The concept of intense and relaxation practice as a necessary therapy for the resolution of what is diagnosed as prostatitis, chronic pelvic pain syndrome, pelvic floor dysfunction among other diagnoses, may well produce a head scratch to the casual observer. What does relaxation have to do with pelvic pain?   In this essay, I want to discuss why the practice of profound relaxation is essential to the healing of pelvic-floor pain.

There are, certainly, some people whose pelvic pain gets better spontaneously without doing anything. And then there are those who plug away at many, many different treatments but their pelvic pain remains. In general, however someone whose pelvic pain has become chronic and is not able to calm down in deep relaxation regularly, I think the likelihood of really recovering from pelvic-floor muscle-related pain is small. I realize this is quite a strong statement. I say it because of how I see pelvic pain from the inside after my own person al experience with pelvic pain of 22 years, my continued state of being pain free and my ongoing relaxation practice.

Why is regular quieting of the body necessary for the healing of pelvic floor related pain and dysfunction? After all, people without pelvic pain don’t need to do any kind of relaxation in order to remain pain-free – but, people without pelvic pain also don’t have sore pelvic-floor tissue that needs to heal. When you have sore, tightened pelvic muscles that are continually re-irritated by the normal functions of life (including urination, defecation, sexual activity, daily stresses, and even sitting), irritated pelvic tissue is unlikely to heal without the ongoing environment provided by the regular practice of relaxation. As I’ve discussed in other podcasts and as we discuss in our book A Headache in the Pelvis, sore pelvic tissue needs a regular sanctuary – a healing chamber, free from the activities and stresses of life that keep it from healing. In our protocol, regular relaxation, done for two-to-four hours each day in an environment that gives the natural mechanisms of the body a chance to let sore pelvic tissue heal, is necessary for the possibility of any real healing to occur.

So, how do you put the sore pelvis into a healing chamber? How do you put up a sign that says to the brain, and to the world, “Do Not Disturb” when you are suffering from prostatitis/chronic pelvic pain syndrome, pelvic floor dysfunction and related conditions? Being able to become deeply quiet and serene in the midst of a crazy world and a demanding life isn’t simple, but it is doable to the person who says, ‘however high I have to jump, I will’.

There are several steps in learning how to profoundly relax. The first is understanding that relaxation is a skill which takes ongoing practice. Like learning to play the violin or to fly an airplane, or any skill of value, you have to put the time in. There are relaxation apps, and relaxation lessons to buy, but I don’t personally think much of them. In my experience, quick fixes, simple breathing methods, and other gimmicks always wind up on the shelf. We all know that there’s no quick way to become skilled at playing the violin. In exactly the same way, there’s no quick method to being able to quiet the body and mind – especially when someone is anxious and experiencing chronic pelvic pain.

It took me years to learn. I was a student of Edmund Jacobsen, the father of relaxation therapy in the United States. He developed a method called progressive relaxation and began practicing it in the early 20^th century, writing a book in 1929, later edited in 1939, called Progressive Relaxation. He was one of the first physicians to treat what we would now call “stress-related disorders” like headache, idiopathic dyspepsia, stomach and digestive problems like esophageal spasm and IBS, hypertension, back pain, and constipation. It took me many years, both at the feet of the master and then on my own after his passing, to really “get” what relaxation is and what is necessary to regularly enter its state.

We all can recall “feeling relaxed.” When we talk about being relaxed, in a way even the word trivializes the experience. In my view, being relaxed is a holy, profound state. It is a state in which life has meaning, and we enjoy things, and we have the experience of just being – being able to delight in the present, in the things that have meaning to us, in our love for others, in the food we eat… in the many things that bring us joy. In the state of real relaxation, the sense of separation between people and the world dissolves.

Relaxation isn’t about breathing exercises. It’s not about visualizing a sun-drenched desert island or some ideal home. Relaxation is about the experience of effortlessness. The idea that breathing exercises are a method of relaxation, in my view, is a misunderstanding by people who don’t know how to do it themselves. When you’ve been relaxed, I doubt you got there through breathing exercises. The sleeping child who is deeply relaxed didn’t need to do anything. Rather, relaxation is the voluntary shifting of the nervous system from sympathetic dominance to parasympathetic dominance. And what does that mean, exactly? Well, physiologically speaking, relaxation is a state in which one of the parts of the autonomic nervous system, called the parasympathetic division, is dominant – as opposed to the sympathetic division. The parasympathetic division has been called the rest-digest-recuperate aspect of the nervous system, while the sympathetic division is involved in activity, nervousness, focus, and anxiety and is often called the fight-flight aspect.

