As I reflect on this blog post, I thought back to a few key courses that have had a significant impact on my clinical practice as a pelvic health physiotherapist. It began with my first pelvic floor course with Dianna MacDonald in Alberta, back in 1997. This course was a game changer for me as it led me down the path of pelvic health. I have not looked back since! My next moment of clinical clarity came during Rhonda Kotarinos’ course, where I was enlightened about the existence of short and tight pelvic floor muscles. My outcomes in patient care skyrocketed but I felt that I needed more as my practice started to include persistent pelvic pain. I began to make some observations.
Why was it that for some patients, significant changes could occur in a few sessions, but in others, the same treatment approach was ineffective? One particular patient stood out for me. She was a patient that reported rectal pain that had persisted for more than 5 months. She was worse with sitting, pain with bowel movements and dyspareunia. Focusing on the short and tight pelvic floor, I was able to provide her with a few days of relief but the pain always came back. I began to feel frustrated and felt that I was missing something. During one of our treatment sessions, as I was doing an internal exam, I gently began to ask questions. How are things at home? How are the kids? My next question was key. How is work? As soon as the words came out of my mouth, I felt (and so did she) her pelvic floor tense! Her pain increased and treatment had to stop. My patient divulged to me that her boss was verbally abusive towards her at work and the 8 hours she spent there were insufferable. Over the next few sessions, I gently broached the subject of her work situation. I suggested that perhaps there was a link between her pain persisting because of the stress she was experiencing daily while at work. This was difficult for her but she did have the courage to leave and seek other employment. She called me a few months after she left her work and stated that her pain has disappeared. No more treatments were necessary. This patient had an impact on me and again, I sought to understand the role between stress, trauma and the impact on pelvic pain.
For that, I have to thank my friends and colleagues, Carolyn Vandyken and Sandy Hilton. Their enthusiasm and dedication in helping me gain understanding in the complex world of pain and the biopsychosocial approach continues to help me improve my skills.
Most recently, I attended a course taught by Lisa Aldworth, MSW, RSW through Pelvic Health Solutions. Her knowledge, passion and compassion as a therapist and trauma specialist were evident throughout the weekend. The focus of this course was to discuss the effects of trauma, including Birth Trauma, and Childhood Sexual Abuse on our pelvic pain population. Over the years, I have strived to provide a safe and nurturing environment for my patients. I have made mistakes but learnt from them as well. My patients have allowed me into their circle of trust and for that I am grateful.
But it became clear to me that I was lacking some skills to help me practice with a trauma-lens. How do I best manage a patient that has the courage to share his or her trauma experience with me? How do I support them? How do I do this without going home emotionally drained after giving them all of my attention?
Do we really know how many of our patients, pelvic health or orthopaedic, have lived through some form of trauma? What impact does this have on their quality of life, health, relationships and ability to heal and recover from their injuries?
Here are a few daunting statistics. In Canada, 1 in 3 girls and 1 in 6 boys experience an unwanted sexual act in both childhood and adolescence. The stats state that 95% of children are at the greatest risk of being sexually assaulted by someone they know.[i]
The ACE (Adverse Childhood Experience) study highlights that children exposed to trauma have a higher risk of developing chronic illnesses in adulthood. Such illnesses include: cardio-vascular disease, diabetes, gastrointestinal disorders and cancer. This ground-breaking study has led the researchers to discover that traumatic events dysregulate the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. Recent studies in the field of psychoneuroimmunology have contributed further understanding that trauma affects the inflammatory responses (immune system) in the body. As such, researchers in this field have concluded “past trauma primes the inflammatory responses, HPA and SNS to respond more rapidly to subsequent life stressors.”[ii] Theses stressors seem to suggest an increased likelihood of chronic illness, including persistent pain in adulthood.
These childhood events included all types of maltreatments: psychological, physical, sexual abuse, exposure to parental substance abuse, mental illness, intimate partner violence and criminal behaviour.
Let’s also recognise that some of our adult patients may currently be experiencing maltreatments and may have recently suffered through a traumatic event leading to PTSD. How prevalent is PTSD? A recent Canadian Forces survey estimates that 11% of regular personnel have experienced PTSD at some time.[iii] Another report stated that 36% of male corrections officers suffer from PTSD.[iv] As well, the Canadian Mental Health Association has noted the “military personnel, first responders, doctors, and nurses experience higher rates of PTSD than other professions.”[v] And it has also been suggested that between 25-35% of women reported that their birth experience was traumatic and that a third of these women may develop PTSD.[vi] We are walking every day amongst trauma survivors!
How may you recognize that your patient is a trauma survivor?
It seems that trauma survivors are the highest consumers of healthcare and physical problems are more prevalent in women with a history of sexual assaults. What physical problems can we see in this population? Diabetes, obesity, arthritis, asthma, recurrent surgeries, chronic pelvic pain, IBS, back pain, headache, eating disorders, poor reproductive outcomes, pelvic inflammatory disease, respiratory problems, neurological problems and hypertension. Trauma affects the ability to regulate basic biological functions and leaves a deep impression on the body.
What are clues that may suggest a history of trauma?
An inability to tolerate conflicts with others, a sense of worthlessness, dissociation, self-blame, intense anxiety, depression, inappropriate attachment to unhealthy people, addictive behaviours and possibly self-harm are just some indications of the presence of trauma.
As we sit and ponder the stats and the implications of trauma, we need to ask ourselves what can we do to help navigate care for our trauma survivors. How do we listen to our patient’s story without feeling the emotional toll ourselves?
This will be discussed on my next blog post “Creating a survivor friendly practice”.
“Anything that’s human is mentionable, and anything that is mentionable can be more manageable. When we can talk about our feelings, they become less overwhelming, less upsetting, and less scary. The people we trust with that important talk can help us know that we are not alone.”
[i] Source: Child Sexual Abuse (The Canadian Badgley Royal Commission, Report on Sexual Offences Against Children and Youths), 1984. (pg. 215-218)
[ii] Kendall-Tackett, K., Psychological Trauma and Physical Health: A Psychoneuroimmunology Approach to Etiology of Negative Health Effects and Possible Interventions, Psychological Traum: Theory, Research, Practice and Policy, 2009, Vol. 1, No. 1, 35-48
[iii] Zamorski, M. et al, The 2013 Canadian Forces Mental Health Survey, Can J Psychiatry, 2016
[iv] Exposure to Critical Incidents: What are the effects on Canadian Correctional Officers, Correctional Service Canada Forum on Corrections research, Volume 4, Number 1, 2015
[v] Post-Traumatic Stress Disorder, Canadian Mental Health Association