There is a deep insight in a book called the Course in Miracles that says: “ In my defenselessness my safety lies”. This means that we only feel safe when we are not tightening up in self-defense and self-protection. Protective guarding typically reflects a state of fear, a state of not feeling safe. Only after one is willing to trust that there is no threat and one let’s down one’s guard, anticipating nothing threatening, can we feel the relief of feeling safe. Only then can the muscles relax, the nervous system ease and the systems of the body can rest.
Most of us intuitively understand that there are groups of people who respond to stress in different parts of their body. We all know people who under stress get headaches, or who suffer with gastrointestinal symptoms, have high blood pressure or non-cardiac chest pain among other physical reactions. I am clear that there is a group of patients who can be called pelvic responders, people who have symptoms of pelvic floor pain. I know this group very well as I was a member of this group. I have treated many people who are pelvic responders over the years as well.
Just like cars that respond to wear and tear in different places… some cars are known to variously have problems with the fuel system, charging system, electrical system, among others — all of these different problematic mechanisms, are brought about by the stresses and aging of a car. So it is with people. In another podcast I have discussed pelvic pain as a local and systemic problem. It is local in that the local area of the pelvic floor becomes sore, irritated and contracted. It is systemic in that it is the stress on the car by virtue of simply driving it, that can trigger the various local reactions.
Understanding this, the reduction of stress and reduction in nervous arousal is helpful for many what could be called functional disorders. There is a significant, published scientific literature documenting the relationship between the reduction of stress and the resolution of stress related disorders. In the Wise-Anderson Protocol for pelvic floor pain, we treat both the local and systemic dysfunction. We train our patients to do all of their internal and external myofascial/trigger point release, which is the focus on the local component of the disorder. In training our patients in Extended Paradoxical Relaxation, we train our patients in addressing the systemic aspect of pelvic floor related pain.
Just like it is recommended to change the oil the oil in a car every 3000 or 5000 miles allows the car to last much longer and to not break down, so the regular practice of reducing anxiety and autonomic arousal is critical in helping to heal a painful pelvis. While what I am describing may feel like a huge and onerous burden, in fact it is one of the most pleasurable, soothing and healing of practices. While it takes several months of daily practice to begin to gain some skill in it, the practice of reducing anxiety and nervous arousal, in which the practitioner struggles to learn the method, once learned it is a life long practice of inestimable value. It was a huge revelation to me that giving up my guarding was the only way I could finally feel safe.
In an earlier podcast I discussed ‘letting go’ as the medicine of the Wise-Anderson Protocol. By letting go, I mean the release of muscle tension inside and outside the body and daily reduction of nervous arousal enabling the healing of sore pelvic tissue. By letting go I mean ceasing to hold the sore, irritated pelvic tissue captive in the reflex tightening that the pelvic floor does when it feels pain or intrusion.
The methods we use to help patients let go of a painful, contracted pelvic floor in the Wise-Anderson Protocol are both physical and mental/behavioral. The physical way we help patients learn to relax is by self-treatment doing myofascial release and trigger point release using our internal and external trigger point release devices. The physical release of chronically sore and tightened tissue using these methods is essential in helping someone to reach a level of relaxation and ease of the pelvic floor that relaxation alone cannot reach. When muscles have shortened and trigger points form, the muscle can only loosen to a certain point, just like a rubber band cannot extend to its full length if there is a knot tied in it.
In a daily protocol, after the tissue is repetitively loosened physical, a specific relaxation method, when done skillfully and in conjunction with the physical self-treatment, can help the pelvic pain patient reach areas of profound relaxation that are not able to be reached otherwise. This profound relaxation is what I think of as a healing chamber for the sore and irritated tissue of the pelvic floor.
Learning to let go, is the practice of being effortless. One of the central instruction of my relaxation teacher, Dr. Edmund Jacobson, was to discontinue effort. Babies are the best at being effortless and do not need any training to help them relax. In fact no one needs to learn how to relax. The ability to relax is hard wired in us. ……. The obstacles to relaxation are what must be overcome to be able to engage our natural ability to profoundly relax. These obstacles centrally involve anxiety, reflex guarding against pain and an upregulated nervous system. The relaxation method we use and have done research on over the years in the Wise-Anderson Protocol,addresses the real-life, moment-to-moment inner obstacles to lying down to do a relaxation session and calm down a nervous system. Over the years we have honed this practice, which we call Extended Paradoxical Relaxation, to help someone who is anxious, chronically clenched and in pain. Anxiety and chronically tightened core muscles are often-overwhelming and defeating barriers to relaxation. The goal of our relaxation method is to enable one to enter into a state of profound relaxation. The practice of relaxation can also be called the practice of conscious effortlessness. In this state the body’s healing mechanisms are called forth.
It takes courage to do learn to deeply relax. To profoundly relax, you are asked to lie down, stay awake, rest your attention in sensation, and allow anxiety, discomfort and protective guarding against pain to come and go as a strategy of moving past them. When you’re anxious or in pain, it’s hard and often scary and unpleasant to lie down for a relaxation session, because it means being alone with your anxiety, discomfort, and uncertainty. Our aversion to these feelings typically sidetracks many people’s attempts to put an end to their anxious state and to enter a state of inner quiet.
Many of our patients have been told to breath deeply or do certain exercises to relax the pelvic floor. It is my view that such instructions are of little use and usually suggested by someone who is not able to profoundly relax themselves. There is no quick and dirty way to relax the pelvic floor. Relaxing the pelvis floor and permitting the sore tissue of the pelvic floor to heal by bringing it into an regular environment of daily equanimity is not achieved by a breathing maneuver and can take up to several hours. Attention must be trained to rest in sensation in an extended period of time, outside of the reach of the discursive, anxious narrative that runs through most people’s minds who are anxious and in pain.
The method we use of Extended Paradoxical Relaxation specifically address what to do with the subtle psychological resistances to lying down with anxiety and discomfort. The method addresses the issue of attention and how central it is to be committed to developing what you can call the ‘muscle’ attention.
When you’re motivated to learn relaxation, you’re often upset emotionally in some way. These feelings are usually unexpressed; they remain inside and are felt as a kind of pressure, anxiety, constriction, or deadness. When unresolved, they are obstacles to your nervous system calming down. Fear, sadness, grief, anger and frustration are among the emotions that may arise. What we train our patient to do with them is critical to learning how to deeply relax.
Anxiety and chronic tension are states of self-defense and concern about survival. When you’re anxious or chronically tense, some deep part of you, usually unspoken, feels like you need to protect yourself. In a kind of unconscious reasoning, some part of your mind believes that tension and anxiety are helping you stay safe. We discuss this in our book as pleasure anxiety, catastrophic thinking, and the desire to avoid disappointment by rejecting the experience of feeling safe.
Pleasure anxiety and the fear of feeling safe and undefended are not just concepts. They are the engine the drives people to compulsive working and workaholism, and we must address them with the aim of overcoming their influence or they remain obstacles to our relaxation.
Extended Paradoxical Relaxation is the Practice of Un-defending Yourself
If tension is part of how you defend yourself, our relaxation protocol is the practice of letting go of defending yourself. When people who are anxious or who suffer from the symptoms associated with pelvic pain and its accompanying anxiety begin to learn relaxation, they usually feel fear about letting go. Sometimes people are uneasy about what they’ll find inside, or afraid that they might lose control, or that something bad will happen if they let down.
Underneath Tension and Anxiety is Peace
I have learned that under all anxiety is peace. It is difficult to discover this on your own. I had Edmund Jacobson, the father relaxation training in the United States as a teacher. His example and instruction gave me the courage to dare to let go in the way that he taught me. Underneath suffering, tension, anxiety, and pain, lies serenity. I tell our patients that they only need only trust my words up until they have the experience of this themselves. Then it’s theirs, and they don’t have to rely on what I or anyone else says anymore. When you practice Extended Paradoxical Relaxation in the safety of knowing that someone else has been there, it is far easier to trust that you are safe in resting even when anxiety, fear, sorrow, and uncertainty are present, because underneath these disturbing emotions is the ease we all want.
What is unconscious controls us. If difficult emotions are not acknowledged during relaxation, they typically remain huge obstacles in entering into the healing state that relaxation provides.
Learning to relax requires a commitment of daily practice. Without real earnestness, reliable ongoing ability to relax in my experience is not possible.
In our protocol, Extended Paradoxical Relaxation is best done in conjunction with loosening the body with trigger point release and its related practices. This combination is found in the practices of types of yoga and meditation that have withstood the test of time over millennia. In the yogic traditions, the body is stretched through the asanas or yoga postures and then meditation is done. In fact practicing effortlessness – which is commonly called relaxation is both a mental and physical event. Practicing the physical methods of releasing the body’s deep tensions followed by the practice of focusing attention within, in my view is the best way to practice conscious effortlessness in order to provide a healing chamber for the sore pelvic tissue at the heart of pelvic floor pain.
PART 1 – INTRODUCTION: PELVIC PAIN IS A PSYCHO-PHYSICAL EVENT TO REDUCE ANXIETY
Learn the importance to reduce Psycho-Physical events to help reduce Anxiety. During the writing of the fourth edition of our book, a physical therapy colleague of ours reported an important story that occurred with one of her patients. The patient was a woman with pelvic pain who had experienced an intense flare-up of her symptoms, and she had started seeing our colleague in an attempt to reverse the flare-up. In one of their physical therapy sessions a remarkable event occurred. It was remarkable not because it was uncommon (indeed we see it often in our patients) but because the event was witnessed in a therapeutic setting and the relationship between cause and effect was so clear. While the therapist was pressing on trigger points inside the vagina of her patient, the patient began to talk about a politician she despised. As the woman shared her anger, the therapist felt her finger being crushed in a vise-like grip of the woman’s pelvic muscle contraction.