I’m going to do my best to explain how the divisions of the autonomic nervous system work and relate it to the condition that is typically diagnosed as prostatitis/CPPS or pelvic floor dysfunction. You can think of the human body as a computer that comes hard-wired from the factory with two automatic computer programs that are generally not under the owner’s control. These programs refer to the activity of either the sympathetic and parasympathetic divisions of the nervous system. Neither is under much conscious control unless you make effort to learn to control them – which is what we do in the relaxation protocol that is a central part of our program. Generally, these two aspects of the autonomic nervous system work automatically reciprocally: when one is on, the other is off.

The activation of the sympathetic system can be thought of as what happens to a car when you press on the gas pedal, and the activation of the parasympathetic system is what happens when you take your foot off if the gas pedal. When one system is operating, the other isn’t. The balanced system is meant to preserve survival – it allows us to respond to danger, to flee, fight or freeze, or to rest, digest and rejuvenate when danger has passed. As a survival mechanism, the body postpones recuperative tasks when there’s an emergency. The parasympathetic system has to wait until it feels safe from danger before it can fully activate`. This is important.

We’re often unaware of the autonomic nervous system because it functions involuntarily and automatically. For instance, we generally don’t notice changes in the size of blood vessels or the rate of our heart, because those are automatically regulated by the nervous system. The parasympathetic division of the nervous system is the part that allows recuperation, but it has to be patient… it waits for the right time to do its work. If there’s an emergency, the parasympathetic system waits to rest, digest, or recuperate, for its immune function to fight off infection, or to do the other tasks it performs. However, you can’t postpone parasympathetic functions indefinitely. You can only ignore your body for so long without paying a price.

Back to cars… you can run your car at 100 miles per hour all day, but if you keep doing it you’ll be in for a trip to the mechanic. Arousal of the sympathetic nervous system postpones parasympathetic response, and you can’t postpone it forever without something breaking down. Chronic pelvic pain, in my view, is one consequence of ongoing parasympathetic postponement, where the normal relaxation required to heal sore, irritated pelvic-floor muscles doesn’t occur. The pelvic-pain cycle is a sequence of tension leading to anxiety, leading to a sore pelvic floor, leading to a protective guarding that causes more tension and anxiety and pain. This cycle is basically what happens when the sympathetic nervous system goes into overdrive and doesn’t get a chance to turn off.

When a person is healthy, these two systems are reciprocal, shifting back and forth depending on the body’s activity at the time. We can tell which system is dominant through certain physiological signs. For instance, sympathetic dominance in its extreme, involves sweaty palms, narrow pupils, muscle tension, dry mouth, and increased blood pressure or heart rate. The parasympathetic response is very different. In a book called The Relaxation Response, Dr. Herbert Benson discusses the “relaxed state,” which is essentially parasympathetic dominance. This is the state in which we sigh deeply and say, “Ah, I feel so good.” Nobody feels relaxed and not good – the experience of parasympathetic dominance is relaxation and pleasure.

Sympathetic arousal is certainly not always a negative thing. Sympathetic dominance is about alertness, activity, focus, and getting things done. When someone is “on the case” about something, being attentive and productive, the sympathetic nervous system is on.. Conversely, the parasympathetic nervous system supports rest, rejuvenation, and rehabilitation. It’s the state of ease and unguardedness, of being unconcerned about survival, of not being vigilant but instead feeling safe and open. We know that we’re in a parasympathetic mode before going to sleep, when we feel tired and are just looking forward to nodding off. When people can’t drift off and instead just lie awake, it’s because their sympathetic nervous system is still activated and they are not able to shift into parasympathetic mode to relax.

So, I repeat, what does any of this have to do with pelvic pain? As we discuss in A Headache in the Pelvis and in previous podcasts and articles, pelvic pain results from sore pelvic tissue put in an inhospitable environment of contraction and anxiety, when sympathetic dominance of the nervous system doesn’t support healing of this tissue for the soreness to go away. An unfortunate dilemma with pelvic pain is that pain makes you anxious and anxiety puts you in heightened “survival mode” where sympathetic dominance is the rule.

This creates an environment unsupportive of healing because the survival state focuses on in-the-moment-action and not long-term health. Sympathetic dominance tells the body to put aside all functions not immediately related to survival. When your house is on fire, you don’t start doing the laundry or washing dishes – the maintenance functions that keep things happy and nice in your house are put aside as you run for your life. The same thing happens in the body when the sympathetic nervous system is perpetually activated – the body never gets the opportunity to do the maintenance functions necessary for pelvic-floor tissue to rest and heal.

