From Fear to Function: Understanding Pain in Pelvic Health

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Transcript

Thank you for listening to the OTs and Pelvic Health podcast. I love when you join me. 

Today, I want to talk about pain because in Pelvic Health OT, pain is rarely just a symptom.

 Pain is the thing that changes how someone uses the bathroom, how they relate to intimacy, how they sit at work, how they move through postpartum recovery, and how they trust their own body after years of being dismissed. Now, the question I want to explore is this, is pain automatically a bad thing? And if it's not always bad, then the question right behind it is, how do we as occupational therapy practitioners decide what's acceptable, especially when we're working with dyspnea, constipation, postpartum bodies, and endometriosis? You already know my answer. It depends.

But I'm going to make it depends actually usable.

Intro:

New and seasoned OTs are finding their calling in pelvic health. After all, what's more ADL than sex, peeing, and poop? But here's the question. What does it take to become a successful, fulfilled, and thriving OT in pelvic health? How do you go from beginner to seasoned and everything in between? Those are the questions and this podcast will give you the answers. We are inspired OTs. We are out-of-the-box OTs. We are Pelvic Health OTs, I'm your host, Lindsey Vestal, and welcome to the OTs in Pelvic Health podcast. 

Here's where I start clinically when I'm making decisions around pain.

I'm holding three things at once. I'm looking at what evidence generally supports. I'm looking at my clinical experience.

So what I've seen help, what I've seen not work as well. And I'm always thinking about patterns that show up again and again. And then I'm looking at the client right in front of me, their priorities, their lived context, their nervous system state, their safety, their history, and what occupations matter most to them.

In pelvic health OT, that last piece is not a footnote. It's the whole thing. Because a client rarely comes to us just wanting less pain.

They want their life back in very specific ways. They want to have a bowel movement without bracing like they're preparing for impact. They want to have sex without anticipating burning, tearing, or days of pain afterward. 

They want to pick up their baby and feel good in their body when they do it. They want to stop being afraid of their own body.

So when we ask whether pain is bad, we're not asking a theoretical question. We're asking, Is this pain a stop sign, a detour sign, or just a dashboard light that we can monitor while we continue toward function 

One of the simplest distinctions that helps is the difference between pain that's more acute and pain that's persistent. Acute pain is often more clearly linked to tissue irritation, inflammation, or healing.

Think about postpartum perineal pain early on. Think surgical recovery. Think an acute hemorrhoid or fissure flare.

It tends to be more local, right? Like more tied to a recent event or more responsive to protecting and supporting healing. Persistent pain or chronic pain is where things often get a little bit, I guess, messy is the best way to say it. It may have started with something like a clear driver, like for instance, endometriosis or birth trauma or recurrent infections or a long period of constipation.

But over time, pain becomes less about a single injured structure and more about a whole system. We call this sensitization. We can also refer to it as threat detection, avoidance, or even a long history of not being believed by their practitioner.

Let's do a short story here about a client of mine who has dyspareunia.

She has tried to push through everything because she was told it was normal. She didn't want to disappoint her partner.

It was after she had a baby. So there's just a lot of role changes and things going on in her life. Over time, her body learned a very efficient lesson, Penetration equals danger. 

So now pain isn't only happening during the act, it's showing up beforehand as anticipatory tension, breath holding, pelvic floor guarding, stomach dropping. Pain shows up after, such as burning, heaviness, urinary urgency, and that deep ache that can linger for a couple days.

So in this situation, if we do an intervention, I'm thinking something like graded exposure with dilators or vulvar desensitization, and the client reports pain, the question isn't simply, did we do damage? Most of the time, a more useful question is, What did the nervous system learn from that session? Did the session teach I survived it, but it was awful and I wasn't in control, which can reinforce threat? Or did the session teach, if I approach this safely, I can stop, I have choices I can recover, and that builds tolerance and confidence. This is why pain isn't automatically bad, but unpredictable pain, uncontrolled pain, or pain that feels like danger is a problem, even if no tissue is harmed.

