When your signals don’t function properly you have to come up with new systems to get through the day. This is one I found very useful, it goes something like this: Don’t forget to wee!
When your signals don’t function properly you have to come up with new systems to get through the day. This is one I found very useful, it goes something like this: Don’t forget to wee!
My creativity has been one of my main coping mechanisms through my chronic pain life. It’s the place I go to feel free, release the steam, express my pain, and to get distracted to the point of pain! But it’s worth it every time. There isn’t a lot I can achieve with my capacity so one drawing, one painting over months, one post on my blog… anything, it’s all worth it.
Art helps with many health issues, even if you can’t participate, finding a piece that connects with you can also be helpful. And it’s something you can do from your own comfy seat (if you have one, I’m yet to find one!!).
Here are a few art sites that you can either contribute to or simply subscribe to for regular, beautifully distracting, updates. They are not all related to pain, I, for example try and avoid talking or expressing pain and rather choose to paint my happiness, it just feels like I don’t get away from the issue otherwise. I also prefer to seem like the old me, it’s my target. I like saying the words ‘I painted, I did, I am going to’ without having to add the ‘it took/will take me ages’.
Gallery of Pain. The Art of Releasing Emotional or Physical pain..Ambience of Pain.
Thank you for visiting the online version of the PAIN Exhibit, which showcases approximately 100 pieces of art from people with chronic pain from across the globe.
artwhatson.com.au is a meeting place for art lovers, artists and galleries. Our e-news delivers a weekly snapshot of what’s happening in Australian art.
Jennie works to maintain the image of the nude in art and writes a blog about censorship in art. She also leads a group for artists with disabilities.
Personal stories of struggle, strength, and success expressed through art.
Living Beyond Pain showcases the challenges of, and responses to, chronic pain in daily life. It contains artistic expressions of success—real stories of coping, managing, and moving beyond pain.
To the German artist, known in art circles as “Headcrime”, music provides instant visual associations. Literature, history, art, archeology and, unfortunately, life experience with chronic pain, influence his work.
Music, Opera, Knitting, Food – the essentials as far as we are concerned.
Art opens up something inside of you that sometimes you forget is even there. Art transforms. It brings hope, peace and possibility. It brings life.
How many definitions for chronic pain can there be? It doesn’t stop and I have to be really honest here, it all sounds like hogwash for a person who was unstoppable and prior to her injury had the stamina of a bull (as a friend once described me).
I struggle with the explanation that my brain is protecting me… It makes no sense that my mind would want Soula to be like this, why it doesn’t stick to the occasional low pain levels if it recognises them, and above all, if my brain is so damn smart why is it stuck in pain land since 2007!!!!!! Can we please get on with life brain.. can you please just get over it?
Do I have the Explain Pain book? Of course I do.
Explain Pain has been a huge stepping stone for patients and clinicians – not only in understanding pain but being able to communicate the concepts to others. Over 5 years on, and the book is still unprecedented in its layout, descriptive illustrations and incredible bank of information. Backed entirely by scientific evidence, Explain Pain is a recommended text at many universities but also read and enjoyed by everyday people in pain.
I’ve always been curious and I wanted to understand and visualise my area of pain but for 4.5 years that wasn’t possible as I was never diagnosed accurately and didn’t have the visual reference in my head either. From my yoga practice I remember sending the breath to different areas of my body and it was not only relaxing, but it I felt I was sending great energy to that area… sort of loosening it up, relaxing, letting go. I wanted to get back to that after diagnosis and I found this brilliant resource to help me do just that.
The following info was originally from the tipna.org website (which is now owned by pudendalhope.org) and refers to Anatomy: A Regional Atlas of the Human Body, 4th Edition, by Carmine Clemente, 1997. These are very detailed, very well illustrated images. I’ve seen alot on the internet and some photos can be confronting, these however are great. Clear and thorough.