And that is why relaxation is so important for healing pelvic pain. Relaxation addresses the inhospitable environment that sore pelvic tissue finds itself in. By creating a hospitable, healing environment, relaxation reduces the anxiety that is such a central component of pelvic pain.

In another podcast, I’ll discuss the principles of taking control of the body and mind to move from sympathetic to parasympathetic dominance.

Men who suffer from pelvic floor pain, whether it’s called prostatitis or pelvic floor dysfunction, tend to be intelligent, successful, ambitious, conscientious, and accomplished type-A personalities. And these men share the common characteristic of worrying. Pelvic floor dysfunction related to pelvic pain often occurs in men who work too much, care too much, want too much, desire to be appreciated, and strongly aim for success—and underlying all of that, who worry too much and have too little faith that things will turn out well.

Indeed, what we see in our practice is that men with pelvic pain tend to be intelligent, ambitious, thorough, and accomplished. Now, what do these characteristics have to do with pelvic floor pain? Underlying all these positive attributes is a worry about life—a sense of not trusting that the outcome of life will be favorable. It is my hypothesis in understanding this phenomenon, that this underlying unease leads these men to the stress response of tightening their pelvic floor. Really, they often tighten their whole body, but the focus shows up in the pelvic floor.

This highlights the larger picture of pelvic pain—like other parts of the body that bear the brunt of the stresses of life, the pelvic floor is a physical place people react to when they worry. The vernacular expression that someone is “anal” in what they do reflects an attitude of needing to get everything right and not make a mistake. This perfectionistic attitude is a way of guarding against something bad happening if you’re not very careful and not doing things correctly. There is an upside to wanting to do things right and caring about the outcome of what you do. These tendencies move men to be successful in their careers. At our clinic we often say that if we started a new business we’d want to hire many of our patients, because these men are typically very responsible, conscientious, thoughtful, creative, and intelligent.

However, there can be a downside to these tendencies, because often under this conscientiousness, care, and perfectionism is fear. Indeed, muscle-based pelvic pain is, in a certain sense, part of the physical expression of fear that leads to symptoms in a certain group of people. It’s a physiological response to the worry that somehow something bad will happen.

Pelvic Pain is a Squeezing in the Core of the Body

People who don’t care about outcomes, who don’t care about being conscientious, generally don’t suffer from pelvic pain. There isn’t that pressure to “do things right” and an underlying mistrust about the future and one’s safety. The physical consequence of this habitual worry is an ongoing squeezing in the core of the body, and this habitual squeezing is a big contributor to pelvic pain.

We use colloquial language to describe this chronic inner squeezing, such as gut-wrenching or a gut-response or being punched in the gut. These terms reflect a physical reaction that occurs in the sensitive inner core of the body. The “gut,” which colloquially refers to the colon, and in real life involves the pelvic floor muscles, is a Geiger counter for what’s going on in our lives. In our book A Headache in the Pelvis, we share an anecdote about doctors in the 1950’s examining army recruits with sigmoidoscopy to observe the behavior of the colon in relation to stress. When a doctor said, deliberately within earshot of the patient whose colon they were examining, “Look at that cancer,” the distressed patient’s colon would immediately go into spasm. And when the doctor said, “We were just doing an experiment to see the response of your gut to this kind of news,” the gut spasm reversed. Our gut is instantly responsive to things that frighten or stress us. Many people who have pelvic floor pain also suffer from irritable bowel syndrome, which used to be called a “spastic colon.” The gut and pelvic floor are not in separate rooms, and typically respond together to fear or stress.

In addition to all these tendencies, a person with pelvic pain tends to feel things deeply, even if outwardly this sensitivity is not obvious. There’s a Stephen Sondheim song that says “Children may not obey but children will listen,” meaning that though you might not see the effect of what you’re saying on your children (or really on any individual), they nonetheless hear it. In the same way you may not see the effect of the stresses the pelvis is exposed to until it becomes painful. The “listening” of the pelvis happens deep inside—the physical inner core of a pelvic-pain patient deeply hears and responds to the stresses of life.

I know this subject well because I myself suffered with pelvic pain for a long time, until recovered after I spending several years undertaking a rudimentary version of the protocol we teach our patients. In my view, the answer to being someone with pelvic pain who inwardly is sensitive, caring, and easily responsive to the slings and arrows of life is to regularly practice a method for relaxing the inner core and releasing it from ongoing, irritated contraction.