Emotional upset, anxiety and sympathetic nervous system arousal can trigger clenching, contraction, and spasm in the pelvic muscles
The patient was middle-aged and the physical therapist was amazed at the strength of contraction of the muscles of this woman’s pelvic floor while she shared her upset feelings. The vice-like pelvic contraction appeared suddenly in this patient and the strength of the contraction was intense. The physical therapist shared with us that it felt like her finger was about to be crushed and she felt frightened that she might be injured.
“Did you feel that?” the physical therapist asked her patient. “Did I feel what?” replied the patient. “Can’t you feel the spasm that your pelvis has gone into right now while you are talking about your hatred of this man?” asked the physical therapist. The patient was dumbfounded. “Feel what? I don’t feel anything,” replied the patient.
Almost unbelievably, the patient had no sense of the relationship between her emotions and the reaction of her pelvic muscles. And while this particular example was striking given the setting and acute cause/effect detection of our colleague, we have seen this psycho-physical inner behavior in all of our patients over the last 21 years and believe it to be the primary causative and perpetuating factor in chronic pelvic pain syndromes.
Chronic pelvic pain syndromes represent a psycho-physical event
Indeed, the chronic pelvic pain that we treat is a psycho-physical event. Unfortunately, the historical treatment of pelvic pain has almost entirely been a misdirected physical treatment of the organs of the pelvis such as the prostate or bladder. Indeed, the conventional medical establishment unfortunately continues to place most of the blame for pelvic pain on the pelvic organs, and attempts to throw various pharmaceuticals at the condition, including antibiotics, anti-inflammatories, botox, and other classes of medications, as well as procedures such as nerve blocks and even surgery, all of which have had, at best, mixed results. And, when physical therapy for the pelvic muscles is prescribed, it is almost always prescribed alone, that is, with no accompanying psychological/cognitive support, relaxation training, or self-treatment training.
In our experience, a limited course of solitary physical therapy produces mediocre to poor results in the pelvic pain patient. In our FDA study that led to the approval of our internal trigger point wand, approximately ¼ of our patients had previously undergone some physical therapy and their baseline level of symptoms was no different than those who had received no previous physical therapy. It has been our strong collective experience over the years that simply treating pelvic pain as a physical event and trying to rehabilitate the pelvic muscles to a supple and pain-free state without addressing the psychological environment and inner behavior of the patient is ultimately not helpful and can often result in the patient abandoning his/her treatment regimen.
Of course, we are not saying that the physical therapy aspects of our protocol are not important in recovering from chronic pelvic pain and dysfunction. It is essential to understand, diagnose, evaluate and treat the myofascial trigger points and muscular restriction that has developed inside and around the pelvic floor in muscle based chronic pelvic pain syndromes. We consider ourselves disciples and champions of the work of Drs. Janet Travel and David Simon and their seminal medical textbook Myofascial Pain & Dysfunction. We comprehensively treat our patients for myofascial trigger points, conducting what we believe to be the gold standard evaluation and identification of trigger points, and then we treat them over multiple sessions in our immersion retreats with specific manual trigger point release, myofascial release, skin rolling, and other myofascial trigger techniques. We train our patients extensively in self-treatment of trigger points using our FDA-approved internal trigger point wand, the theracane, trigger point balls, and other tools, and teach specific yoga-type stretches following trigger point self-treatment. We have developed an unrivaled 300 plus page manual regarding physical therapy self-treatment that our patients take home with them, which includes our “Pressure Principle” concept that details how to determine the level of pressure to use in trigger point self-treatment. Thus, as one can see, we have a world class physical aspect of our protocol and continue to enhance and improve it. What sets us apart from most providers, however, is our deep understanding of chronic pelvic pain syndromes as a psycho-physical disorder and that we pair with our physical protocol with a comprehensive and continuing relaxation/behavioral protocol.
Ignoring the psychological environment of muscle based pelvic pain means that it typically sticks around
The psychological environment that perpetuates the physical contraction, irritability, pain and dysfunction of the pelvic floor has simply not been fully addressed in conventional medicine. When the psychological/anxiety environment that regularly tightens up the pelvis is ignored, pelvic pain typically remains a gnawing and ongoing problem. Even if the relationship between anxiety and pelvic floor pain is acknowledged, and drugs, psychotherapy, mindfulness, or breathing exercises are casually or partially suggested, these mechanisms still usually fail, in our opinion, because the practitioner fails in adequately advising and informing the patient of how significant the intervention needs to be in order to profoundly and reliably down-regulate the patient’s sympathetic nervous system and anxiety.
Over the last 20 years of enhancing the Wise-Anderson protocol, we have developed both a strong and substantial behavioral and psychological protocol of intervention to help patients stop their pain and dysfunction. In the psychological area, we have come to an understanding and treatment of anxiety and the nervous environment of the pelvic pain patient that we believe is remarkable and unparalleled. In this essay, we describe in more detail our method of teaching patients to reduce their anxiety and sympathetic nervous system arousal.
PART 2 – THE TENSION-ANXIETY-PAIN-PROTECTIVE GUARDING CYCLE AND THE METHOD OF EXTENDED PARADOXICAL RELAXATION TO BREAK IT
How anxiety keeps the pelvic muscles tight and painful
The typical etiology (the manner of causation) in chronic pelvic pain syndromes we treat is that the muscles of the pelvis in someone with a tendency toward anxiety tighten up in response to their daily anxiety over a long period of time, often months or even years and decades. During this extended period of anxiety-related pelvic muscle contraction, myofascial trigger points form in the chronically contracted muscle tissue and then, often with an intense period of acute stress, these tightened and restricted muscles get pushed over a certain threshold, become painful and produce a variety of physical dysfunctions and pain. When pelvic muscles remain in this chronically squeezed and contracted posture, they become very sore, painful (including all types of pain such as burning, stinging, aching, shooting, piercing, etc), and irritated. In this constricted state blood flow becomes inhibited, range of motion is restricted, and interference occurs with the neurological relationships that allow for normal and symptom-free life functions: urination, defecation, sexual activity, sitting, exercising, and any other movement or function that involves the pelvis.
The Tension-Anxiety-Pain-Protective Guarding Cycle is the heart of the self-feeding vicious cycle of chronic muscle based pelvic pain
The major concept we introduced in the early editions of our book, A Headache in the Pelvis, is the self-feeding vicious cycle of tension-anxiety-pain-protective guarding. This cycle is the causative and perpetuating heart of muscle based chronic pelvic pain disorders, and is the reason why the sore, irritated and painful pelvic muscles cannot achieve the environmental space to heal like other conditions the body heals on its own. The reason for this is the significant multitasking required by the pelvic floor and the normally inaccessible environment of the internal pelvic floor (vs. the shoulder, for example). Immediately below is a helpful graphic demonstrating this vicious cycle:
The pelvic floor muscles are like a hub of many highways
The pelvic floor is like a hub in which many freeways converge and the pelvic floor, like the heart, is almost always moving and called upon for different tasks including key life functions like urination, defecation, sexual function and structural support. Even breathing in and out moves the pelvic floor. Even the most basic full body movements involve the pelvic floor muscles because of their intimate support of the body’s core.
Once the pelvis becomes sore and painful, and normal life functions are disturbed, the pelvis becomes hyper-sensitive to anxiety and/or nervous system arousal, which we refer to herein interchangeably. Indeed, the onset of anxiety can immediately aggravate hyper-irritable pelvic tissue and directly result in the further tightening or “guarding” of the muscles. Beyond this initial reflexive protective clenching that occurs in response to anxiety and nervousness, an additional layer of reflexive tightening can occur in the pelvic pain patient in response to the actual pain, and all of this inner behavior usually occurs outside of a person’s awareness if the patient does not understand and comprehend this cycle.
Pelvic pain as a tail-pulled-between-the-legs phenomenon
We have discussed in several previous writings how pelvic pain can be understood biologically and psychologically as a tail-pulled-between-the-legs phenomenon where fear causes a contraction of the pelvic muscles that pull in the mammalian tail as an evolutionary reflexive response to stress and anxiety. There are a number of ways to comprehend the fact that the pelvic floor muscles, once they have become painful and dysfunctional, fail to heal in a way that normally occurs in other, less complex, more easily treatable parts of the body. Indeed, the reflexive and ongoing engagement and clenching in the pelvis interferes with and prevents the kind of rest, relaxation, blood flow and protection from stress that is required to restore the pelvic tissue back to a supple, relaxed, functional, pain-free state.
Anxiety is the fuel to the fire of chronic pelvic pain syndromes
Some level of anxiety or sympathetic nervous system up-regulation is what almost all patients with chronic pelvic pain syndromes live with day in and day out. Anxiety can trigger pelvic contraction and, as Gevirtz and Hubbard demonstrated in their 1995 experiments, electrical activity strongly increases in trigger points with increased anxiety. Anxiety regularly exacerbates the condition and this mental state is further fed by the patient’s catastrophic thinking, the isolation of often being unable to share the feelings and experiences of pelvic pain, and a conventional medical establishment unequipped to provide any significant help or relief to the sufferer. Most pelvic pain patients who have not been trained in our protocol have no way to reduce their level of nervous upset and anxiety other than with drugs, which of course, have their own significant side effects and problems.