The core idea for OTs here is that we treat participation, not just symptoms.

A lot of pelvic pain care is about explaining what someone can do while reducing threat.

For one client, progress might look like, I can tolerate 10 minutes of sitting without clenching my jaw and bracing my abdomen. 

For another, it's, I can have a bowel movement without straining and not thinking about it all day afterwards.

For a postpartum client, it's, I can walk while baby wearing without feeling heaviness and then crashing for two days. 

For someone with endometriosis, progress can look like, my flares still happen, but I recover faster, I panic less, and I can keep participating in my roles. 

So when we ask how much pain is acceptable, the OT answer is often tied to recovery and function, not a single number on a pain scale. 

So what do I say clinically when a client reports a flare? 

All right, first, let's talk about the moment that can make an even experienced clinician feel a hot flash of panic. The client comes back in and says, I feel worse after last time. Here's the stance I recommend.

Take it seriously without amplifying fear. I might say, I'm really sorry about the flare, Thanks for telling me, Why don't we map what happened so we can adjust the pain? 

Now that sentence matters. It communicates you believe them, that you're not brushing them off, and also that you're not catastrophizing. Because one of the worst things we can do with a pelvic pain client is accidentally reinforce their belief that the body is fragile and unsafe.

I go into curiosity, not an interrogation, curiosity. I'll ask, was there a specific part of the session where you noticed the shift? Now, sometimes the client knows immediately. It was the dilator step, or it was when I tried the toileting posture change.

Then I ask, what did the flare look like for you? Because pelvic flares are not generic. A flare could be burning at the vestibule. It could be deep pelvic ache.

It could be a urinary urgency sign. It could be constipation worsening. It could be an emotional crash that comes when someone feels like they failed again.

Then I ask the question that often gives us the most useful information. How long did it take for you to settle back to your usual baseline? If it was uncomfortable that evening, and by the next morning they went back to their baseline, that's a different situation than saying it set me off for three days or it's still worse a week later. And then this is the pelvic health OT piece that's easy to miss.

I ask, what was happening in the rest of your life around that session? Because maybe it wasn't the intervention. Maybe it was the three hours of interrupted sleep plus dehydration, rushing in a public bathroom at work or a partner conversation where they fought. The pelvis rarely responds to one input.

All right, let's get into a constipation example because I don't know how many of you know this, but I got into pelvic health originally. I got my first job opportunity to mainly work with GI clients. So anytime I share stories, bowel stories are usually close to my heart.

So I've had this client who had been chronically constipated for years. They normalized straining, they learned to override cues, their pelvic floor is guarding, not because they're too tight as a personality trait, but because their system is protecting against pain. 

So we were working on a toileting routine, right? The usual supported feet, a forward lean, good breathing, pelvic floor drying, and a plan for not sitting on the toilet for 20 scrolling.

 They come back and say, I tried the breathing and it didn't work, and then I had more pain. If I stop at the breathing didn't work, I might throw out a useful tool way too quickly. But if I ask, walk me to the bathroom trip, we often find the real issue.

Maybe they tried it when they were late for work and already braced. Maybe they were anxious and breath holding between breaths. Maybe they added effort like the breathing became another performance demand.

Maybe they were on a flare and their stool was harder than usual. Maybe they sat too long. 

So instead of abandoning the plan, we modify dose and context.

We might shorten time on the toilet, right? We could shift to a first line plan for flare days, heat, hydration, gentle mobility, down training, before attempting a more active strategy. We might add pacing and a realistic expectation. We're not trying to fix years of constipation in one week, people.

So in other words, we treat it like OT. Routines, environment, nervous system, habits, and graded skill building. I want to say this really clearly.

In pelvic health, I'm not trying to create pain in a session. I'm not aiming for no pain, no gain, particularly with dyspnea and endometriosis, because that mindset is genuinely harmful. But the reality is many clients start at a place where nearly everything relevant is somewhat symptomatic, right? I'm talking sitting, inserting anything, bowel movements, even just thinking about sex.

