It is important to target cortical structures (the brain) in your treatment plan when there is evidence of central pain mechanisms in the patient’s presentation [3]. Inhibitory neurons descending from the brain to the spinal cord help downregulate the sensitive nervous system and can limit the impact of nociceptive input [31]. Downregulation involves the release of inhibitory chemicals into the synapses to decrease the sum of the neural response that occur when the brain concludes that a threat exists. The activity in descending pathways is not constant and can be modulated [32]. The use of techniques that decrease vigilance and modify the stress response may enhance the activity in the descending pathways and help to decrease the sympathetic nervous system response [33, 34]. As a result, the techniques below may directly or indirectly facilitate decreased activity in the overactive pelvic floor. There are many different techniques that may improve the patient’s mind-body connection by targeting the upregulated sympathetic nervous system. Treatment options may include the following:

Persistent pain associated with an overactive pelvic floor may have primarily top-down drivers associated with a sensitized nervous system. The evaluation as described previously can provide clues to the necessity for reconceptualizing pain in each individual patient presentation [24]. Pain is a powerful defense. An important question to answer with your evaluation is “what protection does the pain provide for this person?” A follow-up question should be, “Is that protection needed now or is the pain itself driving the symptoms?” If the pain associated with an over active pelvic floor has been persisting for greater than 3 months, it is likely being driven at least in part by central pain mechanisms and careful pain biology education is warranted.

Dickens enjoyed immense success b ecause he published his writing in installments, which made it affordable and anticipatory. It was meant for the common people—not just for the aristocracy or the elite few. Treatment of pain needs to follow the same suit and be available to all. Pain biology education is key to empowering patients—it is affordable, nonaddictive, easily understood and it can be made available individually or in groups [7]. Simply put, pain biology education is the process of sharing accurate information of the biology of the pain system, using current pain science in clear terms, often with the use of metaphors for explanation in a way that each person can understand. Pain biology education reconceptualizes pain, helping a person in pain to develop an understanding of the nature of his/her pain, and understand the role that he or she plays in treating their pain [24, 50]. Passive pain management with pain medication should only be a short-term solution to help patients get moving [2]. Pearson [51] suggests telling the patient that the purpose of pain medication is to help them move better; essentially, they should be told that they are “movement pills.” However, asking a patient in pain to move, even in graded amounts, can be overwhelming and the movement may cause an increase in symptoms in highly protective individuals. Clinically we find that this request to increase movement is best preceded by pain biology education [7].

Pain biology education can be provided in the clinic as part of routine treatment. With an appreciation of the pain system, patients start to reconceptualize that pain is “not in their head.” They learn that the nervous system has physically changed as part of a complex protective response [15, 52]. One of the current challenges in medicine is the lack of imaging which can capture these changes in central pain mechanisms for patients and clinicians. Pain needs to be re-conceptualized by the patient so that they have an understanding of the protective nature of pain, often in the absence of tissue damage. Through education, the patient can be empowered to change their beliefs and reduce the threats that perpetuate their pain cycle. This change in the understanding of the nature of pain can lead to a change in their pain response. This is a reasonable and achievable goal that has been studied in back pain and complex regional pain syndrome [24]. Educating patients about pain can change their pain levels more than any other modality that we currently have in persistent pain [7]. Through pain biology education, our goal is to help them to understand, respect, and most importantly, not fear their pain experience. Mantel [11], author and chronic pain sufferer, expressed this importance as “Pain cannot be easily divided from the emotions surrounding it: Emotions sharpen it, apprehension intensifies it, and loneliness protects it, by making hours seem like days. The worst pain is unexplained pain.”

It is critical for central pain mechanisms to be considered in all pain states as a primary diagnostic indicator in pain that lasts longer than 3 months. The evidence suggests central pain mechanisms play a considerable role in patients with persistent pain, even in those thought to have strong peripheral mechanisms, such as rheumatoid arthritis and osteoarthritis [2]. Lumley cautions [54] “The medical profession has unwittingly created a form of mental imprisonment that I call medicalization, when diagnosis and treatment causes an increase in pain and suffering.” We do best for our patients by consistently using a three-pronged approach for both acute and chronic pain, a biopsychosocial framework. The following case series demonstrates this framework in clinical practice.

This case series demonstrates the use of the assessment and treatment framework (Figs. 18.2 and 18.3) first presented in 2011 and 2012 with three distinctive patient presentations [9, 55]. All three patients had significant physiotherapy intervention with an orthopedic physiotherapist prior to their treatment with a pelvic floor physiotherapist as presented in this case series. Orthopedic physiotherapists are often missing a deep understanding of the biological tissue drivers of pelvic floor dysfunction; this fact alone can change the outcome of persistent lumbo-pelvic pain states significantly [36, 56]. Furthermore, all physiotherapists need an understanding of a biopsychosocial framework within persistent pain states. This case series provides an example of the possible blend of central pain mechanisms and tissue-based drivers in persistent pain states by using a biopsychosocial framework.

The first case study (Patient #1) demonstrates no specific components of central pain mechanisms. She meets the criteria of persistent pain based on the duration of her symptoms but she responds to treatment in the same way a patient with acute mechanical pain might respond. It is interesting to note that she had been treated with a biomedical approach by another orthopedic therapist; however, symptom resolution was not achieved since the pelvic floor, as a potential tissue driver, was previously overlooked. The second patient (Patient #2) demonstrates a combination of mechanical tissue-based pain and central pain mechanisms. This provides an example of the application of a clinical framework to successfully guide treatment in a time-limited fashion [9, 55]. The third case study (Patient #3) demonstrates dominant components of central pain mechanisms only. Patients with pain , deeply rooted in central pain mechanisms, can respond in a time-limited fashion if the correct tissues are targeted, specifically the cortical structures instead of the musculoskeletal and visceral tissues. In this case series, the information that helped to guide the therapeutic assessment and treatment process has been bolded. These bolded findings specifically helped to guide the therapists’ clinical reasoning.

Treatment sessions were 30 min long with 1:1 care with a physiotherapist but also involved the use of a physiotherapy assistant to teach some of the exercise components. The exercise teaching occurred in addition to the 30-min therapeutic sessions, for an average of 15 min/visit. Audio exercises were used to retrain the sensory-motor cortex with body mapping exercises, Franklin exercises, Feldenkrais exercises, Qi gong, therapeutic yoga, guided imagery and relaxation [57, 58]. The patients were sent these exercises electronically in downloadable format to ensure ease and compliance of their home exercise componen t for the sensitive nervous system (Tables 18.1 and 18.2).