In the presence of anxiety and reflexive protective guarding, the sore contracted pelvis cannot find the healing space and environment to restore to a normal, non-symptomatic state. Added to an individual’s anxiety is the puzzlement of the doctors. The doctor is often frustrated about his inability to help the problem and is not infrequently worried that perhaps he has missed something. Doctors are problem solvers. As we have discussed in our book and other essays, certain doctors do not respond well to their own helplessness to solve the problem of chronic pelvic pain syndromes. Any anxiety, uncertainty or helplessness felt by the doctor is almost always communicated to the patient – a communication whose impact can be overwhelmingly upsetting to the patient.
That pelvic pain is hugely affected and perpetuated by anxiety is why the placebo effect reduces the anxiety that helps fuel the condition. This is also why many people have a reduction in symptoms after they read our book. Many of our patients whose symptoms reduce after reading A Headache in the Pelvis report their emotional relief after finally finding something that makes sense about what is going on and offers some intuitively viable solution.
Anxiety, sympathetic nervous system arousal, and reflex guarding is the environment that keep the pelvis painful; the concept of a stopping anxiety and protective guarding to create a “healing environment” for pelvic pain and dysfunction
During our 21 years of treating muscle-based chronic pelvic pain syndromes with the Wise-Anderson Protocol, we have often said that the challenge of healing and rehabilitating the pelvis would be much easier if we could send the pelvis on a long island vacation where it had nothing to do but relax and heal its chronically tightened, sore, irritable and painful state. While meant comically, our saying this acknowledges a very important question in the understanding and treatment of pelvic pain, and one that is rarely discussed in the realm of conventional treatment for pelvic pain: namely, how can we create a healing environment that allows for the sore, contracted and painful pelvic muscles to heal? How can we interrupt the tension-anxiety-pain-protective guarding cycle in a profound enough way to fully permit the pelvic floor muscle irritability to heal, just like other muscle conditions heal?
The inner healing environment of Extended Paradoxical Relaxation
This idea of a “healing environment” to allow physical healing both in terms of an external environment and a “local or internal” environment, is intuitively understandable and practiced in a multitude of medical conditions and treatments, including the following very familiar ones –
a cast for a broken bone to ensure bone immobilization and a reliable healing environment for the process of bone healing;
a neck brace for the neck after certain types of neck injuries;
band-aids and tourniquets along with antiseptic ointments for cuts and wounds to heal;
stroke and brain rehabilitation centers for the regaining of function lost in stroke and brain damage disorders;
in-patient addiction retreat centers for drug and alcohol users that remove the abuser from the aspects of his/her life that make it difficult to abstain from drugs or alcohol.
As one can see, these examples include both external, social-psychological healing environments (addiction retreat centers, stroke rehab centers, etc.) and local, body-focused healing environments (cast for a broken bone, wound healing, neck brace, etc.). Both of these aspects of the healing environment are crucial in chronic pelvic pain syndromes because the factors of the external, social-psychological healing environment (anxiety, work and family stresses) are so inextricably intertwined with the local function and state of the muscles in and around the pelvis. It is unfortunate that we could prepare an exhaustive and long list of healing environments like those listed above for myriad conditions in conventional medicine yet a similar concept for chronic pelvic pain syndromes has hardly ever been discussed.
When we get a cold, we don’t have to change our environment in order to recover; perhaps we get some extra sleep and stay home for a few days but otherwise we maintain our normal lifestyles of work and relationships. Healing from pelvic pain and other conditions similar to the above examples, however, requires a heightened and more intentional intervention to our normal schedule. Drug rehabilitation is an obvious and well known example where “time away” is almost universally accepted and supported by the entire medical community as well as a patient’s family and friends. This type of caregiver and social support is exactly what the pelvic pain patient needs in attending to his/her recovery as well.
The Wise-Anderson Protocol helps patients create a daily “healing environment”
In our view, when the symptoms of the pelvic pain patient get routinely better, like in the morning, on week-ends, on vacation or in a hot bath, they are in an “inner healing environment.” The muscle tension has eased, the nervous system is quieter. We are convinced that chronically contracted and dysfunctional pelvic muscles need a “healing environment” in order to optimize recovery potential in the patient. In this healing environment the pelvic muscles are not caught in the tension-anxiety-pain-protective guarding cycle. The Wise-Anderson Protocol is focused on helping the patient create this healing environment regularly in order to interrupt the self-feeding cycle that keeps the pelvic muscles sore, irritated and painful.
While we cannot place a literal “cast” on the pelvic muscles, like you can on a broken leg, or send it to a tropical island for an extended healing vacation free from the onslaught of a vigilant and aroused nervous system, we have developed a 2-4 hour daily practice that can help turn off the relentless self-feeling cycle of tension-anxiety-pain-protective guarding. We do this by using the practice of daily Extended Paradoxical Relaxation (EPR). The practice of EPR allows for a profound down-regulation of our sympathetic nervous systems, which in turns stops fueling the fire of pelvic pain and allows the pelvic muscles time to heal.
The concept of taking a significant and continuous 2-4 hour daily break from your normal life in order to heal from pelvic pain (which we mean to include the variety of diagnoses given to pelvic pain including prostatitis, pelvic floor dysfunction, interstitial cystitis, chronic proctalgia, levator ani syndrome, among others) is not something that is part of the current conversation among professionals who treat pelvic pain. While certain conditions like stroke and drug rehabilitation have been treated in month long immersive formats, it is rare for a patient of a functional somatic disorder to be encouraged to do this. In a recent essay we wrote for our blog comparing a locked up computer to the state of a dysfunctional, up-regulated nervous system, we stated:
With regard to people who have chronic pelvic pain, their bodies can be said to be experiencing a similar overwhelm to that of the frozen, locked-up computer. Too many tasks, stresses, demands, and pressures have accumulated over time and the body has found itself in a distant place from its homeostatic, healthy, default mode. In response to the demands of our hectic lives, the muscles of the pelvic region have engaged in a pattern of chronic, unyielding protective guarding as a method of coping with and getting through these stresses. These pelvic muscles, normally supple and pain-free and able to relax and contract easily, are rigid and chronically contracted and dysfunctional. In other words, the pelvis has become part of the body’s lock up, just like the locked up computer.
Using an Extended Paradoxical Relaxation retreat to train the patient in EPR and “Kick-Start” their recovery journey
What Extended Paradoxical Relaxation provides is a regular daily hiatus from the tasks, stresses, demands, and pressures that have played a causative and perpetuating role in a patient’s symptoms. When a soldier returns injured from war, or a patient survives a stroke, usually all of the caregivers and family support a comprehensive, immersive, long term treatment program. The physicians, physical therapists, psychologists/counselors, and loved ones of the patient are all on the same team and understand that a sustained, repetitive healing environment will be required for many months or years for the patient to reach his/her full potential of recovery.
We are studying a similar methodology for the functional somatic disorder of chronic pelvic pain where treatment begins with a multi-week, (9-30 days) immersion, in-patient clinic, in which the patient receives all of the training in the physical therapy aspects of our protocol and engages in 4-7 hours of our Extended Paradoxical Relaxation method in order to profoundly intervene in and break the vicious cycle causing and perpetuating their pelvic pain and dysfunction.
This extended, intensive immersion retreat sets the patient on the path to recovery by helping patients regularly turn off the ongoing mental narrative and regular experience of being ‘on’ in order to respond to personal and work demands, and by spending enough sustained hours in a state of Extended Paradoxical Relaxation in order to create the healing cast for the pelvic muscles to return to a supple, relaxed, functional pain free state. Indeed, our goal in conducting research into this extended EPR retreat is to place the patient into an almost permanent “airplane mode” for several weeks and essentially bring the ancient practice of the meditation retreat into the 21st Century as medical treatment for functional somatic disorders like chronic pelvic pain.
PART 3 – BRINING THE TRADITIONAL MEDITATION RETREAT INTO THE 21ST CENTURY TO DOWN-REGULATE THE NERVOUS SYSTEM AND HEAL THE PELVIC FLOOR
For thousands of years, in most spiritual or wisdom traditions, it has been common for those seeking deep inner understanding to spend long periods of time in meditation and contemplation. Innumerable books and texts over the centuries have extensively documented and profiled the concept of the meditation retreat in the Buddhist, Hindu, Judeo-Christian, and Muslim traditions.
Indeed, among other Biblical examples, Jesus was purported to have spent 40 days of contemplation in the desert, and all of the other religious traditions have similar stories in their sacred texts. From Buddha to St. Francis to Hindu sadhus to contemporary meditators like Thomas Merton, quieting the body and mind through meditation has been a lofty practice. Even today, the explosion in popularity in the practice of yoga, including its brief forms of meditation at the end of most hatha yoga classes, demonstrates a collective intuition that quieting down the nervous system through meditation is good for us.
Paradoxical Relaxation practice is a secular form of meditation
My teacher Edmund Jacobson went to great lengths to make a distinction between his protocol, which he called Progressive Relaxation, and many other practices including meditation. He wanted make a distinction between Progressive Relaxation and other practices and phenomena that produced relaxation like meditation, transference in psychoanalysis, spiritualism, yoga, and hypnosis, among others.
Jacobson wanted to identify Progressive Relaxation as a scientific and medical protocol aimed at reducing nervous system arousal that only relied on practitioners following the given instructions during a session. He did numerous scientific experiments with barium and fluoroscopy to demonstrate the scientific efficacy of his method. He worked with Bell labs in the 1940s to invent the electromyography that was able to measure electrical activity in muscles that he used to document the efficacy of his method.
