A disciplined, daily focus for helping to resolve pelvic pain including conditions diagnosed as prostatitis, chronic pelvic pain syndrome, CPPS, pelvic floor dysfunction, levator ani syndrome, pudendal neuralgia, perineal pain among others

by Robert Grahameon 15 May 2023in Levator Ani Syndrome, Paradoxical Relaxation, Pelvic Floor Dysfunction, Pelvic Pain, Prostatitis

Why a disciplined, focused daily program is necessary to have a chance of recovering from pelvic pain (including prostatitis, chronic pelvic pain syndrome, CPPS, pelvic floor dysfunction, levator ani syndrome, pudendal neuralgia, perineal pain among others)
We tell people who do our program that it takes time and diligent practice to have the best chance of a reliable reduction or resolution of pelvic floor related symptoms? Let me summarize what this means. Unflagging daily program over time of myofascial trigger point release and relaxation is the key to helping heal a sore pelvis. If you have pelvic pain, healing pelvic pain needs to be the top priority of everything you are doing using tools that work and a method that cooperates with what the pelvic floor needs in order for it to heal.
In some people, pelvic floor related pain spontaneously and mysteriously goes away with no treatment. Sometimes, it’s a one-time or two-time occurrence, and that’s it. It’s also not uncommon for pelvic pain to reappear later. More often than not, however, pelvic pain becomes chronic and occurs on a daily basis.
Having chronic pelvic pain is typically a very distressing, frustrating, and scary experience. I suffered from pelvic pain for over twenty years. Those were very difficult years. I first developed the method we now use through my experimentation to help myself when I was in a desperate way.
Later, I met with Dr. Rodney Anderson in the Urology department at Stanford University Medical Center with whom I spent eight years. The result of our collaboration was the development of a private immersion clinic that our group has been holding regularly now for twenty years. And significantly, when the normal scheduling of our immersion clinic was curtailed by Covid,-19, a home program was developed not requiring people to come to see us in person. Gratefully we continue to do our in-person clinic 8 times a year.

It’s important to understand that there has never been an effective treatment for muscle-based pelvic floor pain in the history of medicine. In my experience few doctors have an interest in this problem, really understand what it is and what is needed to resolve it. You can’t see pelvic pain like you can a broken bone which includes conditions named prostatitis, chronic pelvic pain syndrome, CPPS, pelvic floor dysfunction, levator ani syndrome, pudendal neuralgia, perineal pain among others)

No visualizing technology like an X-ray, CT scan, MRI, or sonogram can detect it. No blood, urine, or other fluid tests will pick it up. So, pelvic pain is essentially invisible to the doctor. If you are a doctor and a patient complains of pelvic pain and a variety of peculiar symptoms, which you yourself have never experienced, but you can’t detect the problem with your eyes or regular tests, then you have to project a concept of what’s wrong with the patient. If the concept you project is wrong, the solution won’t work. In our book A Headache in the Pelvis we say that open-heart surgery on someone with heartburn isn’t a good idea – you need a correct understanding of the problem to effectively treat it. And if you’ve never suffered from pelvic pain, it is very difficult to understand what it is. Our view of pelvic pain comes from my decades long first-hand experience and of my recovery from it.
Pelvic-floor pain has no conventional recognizable pathology associated with it other than the obvious misery of that the sufferer complains of. It has been clear to me for many years that pelvic floor pain is a stress-related disorder that tends to occur to sensitive, ambitious, successful, conscientious, deeply felt, people who inadvertently and repeatedly tighten their pelvic muscles over years when they get anxious. Over time, this anxiety-driven tightening causes the pelvic muscles to shorten, form painful trigger points, become irritated and remain in a chronically painful and tightened state.
In our program, patients learn to physically release these chronically tightened pelvic muscles themselves by inserting our FDA certified/approved Internal Trigger Point Wand internally and actually press on the painful trigger points in the pelvic floor in order to release them. Our patients use our FDA certified Trigger Point Genie to do external trigger point release of the external muscles that are connected to the painful pelvis. This goal of this treatment is to repeatedly physically restore pelvic muscles to a normal ease and tone. When the pelvic muscles are not chronically tightened, trigger pointed and sore, they don’t hurt.
But the physical untightening, I know from personal experience and the observation of many patients I’ve seen over the past 30 years, is not enough to restore the normal tone and ease of the pelvis. In addition to physically working in the pelvis floor and related muscles, in is generally necessary for most patients to daily reduce the arousal of their nervous system. To this end we teach them a method called Extended Paradoxical Relaxation. Extended Paradoxical Relaxation borrows from my teacher Edmund Jacobson, developer of Progressive Relaxation and who is considered the father of relaxation therapy in the United States.

