Dry Needling: An overview of benefits and risks for chronic pelvic pain patients
Dry needling, also called Intramuscular Manual Therapy, is a treatment technique recognized by the state licensing board in 33 states to be within the scope of practice for physical therapists. It was first cited over 25 years ago but has picked up in popularity in just the last 5 years. It involves a solid needle similar in diameter to an acupuncture needle that is inserted into tissues for the purposes of managing pain and/or dysfunction. This is typically achieved through placing the needle in a muscle trigger point but could also include targeted areas of tendons, ligaments, scar tissue, and peripheral nerves.
Based on current research and clinical success, dry needling is generally thought to be effective in offering relief for a variety of neuromusculoskeletal conditions. There are several theories as to how exactly dry needling causes the relief of pain. It could be that several of these theories are interconnected and working together.
Though dry needling offers an avenue for pain management, several cautions should be noted if you are considering this line of treatment.
1. Halle S John Halle J Rob Pertinent Dry Needling Considerations for Minimizing Adverse Effects – Part One. Intl J Sports Phys Ther. (2016); 11(4): 651-662
2. Halle S John Halle J Rob Pertinent Dry Needling Considerations for Minimizing Adverse Effects – Part Two. Intl J Sports Phys Ther. (2016); 11(5): 810-819
Reflexology Basics & CPP
1. Be Cautious About Routine Exercises You May Already Be Doing
The pelvic region has many more joints, muscles, and ligaments than you may imagine. Some exercise practices such as the use of stationary bicycles and stair climbers, may otherwise be healthy for you, but if you experience sexual and pelvic pain these types of exercises might cause extra stress and spasm.
2. Seats and Clothing
3. Give Up the Attitude of "Playing Through the Pain"
4. See a Pelvic Floor Physical Therapist
Myth #1: Kegels Cure Vaginismus
Myth #2: Vaginal Dilators are Used to 'Stretch' the Muscles
Myth #3: You Just Have to Try to Relax and Keep Practicing Sex
Easing Vaginal Penetration PaiN
Q: Can sexual abuse make nerves in the vaginal opening more sensitive? If so, how do you ease the pain?
A: Sexual, physical, and emotional abuses remain so prevalent in our society and are a tremendous burden. Like anxiety, depression, stress, genetic and hormonal influences, injuries, accidental traumas, pelvic surgeries, falls and straddle injuries, abuse is a predisposing factor for female pelvic and sexual pain. This means that all of these factors can make an individual woman more inclined to these conditions. Pain that results from sexual and/or physical abuse can absolutely contribute to an over sensitization of the pain receptors at the vaginal opening (the vestibule). The experience of this “bad” pain is "remembered" by the nerves. Our nervous system stores these bad memories chemically and awakens them when it is feeling threatened and trying to protect itself (when you’re attempting pleasurable, consented sexual intercourse for example).
So sexual abuse is one of many possible traumas that can be precursors of pain and sensitivity of the vaginal opening. Vestibular pain (vestibulodynia) is by far the most common reason for entrance pain and sensitivity in the vaginal opening in reproductive aged women. It is a common subset of a condition known as Vulvodynia (pain in the vulvar or genital region of women). It is estimated that about up to 15 million women suffer from vulvodynia in the United States alone. All too commonly, even when young women are barely able to be touched by the use of tampons, having a Pap smear, or by any sexual activity, they can be diagnosed mistakenly with "yeast infections" and/or bacterial infections. Those types of infections rarely cause the severe pain and inflammation experienced with those individuals suffering with vulvodynia or "provoked" vestibulodynia.
Various oral medications to help quiet the nerves firing off in this very sensitive area are similar to medications used to quiet other hypersensitive nerves (neuropathies), in other parts of the body. These may include combinations of low doses of tricyclic antidepressants such as imipramine, amitriptyline, and nortriptyline, as well as medications used in pain management for nerve related pain such as duloxetine, gabapentin, pregabalin and others. There are also various prescription ointments such as 5% Lidocaine ointment, and compounded ointments that can include medications such as amytriptyline, baclofen and gabapentin that can be helpful for some, but not all women. You can also find over the counter soothing creams, such as Medicine Mama’s V-Magic, Neogyn Cream, coconut oil, etc. Find a specialist to assist you by visiting NVA.org the web site of the National Vulvodynia Association.