Despite Jacobson’s protests and attempts at drawing clear distinctions between his relaxation method and other practices and phenomena that produced relaxation, contemporary methods of relaxation and ancient methods of meditation have more similarities than differences. Relaxation methods and meditation methods all aim at controlling attention to bring about the quieting of body and mind. While relaxation teachers don’t don robes, light candles or incense, or lecture students on spiritual subjects, the basic principles apply to both the directing attention away from discursive thought and cognitions and back to a focus that allows the reduction of thinking and mental activity. These instructions are the main ingredients in helping reducing sympathetic “fight or flight” nervous system arousal.
Meditation and relaxation methods, from the largest perspective, are essentially the same and both borrow from the universal principles that allow for the nervous system to quiet down. While psycho-physiologists may call the goal of relaxation “stress reduction” and “autonomic down-regulation,” while meditation teachers may call meditation the “practice of inner peace,” there is no essential difference to them on the inside if the practitioners gains entrance to the relaxation response and gains peace and equanimity; in short, it is a healing environment whether the practitioner calls what she did meditation or relaxation.
Brief periods of regular relaxation have been shown to help certain health difficulties and reduce anxiety but the effects of longer periods of relaxation have not been studied
Conventional wisdom in the 21st century easily understands the relationship between stress and illness. In the last few decades, stress reduction has become a subject of much interest not only because the relationship between stress and illness is often reported in the popular media, but many people feel the effects of stress with the increasing non-stop computer culture that routinely bombards one with stimuli, often disturbing, from numerous portals such as email, text, instant message, Twitter, Facebook, etc. The sources of our nervous system stimulation has become endless with the explosion of communication technologies.
Much has been written about the benefits of meditation for stress reduction. As with relaxation methods, such meditation interventions are prescribed in the form of relatively short periods of time – perhaps a ½ hour to an hour a day where one is asked to sit upright and quiet, and direct attention to the breath, a sound or a visual image. Indeed, meditation has been shown to help depression, anxiety disorders, chronic fatigue syndrome, and functional somatic disorders, including irritable bowel syndrome. It has also been shown in helping reduce the symptoms related to heart disease, and in our own work and previous studies, in the reduction of pelvic pain symptoms. These studies, however, typically do not include long, extended periods of relaxation/meditation. They tend to be confined to daily, ½ hr – 1 hour periods. Thus, to be sure, meditation does have the capacity to lower nervous system arousal to some modest degree or another when done regularly and reliably in short periods of time on a once a day basis.
Like these studies, for the past 21 years of our work with pelvic pain, we have asked patients to do short periods of Paradoxical Relaxation, typically between 30 minutes to 50 minutes, twice a day. We have had excellent results with a large number of our patients with this regimen. There are certain patients, however, who seem to require several hours to calm down enough to enter into the healing state of nervous system down-regulation. In recent times, for these patients, we have been recommending significantly longer periods of Extended Paradoxical Relaxation – between 2-4 hours, if not longer, on a daily basis for those whose symptoms continue to be at a plateau.
In the ways we live now, however, long periods of meditation/relxation that range from multiple hours to days (or even weeks or months) do exist but are very uncommon. Modern life, and its demands for real-time access and constant production of content, strongly discourages us from taking that unwired, unconnected sabbatical. Busy is good the society tells us. Taking a hiatius where one is “unwired” and off the communications grid is not on the radar screen of what people think about in the 21st century. Indeed, even a two or three week vacation can cause anxiety in many people for fear that their employer will consider such a break excessive. And while meditation retreats are offered at a few centers in the world, they typically are not done as part of a treatment for a specific medical disorder, as we use in the Wise-Anderson Protocol for chronic pelvic pain syndromes.
The Meditation Retreat as specific medical treatment in the Wise-Anderson Protocol
Little scientific research has been done in terms of documenting the real physiological healing potential of long relaxation retreat periods that give the nervous system a profound rest from the ongoing stimulation of the demands of life. Because meditation retreats are typically done for spiritual reasons and not for medical reasons, and because there appears to be no economic advantage to be gained by a company in investing time and research energy into the benefits of extended periods of nervous system quieting, little reliable data is available on the true, scientific healing potential of such a practice. It may be clear to some that if you were able to calm down and be peaceful for a long period of time it would have the potential to heal your medical condition; however, many people have little exposure to scenarios of recovery outside the conventional medical system and its drugs and procedures.
In the Wise-Anderson Protocol, we are now studying a modern-day, 21st-century version of the meditation retreat done at the same time and in combination with our medical, physical therapy, and psychological protocols. We believe an extended, intensive relaxation retreat combined with our Protocol has huge undiscovered potential in helping even the most refractory chronic pelvic pain patients.
From Spiritual Focused to Medical Focused: Bringing Meditation into the 21st Century
There is little difference between meditation instructions today and meditation instruction given centuries ago. Indeed, in meditation communities there tends to be a reverence toward ancient instructions. The concept exists that somehow ancient instructions have a certain power that should be adhered to up to the present day, and it is heretical to do otherwise. It is not uncommon for meditation instructions to be relatively brief and sparse, done at the beginning of someone’s interest in meditation, and infrequently reiterated or explored as someone continues meditation over their lifetime. One is expected to remember of their own accord the instructions on how to do meditation; for example, in many traditions one is often directed to attend to one’s breath and every time one’s attention wanders away from the sensation of the breath, one should return their attention to it. The meditator, however, is charged with being responsible for these self-instructions and self-motivation themselves.
In the most popular meditation traditions still active today, there are usually some instructions given about what to do when one’s attention is distracted by thinking, but again, the instructions for bringing attention back to focus is very uncommon. The meditator is expected to coach him or herself regarding directing attention on a moment-to-moment basis after the initial instructions are given and no one has truly researched what actually goes on in the mind of the meditator over time. When I first learned meditation, the instructions were given by a relative neophyte and I struggled for many years with the instructions to keep my posture straight and to focus my attention in the lower part of my abdomen. This was often difficult for me to do and at the end of meditations I would notice that, while some inner quieting had occurred, nothing really remarkable occurred in my nervous system.
Simply put, the ancient meditation instructions suffer from the problem of not having the necessary psychological insight to support the patient within the context of the stresses and demands the patient faces in modern times and its particular relation to the patient’s medical symptoms. To sit on a pillow in a cross legged position and keep a straight spine, among other ancient instructions, prove to be very difficult to a symptomatic pelvic pain patient in 2015 in facing the terms of his/her nervous system up-regulation. We do not put counseling and psychotherapy sessions on a recorded CD nor do we rely on ancient texts to determine how we counsel psychology patients in modern times. In Paradoxical Relaxation, we bring the instructions of relaxation practice, and the relationship between instructor and student, into a modern context where all of the nuances and subtleties of a reliable relaxation practice can be addressed and enhanced.
The Evolution of Extended Paradoxical Relaxation
In our experience of teaching Paradoxical Relaxation, instructions and how to focus attention usually can be held in the mind for about 10 to 30 seconds. After that the mind will tend to wander unless someone is very practiced in focusing attention and is good at self-coaching. Paradoxical Relaxation has been informed by the work of Edmond Jacobson and the number of meditation traditions that I have studied over the years. The relaxation method of Paradoxical Relaxation has mostly been informed by my attempt over the years to down-regulate my own sympathetic nervous system, and borrowing from different teachings I have experienced has been helpful to some degree.
Extended Paradoxical Relaxation that is done over a 2-5 hour period daily has evolved over the last 21 years as a relaxation/meditation method that very particularly and specifically bring meditation into the 21st-century. As someone becomes skillful in doing Paradoxical Relaxation over this long period of time daily, we have noticed that there is a qualitative shift in the effectiveness of the methodology.
Chronic pelvic pain is a problem that is fed by nervous system arousal. If someone were able to calm down mentally and emotionally and release the chronic contraction of their pelvic muscles and related areas, their pelvic pain would resolve relatively quickly. The main problem with pelvic pain recovery comes from the pelvis not being given a rest from the onslaught of nervous system stimulation that is relentlessly delivered throughout one’s day by anxiety and the common stresses of modern life.
The purpose of Extended Paradoxical Relaxation, in the form of an “off the grid” relaxation retreat, is to give a hiatus or sabbatical to the nervous system arousal over a period of two or three weeks (or possibly longer) that can initiate the healing of the pelvic muscles from their irritable, sore, dysfunctional and painful state. During the retreat we engage the patient in 4-7 hours of Paradoxical Relaxation sessions. Often times “opening the door” is the hardest process in recovery; once the body’s momentum gets started in a healing direction, the patient usually is easily able to stay reliably committed to the protocol and the healing journey. This is the goal of the intensive, multi-week Extended Paradoxical Relaxation retreat.
Here are some of the methodologies we are using in Extended Paradoxical Relaxation:
Noise canceling headphones to help block out any distracting noise in the environment.
A sophisticated, light stopping sleep mask to help keep the light out that can help calm down nervous arousal.
We help the patient find the ideal position to rest in during the practice, not based on ancient traditions but what works best for the patient in light of their current physical symptoms.
Importantly, we give detailed and optimized instructions to the real live person doing relaxation every 20 or 30 seconds to a minute and we address in our instructions the obstacles to relaxation, for example: (1) the desire to escape from discomfort that is inevitable when you sit down with a condition that involves pain; (2) the desire for pleasure and the avoidance of pain; (3) the desire to reach an ideal outcome instead of staying focused in the present moment which is paradoxically the essential ingredient in shifting a painful and uncomfortable physical state to one that is comfortably pleasurable and provides a healing environment for the pelvic tissues.