We originally thought of calling our book TMJ of the Pelvis instead of A Headache in the Pelvis. It is helpful to understand the need for ceasing the anxiety driven clenching of the pelvic floor by seeing that even if you are able to release the shortened contracted muscles of the jaw when you have TMJ, unless you stop clenching your teeth, all of the work of loosening the muscles of the jaw won’t stop the jaw pain.
I suffered with pelvic pain for over twenty years – bumbling through a series of incorrect diagnoses and treatments. From what I learned, I want to discuss the nature of pelvic pain and what I believe are the requirements to resolve it. It has been my experience that it is necessary to have the discipline of doing a daily program to release the painfully tightened and trigger-pointed muscles in and around the pelvic floor alongside a daily program providing significant daily time of significantly reduced or no anxiety if you want to have a chance of resolving the vexing problem of pelvic-floor pain and dysfunction. As it is with stopping teeth grinding/clenching in TMJ to stop jaw pain, so one must stop the ‘grinding’ of the pelvic muscles along with the releasing of the pelvic trigger points in order to stop pelvic pain. This is not a small thing to do. But it is possible.
Said very simply, pelvic floor pain is a condition in which the center of the body chronically, what has been called the ‘core’ of the body, physically tightens and ultimately isn’t able to relax. Again, this is all driven by anxiety. At a certain point, often triggered by intense or prolonged stress, this chronic tightening doesn’t untighten and becomes a chronic painful normal state. This is a different paradigm than is conventionally held of conditions with the names including prostatitis, chronic pelvic pain syndrome, CPPS, pelvic floor dysfunction, levator ani syndrome, pudendal neuralgia, perineal pain among other diagnostic terms.

This pelvic tightening throws a monkey wrench into the normal feeling of ease, and into normal functions that the center of the body is involved in like urination, defecation, sexual arousal and orgasm, balance, and even sitting. This disorder is labeled differently by doctors having different sub-specialties – the names include pelvic floor dysfunction, prostatitis/CPPS, anorectal pain, levator ani syndrome, or pudendal neuralgia among others. In pelvic pain patients, the center of the body is unhappy — the nerves and muscles of the pelvic floor are in a state of what could be called ‘freeze’ in the famous distillation of the stress response as fight, flight, freeze.
The pelvic floor muscles are in a state of freeze. This tightened, painful state becomes the unhappy normal state, and is fed hourly and daily by chronic pelvic tightening fed by pain, anxiety, and sore, irritated tissue. It is further exacerbated by the underlying worry that nobody understands what’s going on, nobody can help, and it will never go away.
This all brings me back to why I am saying here that a prolonged and concerted effort is needed to have the best chance of resolving this problem. In a word, it is a very big deal to change how you hold yourself in the center of your body, and to change the reflexive habit of how you automatically tighten yourself physically up as you worry. In our program, addressing chronic pelvic pain involves the very big job of calming down the body physically as well as mentally and emotionally on a daily basis – a problem that conventional medicine isn’t very helpful with. In my experience, the anxiety driving the protective guarding response of pelvic tightening isn’t resolved through medication. In fact, drugs often worsen someone’s pain as the medication stops being effective, and most typically becomes addictive.
Easing the chronic tightening of the pelvic-floor muscles in the core of the body and the related muscles requires a concerted and long-term daily effort of releasing them and reducing anxiety on a daily basis. There are ups and downs. There are flare-ups. There are periods of great optimism and periods of anxiety related to flare-ups or lack of progress as it appears in the moment. All this needs to be understood and accepted, and the practice of releasing the sore, tightened muscles and quieting the nervous system must nonetheless be doggedly pursued.
In my view, a daily quieting of anxiety and nervous-system arousal must be done. For any long-term resolution of pelvic-floor pain, focusing on only the physical release of the pelvis (which itself requires skill and patience and knowledge) is not enough. Again, pelvic pain is ultimately a stress-related disorder, and addressing the physical pain without providing the pelvis with a stress-free/guarding-free environment every day is like continually cleaning up spilled water from a leaky faucet rather than replacing the leaky faucet.
I myself was dogged in treatment of myself when I was symptomatic because there was really nothing else to do. And gratefully, I now sit here and write this essay without pelvic pain.
Pelvic pain doesn’t occur overnight, even if for some it feels like it does. I like the aphorism, “the fruit falls suddenly, but the ripening takes time”. While there are no studies about this, I believe it takes years of chronic tightening from anxiety to create chronic pelvic pain. Similarly, when pelvic pain heals, it doesn’t heal overnight. Healing pelvic pain takes dedication, trust, and a significant amount of time every day doing what is necessary to address the problem – physically releasing the painfully tightened pelvic muscles, yes, and simultaneously interrupting the habit of chronically tightening the pelvic floor. This means taking the time to give the sore pelvic tissue an opportunity to be free from anxiety, and to heal. This concept applies to conditions including diagnoses of prostatitis, chronic pelvic pain syndrome, CPPS, pelvic floor dysfunction, levator ani syndrome, pudendal neuralgia and perineal pain among others.
There are a number of mainstream treatments for pelvic pain, from taking drugs to undergoing surgery to simply doing physical therapy. However, in my view, the painful pelvis has little chance of healing without the long-term practice of regularly releasing stubborn pelvic floor muscle related trigger points (which is best done by the patient himself or herself), and without the devoted, daily practice of resting in an environment free from the major pelvic irritants.