The solution we offer to the sensitive person suffering from chronic pelvic pain is both physical and mental and aims to release the sensitive inner core of the pelvic pain patient from its worried, irritated constriction. We teach our patients to regularly physically release the trigger points, muscle constriction and guarding inside the pelvic floor. Equally important we teach our patients to mentally/behaviorally, to practice a method called Extended Paradoxical Relaxation, whose aim is to regularly bring sore pelvic tissue into a healing inner environment in which the nervous system has shifted to the relaxed parasympathetic activation. In patients we treat whose pelvic pain significantly reduces or resolves entirely, the ongoing practice of Extended Paradoxical Relaxation cannot be avoided in order to allow the pelvis to remain relaxed and pain-free in the midst of often-stressful lives. While I don’t have pelvic pain anymore, I practice Extended Paradoxical Relaxation daily and love doing it. If I did not manage my type A personality and tendency toward anxiety by doing this, I think I very well might become symptomatic again.

The resolution of pelvic floor pain and dysfunction is both physical and mental and has to do with changing one’s way of dealing with a body and mind that is sensitive in which anxiety is easily turned into physical symptoms. In my view, only through daily practice of methods that releases the automatic, frightened physical guarding and tightening, can the pelvis have a real chance to heal and remain pain-free.

There is a large and growing body of literature documenting how emotional arousal interferes with the body’s ability to heal. Wounds are typically slower to heal in the presence of anxiety; the area of medicine called psychoneuroimmunology has much literature to show how one’s troubled psychological state negatively affects the immune system. In this talk I want to discuss the body’s healing mechanisms and how pain goes away in the case of pelvic floor related pain.

One of the Wise-Anderson Protocol’s major contributions to the field of pelvic pain treatment is the understanding that in chronic pelvic pain syndromes, the center of the body becomes sore and painful because it has been squeezed tight for a long period of time. This inner squeezing is usually an anxiety response much like a dog tightens its pelvis muscles to pull in its tail when it is threatened. In pelvic pain syndromes, the tail is chronically pulled up.

When the pelvic tissue has become chronically tight and painful, there is a primitive reflex inside the pelvis to guard against pain. It is not unlike an amoeba that sucks in if pricked with a pin to protect itself. So, when the tissue of the pelvis becomes sore and irritated, a primitive reflex occurs wherein the pelvis tightens up even more to guard against pain from this sore tissue. This reflex guarding traps and interferes with the sore pelvic tissue healing up, the way other sore tissue can easily heal up. We experience many small injuries to our bodies, where maybe we scrape ourselves or overuse muscles and they become painful, but they readily heal up because nothing interferes with their healing. When the tissue inside the pelvis becomes painful, the tissue tightens against its own soreness and interferes with its own healing.

It is helpful to talk about the phenomenon chronic pelvic pain by comparing it to what would happen if you’re walking around on a broken leg. The break in the bone would not be given a chance to heal up because what it needs for healing — namely a protected environment to allow break in the bone to heal. In the same way we need to provide an environment in which the sore pelvic tissue to heal up as sore tissue in other parts of the body need such protection.

But in the pelvis of those with chronic pelvic pain, there is a self-feeding cycle that interferes with the healing up of the sore pelvic tissue. Combined with normal activities and stresses of life (that normally don’t cause those without pelvic pain to experience any tightening or distress) like sitting or sexual activity or urination/defecation, the sore tissue of the pelvis in those with chronic pelvic pain remains unhealed. The typical life of the pelvic pain patient creates a unwitting situation in which they are continuously ‘walking on the broken leg’ of pelvic pain.

Once one has pelvic pain, the nervous system is necessarily aroused. Glomieski et al demonstrated this in the Journal Pain in 2015

Pain. 2015 Mar;156(3):547-54. doi: 10.1097/01.j.pain.0000460329.48633.ce.

Do patients with chronic pain show autonomic arousal when confronted with feared movements? An experimental investigation of the fear-avoidance model.   Glombiewski JA¹, et. al

The nervous system becomes activated and the neurons that flow in the nervous system move quickly and are more reactive. It is like a car that is idling at too high of a speed. Our nervous system becomes ‘jumpy’ when we are in chronic pain. Because pain itself increases the responsiveness of the nervous system, the pelvic pain patient feels in a trap that keeps the symptoms chronic because the arousal inhibits the healing of the sore tissue. The pain and subsequent up-regulated nervous system causes one to be more reactive.