So the clinical question becomes, can we find a version of the task that feels safer and more tolerable so we can build capacity from there? If a client feels a mild increase in symptoms during a graded exposure, but they feel in control, the symptoms can settle into a predictable window and the patient trends upward over time, right? That could be all part of the progress. Whereas if a client feels overwhelmed or powerless and flared for days afterwards, that information is telling us to the plan. Now postpartum pain is kind of in its own category because the occupational load is intense and non-motionable.

A postpartum client may not have the option to rest more in a way that a textbook suggests, right? They're feeding a baby, they're lifting a car seat, they're sitting for long periods nursing, they're healing tissues while underslept. So when a postpartum client's flare after a session, I look very carefully at what their day demanded after they left me, right? They may have done great in my office and then went back home to cluster feed in a slumped position for three or four hours, or they walked more than usual and felt heaviness. In postpartum care, one of the most powerful OT interventions is often permission plus planning, realistic pacing, positioning, task modification, and micro-recovery built into the day because the after matters as much as the during.

Endo also deserves a special mention because it's a place where people can get harmed by oversimplified pain education because here's the deal, endopain can have real inflammatory and structural contributors, right? Pain is not just a brain thing. At the same time, persistent pain patterns and guarding can develop around it, especially after years of delayed diagnoses. 

So in endo, I tend to frame our work like this.

We're not arguing with your pain. We're not pretending it's not real. We're building tools so that when pain shows up, whether from inflammation, pelvic floor guarding, GI involvement, you have options.

Options to reduce amputation, options to recur faster, and options to keep participating in what matters. Because endo often fluctuates with cycle pain, The OT approach is often cyclical too.

Flare plan versus build plan rather than one linear progression. So how much pain is acceptable? I'm going to keep this part kind of simple. When I'm deciding whether an amount of pain is acceptable, I'm actually watching for three things.

First, does the client feel safe and in control? In pelvic health, control is medicine. The ability to stop, change positions, to say not today, to downshift. Those are therapeutic.

Second, does the pain return to baseline predictably? If symptoms spike and settle back within a time frame we've agreed is okay, that's one thing, right? But if symptoms keep escalating session after session or the recovery window keeps getting longer, That's a sign we're overdosing the system.

The third question is function trending up over time. Are they showing more participation, less avoidance, improved intimations, improved confidence.

Pain may not be gone yet, but life is expanding. If I'm not seeing those trends, if we're stuck in a cycle of flare, fear, and avoidance, then I change the plan.

So people often ask me in my Level 1 program, when do we refer out? If someone is getting worse over a few weeks or if they plateau for a long stretch, if there are red flags, or if the presentation is pretty complex, more than what we can address in the OT scope alone, we collaborate. And I talk about it like this. I don't want you guessing.

I'd like another set of eyes on this because you deserve a thorough medical and rehab team. We can keep working on the occupational side while they assess the medical side, right? For endoclients, this might mean pelvic pain-informed gynecology. For severe constipation, it might mean GI or colorectal.

For dyspnea, especially with significant trauma history, it might mean mental health support. Pelvic health is a team sport. 

Okay, I'm going to close with what I wish more clients knew.

Getting better doesn't always look like no pain ever. Often it looks like a different relationship with pain. It looks like I had a symptom spike and I didn't spiral.

I noticed early warning signs and I used my plan. I can tell the difference between effort and threat. And my day isn't organized around avoiding the bathroom or intimacy.

So is pain automatically bad? No, I don't think so. But pain is always meaningful data. Our job as a pelvic health OT is to interpret that data in context, respond without fear-mongering, and keep the client moving forward towards participation safely, realistically, and with a plan.

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Outro: Thanks for listening to another episode of OTs and Pelvic Health. If you haven't already, hop onto Facebook and join my group, OTs for Pelvic Health, where we have thousands of OTs at all stages of their pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and post it to IG, Facebook, wherever you post your stuff, and be sure to tag me and let me know why you like this episode. This will help me to create in the future what you want to hear more of. Thanks again for listening to the OTs and Pelvic Health podcast.