In addition to medications to quiet the nerves, the brain also needs to be retrained to not perceive gentle touch as a threat. You can accomplish this by use of vaginal dilators starting with a very small dilator to allow for touch and insertion and movement and gentle pressure in the vaginal canal with low to no pain. We would recommend seeing a women's health PT to instruct you how to use the dilator to decrease the tension in your pelvic floor muscles as this can also play a role with your "ramped up nervous system". Once your muscles are more relaxed and there is increased blood flow into the vaginal region and decreased pressure placed on the nerves, then the vestibule is allowed to be less sensitive.
In addition to utilizing dilators and physical methods of retraining the brain and nervous system's responses, we recommend seeking psychotherapy with someone who specializes in treating trauma with neuro-therapies, such as EMDR (Eye Movement Desensitization and Reprocessing), EFT (Emotional Freedom Techniques), and Mindfulness-Based Stress Reduction. Neurotherapies help retrain the brain to get out of "fight, flight, or freeze" mode that is the body's normal response to stress and trauma. Addressing and healing past traumas are integral in the healing of the nervous and immune systems.
Each digital package is designed to address five main topics:
1. Explaining Pain: The science of pain and as it relates to chronic pain 'down there'. Everyone should know this information. Our team doctor uses these chapters to prep his patients before an appointment because everything he's going to tell them about pain science as it relates to Chronic Pelvic Pain disorders is in here.
2. Brain Neurobiology & Healing: Don't let the title scare you! Easily learn the basics of brain systems and strategies for healing the brain, including mindfulness-based stress reduction.
3. Physical Therapy (Breath, Posture, Stretching): Practicing appropriate breath, posture, and stretching techniques for pelvic floor and core functionality and health.
4. Physical Therapy (Relaxation and Strengthening): Practicing relaxation and strengthening techniques for the pelvic floor and hip musculature.
5. Physical Therapy (Dilator Use): Specific guidance and instruction in the use of dilators to desensitize pain responses in the pelvis for decreasing pain with sexual intercourse.
Each digital package is priced individually so that if you're only interested in one or two packages you only pay for what you want, making our guide more accessible and affordable.
Chapter 31: Ongoing Treatment
Now that you have the tools to treat the problem, decide what you need to continue in order to maintain healthy function and to manage your pelvic, genital, and sexual pain disorder. Many women experience painful sex for such a long period of time, they have no idea where the pain is coming from at first. But as you are able to map out your pain and understand where it is coming from (and why), you will begin to notice improvement. And you will begin to be confident that you have control over your pain. Should your pain return, you will begin to know why, and your confidence will build. Your learning curve about your own body will gradually increase and you will know how you can work to relieve it each time. With the techniques you have learned you can maintain proper function of the pelvic floor muscles and experience sexual intercourse with much less apprehension and discomfort.
Prior to this educational experience you may not have even heard of such conditions as Painful Bladder Syndrome or Interstitial Cystitis, Generalized Vulvodynia, Vulvar Vestibulodynia, Pudendal Neuralgia, and Pelvic Floor Dysfunction. These conditions and others just as common, such as Endometriosis and Irritable Bowel Syndrome all can be causes of and triggers for a variety of pelvic and sexual pain disorders. The more you know and the more you advocate for yourself and others with these conditions, the sooner the health care system will trend towards recognizing how common they are and how important it is to diagnose and treat them as early as possible. The quality of life of so many young people will depend on these issues being included in the routine evaluation of their health care into the future.
Chapter 6: The Pelvic Floor: An Overview
This chapter introduces the physical therapy component of the DVD. Hear from Karen Liberi, a physical therapist specializing in women's health and pelvic pain for over 16 years. Learn how to view pelvic pain as a threshold of pain and how to affect and move this threshold through techniques we will teach you.