How do you turn down the nervous system activity and free up the pelvic floor from its chronically tightened, healing-inhibited state to allow it to heal? Over the past 25 years we’ve come to see that the treatment must include a physical component, a behavioral component and a psychological/mental component. There must be extended periods of time in which nervous arousal is turned down. The mind and body components are not separate from each other.

Reducing nervous arousal to heal pelvic pain

We teach our patients to regularly loosen the tissue that is in a knot. The physical component of our program includes training in the use of our internal trigger point wand, our trigger point genie, the use of hands finger as well as other methods to loosen the chronically tight tissue between the knees and the sternum. This is not a simple matter but it is doable with the right skilled instruction and regular practice. We teach patients to implement the physical loosening of the tissue using myofascial/trigger point release methodology that we’ve developed, researched, and reported on over the years.

The physical release of the tightened pelvic tissue is essential. Equally important we have found that it is not enough to resolve chronic pelvic pain. If we do only the physical part of the loosening of the tissue of the pelvic floor and we don’t address the environment that is perpetuating this irritated and painful tissue, it is like dealing with a leaky water faucet by just cleaning up the spilled water from the faucet but never finding and fixing the leak in the faucet itself. The leak in the faucet of pelvic pain is the aroused nervous system keeping the pelvic floor tight and the nervous system inhospitable to what is needed for the healing of the sore pelvis.

When you’re relaxed and you were to say to yourself “relax” relaxation is easy. If you’re relaxed you can drift off into sleep, you can let go and just enjoy music or lie in the sun, watch a movie, just let go and enjoy yourself. If you are tense, anxious, worried or in pain and you were to say to yourself, “relax”, relaxation is difficult. Drugs, alcohol, and a variety of addictive behavior are the ways in which tense human beings relax. Without substances, most people have little ability in calming down when they’re anxious and nervous.

In a way, our nervous system has a life of its own. Imagine that you are relaxed and you’re about to go to sleep and inadvertently you drink a strong cup of coffee. You well might find yourself very awake, while the caffeine circulates in your body not allowing you to calm down to be able to sleep. The typically upregulated nervous system is the dilemma of the pelvic pain patient in learning to calm down their nervous system to allow the healing of the sore tissue in the pelvic floor.

Our program is focused on both helping our patients reduce their pain by learning to loosen the pelvic tissue physically and simultaneously reducing the nervous system arousal that arises from and is perpetuated by the anxiety, worry, fear associated with the pain.

We have developed a relaxation methodology for reducing the ongoing state of nervous arousal. Learning to do this was essential to me personally, in overcoming my pelvic pain. This reduction in nervous arousal is a central aspect of what we teach in the Wise-Anderson Protocol.

I’d like to talk about the opioid epidemic that has been in the news the past several years in relationship to the inside job of healing pelvic pain that is outside the reach of all drugs. In recent years, there is what is now called an opioid epidemic has been in the news. Opioid addiction has often begun with the legal prescription of opioids, often after surgery or some procedure. Some group of patients using opioids in this context continued to use them and subsequently became addicted. When I discuss opioids here, I am also including the use of benzodiazepines, like Valium, Xanex, Ativan and clonapin that are used for pain and, like opioids, are also addicting with ongoing use.

There are many people with chronic pelvic pain who have become addicted to opioids and benzodiazepines. These pain medications were probably the only way many doctors felt they had to help these patients with their pain. As we have discovered in our clinical practice with patients who have become dependent on opioids and benzodiazepines, these drugs can work well in the beginning and then progressively diminish in their ability to reduce pain. Also, the pain threshold drops so what didn’t hurt before, hurts with continual opioid use.

The benzodiazepines, we have seen, can be used skillfully to periodically help with pelvic pain when not used regularly, which then helps avoid addiction.   When used occasionally in this way, the benzodiazepines can help someone over the hump of certain flare-ups while not causing addiction. With continued and regular use of opioids or benzodiazepines, however, a higher dosage typically has to be used, to achieve the initial levels of pain relief. After continued regular use, the effectiveness of opioids diminishes in helping pain.

Opioid were primarily used in the past to treat terminal, end-of-life pain. Then, for reasons that are beyond the scope of this discussion, these drugs more and more were prescribed for patients who had chronic, non-end-of-life pain. Our society has painfully learned, that the benefit of pain reduction with the regular use opioids and benzodiazepines comes with what could be called a back-end price… namely after extended, continual use, patients both suffer from addiction to the drug, and a diminishing ability of the drug to help their pain. And then there is the issue of opioid deaths. In 2017 a staggering 47000 overdose deaths were recorded in the United States. I doubt any of this.