Finally, when someone goes home after their relaxation retreat with us we ask them to do what is rarely asked of any patient, which is to take 2 to 3 hours a day to create a hiatus for the nervous system. We ask them to get up early or to somehow create the time that they would take if their pain was some critical condition like a stroke recovery that demanded a certain amount of rehabilitation time. We do this for a very specific, medical reason: we have found in our 21 years of experience that this is the kind of commitment necessary to break the vicious tension-anxiety-pain-protective guarding cycle that forms the causative and perpetuating foundation of pelvic pain and dysfunction.
We have found that the length of the relaxation session is critical to the efficacy of the method in a certain sub-population of our patients. This is the same difference between taking a sub-minimal amount of a drug that doesn’t have enough traction to affect the disorder and increasing the dosage to a dosage that demonstrates efficacy. In a 14 day immersion program we just concluded we found a qualitative difference between a brief Paradoxical Relaxation session and the hours-long session. It is clear that there is a minimum dosage for the efficacy of certain drugs; likewise, we are seeing that for certain patients, there is a minimum “dosage” of relaxation in terms of the time allocated for it. For certain patients, the difference between doing Paradoxical Relaxation for ½ hr/ day and 3 hours per day makes the difference between remaining in pain and resolving the pain.
We are also excited to announce that in conjunction with our research into these longer, multi-week relaxation retreats where we do 4-7 hours a day of Extended Paradoxical Relaxation, we are developing a “take-home kit” that will include a comprehensive book, audio-visual materials, Paradoxical Relaxation recordings, and other support tools. Our goal with this kit is to provide as much environmental support as possible so that the patient can “re-create” the healing environment of the relaxation retreat at home as much as possible. Because of its personal nature with audio-visual recordings, the kit will also reinforce the teacher-student connection that occurred during the relaxation retreat. We will also be exploring the possibility of the kit as a stand-alone product for the treatment of a wide range of anxiety and functional somatic disorders.
Pelvic Pain Symptoms and Treatments: Using Modern Terms to Explain Nervous System Arousal
Airplane mode, in fact, is an excellent metaphor in terms of describing the pelvic pain symptoms and treatments of the pelvic pain sufferer.
Using the term “airplane mode” to explain the nervous system of the pelvic pain sufferer.
“Airplane mode” consists of two elements:
Setting aside enough sacrosanct, uninterrupted time and space for Paradoxical Relaxation sessions (which we discuss as carving out 2-3 hours a day);
Doing the mental practice of Paradoxical Relaxation during this uninterrupted time and space that allows the nervous system to “down regulate”, reduce its frenetic activity, and cease prompting the squirting of adrenaline into the bloodstream with every thought that worsens the chronic pelvic floor contraction and the feeding of the tension-anxiety-pain-protective guarding cycle.
The meaning of airplane mode
To be sure, the technological revolution of the past 20 years has given us not only the ability to be electronically connected at all times but has also provided a new vocabulary to describe our new behavioral world of texting, instant messaging, emailing, and twittering. For example, the term airplane mode is a new concept that has come about to address the idea of temporarily disabling our communication devices from the information and connectivity superhighway. As we know, airplane mode is used when someone is on an airplane or other situation where sending or receiving communications and data are disallowed. In airplane mode, our phone or tablet assumes an unresponsive state where it is not vulnerable to the dings and rings of incoming calls, texts, emails, and other data.
Indeed, when your phone is on airplane mode, you essentially resume the situation humankind was in before the advent of cellular communication systems. You are alone, and unless someone actually engages you in person, you are not vulnerable to being disturbed or prompted. The situation is not unlike the old context of placing a “do not disturb” sign on your hotel room door – you are creating an environment where you cannot be disturbed by the world nor it by you.
A frozen, locked-up computer
Anyone who has ever worked with a computer has experienced the frustrating situation of the computer “freezing up” or “locking up” and having to be manually re-set. Many times we intuitively attribute the freeze to requiring the computer to do too much too quickly. Overwhelmed, it simply stops working properly and ceases to fulfill our processing demands. One perspective is that the computer has simply gotten too far away from its default modes, and the complexity of processing so many demands in a matter of seconds has interfered with basic functions. Interestingly, despite all of the advances in technology, a standard method for fixing the freeze is to manually reset the computer by holding down the power button. By turning the power off and then back on again, we reset the original default modes. This almost always results in the computer resuming its proper functioning.
An analogy can be drawn between our intuition about why computers freeze up and why Colin Powell’s observation that “things always look better in the morning” is intuitively correct. It is also why we have a sense that a good night’s sleep makes everything better. Once locked up elements of body and mind come back into full function. This is also true of going away on vacation. After several days on the beach, away from the demands of business and life, our system is renewed.
With regard to the symptoms and treatments of chronic pelvic pain, a person experiences a similar overwhelm to that of the frozen, locked-up computer. Too many tasks, stresses, demands, and pressures have accumulated over time and the body has found itself in a distant place from its homeostatic, healthy, default mode. In response to a hectic life, the muscles of the pelvic region have engaged in a pattern of chronic, unyielding protective guarding to cope. These pelvic muscles, normally pain-free and able to relax and contract easily, are rigid and chronically contracted and dysfunctional.
Just like the number of programs running on a computer when it freezes up, pelvic pain patients cannot ignore the circumstances of their lives. In our patients, we often see that a vicious, self-feeding cycle has developed in the patient that looks like this:
Even in the face of significant pelvic pain and muscle dysfunction, fear, and anxiety, many of our patients continue to meet the demands in their lives without being able to reset. Typically each day the patient tightens up the pelvic muscles as a coping mechanism to the pressures of life. As the pelvic muscles get more restricted and painful, function deteriorates. In many patients, the pelvic muscles become so contracted that basic functions such as urination, defecation, sitting, and sex become very difficult and painful.
Resetting the default mode of the pelvis by resetting the nervous system
In order to restore the nervous system and the pelvic floor that it controls to a healthy default mode, we propose that the body requires a regular “airplane mode”. This frees the nervous system from stress, demands, pressure, expectations, and requirements. You can have a safe zone protected from disturbance or stimulation. The pelvic floor needs time to ease painful hypertonus and myofascial restriction and be free of any stressful or taxing input from the nervous system. By practicing long hours of airplane mode through the use of our method of Paradoxical Relaxation, the quieted nervous system allows the pelvic floor to “let down its guard” and heal from the effects of the chronically upregulated and aroused nervous system. Through this practice (and along with our trigger point physical therapy regimen), the pelvic muscles are led back to their natural default mode of supple and functional myofascial tissue.
Man as a response animal
Indeed, we can look at the human being as a “response” organism, constantly adjusting to our various issues. Most important is the survival instinct, and while we no longer face the reality of wild animals or food scavenging, the nervous system equates many non-survival issues to survival. This is especially true when the nervous system is hypersensitive to stress in the form of an email, text, or task at work.
We have all experienced that domino effect of catastrophic thinking where one largely insignificant email can be turned into a disastrous conclusion by a fearful mind. When catastrophizing is a common event in someone’s thinking, the pelvic muscles typically contract and often out of a person’s awareness. In the 6th edition of our book, A Headache in the Pelvis, we discuss the remarkable story of a middle-aged woman who was in the middle of an internal myofascial trigger point session with an experienced physical therapist. While the physical therapist had a finger inside her vagina, pressing on an internal trigger point, the woman began to talk about a politician she loathed. Our colleague, the physical therapist, reported that as her patient expressed rage about this politician, her pelvic muscles tightened around our colleague’s finger to a point where our colleague was afraid her finger would be injured. When our colleague said to her patient, “can you feel that?”, referring to the astonishing tightening of her pelvic floor muscles, her patient said back to her “Feel what?” Our colleague’s patient tightened her pelvic muscles ferociously and didn’t even know it!
When you switch to airplane mode and step beyond the world’s ability to stimulate you, you are actually saying: “You can rest. All is calm, everything is okay.” You are giving yourself permission to relax. We tell our patients that this is the environment we want to create for the practice of Paradoxical Relaxation, one of the key methods of the Wise-Anderson Protocol. Spending enough time in this airplane mode, while doing Paradoxical Relaxation (and in conjunction with our physical therapy protocol), may be the most powerful way to break the cycles of protective muscle guarding and to assume a posture of the deepest and most profound relaxation. The muscle tension physiologically returns to a normal, homeostatic state and the organism can take a much-needed break from survival responses.
The problem of treating pelvic pain as solely a physical problem
The vast majority of articles written in medical literature about the kind of pelvic pain we treat focuses solely on the physical dimensions of this condition and the traditional treatment of drugs and procedures, injections, nerve blocks, and sometimes surgery. Recently, there has been interest in the psychological/behavioral dimension of pelvic pain, discussing patients who suffer from trauma, anxiety, or other forms of emotional disturbance. And yet these discussions usually only address what we consider to be paltry and not commensurate with the enormity of the problem being addressed, believing that small doses of cognitive therapy, mindfulness meditation or breathing exercises mixed in with traditional treatments could be helpful. We see these overtures as merely “half-measures”. In our experience with thousands of patients over the years, these minor interventions have had little effect on long-standing, chronic symptoms. While we welcome discussions of the psychological/behavioral aspects of chronic pelvic pain, and believe that cognitive therapy and mindfulness are legitimate and important treatments for certain conditions, our work with patients who have suffered from chronic pelvic pain for many, many years has led us to believe that only more profound nervous system intervention has a chance of any real traction.