What feels like "there is no rhyme or reason for my pain" will start to have a rhyme and a reason. The feeling of "I don't know where the pain is coming from" becomes "this is the reason for my pain and I can do something about it". The global feeling of pain in the pelvis becomes an identifiable, local area of pain that can be addressed with the strategies given.
Join Laura online as she discusses her personal experience with post-surgical pain and recovery on Friday September 18th as part of The Healing Pain Summit. Registration is free! Laura will talk about her Physical Therapist's Guide for Healing from Surgery and include tips for optimizing surgical healing.
The free online summit launches September 14th so take advantage of other great presenters and topics and register for free now.
Here are a few starting points:
1. Learn about the psoas from the point of view of Liz Koch at coreawareness.com. She has dedicated more than 30 years to this muscle. You may enjoy her Yoga Journal article here or if you learn better via video/audio check out her video segments. What I've gleaned from Liz so far is that our psoas muscles are primal muscles. So they are the "messengers" of the nervous system, holding trauma and emotion. As such, releasing the psoas should be a tender and gentle process, as she teaches through her articles, books, and videos.
2. Consult a Women's Health Physical Therapist. They can evaluate for this and other areas of muscle tension that may be contributing to painful sexual intercourse one on one. Manual "trigger point release" of muscular tension can prove immediately relieving. If you find you identify with Liz Koch's view of the psoas, this myofascial release technique on the psoas in particular may be controversial. You'll need to balance the approaches for yourself.
3. Learn safe and gentle stretches for the psoas muscle. Find stretches from sources you trust online or take a yoga class. Your Physical Therapist can also teach you stretches. We teach you how to stretch the psoas and other hip musculature in our DVD guide: Healing the Pain 'Down There'.
4. Take care of yourself. You can't expect your psoas to be happy and healthy if you treat yourself poorly. Maintain good posture and sit on your sits bones. Breathe from your belly and not from your chest, allowing your pelvic floor and core muscles to expand and relax as you breathe in. Eat natural, whole, nutrient rich foods. Drink plenty of water. Move and play. Keep your stress under control: practice guided meditation, see a therapist or spiritual advisor if you need support coping with painful or traumatic events or circumstances (past or present), be nice to yourself and treat yourself to cuddles with a furry friend, a hot bath, a massage, a cup of tea.
Fees are stated upfront and start at $18. And the App is super user-friendly.
1. Pick a practitioner
2. Book the appointment and confirm the cost then meet via the app in real time
3. Have access to history and appointment notes from your provider. Easily schedule another appointment.
Our own Physical Therapist, Karen Liberi, can meet with you over the Maven digital clinic app. Download the app to your Apple device and use promo code: KARENLFRIEND for 10 minutes free between now and August 31, 2015.
A woman with chronic pelvic pain brought together a team of multidisciplinary professionals to create this instructional and educational DVD guide for those suffering with “pain down there”. The team represents over 50 years of experience in women’s health related fields including OB/GYN, physical therapy, mindfulness techniques, and human sexuality with their focus being on the treatment of pelvic pain. This educational video is intended for women of all ages who are experiencing pain during intercourse who want to learn why they have their symptoms and learn strategies to improve them. This video is also for teens and young women who may be at risk for developing these symptoms, and for clinicians who are practicing in the field of women’s health.
“Groundbreaking … “
Jill Osborne, MA
ICN Founder & CEO
“A well designed comprehensive view of pelvic pain from a multidisciplinary perspective and clear options for returning to health and well being.”
Sandra Hilton, PT, DPT, MS
“A very important resource for many women...”
Frank Tu, M.D., MPH
" Respected pelvic practitioners create a road map to navigate the challenging path of healing pelvic pain."
Dustienne Miller PT, MS, WCS
The amount of danger signals that are sent up to the brain
The level of threat that is perceived by the brain
= The amount of pain we experience
In the context of chronic pelvic pain, the brain either perceives safety or danger. The more it perceives danger, the more pain we experience. It is important to note that chronic pain is not prolonged acute pain. "Chronic Pain" is the result of our brain interpreting signals through our nervous system, commonly long after the actual tissue damage has healed.