Female Pudendal Nerve – Two thirds of PN sufferers are women, according to Dr. Robert’s statistics of over 3,000 PN patients (and over 400 PNE sugeries) since 1987 as of 2002. This image shows the entire region served by the female pudendal nerve in extreme detail. To study it, find the pudendal nerve and follow it. Note how it is perfectly symetrical, with left and right sides. Observe the many fine branches, not all of which can be shown on the drawing. Note also the other nerves. (From Clemente)
Male Pudendal Nerve – The male version of the above. (From Clemente)
These are the images to print out and show your doctor, and are sized to print well on a sheet of paper. Use Normal or Best mode (not Draft), and print in color if you can. Mark where your pain is and discuss what could be causing it. With the right doctor and good preparation on your part, you can move swiftly through the diagnosis step.
Comparison of Pudendal Nerve Drawings – This compares images prepared by Doctors Robert and Beco. Placing them side by side and identifying the key items allows you to more easily grasp the route of the pudendal nerve, along with the potential entrapment locations on the route. The most common point of entrapment is at the ischial spine, where the pudendal nerve runs under the sacrospinal ligament. The second most common is in the pudendal canal. These are the two principle entrapments that Dr. Robert’s surgical protocol resolves.
This single image was prepared from these two separate images:
Pudendal Nerve by Dr. Robert – Submitted by Kevin Harwood. As he describes it: “Be certain that you see the last attachment, as it is an ‘autographed,’ Netter image personally-manipulated by Professor Robert. He manipulated this image to demonstrate the pudendal nerve exactly as he finds it in situ. I am not sure if this is an artist’s proof edition, signed and numbered, or just a regular lithograph, but Professor Robert did give it to me.”
Pudendal Nerve by Dr. Beco – The pelvic region and route of the pudendal nerve are so three dimensional they are hard to visualize. This image does an excellent job of showing bone structure, nerve paths, and ligaments in a 3D manner. Note especially Alcock’s Canal and where the pudendal nerve passes under the sacrospinal ligament where it attaches to the ischial spine. These two locations are where most pudendal nerve entrapment occurs, and is what Prof Robert’s surgical procedure alters to “free up” and “decompress” the nerve.
Body and Pelvic Region, Rear View – To the non-medical person (the layman), the pelvic area is hard to understand due to its 3D nature and complexity. This image starts you off on understanding this region by showing the key items: the pelvic bone, the ischial spine, and the ischial tuberosity. Note where the fold of the buttocks is in relation to the ischial tuberosity. When you sit, the two ischial tuberosity bones take about 75% of your body weight. These bones are frequently called the “ischials” or “sitting bones.” The coccyx can also be seen. (From Clemente)
Pelvis and Ligaments, Rear View – The above image of the pelvis was just bones and the body was drawn in, so you could see where the pelvis is. This image takes the next step. The body is removed. Ligaments are added. The features of interest are the sacrotuberous and sacrospinous ligaments. These are the two ligaments that Dr. Robert’s surgical procedure modifies to free the pudendal nerve. As his article says on pages 7 and 8: (From Clemente)
“The surgical principle is simple: the gluteal incision is made in the axis of the fibers of the gluteus maximus m. on either side, with a transverse limb passing over the coccyx and thus situated at the level of the ischial spine. The posterior aspect of the sacrotuberal ligament is stripped free of its muscular attachments. The sacrotuberal ligament is windowed over 2-3 cm (Fig. 10).
“The pudendal neurovascular bundle is then seen crossing behind the sacrospinal ligament. The latter is divided and the nerve can then be transposed in front of the spine, thus gaining precious centimetres thanks to this freeing (Fig. 11). The sacrifice of these two ligaments is not accompanied by any biomechanical disorder.”
