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WHAT IT IS NOT The diagnosis of CPP doesn't convey a great deal of information. It establishes that a woman has pain that appears to originate in the pelvis or pelvic floor and that isn't related to menstrual issues or to other organ-related problems. This rules out the possibility that uterine fibroids, ovarian cysts, lesions in the colon, and any kind of infection, tumor, or cancer might be causing the pain. Obviously, to achieve this diagnosis requires extensive, invasive, and expensive testing that includes manual pelvic exams, cystoscopies to examine the bladder, and pelvic laparoscopy—all to find nothing wrong. It is important to point out that any combination of these pathologies may have been a problem for a person in the past, but in a diagnosis of CPP, it is understood that these issues have essentially been resolved, while pain persists or even gets progressively worse. WHAT IT MIGHT BE Contributing factors or precipitators for CPP may include any number of hard-to- define issues, including myofascial trigger points in the abdominal wall or levator ani muscle, irritated nerve endings (pudendal neuralgia), painful bladder syndrome, irritable bowel syndrome, pelvic congestion syndrome (a condition with varicose veins near the ovaries), postsurgical scarring, and a history of sexual and/or physical abuse. None of these are simple to diagnose, and they seldom appear by themselves; more often, they present in combinations. COMMON COMPLICATIONS Given the challenges inherent in living with this difficult condition, it is not surprising that many women with CPP also live with some combination of anxiety and depression. These mood disorders can exacerbate physical symptoms, and they can promote behaviors and health-care choices that interfere with effective treatment. Pain-promoting behaviors, like eating poorly, limiting movement, and isolating oneself from a support system, can perpetuate the problems. Hilton observes, "A person can feel completely betrayed by her own body. You do all the things people tell you to do, and it still hurts." It is common for women with CPP to struggle to hold on to a job, maintain a relationship, or feel like they can be vital, contributing members of society. THE PROBLEM OF PAIN The study of the science of pain is undergoing some exciting transitions that have major implications for manual therapists, but this article will not attempt to reteach everything we know about this phenomenon. However, here are a few issues that are worth reviewing, particularly in the context of CPP: • Pain is a protective reaction to the perception of threat, and, in this, it serves a valuable purpose. The pain we perceive when we damage tissues is an appropriate defensive response to tissue damage and a risk of further injury. Understanding this doesn't make pain disappear, but it does allow us to attach meaning to our experience. • Pain is not fair. It is a product of several factors: tissue damage, perceived threat, our level of arousal, our social context, personal history, and many other considerations. It can occur without identifiable tissue damage, or it can outlive recovery so that even where tissue has healed, the pain persists. Most of us experience occasional abnormal impulse generation, but for some people this becomes a chronic, self-sustaining pattern. • Pain can make pain worse. People who live with pain may go through changes in their nervous systems that allow more pain signals to be transmitted, while the neurotransmitters that would normally filter some of that out are suppressed. Furthermore, pain is exacerbated when we feel threatened; safety is paramount. No therapy or exercise that feels unsafe is likely to be successful. • The traditional strategy for tracking progress in pain treatment is as a measure of severity: we look for the treatments that make pain less severe. This approach is shortsighted and problematic because the most effective way to reduce pain severity is through opioid drugs—and this leads to a host of other problems. Clearly, severity alone is not an adequate way to track progress with pain management. • Pain can be managed. One of the most important strategies in dealing with chronic pain is to help someone learn that "her pain must be respected, but it need not be feared," Hilton says. In this way, a person may not get her pain down to zero (who does, really?), but she may be able to manage it in a way that allows her the power to do the things she needs and wants to do. In other words, it comes back to patient-centered care and that key question: "What does better mean to you?" C h e c k o u t A B M P 's l a t e s t n e w s a n d b l o g p o s t s . Av a i l a b l e a t w w w. a b m p . c o m . 43

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