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The Effects of Yoga and Meditation as a Pain Management Technique in Women with Chronic Pelvic Pain

 Yoga

By: Abbie Marrale, SPT

Background:

Through multiple observation opportunities with pelvic floor physical therapists, I have discussed the impact of chronic pelvic pain with many individuals who suffer with this condition. Some of the main functions that chronic pelvic pain can affect are the ability to sit for prolonged period of time and engage in sexual intercourse. Many people are able to find relief for their pain through physical therapy treatments, which often include internal manual therapy and/or biofeedback. However, pelvic floor physical therapy is generally used for a short duration and does not always address the issue of the chronic nature of this condition. Learning about alternative methods that patients can engage in would benefit the patient in being able to contribute to their own pain management and would help clinicians offer more direction to patients on their home plan.

The goal of yoga, meditation, and/or breathing techniques in this situation is to decrease stress1-2, decrease muscle tension2, specifically pelvic floor muscles, and give the individual techniques they can use anywhere. Considering my interest in pelvic floor physical therapy, the aim of this investigation was to determine if learning yoga, meditation, and/or breathing techniques is an effective tool for chronic pelvic pain reduction or pain management. Additionally, the project’s secondary aim was to further explore how yoga could be used in the physical therapy setting to promote healing, health, and wellness.

Overview:

Chronic persistent pain is the presence of pain in the pelvic girdle region for over a 6-month period.3 Up to 20% of women will suffer from pelvic pain at some point in their lives, with chronic pelvic pain accounting for 10% of all visits to the gynecologist.3-4 Yearly direct cost of chronic pelvic pain is estimated at $2.8 billion for evaluation and management strategies.3 Due to its prevalence and cost alone, it is important to have a broad array of management techniques.

As understanding of chronic pain continues to evolve, so does the treatment for pain. Currently the theories around chronic pain suggest central sensitization, causing alterations in central nervous system processing and allowing non-painful stimuli to be perceived as pain.5 Since the pain is not originated from solely from physical impairments, but also in large part to changes in the central nervous system, it is important that treatment also take on a bio-social-psychological nature.

Yoga is a comprehensive system for wellbeing on all levels including the physical, mental, emotional, and spiritual.6 There is evidence that yoga and mindfulness based stress reduction have positive effects on pain and pain management in individuals suffering from chronic pain.7-8

The Project:

The project began with a question posed in Evidence-Based Practice II, “In middle age females with chronic pelvic pain are relaxation techniques [yoga, meditation, breathing techniques] better than pelvic floor physical therapy alone in patient reported reduction or management of pelvic pain?” Based on my overlapping interests in pelvic floor physical therapy (Women’s and Men’s physical therapy) and yoga, I was curious to discover how yoga, breath work, and meditation could complement physical therapy treatment in women with chronic pelvic pain. This project led me to understand the existing research, limitations, and evidence that support the use of these alternative methods. It was determined that in regards to middle age women with chronic pelvic pain, research suggests that yoga and other movement-based therapies may be beneficial in reducing pain. It is not conclusive that this is a better option than physical therapy, however it has been shown that yoga may significantly increase pain reduction. Recommendations based on this literature would suggest that physical therapists recommend yoga in conjunction with, although perhaps not in lieu of, physical therapy treatment for pain management. The final critically appraised topic (CAT) can be accessed Here.

Additional research was needed to specifically address the question, “In middle age adults with chronic pain, is meditation an effective means of reported pain management or pain reduction?” A similar CAT was created for this topic, and concluded that the ultimate goal of mindfulness based stress reduction therapy, or meditation, should not be primarily focused on pain reduction, but on cultivating a better relationship with the pain. It should also be noted that while meditation may be an effective strategy for pain management, it is not a replacement for standard treatment. The final CAT can be accessed Here.

Based on the evidence, a PowerPoint Presentation was created and will be given to the Triangle Pelvic Health Group, a group of physical therapists, occupational therapists, and other providers who treat pelvic floor conditions. An additional Yoga Posture Handout was created that will be provided to those in attendance, which reviews common poses, their benefits, and how to cue each posture. For added benefit, an example of a guided imagery meditation for pain relief can be accessed Here (YouTube version is available Here).

Evaluation:

I have created a brief Survey that will be given to those who attend my presentation. This survey will encompass feedback regarding both the PowerPoint presentation and the yoga posture handout that I will be providing.