Pelvis and Ligaments, Front View – Next we walk around to the other side for the front view of the pelvis. This is radically different. Since we can no longer see where we sit down, the features of interest are mostly hidden from view. The two ischial tuberosities can still be seen. They make great reference points. The tip of the coccyx can just barely be seen. The important concept in this image is the way the pelvis holds up the internal organs in the abdominal cavity, much like a bowl holds jello. The next image will take a look into that bowl. (From Clemente)
Pelvis and Ligaments, Front View from Above – Pretend you have poked your head inside your stomach and are looking down. This is what you would see, if everything except pelvic bones and ligaments were removed. Notice the two key ligaments again. Imagine all your organ weight pushing down as you go about your everyday vertical existence. Now, imagine adding to that pressure by sitting long amounts every day. This pushes from the bottom, right on everything that’s down there. Pushing forces are magnified wherever there is a bone protruding into the pelvic cavity. Guess which one takes the cake here? Why, it’s our old friend, the ischial spine, once again. Prof Robert describes the problem this boney protrusion causes in his article: the pudendal nerve “describes a curve which drags it around the region of the ischial spine, which it straddles like a violin string on its bridge.” A similar problem occurs in Alcock’s canal. For those who are susceptible, the result of all this pressure and nerve vulnerability is PN or PNE. (From Clemente)
Pelvis and Ligaments, Cadaver, Front View – This is a little gruesome, but the detail is there. Note the roughness on the ischial tuberosities and the very bowl like shape. When you stop and think about what you’re looking it, what it does, and how well it does it, it’s really an engineering marvel.
You may be wondering, “Why all these views of bones and ligaments? Isn’t this a nerve problem?” This is true, it is a nerve problem. But to best self-manage our case, we need to have an accurate, complete model of understanding of why the nerve becomes inflammed or damaged. The nerve doesn’t damage itself: something else has to do that. That something else, for PNE, is bones or ligaments pushing for a long time at a pressure level far above what our poor little bodies were designed for. Muscle, fat, and other soft tissue doesn’t cause concentrated pressure: only harder things can do that. As you probably know, Homo sapiens was not designed for sitting. Our body evolved to mostly hunt and gather, and to sit only a little. Modern civilization has reversed this: we sit a lot and walk or stand very little. The inevitable result? A design mismatch and PNE. Some doctors have remarked it’s a wonder that many more people don’t have PNE.
Pelvis and Ligaments, Vertical Cross Section – Now we get really bold. Imagine you have just followed Alice in Wonderland into her magical, miniature world and are now two inches tall. You are standing in the bottom of the pelvic cavity. Your view has been improved by splitting the spine temporarily. (After all, we wouldn’t want to hurt anyone. You look over towards the right hip. This is what you would see. All our old friends are there: the sacrospinal and sacrotuberous ligaments, the ischial tuberosity, and the by now infamous ischial spine. (From Clemente)
Pelvis Cross Section, Horzontal – You are still two inches high. Now put on your best X-ray glasses. Imagine a patient is lying down, perhaps after a pleasant picnic on the Rhine. You step between their legs and look towards the bottom of the pelvic region. You see a perfect cross section, exposing all those little things runnning up and down at the point of cross section. Be sure to notice where our best friend, the pudendal nerve, runs. The poor stressed out fellow has not yet reached the ischial spine, which it does only about two inches futher down. Note also the nerves running under the ischial tuberosity. These nerves are heavily padded by the gluteus maximus muscle and fatty tissue, but are still highly vulnerable to damage, because they have rock hard bone behind them. (From Clemente)
Now, imagine the patient you are viewing gets up and sits down in a chair. Can you see how the chair pushes on the all that tissue, which in turn mashes those nerves against the bones or ligaments they run over? On, I pity the nerve that lives such a down trodden life! Next, imagine sitting on a bicycle. The bicycle seat gets right up in there and pushes ever so hard on the pudendal nerve, who frequently is totally overwhelmed by the experience and has been known to go on strike! Or so all these little nerves have been telling me….
Thank you for joining us on our tour of the pelvic region. If you have any further questions, just ask our intrepid guides, who can be found in the group discussion areas. The next tour will start in approximately 30 minutes….