Paradoxical Relaxation: Relieving a Painful Pelvic Floor

by PPadminon 27 October 2014in Paradoxical Relaxation

https://www.youtube.com/watch?v=kBnu9Hl0B1A

Paradoxical Relaxation relaxes the tension and shortened muscles within a painful pelvic floor.

This involves a daily practice of the cultivation of effortlessness in the presence of pain, anxiety, and tension.

Paradoxical Relaxation has two components: The first is a breathing technique used at the beginning of relaxation, a coordination of heart rate and breathing. This reduces respiration to approximately 6 breaths per minute. The second component is the instruction given for the remainder of the session. These direct the patient to focus attention on the effortless letting go of tension in a specified area of the body, accepting residual tension that does not easily release.

b. Patients are asked to listen to approximately 1 hour of recorded relaxation instruction daily. These allow the focus of individual predetermined sites, including frontalis, jaw, neck, shoulders, arms, hands, upper back, chest, stomach pelvis, legs, and feet. Each site is the focus of practice for approximately 2 weeks, and the entire course lasts for approximately a year and two months. Home practice is done daily and includes the use of 46-recorded lessons varying in length from 7 minutes to 45 minutes. The focus on the relaxation of a painful pelvic floor is generally avoided for the first several months of relaxation training. This is because such a focus can exacerbate symptoms until competence in relaxation is gained in neutral, non-painful areas.

c. Relaxation instruction guides the patient to redirect attention away from discursive thinking and daydreaming. The target range of brain wave activity is low-frequency alpha.

d. Catastrophic thoughts that increase sympathetic arousal arising during relaxation are identified. A cognitive therapy protocol is used to help the patient reduce the impact of such thinking.

The process of Paradoxical Relaxation is a slow one.

Respect for and cooperation with this very slow process is essential to success. When the desire of the patient aims to hurry the body’s slow letting go of deeply ingrained tension, they usually fail to relax a painful pelvic floor. In Paradoxical Relaxation, the instruction is given to let go of tension. This effortless relaxation usually occurs in small and unremarkable steps. Recognizing and working with these small gradations of relaxation is essential.

Edmund Jacobson described residual tension in detail in his long career in the development of relaxation therapy, which began in 1908. The patient is instructed to keep attention focused on residual tension without trying to change it. When attention is distracted by visual or conceptual thinking throughout the protocol, the patient is instructed to refocus attention on the remaining tension without aiming to achieve any result. It is essential that the patient understands that deep relaxation occurs when attention rests in sensation and not in thinking.

Instructions alternate between letting go of the tension that easily lets go and effortlessly feeling the remaining tension. The tension that is being focused upon without effort usually abates during this process. The patient is instructed to permit this abatement to occur. Sometimes the tension does not abate or even increases, and the patient is instructed to remain softly focused on the remaining sensation without an intention to change it. The concept underlying this protocol is that one does not relax stubborn, residual tension directly but instead is effortless in remaining continually aware. Relaxation occurs without any effort on the part of the patient. Exerting any effort increases tension. This is because relaxation is identical to effortlessness.

We specifically discourage patients from focusing on the relaxation of a painful pelvic floor for the first 4 months of treatment, as the patient’s attachment to the relief of symptoms tends to interfere with the conscious and simultaneous effortless attention on tension. The focus on the relaxation of the upper body is most easily accomplished and usually results in a reduction of pelvic tone. The focus on the relaxation of the pelvic musculature requires that the patient makes the distinction between pain and tension. The aim of the protocol then becomes directed to the tension and not the pain in the area of a painful pelvis.

https://www.youtube.com/watch?v=ToZQDIq90rs

Learn to profoundly relax pelvic tension in the presence of pain and anxiety.

Pain and anxiety stimulate additional tension and aversion. Without instruction, most patients who are not properly instructed are loathe to sit still in the presence of unresolved pain. The instructions of Paradoxical Relaxation train patients to stop the tension-anxiety-pain cycle by focusing on tiny residual tensions that they can easily relax. At the same time, they can accept the tension and pain that remains. Attention is redirected from negative cognitions and focuses on letting go of tiny and often ignored tensions in the body unconsciously aimed stopping the pain and tension – efforts that only exacerbate symptoms. In the paradoxical acceptance of pain and tension that does not easily relax, the patient learns how to ride the tension down in small steps that require acceptance of what formerly has been unacceptable and frightening.