The engine of muscle based pelvic pain is chronic anxiety and an upregulated nervous system
In our two decades of treating this condition, we see that the engine of muscle related pelvic pain is an upregulated nervous system acting on a chronically shortened and trigger pointed, myofascially restricted pelvis. What we mean by “upregulated nervous system” is this that the human computer – the mind and central nervous system – is running much faster and processing more stimuli than is healthy. We propose that the pelvic floor is in dire need of a break, in dire need of airplane mode for long periods of time every day. All of the wisdom and spiritual traditions in the world have a concept of “Sabbath” where rest is not only allowed but understood as absolutely critical for health and well-being.
We see pelvic pain as a functional disorder. It generates a self-feeding cycle of tension and the resulting formation of pain. Treating the muscles with a specific method of trigger point physical therapy is essential. However, our experience has shown us that the great perpetuating factor of this condition, indeed the foundation of it, is an upregulated nervous system generating unhealthy amounts of pelvic floor tension. Pelvic floor tension that is constant and unrelenting and from which there is no adequate amount of airplane mode, no Sabbath. This reflects our current societal predicament of a 24/7 society where few if any days are held sacrosanct, where there is little or no time off, and no airplane mode. Patients who commit wholeheartedly to reducing their nervous arousal and anxiety do far better than patients simply focusing on the physical state of their pelvic muscles.
It is essential to commit enough time to airplane mode
We have found that most of our patients require a good 2-3 hours of airplane mode daily in order to create the environment of healing necessary for the rehabilitation of the pelvic muscles. If you are “on” all day, the sore pelvis is continually being contracted and irritated by the avalanche of stimuli agitating the nervous system. The researchers Gevirtz and Hubbard have shown that even the slightest increase in nervous arousal is immediately reflected in increased electrical activity of painful trigger points. Their studies on electromyographic monitoring of their patients’ trigger points demonstrate this dramatically.
Symptoms and treatments in pelvic pain: 2-3 hours of paradoxical relaxation per day
It is important to say that airplane mode is an inner state as well as an outer space where stimuli from the outside do not intrude. Paradoxical Relaxation is airplane mode for the mind and body and involves engaging the will to practice doing nothing, practicing effortlessness, of not judging, guarding, tightening, resisting, trying, accomplishing, or any other activity that requires effort and nervous system upregulation. For many of our patients, we have observed that it is not enough to practice Paradoxical Relaxation for short, half hour or even one hour lessons. Symptoms and treatments of pelvic pain at small intervals, in patients who are chronically hyper-aroused whether they realize it or not, simply do not allow enough time on airplane mode to quiet down the roaring nervous system. A significant number of our patients do far better with 2-3 hours of Paradoxical Relaxation daily to release the pelvic muscles from their chronic guarding and contraction. In airplane mode you are free, and you can take a sigh of relief. Your body is in a position to reset the default mode of the nervous system that then permits the pelvic floor muscles to return to normal.
In our Paradoxical Relaxation lessons, these instructions are reiterated every 30 seconds or so to help our patients let go of any effort and rest solely in sensation. In the state of resting attention in sensation, the nervous system is put in airplane mode and the pelvic floor can release.
On its face, a daily practice of 2-3 hours of uninterrupted time to do Paradoxical Relaxation may seem daunting. Most pelvic pain patients are busy. Sparing any time can be a challenge. Because of this, we always say that our prescription is not for everyone. Indeed, our patient feedback reminds us that the patients who do the best with our protocol are the ones who decide that they will do whatever it takes to end their suffering.
Truth be told, if one’s pelvic pain doesn’t hurt enough, if the dysfunction isn’t bad enough, if there is a way to decently cope and avoid facing the music of a full measure treatment for pelvic pain, then contemplating 2-3 hours of airplane mode Paradoxical Relaxation a day is not going to be seriously considered, let alone completed. For those, however, who are ready to do whatever it takes, airplane mode will be done without hesitation, and once done, enjoyed beyond measure as the pelvic floor muscles are placed in an extended environment of healing.
Abstract Appl Psychophysiol Biofeedback DOI 10.1007/s10484-015-9273-1 February 2015
Chronic Pelvic Pain Syndrome: Reduction of Medication Use After Pelvic Floor Physical Therapy with an Internal Myofascial Trigger Point Wand
R. U. Anderson Stanford University School of Medicine, Stanford, CA 94305, USA e-mail: email@example.com: R. H. Harvey Department of Health Education, San Francisco State University, San Francisco, CA, USA D. Wise _ T. Sawyer National Center for Pelvic Pain Research, Sebastopol, CA, USA; J. Nevin Smith Sonoma, CA, USA; B. H. Nathanson OptiStatim, LLC, Longmeadow, MA, USA_
This study documents the voluntary reduction in medication use in patients with refractory chronic pelvic pain syndrome utilizing a protocol of pelvic floor myofascial trigger point release with an FDA approved internal trigger point wand and paradoxical relaxation therapy. Self-referred patients were enrolled in a 6-day training clinic from October, 2008 to May, 2011 and followed the protocol for 6 months. Medication usage and symptom scores on a 1–10 scale (10 = most severe) were collected at baseline, and 1 and 6 months. All changes inmedication use were at the patient’s discretion. Changes in medication use were assessed by McNemar’s test in both complete case and modified intention to treat (mITT) analyses. 374 out of 396 patients met inclusion criteria; 79.7 % were male, median age of 43 years and median symptom duration of 5 years. In the complete case analysis, the percent of patients using medications at baseline was 63.6 %. After 6 months of treatment the percentage was 40.1 %, a 36.9 % reduction (p\0.001). In the mITT analysis, there was a 22.7 % overall reduction from baseline (p\0.001). Medication cessation at 6 months was significantly associated with a reduction in total symptoms (p = 0.03).
There are a growing number of scientific articles on stress and pelvic pain syndromes.
There have been a growing number of articles appearing in the major journals like the Journal of Urology and World Urology that point out the significant association between stress and prostatitis and related pelvic pain syndromes. This is a new phenomenon because, in the past, urology has largely been uninterested in the psychological aspects that are related to chronic pelvic pain syndromes.
What does psychological support for those with pelvic pain syndromes mean?
In an article written recently in the January/February edition of Rev Med Brux, (Rev Med Brux. 2013 Jan-Feb;34(1):29-37), a Belgian medical journal, the authors, Issa, Roumeguere and Bossche, talk about the essential role of psychological support: “the role of psychological support remains essential.” This kind of discussion about chronic pelvic pain syndromes and their proper treatment is new in medical discourse.
Unfortunately, even though the role of stress is finally being acknowledged after many years of being completely ignored, the understanding of the psychophysical relationship between stress and pelvic pain and prostatitis is not well understood. To talk about psychological support for those suffering from chronic pelvic pain syndromes misses the point if you have an interest in offering any substantial help to these people.
Conventional psychological support does very little for pelvic pain.
Psychological support in the conventional sense of a psychologist/counselor who offers insights and cognitive strategies to deal with dysfunctional thinking, in my view, does very little to help those who have chronic pelvic pain syndromes. In my experience, a psychologist/counselor can spend a day with people who have chronic pelvic pain, give them the experience of being heard, and deal with their cognitive distortions, and it will make very little difference to their symptoms or to their life. I say this as a psychologist who has been in practice for 40 years and who has done tens of thousands of hours of psychotherapy and who had chronic pelvic pain himself for many years. Psychological support in the normally understood sense is NOT significant in helping the stress component of chronic pelvic pain syndromes, prostatitis, pelvic floor dysfunction, interstitial cystitis, etc.
It is the basic fear that the pain will never go away that drives the psychological component of these disorders.
Lack of psychological support is not the problem that needs to be solved for people who have chronic pelvic pain syndromes. Offering support without giving them the tools to reduce their pain, in my many years of experience, does essentially nothing to help. When you have aching, burning tightness in the area of your pelvis and genitals and you have pain with sex and you cannot sit down, these symptoms fundamentally impair your life. They impair the basic building blocks of life – of urination, of defecation, of orgasm, of being able to sit and sometimes even being able to stand. Reassurances and psychological support alone will do little to help these symptoms.
Empowering the patient to reduce his or her own pain is the best psychological support you can offer.
What calms anxiety and catastrophic thinking is the experience of being able to reduce your own pain yourself. When you are able to put a finger on your own pain, or put an instrument on your own pain, and work on it, this is life-changing. This is essentially the antidote to the thought that the pain will never go away. This also increases your quality of life.
Data from our Internal Trigger Point Wand Study
In another essay in this blog, I have discussed the essential unhelpfulness of psychological intervention in which the patient is not empowered to help and release his own symptoms. During the years of the clinical trial for our Internal Trigger Point Wand, we saw that emotional distress is directly related to the reduction of symptoms. When people’s symptoms do not get better, their emotional distress generally does not get better, unless they have glimpses of their ability to reduce their own pain themselves.
While our study did not distinguish between cause and effect and which came first, it is my observation that what comes first is the ability to reduce symptoms, leading to or causing a reduction in emotional distress and anxiety. This positively feeds into the reduction of the pain and psychological distress. If tension, anxiety, pain, and protective guarding is a description of the downward cycle which perpetuates chronic pelvic pain syndromes, then the ability to reduce your own pain increases empowerment. You will be entered into a new self-feeding cycle of emotionally feeling better, physically feeling better, emotionally feeling better, physically feeling better.
What is real psychological support – what does that really mean?