The pudendal canal, also called Alcock’s Canal, is the second most common location of pudendal nerve entrapment, after the ischial spine. During Dr. Robert’s surgical procedure, if necessary the pudendal nerve is “freed up” from the pudendal canal by very carefully cutting the obturantor fascia (sheathing) that lies over the canal, and gently working the nerve out. This is a rather delicate surgical technique. Do not try this at home.
Pudendal Canal Closeup – This image is taken from the one below and enlarged so you can see enough detail. Note the bundle of pudendal nerves, veins, and arteries runnning together through the pudendal canal. This image also gives amazing detail on all those tiny yellow nerves in the anal and perineum regions. This is top notch artistry. (From Clemente)
Male Perineum, Superficial Dissection – This shows different detail from the Male Pudendal Nerve image in Key Images. Superficial dissection allows showing many more nerves, as well as the pudendal canal. (From Clemente. No thumbnail shown since so similar to the above image.)
Pelvis and Perineum Frontal Section – This shows the pudendal canal as it travels along the lower obturator internus muscle and pelvic bone. The canal has been highlighted in yellow. Note the potential for intense compression of the canal by bicycle riding. Many new bicycle seat designs have a depression in the center to reduce perineum pressure. However, this only increases pressure elsewhere, resulting in an even higher chance of injury. Please don’t be fooled by such fancy seat designs. (From Clemente)
Perineum with Pudendal Canal Probe – The route of the pudendal canal is so hard to show in illustrations that this image takes an ingenious approach. A thin steel probe has been inserted to show where the canal runs. Note how deep into the patient a doctor would have to go to free up the pudendal nerve in the canal. This, of course, is why this surgery is so demanding. (From Clemente)
Pudendal Canal Probe Detail – This shows detail from the above image. (From Clemente. No thumbnail shown since detail from above image.)
Pelvic Wall Blood Vessels and Nerves – This shows the various pelvic nerves as they leave the lower spine. The pudendal plexus is where the pudendal nerve orginates. Plexus means “a structure in the form of a network, especially of nerves, blood vessels, or lymphatics.” From the pudendal plexus, the pudendal nerve travels down to the anal, perinum, and genitalia. This image does a good job of showing how, in the seated position, the pudendal nerve receives so much pressure. (From Clemente)
Path of Pudendal Nerve, Male – This well drawn sketch is from Dr. Antolak, formerly of the Mayo Clinic. Note how the nerve travels under the sacrospinous ligament near the ischial spine and then branches out. This is a great job of showing the three dimensional route of the nerve. Note the three branches of the pudendal nerve and how they serve different areas. Many male sufferers have severe pain in these areas. If you are unfortunate enough to be one of them, this image allows you to almost feel where the offending nerve is. Hopefully that will help you better discuss your case with your doctor. See source. (This link is broken. Can someone find it on the Prostatitis site?)
Innervation of the Female Genital System – This shows the route the pelvic and pudendal nerves take as they feed off of the sacral plexus. The text explains much futher detail. This image is from Volume 1, Nervous System, by Frank H. Netter M.D, 1968. Provided by Renee. Happy reading!
Innervation of the Male Genital System – The male version of the above. No thumbnail shown.
Neuro Orthopaedic Institute (NOI) Australasia has been in operation for 20 years, with highly qualified instructors working on all continents with multidisciplinary audiences. Organising over 100 seminars a year throughout the world, NOI’s faculty members are active in many conferences, university programmes and other postgraduate education sessions. The company reinvests in education and clinically based research and Noigroup Publications has grown from the demand for resources to support this emerging research.
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Our vision is to seed ‘healthy notions of self through neuroscience knowledge’ worldwide. Read on…
I was referred to two pain management centres in Melbourne. One doctor was happy with my own pain management routine and the other team asked that I agree to accept responsibility for my chronic pain and that I will forget having future x-rays, mri’s etc. if I was going to participate. Well as if I was going to go for that? As reputable as the centre was it didn’t sound right for me and as it turned out, it wasn’t.