Triggers of these signals in the pelvic region can include one or more of the following:
1. Functional Systems (bladder, bowel, uterus, prostate in male pelvic pain)
2. Structural Systems (muscles and ligaments, often in spasm)
3. Nerves firing (causing tingling, burning, itching, dryness, aching, or even stabbing of surface tissues)
All of the signals from these triggers add up in our memories, emotions, and thoughts. These signals are also called "generators". When generators are sent up to the brain, the brain responds by sending down corresponding inhibitors. For example, when we stub our toe it really hurts for a couple of seconds! Until our inhibitors take over. Our brain immediately tells us that by all of our previous experiences, stubbing our toe is not dangerous. So the pain quickly fades away.
But with chronic pain, the generators outweigh the inhibitors and the volume of our nervous system gets "turned up". Over time, the nervous system responds more and more strongly to a smaller amount of signals. This is one reason why sensitivity related to the external genitals and pelvic floor, for example, can increase over time when not treated and managed properly.
The more we understand what is going on in the body, how pain is processed, and the more "tools" we have to temper these signals and how they are reacted to in the brain, the more we are likely to reduce the pain or "turn the volume dial down". Focused training can help us guide us in the process. These tools include: Mindfulness-Based Stress Reduction, diaphragmatic breathing techniques, and physical therapy. As well as other disciplines like medicine, psychological counseling, nutrition and dietary changes, yoga, and massage.
When you start with an extra small dilator and can insert it, move it, do self stretches with no to low pain - then the brain starts to realize that "ok, that wasn't so bad" and the secondary response of muscular tensions ease, allowing for less pain. Scanning and mapping the pelvic floor alongside your dilator use also helps the brain perceive these muscles in a more normalized way. This allows for much less "red flag signals" being sent to the brain. Your overall confidence level with repeated successful sessions with the dilator and vaginal canal mapping allows you return to intercourse with low to no pain. So essentially what you are doing is changing the perception in your brain about the health of your vagina and decreasing the sensitivity of the nervous system to keep muscle tension in check.
Along with dilator work there are other exercises such as flexibility work to the hips and trunk and relaxation breathing to quiet the nervous system. It is important that during this process you abstain from sexual intercourse. But of course this is not to say that you abstain from intimacy. We strongly recommend the personalized training of a women's health physical therapist to guide you. You can also use these and other techniques taught in our DVD guide under the consultation of a health care provider.
*Be advised that some conditions such as Vulvar Vestibulodynia (Vestibulitis) may need further medical management before beginning the use of dilators.
The actual causes of chronic, persistent pain itself are in all of these neuro-myofascial components: Nerves, Muscles, and Ligaments. Bladder, bowel, and reproductive organs are commonly acting as "triggers" that set off painful, but protective responses in the region. Just as in any other area of the body, the muscles, nerves, and ligaments go into a protective bracing mode as a result of current tissue injury, protecting against further injury, and even when the system is reminded of past injury. These structures are trying to immobilize the region in order to control the pain.
Comprehensive assessment and treatment of chronic pelvic pain therefore will naturally include specialized pelvic floor physical therapy to rehab and release long term muscle spasming and trigger points, as well as a working knowledge of diagnosing and managing chronic nerve type pain in the pelvic and genital region.
Stephanie Yeager: Passionate about spreading the word of hope and healing for those like her, influencing a paradigm shift in the medical community toward greater understanding of chronic pelvic pain disorders, and prevention initiatives that may protect young women before onset can occur.
Chronic Pelvic Pain
Health Care Providers
Mindfulness / Mind Body
Mindfulness / Mind-Body
Painful Bladder Syndrome
Pelvic Floor Dysfunction
Pelvic Floor Muscles
Pelvic Floor Physical Therapy
Persistent Genital Arousal Disorder
Real Life Stories
Semen Allergy (SSPA)
Sexual Partners Support
Vaginal Health Guide