Simple manipulation of thinking through cognitive therapy strategies is not very helpful. The core catastrophic thought that triggers emotional distress in folks with pelvic pain is, “I am never going to get better and I am doomed to never be able to relax and have any kind of quality of life.” Yes, that is the villainous thought. Simply identifying it without being able to reduce the pelvic pain symptoms does very little. Simply intervening with words in an attempt to stop cognitive distortion has little traction.
Learning how to be “off” as a stress reduction strategy.
Stress reduction in general, and in pelvic pain syndromes including prostatitis in particular, requires learning how to be “off” rather than “on”. In our experience, working with many people with pelvic pain over the years, the major help that is offered by our behavioral psychological intervention has to do with teaching someone to cease efforting. The deepest relaxation occurs when all of the muscles are “off” and there is no guarding or protecting against something bad happening. My teacher, Edmund Jacobson, who taught me relaxation said, “Turn the power off,” which was his way of guiding me toward becoming effortless.
We all know what it means to have to be “on”. Being “on” means that I have to be ready to respond to others. I cannot just drop my guard or take my attention off of being responsive. When you are in the work mode, and often when you are not in the work mode, you are always ready to respond, always ready to kick in. Being “off,” sort of like being “off duty,” means that you do not have to be watching the environment to be responsive to it. It means being able to let your attention come into yourself and not have to be out in the world, responding and adjusting to the changing conditions of the world.
When I do a pelvic pain clinic I am “on” for 5 days. From the beginning of the clinic to the end of the clinic I am there responsive to other people. I cannot just wander off by myself, being in my own thoughts, being in my own body, being in my own experience. My attention is out in the clinic, responding to the needs of others and to the environment.
Being “off” means your nervous system can heal and regroup.
When the clinic is over, I usually feel exhilarated and I typically utter a sigh of relief. My life is my own again. I am not “on” anymore. I can be “off duty.” We ask people in our clinic to do Paradoxical Relaxation – which means that you must be “off”. This is the reason why we ask parents to ask their spouse to take care of their children, to turn their phone off, to keep pets away, so they do not attend to anything in their environment outside of the instructions that allow them to release their guarding. Creating a space for an hour or an hour and a half to be “off duty” allows the muscles to rest and the nervous system to down-regulate or calm down. And giving yourself the space to be “off” is all important in giving the nervous system an opportunity to down-regulate.
Anger and the response of the pelvic floor.
When you become sensitive to what is going on in your pelvis, you will often notice how the pelvic muscles tighten up and become more irritated and painful when you are anxious, stressed or pushed in some way. A dramatic example of this is something we discussed in our book, A Headache in the Pelvis. A middle-aged woman was seeing a colleague of ours who was an experienced physical therapist in New York. While our colleague had her finger inside the woman’s vagina doing Trigger Point Release, this woman started talking about something that was going on politically that she had a very strong reaction to. As she spoke about this politician she hated, the muscles in the woman’s pelvic floor began to tighten around our colleague’s fingers and our colleague reported that she was afraid that her fingers were going to be crushed. Now, this is particularly unusual because the pelvic muscles of a middle-aged woman are not known to be particularly strong. However, the physical reaction in the pelvis, which was part of her angry response, was unmistakable and dramatic. When our colleague said to her patient, “Can you feel what is going on in your pelvis as you are talking about the politician that you hate?” the woman said, “Feel what?” She was not aware of it at all.
The pelvic muscles tend to overreact to stress in those who have pelvic pain.
The pelvic muscles in those with chronic pelvic pain tend to tighten up to stressful events. While there has been very little or no research has been done on this, it has been my own personal and professional experience that people who have pelvic pain become sensitive to the tissue down there and see a close connection between pain and stress. Some people experience it remarkably strongly and clearly, and actually, that experience of the direct connection between stress and increased pain is a blessing because it makes a concept a clear experience. It validates the fact that there is a psychophysical one.
In muscle based prostatitis, pelvic floor dysfunction and other pelvic pain syndromes, the most effective stress reduction empowers patients to reduce their own pain. Paradoxical Relaxation is the practice of effortlessness, of letting go. While interpersonal support is mildly helpful, it does not go very far. I often say to patients, “My reassurance will probably last about 10 minutes and then you will get back into your scary thinking.”
Effectively dealing with stress related to pelvic pain is giving patients the tools to be able to turn “off” their own fearful contracted pelvic reaction regularly. Give a man a fish, he eats for a day. Teaching a man to fish, he eats for a lifetime. Reassurance and interpersonal support may help for a small amount of time. On the other hand, giving someone the ability to reduce pain and, in the psychological domain, reduce fearful guarding, gives a person a lifelong ability to manage stress and release themselves from the effect of pelvic pain.
Symptoms of prostatitis and pain in the pelvis typically don’t respond to conventional medical treatment.
Traditionally, when men have complained to their doctor about pain in the pelvis, anus or genitals, urinary frequency and urgency, post-ejaculatory discomfort, or sitting pain or the sensation of a ‘golf ball’ in the rectum, they are usually diagnosed with prostatitis. With this diagnosis, they are given antibiotics and told to avoid caffeine, alcohol and spicy foods, ejaculate more frequently, and take hot baths.
Most conventional advice about treating prostatitis, including diet modification and increasing sexual activity, is confusing and sometimes makes symptoms worse.
Most of our patients report to us that the dietary advice they have been given about caffeine, alcohol, spicy foods is confusing as they did not understand its basis. Furthermore, following this kind of dietary advice has little effect on their symptoms. In fact, many men who have come to see us for the Wise-Anderson Protocol for prostatitis have reported that alcohol often improves their symptoms and does not hurt them.
To add to the confusion, increasing sexual activity makes symptoms worse in a large majority of men. We have described the post-ejaculatory discomfort as a ‘pleasure spasm’ in our book, A Headache in the Pelvis. When a man’s pelvis is chronically constricted, instead of orgasm relaxing the pelvis, it actually increases its tension level and causes significant discomfort or pain in the pelvis that can last from a few hours to weeks.
Hot baths can temporarily relieve the symptoms of prostatitis.
One piece of conventional wisdom given to men diagnosed with prostatitis is to take hot baths. Most men report that hot baths temporarily relieve their symptoms. Hedelin and Jonsson in the Scandinavian Journal of Urology and Nephrology report that cold tends to aggravate symptoms of prostatitis and heat tends to ameliorate it (Scand J Urol Nephrol. 2007;41(6):516-20). This is common knowledge among urologists and is quickly learned by patients.
Regular baths tend to be more effective than sitz baths for prostatitis.
Patients are often told to take a sitz bath, a bath in which only the buttocks and hips are immersed in water. Patients have reported to us that taking a regular hot bath is more effective than simply immersing the pelvic area in a small tub of hot water. The sitz bath is often uncomfortable and does not allow for the kind of relaxation of the muscles of the pelvis and the reduction of the arousal of the nervous system that a regular hot bath affords. It is the central reduction of nervous arousal as well as the local relaxation of the pelvic muscles that is therapeutic for those suffering from what is diagnosed as prostatitis.
The heat of the hot water (and not what is put into the bath’s hot water) is what relaxes pelvic muscles.
We often hear of men putting Epsom salts or other bath salts into the bath water in an attempt to help calm down their symptoms. In our view, it is the heat of the bath that is therapeutic and not what is put into the bath. Saunas, steam baths, and hot showers help calm symptoms as well. Most cases of prostatitis, as we have discussed extensively in our research and in our book, are caused by chronically tightened pelvic muscles and not a prostate infection, inflammation, or prostate pathology. Getting into a hot bath is a remarkably fast reducer of muscle tension in the pelvis as well as a strong reducer of anxiety and autonomic nervous system arousal. We have often said that if there were a medication that offered the side-effect free benefit of hot water, it would be a major drug used in medicine.
Hot baths help symptoms of prostatitis but offer no permanent solution.
Heat and hot baths are palliative and can make the very distressing symptoms of what is diagnosed as prostatitis momentarily more tolerable. However, the hot water does not offer a permanent solution to these symptoms. Men will typically report that their symptoms feel better when they are in the hot bath but the effects of the hot water fade soon after they get out. Nevertheless, hot baths are a gift to those suffering from pain in the pelvis as the reduction of symptoms for any length of time is very welcomed by patients.
Hot baths help because most cases of prostatitis are caused by muscle contraction in the pelvis, and not by prostate pathology.
In our experience, most men diagnosed with prostatitis do not suffer from a pathology of the prostate gland but from chronically contracted muscles of the pelvic floor that form a cycle of tension, anxiety, pain in the pelvis, and protective guarding. This is the focus of our book, A Headache in the Pelvis. Once initiated, this cycle has a life of its own.
The Wise-Anderson Protocol (popularly known as the Stanford Protocol) has been developed to teach patients to effectively rehabilitate chronic pelvic floor contraction and lower the nervous arousal that feeds it. The success of our protocol in doing this has been documented to significantly reduce the symptoms of those whom we have treated who were diagnosed with prostatitis. Hot baths can help take the edge off of the pain in the process of this rehabilitation.
Treating chronic prostatitis and chronic pelvic pain: their relationship to mind and body
We are often asked whether the physical or behavioral parts of the Wise-Anderson Protocol for treating chronic prostatitis and chronic pelvic pain is more important for its connection to the relationship to the Mind and body. This is a major issue for patients, researchers and doctors alike because it determines the course of the prostatitis treatment and the outcome of treatment.