This sounds a little more appropriate for me.
Six day Comprehensive Pelvic Pain Intensive Clinics for the Stanford Treatment Protocol
Chronic pelvic pain syndromes have been a puzzle to the best medical minds for a century. Antibiotics, anti-inflammatories, prostate massage, and surgical procedures, which form the backbone of traditional treatments, have been of little use in dealing with these debilitating afflictions. In A Headache in the Pelvis, we describe a new treatment protocol developed at Stanford University’s Department of Urology that has stepped out of the box of conventional medical treatment. It involves a combined medical, behavioral, and physical intervention that has been successful in substantially abating the symptoms of pain and dysfunction in a select group of patients with chronic pelvic pain syndromes. This protocol is based on a new understanding that chronic pelvic pain syndromes are not caused by prostate or organ pathology but instead a chronically contracted pelvic floor that has made an inhospitable environment for the organs and tissues found within it.
This protocol is unusual because it requires the coordination of a physician, psychologist, and physical therapist. Successful results are dependent upon the willingness of the patient to actively comply with the regimen described in A Headache in the Pelvis for an extended period of time. This is in contrast to the conventional form of medical treatment which looks to a quick solution by drugs or surgery with minimal participation of the patient. The solution to this vexing condition is neither quick nor easy and requires a very large expenditure of effort. Our patients are typically people who have had pain and dysfunction for years, have seen numerous doctors, and have unsuccessfully used the conventional treatments.
While we have reached out to the medical community to educate them and to train them to use our approach, at present there are very few who can competently offer our protocol. It is for this reason that we have established these monthly clinics. They are designed to offer the most effective and comprehensive form of the treatment available described in A Headache in the Pelvis.
Perhaps the greatest suffering for patients with pelvic pain syndromes is the sense of helplessness that patients feel in the presence of their pelvic pain and dysfunction. We are not able to help everyone we treat. When we are successful in helping people with this problem, we are able to give them tools to reduce or abate their symptoms. When the treatment is successful and participants comply with the home practice portion of the protocol, some clear reduction of symptoms is usually seen within a period of three to four months. Stable reduction or abatement of symptoms can take several years and in many individuals who respond to our treatment, improvement continues with the use of the protocol.
These clinics train participants to do self-treatment at home. They are done in small groups and consist of approximately 20-30 hours of treatment over the period of 6 days. The content of the workshops consists of:
Medical evaluation is usually done by Dr. Rodney Anderson at Stanford University or other participating urologists in the San Francisco bay area. The Paradoxical Relaxation training is conducted by Dr. David Wise and the Myofascial/Trigger Point Release is conducted by senior physical therapists trained in the Wise-Anderson Protocol at a site about an hour north of San Francisco.
In the event the treatment protocol is not deemed to be appropriate at the time of the evaluation, other treatment options will be discussed, and the participant will only be charged for the cost of the Stanford medical visit. Both the relaxation training and physical therapy are done on site in Sebastopol California and have no medical/financial relationship with Stanford as participants come to Stanford for the urologic evaluation alone.
Six Day Wise-Anderson Protocol Intensive Pelvic Pain Clinics Northern California
January 27-Feb 1
March 3 – 8
April 7 – 12
May 19 – 24
June 23- 28
July 14 – 19
August 11- 16
September 22 – 27
October 20 – 25
November 10 – 15
December 8 – 13
For information and registration
phone: 1 866 874 2225 (toll free)
1 707 874 2225
I am amazed at how occupational physicians translate what I tell them. They seem to add like this: 1 + 1 = 10!!!
Soula: I have a 1 kilo weight limit at the best of times
Occupational Physician suggestion for work: Delivering pamphlets.
So my pamphlets will magically float with me and I will reach, gently so I don’t disrupt my chronic back issue, and pull one from the air placing it in the designated mailbox which will conveniently, always be at the appropriate height for me. Voila!
Workcover, did you really pay for this advice?
