how much pain you have, so you may have lots of pain in your pelvis, but no changes to see on a scan or x-ray, or people may tell you that your pelvis is ‘fairly normal’. Conversely, some people experience very little pain, but may have problems making certain movements, and when professionally assessed, they may appear to have lots wrong with them. We experience differing levels of pain in other areas of our bodies and the extent of the pain we feel can sometimes seem really disproportionate to the associated injury or condition – so this impression is not limited just to the pelvis. For example, why is a paper cut so painful when the damage to the tissue is minor and no other structure is harmed? How can some soldiers feel so little pain on the battlefield that they remain completely unaware that they have lost a limb? These may be extreme examples but they serve to demonstrate that there is no simple ‘cause and effect’ relationship with pain.
This complex relationship goes some way to explaining another confusing aspect of having your pelvis assessed and treated. Your pain does not tell us what is wrong with you. You may have pain in one area, but it may be due to that area taking more load because another area has become stuck, or it may be due to a tight muscle generating pain, as a result of a problem somewhere else. Either way, the painful area is not really the problem, it is the stiffness elsewhere that needs to be treated.
Bearing this in mind, I like to find out all about someone’s pain when I am assessing them, but once I have those details, I really need to leave them to one side so I can concentrate on the joints and their movement because it is a full assessment of these (rather than any details about the pain) that will lead me to determine the best treatment for that individual.
This approach should also go some way to explaining why sometimes treatment may be uncomfortable, or you may feel a bit sore afterwards. If somewhere in your pelvis has become stiff, and so is causing another area to be painful, the only solution is to improve the movement in the stiff area. This may make the pelvic area slightly sore for a short period of time, but it should quickly settle down and should immediately result in an improvement in your ability to move.
Therefore, it is fine to take painkillers before treatment if that makes it easier for you during the session. It does not matter if you do not have your pain at the time of treatment because it’s the movement of the pelvic joints (or lack of movement) that is the real guide to what is wrong. A good manual therapist will still be able to find out what is wrong with you even if your pain has improved. It also means that you can always be treated, even if you are in a lot of pain at the time. It may be that treatment has to be modified for you, but in order to resolve your pain, it’s necessary to improve the mechanical function of the system which is the underlying cause of the pain. If you prefer to avoid painkillers and find that being treated can be painful, it’s important to remember that the pain is not harming you, and the treatment should take away the stiffness or dysfunction which is the reason that you have been experiencing pain.
Your pain may not improve immediately following treatment, though, because of the nature of the pain system, and because it may take a while for inflammation or muscle spasm to settle down. Once the mechanical dysfunction has been addressed with treatment, you should notice straight away that your movement feels different (freer and less constrained) and some tasks may be easier for you to perform, but they may not necessarily be less painful straight away.
Whenever we have pain for more than six weeks (which most of you with PGP have), the pain system itself becomes more sensitive and can generate a pain signal without any immediate cause. This is a well recognised physiological process, and is just as treatable as the rest of your pelvis, but needs managing with painkillers, exercises and activity management. This means that using painkillers and aids such as a pelvic belt can be an important part of your recovery if they allow you to manage your pain. It is important to keep pain under control to allow you to achieve more normal movements. Good pain management is vital to your recovery.
This has been a very brief overview of pain and PGP, but I hope it has highlighted the fact that you are likely to need some form of manual, ‘hands on’ treatment, in order to achieve a full recovery. This can be carried out whatever your current level of pain. Pain in itself does not diagnose what is wrong with you, nor does it relate to how much dysfunction you may have.
Many thanks to Lucy for this helpful and practical article about PGP and pain. Lucy Walmsley is recognised as a leading expert in this field, and as well as lecturing widely on the subject, Lucy also treats a large number of women each year with pregnancy-related PGP and so has been able to build up a wealth of experience. Lucy is based in Bourton-on-the-Water at Stow Physio at Bourton; for more information visit www.stowphysio.co.uk.