Self-Assessment:

This project was the combination of two passions merged into one thought and focus. However, completing this project has been a journey that called upon a variety of different resources, professionals, and ideas I never would have foreseen. Perusing through the literature and finding out how much research was looking at the usefulness of yoga and meditation was one of my favorite parts. However parsing out the best research and the most relevant, while leaving many articles unmentioned, was nothing short of heartbreaking. I would have loved to incorporate it all into this project.

On top of synthesizing the findings, being able to transform the literature into useful, tangible material that could be used for either physical therapy or yoga practice was very exciting. There was so much more I wanted to do with this project, but as we are learning, these projects take time, focus, and a lot of work. For now I am pleased with all the information I was able to put together. However, I hope this is just the start of a long love affair with yoga and pelvic floor physical therapy.

Acknowledgements:

I would like to say a special thanks to my committee members Jennifer Harrington and Lauren Sacks for their ongoing support, feedback, and assistance along the way. I am additionally grateful for the ongoing support of my capstone advisor, Karen McCulloch. It has been such a pleasure to work with this interdisciplinary team to synthesize the information between two similar, yet different professions. I also want to thank YOU for checking this page out! Please feel free to comment or contact me at abbie_marrale@med.unc.edu with any additional questions.

References:

  1. Nosaka M, Okamura H. A single session of an integrated yoga program as a stress management tool for school employees: comparison of daily practice and nondaily practice of a yoga therapy program. J Altern Complement Med. 2015.21(7):444-9.
  2. Hassed C. Mind-Body therapies – use in chronic pain management. Aust Fam Physician. 2013.42(3).112-7.
  3. Apte G, Nelson P, Brismee JM, et al. Chronic Femail Pelvic Pain – Part 1: Clinical Pathoanatomy and Examination of the Pelvic Region. Pain Practice. 2011;12(2):88-110.
  4. Gyang et al. Musculoskeletal causes of chronic pelvic pain: what every gynaecologist should know. Am College Obstet Gynecol. 2013;121:645-50.
  5. Nijs J, van Wilgen CP, Van Oosterwijck J, Van Ittersum M, Meeus M. How to explain central sensitization to patients with ‘unexplained’ chronic musculoskeletal pain: practice guidelines. Manual Therapy. 2011;16:413-418.
  6. Yoga Alliance. What is Yoga? Updated: 2016 Available at: https://www.yogaalliance.org/Learn/About_Yoga/What_is_yoga. Accessed: April 11, 2016.
  7. Lee C, Crawford C, Hickey A. Mind-body therapies for the self-management of chronic pain symptoms. Pain Medicine. 2014;15:S21-S39.
  8. Ward L, Stebbings S, Cherkin D, Baxter GD. Yoga for functional ability, pain, and psychological outcomes in musculoskeletal conditions: A systematic review and meta-analysis. Musculoskelet Care. 2013;11:203-217

 

9 Responses to “The Effects of Yoga as a Pain Management Technique in Women with Chronic Pelvic Pain”

  1. ellese

    Abbie,
    Your capstone project turned out really great. I know you had difficulty finding quality evidence (because there is a real lack of good evidence on yoga in general, and probably even less available for chronic pelvic pain). But you did a great job bringing together different resources to create useful information for physical therapists. I’m not sure if it is just me or not but I wasn’t able to access you yoga postures handout. I would love to be able to look at what you presented if you wouldn’t mind sending it to me. I think you created a project that will be useful for pelvic floor therapists and makes the use of yoga in interventions really accessible.

    Great work!

    Ellese

    Reply
  2. Christopher Ritter

    Abbie,
    I found your Capstone topic extremely interesting. I’m glad that you were able to combine two passionate interests which clearly work well together (women’s and men’s health + yoga). I found your yoga posture handout to be particularly interesting and potentially useful with patients in the future (although I probably need to learn a bit more about the techniques themselves before attempting to go so far as to teach a patient the correct form). I also listened along with your youtube video and found the experience rather cathartic despite my lack of chronic pain, though I was able to substitute some for some acute knee pain. I’ll admit it was a bit strange hearing your familiar voice in such a different context, but you did an excellent job with your tone and timing and before long I lost focus on the fact that it was you and was completely zoned in on the many sensate attributes of my pain shape. Keep up the great work and I look forward to learning more about your exploration of yoga to address pelvic health pain and dysfunction.
    -Christopher

    Reply
  3. KMac

    Yay Abbie!!! Nice work, happy to see it posted for all to see.
    kmac

    Reply
  4. Ginger Garner

    Just noticed a bit of typo (blaming my reading glasses on that one) – the dangers of autocorrect. Choice should read “choir.” Thanks and again, great work!