Article first published online: 11 MAR 2011. © 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG
Extract from: onlinelibrary.wiley.com
I read with interest the paper by Shek and Dietz,1 and congratulate the authors for an informative study. With all its limitations, such as early postpartum follow-up, the authors have described a new form of birth trauma (irreversible overdistension injury), which is distinct from levator avulsion injury, and cannot be detected by static magnetic resonance imaging (MRI). In their study, 13% of women after a normal vaginal delivery had levator avulsion diagnosed. I would be grateful if the authors could clarify how many of these women had an episiotomy and how many sustained a perineal tear. Similarly, I would be grateful for clarification on how many of the 28.5% of vaginally parous women diagnosed with ‘levator microtrauma’ had normal deliveries, and what proportion had episiotomies and perineal tears.
Levator avulsion (macrotrauma) has also been detected on MRI scans, and is believed to result from avulsion from the origin of the muscle at the pubic symphysis. I would be grateful if the authors could suggest how ‘levator microtrauma’ (which implies patchy infarcts or ischaemia) would lead to a permanent overdistension of the levator hiatus. Instead, one wonders whether disruption of the perineal body (which is the midline union of muscles and endopelvic fascia) is another possible mechanism of irreversible traumatic overdistension of the levator hiatus. Indeed, whereas the levator can distend to 1.5 times its size, fascia would probably have a lower threshold for disruptions. On clinical examination, a widened urogenital hiatus is often correlated with a deficient perineum.
Recent work has shown that mediolateral episiotomies are closer to the midline than was previously believed.2,3 One wonders whether acutely angled episiotomies and midline perineal tears (especially anal sphincter injuries) are contributory factors to perineal body disruption and consequent overdistension injury.
The authors conclude by suggesting modifications in current obstetric practices to prevent levator trauma, without specifying what these are. I would be grateful for their thoughts on whether a well-directed mediolateral episiotomy could reduce the risk of overdistension injury, as has been suggested by DeLancey.4
Also, is the timing of the episiotomy important? Is the damage already done by the practice of giving episiotomies at crowning? Would performing an episiotomy prior to the crowning of the head help in preventing irreversible overdistension injury?
In humans, the pelvic floor skeletal muscles support the viscera. Damage to innervation
of these muscles during parturition may contribute to pelvic organ prolapse and urinary
incontinence. Unfortunately, animal models that are suitable for studying parturition-induced
pelvic floor neuropathy and its treatment are rare. The present study describes the
intrapelvic skeletal muscles (i.e., the iliocaudalis, pubocaudalis, and coccygeus) and their
innervation in the rat to assess its usefulness as a model for studies of pelvic floor nerve
damage and repair. Dissection of rat intrapelvic skeletal muscles demonstrated a general
similarity with human pelvic floor muscles. Innervation of the iliocaudalis and pubocaudalis
muscles (which together constitute the levator ani muscles) was provided by a nerve (the
“levator ani nerve”) that entered the pelvic cavity alongside the pelvic nerve, and then
branched and penetrated the ventromedial (i.e., intrapelvic) surface of these muscles. Innervation
of the rat coccygeus muscle (the “coccygeal nerve”) was derived from two adjacent
branches of the L6-S1 trunk that penetrated the muscle on its rostral edge. Acetylcholinesterase
staining revealed a single motor endplate zone in each muscle, closely adjacent to the
point of nerve penetration. Transection of the levator ani or coccygeal nerves (with a 2-week
survival time) reduced muscle mass and myocyte diameter in the iliocaudalis and pubocaudalis
or coccygeus muscles, respectively. The pudendal nerve did not innervate the intrapelvic
skeletal muscles. We conclude that the intrapelvic skeletal muscles in the rat are similar to
those described in our previous studies of humans and that they have a distinct innervation
with no contribution from the pudendal nerve. Anat Rec Part A 275A:1031–1041, 2003.
© 2003 Wiley-Liss, Inc.
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