Over the years we have anecdotally noticed that a small group of our patients have significant improvement in their symptoms with what appears to be our physical treatment alone. On the other end of the spectrum, another small group of our patients appears to do very well with only the behavior component. The large majority of our patients, however, appear to require both the physical treatment which focuses on directly loosening the muscles of the pelvic floor and the behavioral treatment which focuses on helping patients reduce their anxiety daily in the service of releasing the chronic contraction of the muscles of the pelvic floor.
Those practitioners involved in treating chronic prostatitis and chronic pelvic pain rarely converse.
The health specialties in treating chronic prostatitis based on muscle dysfunction and related disorders are usually confined in their own relatively narrow orientations of focusing on either the physical or behavioral/psychological but not both. Historically the subspecialties like urology, colo-rectal surgery, gynecology, pain management, physical therapy, osteopathy on the one hand, and psychology and psychiatry on the other rarely talk to each other. Even when the physically-oriented practitioner recognizes the importance of the behavioral/psychological dimension, or vice-versa, rarely are the physical and behavioral/psychological treatments coordinated or specifically geared to the patient with a pelvic pain disorder. Psychologists and psychiatrists often have little training in the physical components nor do the physically oriented practitioners have training in the mind related dimension of the treatment of the problem.
Successfully treating chronic prostatitis and pelvic pain in terms of mind and body.
Mind and body meet in the pelvic floor in those who suffer from muscle-based chronic prostatitis and chronic pelvic pain. In our book, A Headache in the Pelvis, we discuss the centrality of the tension-anxiety-pain-protective guarding cycle and how this cycle takes on a life of its own no matter what triggers it. The large majority of our patients come to us with years of chronic pelvic contraction that is the way in which they have expressed their anxiety physically. Simply loosening and releasing the chronic contraction of the pelvic floor tends to be short-lived if this loosening is not done repetitively and accompanied by a daily program of relaxing the pelvis and calming down the arousal of the nervous system. All of this is not a small task and is usually undertaken only by those who are in great and ongoing suffering. Yet for those who understand the necessity of this mind and body treatment and diligently pursue it, they have the possibility of real help in a way that it has never been possible in the past.
In an article in 2000 in Physical Therapy, investigators found that teaching patients to do ischemic compression (pressure on Myofascial trigger points) in the neck and upper back was effective in reducing pain and sensitivity.We are gratified to see some studies showing the efficacy of physical therapy self-treatment for myofascial pain.We have found that self-treatment for patients with pelvic pain is by far the most effective treatment in reducing or resolving their symptoms.It goes without saying that self-treatment is the most cost-effective of methods, empowering to one’s self-esteem and in our experience the best therapy for dealing with the catastrophic thinking that comes out of the powerlessness of the pelvic pain patient to do anything about his/her pain.
While learning self-treatment inside and outside the pelvic floor for pelvic pain patients diagnosed with pelvic floor dysfunction, non-bacterial prostatitis, levator ani syndrome and pain related to muscle dysfunction in patients diagnosed with interstitial cystitis and other muscle based pelvic pain diagnoses has huge advantages in the physical and psychological dimensions of pelvic floor dysfunction, it requires careful and competent training.Over the period of our 6-day clinic we teach patients to use the theracane, a tennis or lacrosse ball, their fingers and hands to do trigger point release abdominally, in the area of quadratus lumborum, adductors, obliques, and abdominals.We also teach them with their fingers and our newly FDA approved internal trigger point wand to do internal trigger point release.These are skills that can be learned and can be done with more and more skill over months of doing these skills but the initial training has to be competent.
Below is the 2000 study on teaching patients how to do the trigger point release themselves on areas of pain in their neck and upper back.
Ischemic Pressure Followed by Sustained Stretch for Treatment of Myofascial Trigger Points
Background and Purpose. Myofascial trigger points (TPs) are found among patients who have neck and upper back pain. The purpose of this study was to determine the effectiveness of a home program of ischemic pressure followed by sustained stretching for the treatment of myofascial TPs.
Subjects. Forty adults (17 male, 23 female), aged 23 to 58 years (X?=30.6, SD=9.3), with one or more TPs in the neck or upper back participated in this study.
Methods. Subjects were randomly divided into 2 groups receiving a 5-day home program of either ischemic pressure followed by general sustained stretching of the neck and upper back musculature or a control treatment of active range of motion. Measurements were obtained before the subjects received the home program instruction and on the third day after they discontinued treatment. Trigger point sensitivity was measured with a pressure algometer as pressure pain threshold (PPT). Average pain intensity for a 24-hour period was scored on a visual analog scale (VAS). Subjects also reported the percentage of time in pain over a 24-hour period. A multivariate analysis of covariance, with the pretests as the covariates, was performed and followed by 3 analyses of covariance, 1 for each variable.
Results. Differences were found between the treatment and control groups for VAS scores and PPT. No difference was found between the groups for the percentage of time in pain.
Conclusion and Discussion. A home program, consisting of ischemic pressure and sustained stretching, was shown to be effective in reducing TP sensitivity and pain intensity in individuals with neck and upper back pain. The results of this study indicate that clinicians can treat myofascial TPs through monitoring of a home program of ischemic pressure and stretching.
William P Hanten,
Sharon L Olson,
Nicole L Butts and
Aimee L Nowicki
WP Hanten, PT, EdD, is Professor, School of Physical Therapy, Texas Woman’s University, 1130 MD Anderson Blvd, Houston, TX 77030 (USA) (firstname.lastname@example.org). Address all correspondence to Dr Hanten
SL Olson, PT, PhD, is Associate Professor, School of Physical Therapy, Texas Woman’s University
NL Butts, PT, MS, is a student, School of Physical Therapy, Texas Woman’s University
AL Nowicki, PT, MS, is a student, School of Physical Therapy, Texas Woman’s University
Paradoxical Relaxation and the Treatment of Chronic Pelvic Pain Syndrome
In a recent New York Times article (see excerpt below), the usefulness of concentration as an integral part of a discussion of mindfulness is discussed. The ability to concentrate is not a subject that is often discussed in the psychological literature on pain reduction; thus, this article is a welcome addition to the narrative of what we consider a critical issue in dealing successfully with chronic pelvic pain.
It has become clear over the last decade that nervous system arousal is a central issue to treat in those suffering from chronic pelvic pain syndromes. Gevirtz and Hubbard have convincingly shown emotional arousal raises the level of electrical activity in pain referring trigger points in those with myofascial-related pain. There have been recent studies evaluating the usefulness of hypnosis and cognitive therapy to deal with nervous system arousal, but it has been our observation that psychotherapy by itself has little effect on modulating or reducing chronic pelvic pain. Traditional methods of cognitive therapy help patients recognize their dysfunctional thinking and analyze distorted thoughts in order to discard them. In our work using the Wise-Anderson Protocol over the last 18 years, we have observed that these methods are not greatly helpful when patients’ pain goes on unabated and they remain helpless to do anything about it.
The method of Paradoxical Relaxation used in the Wise-Anderson Protocol is one of the main ingredients we use to help those with pelvic pain lower their autonomic nervous system arousal. Many of our patients who become competent in this methodology commonly report that they can significantly reduce their pain using this relaxation method.
Paradoxical Relaxation is the practice of focusing attention on sensation rather than mental thought. The aim is to take attention away from all thought—not analyze any of it. While it is sometimes useful to analyze dysfunctional thinking, that is not the aim of Paradoxical Relaxation. If someone is helpless to stop their chronic pain, it doesn’t matter how much analysis of dysfunctional thinking is done because the inability to affect the pain is the main driver of the sense of helplessness and disempowerment.
In the Paradoxical Relaxation session, the nervous system is deliberately deprived of the symbolic stimuli that cause it to become aroused. This break in arousal can help break a flare up of symptoms and moves in the direction of downwardly resetting the nervous system ‘idle speed.’
The most profound relaxation occurs when attention is controlled and kept focused in sensation. Just as the deepest sleep is dreamless (non-REM) sleep, relaxation that is void of thinking produces the deepest level of relaxation. This type of deep relaxation allows for an up-regulated nervous system to quiet down. The idea of relaxation depending on the control of attention rather than the releasing of such control is counter-intuitive, yet over the years patients using Paradoxical Relaxation in the Wise-Anderson Protocol have experienced the ability to control attention, to reduce pain, and ‘down regulate’ the nervous system.
Training attention to stay focused is a discipline that, as the New York Times article we quote below understands, has many benefits. In our work with pelvic pain, calming down nervous arousal to reduce pain is the most important of these benefits.
Excerpt from “The Power of Concentration” by Maria Konnikova in the New York Times on December 16, 2012.
The Power of Concentration
By MARIA KONNIKOVA
December 16, 2012
“MEDITATION and mindfulness: the words conjure images of yoga retreats and Buddhist monks. But perhaps they should evoke a very different picture: a man in a deerstalker, puffing away at a curved pipe, Mr. Sherlock Holmes himself. The world’s greatest fictional detective is someone who knows the value of concentration, of “throwing his brain out of action,” as Dr. Watson puts it. He is the quintessential unitasker in a multitasking world…
In 2011, researchers from the University of Wisconsin demonstrated that daily meditation-like thought could shift frontal brain activity toward a pattern that is associated with what cognitive scientists call positive, approach-oriented emotional states — states that make us more likely to engage the world rather than to withdraw from it.
Participants were instructed to relax with their eyes closed, focus on their breathing, and acknowledge and release any random thoughts that might arise. Then they had the option of receiving nine 30-minute meditation training sessions over the next five weeks. When they were tested a second time, their neural activation patterns had undergone a striking leftward shift in frontal asymmetry — even when their practice and training averaged only 5 to 16 minutes a day.