Chronic pelvic pain syndromes tend to be self-perpetuating disorders in which a patient’s pain causes a reflexive tightening of the pelvic floor, which in most patients, often prompting a flurry of negative thinking. The reflex to contract against pain actually increases pain. Negative and catastrophic thinking fan the fire of the pain by igniting the electrical activity in the trigger points referring pain in the pelvis. The tension-anxiety-pain cycle is a major obstacle to the reduction of a painful pelvic floor. It feeds itself in the moment that a patient is asked to relax the pelvic tension. The disruption of the self-feeding cycle of tension, anxiety, and pain can be accomplished by a select group of patients who become competent in Paradoxical Relaxation.

While we utilize an extensive set of recorded tapes in the Wise-Anderson Protocol relaxation method, instruction is necessary to train patients in the method. Below we discuss the issue of stand-alone relaxation tapes.

Why Paradoxical Relaxation cannot be learned from recorded tapes in the absence of instruction.

(This is part of a response sent to the webmaster of the chronicprostatitis.com website on the issue of stand-alone relaxation tapes.)

As we have discussed, I do not sell the audio Paradoxical Relaxation course on a stand-alone basis. There are numerous relaxation tapes that can be bought from many different sources and people are free to buy them. I could sell the recorded lessons I use on a stand-alone basis – I have certainly had enough requests – but choosing not to do this is neither a casual nor a self-serving decision on my part. I have a short answer and a long answer to explain.

Here is the short answer why.

I have no confidence that someone can learn to relax a painful pelvic floor from a relaxation tape without instruction from someone who is competent in the method and without intrapelvic Trigger Point Release. I do not want to associate myself with making available a half measure that appears to offer something substantial but does not.

When I was symptomatic, I tried many remedies that all seemed reasonable but ultimately failed to help me. They left me hopeful at first, then disappointed, and disheartened. A stand-alone relaxation tape, in my opinion, is a half measure. Half measures give little chance of offering real recovery from chronic pelvic pain syndromes. I have decided that if I am to err, I will err in the direction of not offering anything instead of offering a half measure in which I have no confidence.

Here is the long answer why.

Learning to relax the pelvic muscles and muscle tenstion from a relaxation tape is like learning to play the violin by listening to recorded instructions. In my experience, such an endeavor usually fails; the person gets discouraged and usually gives up. To learn the violin, you need instruction from someone who plays the violin. The more accomplished the player, the better. You want to learn the violin from someone who plays it every day, who is excited about it, and whose expertise is obvious. Imagine learning the violin from someone who does not play it. The obstacles to learning to play the violin and learning to relax deeply are very similar — except learning to deeply relax a painful pelvic floor is harder than playing the violin.

Our instinct is to tighten against pain, not relax. Yet, I found that relaxing with the tension of certain kinds of pelvic pain can dissolve it. Learning to do this is a major event in someone’s life because it is from this place that it can become possible to break the cycle of pain, anxiety, and tension and allow the sore and irritated tissue in the pelvic floor to heal.

There may be some unusual individuals who can deeply relax on a consistent basis by simply using recorded instructions and I applaud them and wish them well. The reason I do not have any faith in this is that to relax a painful pelvic floor and maintain a relaxed pelvic floor over time, (and not everybody can learn how to do this) requires guidance with regard to many issues. Examples of the issues that must be addressed are:

What to do with the pain during relaxation
How to not add tension the tension of ‘trying’ to relax tension
When to use breathing to focus distracted mind and when to cease the breathing technique
What to do when emotions arise that the tension in the pelvic floor is suppressing
How to accept the resistance to accepting the tension
What it means to rest while there is discomfort
What to do when a plateau is reached and tension doesn’t reduce
What to do when symptoms abate during relaxation and then resume quickly afterward
How to relax in the office or on the bus

I have seen many patients distort instructions and become frustrated in their practice of relaxation. A relaxation tape usually addresses none of this and the successful resolution of these issues makes the difference between success and failure.

To learn to relax a painful pelvic floor, especially in the presence of pain, is an enigma and the method to do this is anti-intuitive. It is often frightening for someone with pelvic pain to sit still with their pain and their thoughts without guidance. In my experience, people avoid the kind of relaxation required to relax a tight and painful pelvis if there is no support and the recorded tapes wind up on the shelf.

Few professionals whom I have offered to train in teaching this method have been interested. I think that the reason is that they were not motivated, like my pain motivated me, to spend the time learning to do the relaxation themselves. The best teachers of this method are turning out to be the patients I have trained who are doing well and use it on a daily basis.