    Reply
  5. Ginger Garner

    Hello Abbie,

    You are certainly preaching to the choice here! As a pelvic PT and 25-year yogi, the points you bring up are very timely. Chronic pelvic pain is all too common, and most of it preventable if women were getting the care they need. Yes, men have pelvic pain too, but the overwhelming majority of sufferers are women, especially when such disparities in care exist.

    I also agree with your observation that the research separates yoga and therapy. This approach is binarily self-limiting and reveals the rather infant stage of yoga research. Yoga integrated with physical therapy, at least in my 20 years of experience using it in clinical practice, is a much more effective method for addressing (and researching) chronic pelvic pain (or any condition) than “yoga in addition to PT.”

    Yoga Alliance has provided a great organizational body for teachers, but the body itself does not represent yoga as therapy or yoga used as therapy in medicine nor does it do any research. That distinction is important, as it will help the use of yoga in PT grow beyond vocational teaching and into its own realm of medical/rehab specialty. The effects of yoga postures and breath practice, when combined with rehab science, also move so far beyond benefits such as “stretching,” to include better HPA (hypothalamic pituitary adrenal) axis regulation and improved stress response, for starters.

    I am so happy that you have decided to give yoga a try and pursue its deeper meaning within the context of physical therapy. It can provide a valuable dimension to investigation of, and troubleshooting, pelvic pain. I look forward to seeing your future work in this area, and would direct you to my project, which shares the similar focal point of yoga. Congratulations and best of luck in your new adventure!

    Best,
    Ginger

    Reply
  6. Abbie Marrale

    Andrew Foster, please feel free to use any and all materials on or linked to this site! Thanks for reading and commenting 🙂

    Reply
  7. Kelly Walsh

    Abbie,

    I love the topic you’ve chosen for your capstone project! I know yoga-based physical therapy is often used with older adults for strengthening and balance treatments; I’ve never seen it used to treat pain, especially pain associated with the pelvic floor. I think this is such a great idea and I’m glad you’ve found research to support it. Pelvic floor pain and dysfunction can be a very difficult issue for patients to discuss and therapists to treat. By using alternative treatments like medication and yoga, you’re introducing patients to a new way to manage their pain independently. The yoga pose handout you created is an excellent tool for therapists to give to their patients. The images along with cues and explaining the benefits gives an individual the complete picture of how and why to do each pose. As I read through it, I tried to imagine practicing those poses for the first time, without any previous experience with yoga. I think the language you used and the visuals provided explain everything simply and clearly. Great job Abbie!

    Kelly

    Reply
  8. Krissy Ayers

    Hi Abbie!

    Congrats on all of your hard work these past 3 years! Your passion for physical therapy, pelvic health, women’s health, and yoga is inspiring. You are going to be a fabulous practitioner, and I know your women’s health and yoga knowledge will be a wonderful supplement to your physical therapy education.

    I also am SO interested in your Capstone topic! As you know, I am very interested in Pilates and often take Yoga, and I know they both incorporate mindfulness, being in tune with your body and finding a mind-body connection. Some of my favorite parts of your capstone project are the very engaging YouTube video and yoga handout. I am so glad that I watched your video before bed, because your voice is so soothing and relaxing! I will also use this video if I need some relaxation during my rotation! ☺

    I know you focused your video on guided mediation, but what are your thoughts on musical mediation? I know I have casually seen articles on the power of music to shift one’s state and consciousness, but I didn’t know if you came across any musically focused mediation research articles?

    Thank you for sharing your awesome project! Great job!

    Reply
  9. James Foster

    Abbie,
    Thank you for sharing your Capstone and knowledge on an area of PT that many individuals are unaware of. In my experience talking with pregnant and post-partum mothers, pelvic and referring low back pain is a common occurrence. Often these women are unaware of the benefits PTs can provide and especially those like yourself, who are specializing this particular area of therapy. For example, my sister has a 2-year old and is currently going through her 2nd trimester with her second little girl. She is an exercise enthusiast but has never engaged in true yoga program, and has complained of back pain since the birth of her first child. She like so many women lack the education of pelvic floor therapy and information regarding hormonal changes and increased laxity associated with pregnancy. With that being said, I would encourage you to be a loud voice and advocate strongly for PTs performing and specializing in pelvic floor therapy because I know how smart and wonderful you are as a therapist. I thought your information was very informative, materials and handouts are clean and clear, and you do a great job bringing to light information that will truly impact individuals’ lives in a positive way. With your permission I would like to send the capstone link or at least your handouts to my sister.
    Great job!

    Reply

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