It is certainly possible to withdraw from opioid use but it isn’t easy or pleasant. Withdrawal from opioids is a major challenge if the opioids have been used for a long time to deal with chronic pelvic pain. Even if there were no issues of pain, opioid withdrawal is difficult. Significantly, added to the issues of withdrawal, the patient taking opioids suffering from chronic pelvic pain has to deal with the huge challenge of how to deal with their chronic pelvic pain if the opioid is taken away. It is not a small problem when you finally try to stop taking the opioids and you have nothing to help you with the pain.

The Wise-Anderson Protocol for pelvic pain is a non-drug method to stop the pain. In 2015, we published a medical article in which we showed that after 6 months of consistently practicing the Wise-Anderson Protocol, 1/3 of our patients, who had been using different kinds of medications, including some with a current or prior history of using narcotics, had stopped the use of all medication.

Our protocol can help reduce or stop the chronic pelvic pain without drugs because it is aimed at eliminating the cause of the problem.

To be clear, our protocol is based on the understanding that the cause of chronic pelvic pain is sore pelvic floor tissue which continues to be irritated by protective muscle guarding and the irritation of nervous arousal. This protective guarding is a reflex to tighten inside the pelvic floor, whose purpose is to protect against anxiety, but in fact the protective guarding exacerbates it. The normal stresses and functions of life also add to the tissue irritation of the painful pelvic tightening. Our focus is to provide a method to heal this sore tissue by providing a healing environment through the core methods we train our patients in. These include a physical method as well as a behavioral method to calm down the aroused nervous system that aggravates the painful pelvis and interferes with the healing of the sore tissue of pelvic floor.

When someone is taking narcotics or benzodiazepines or other drugs, we advise them to not consider going off of their medications, which we ask patients to get medical help with, until they begin to reduce their pain with our method. It is not uncommon for patients to regularly practice our method for months before they feel comfortable in reducing their medications.

With or without the opioid epidemic, we have found that there are no effective drugs for resolving pelvic pain. Resolving the symptoms of pelvic pain is an inside job of healing the sore, tightened tissue of the pelvic floor. This is something one must do oneself, for oneself. We know of no drugs that are able to do this. Opioids and benzodiazepines can temporarily reduce the pain but does little to the underlying cause of the pain. The Wise-Anderson Protocol is designed to give patients the tools that can allow the possibility of carrying out the inside job of healing a sore and tightened inner core.

Pelvic pain is invisible. It can’t be seen, it can’t be visualized with fancy technologies, there are no fluid tests for it; it’s a difficult phenomenon to understand if you’ve never had it. I want to use a metaphor here that I’m hoping is easy to understand, to understand the less easily understood phenomenon of muscle-based pelvic pain.

The metaphor of the sore arm

Imagine that you’ve had an accident and you’ve fallen down on your side and as a reflex you put your arm out to protect yourself. You certainly survive, everything is basically ok and nothing is broken, but your hand and wrist hurt and your shoulder has a big bump on it and is very painful. Your whole arm is sore and you’re miserable. You go to the doctor, who says that you’re fine, just take care of it, let it rest and it will heal up. Its all intuitive, it all makes sense.

Healing the sore arm

So, the doctor suggests that to help things heal faster and for you to be more comfortable, you put your arm in a sling. In the sling your arm can relax and will be protected from movement and the bumps and grinds of life. It isn’t hard to understand that if your arm gets bumped, it will hurt.   When you see your affectionate aunt who wants to hug you, you say, “Wait,” and you give her a peck on the cheek and tell her you hurt your arm and she shouldn’t grab you and squeeze you like she usually does. You don’t want her to irritate your arm’s healing.

Protective guarding and the sore arm

Drawing away from what might hurt your arm is a reflex; you want to protect your arm against what might jar it because you know it will hurt if something does bump against it and irritate what is already sore and irritated. You go around with pain in your wrist and arm and shoulder feeling vulnerable. You notice you protectively guard your arm and shoulder, especially in public, during this period while they are healing up. Guarding means tightening up, tensing it up, being on alert for anything that might hurt it.

You notice that if you put it in a certain position or inadvertently bump it against something, you tighten up. In other words, any increased pain makes you tighten up to protect your arm. Let’s call this protective guarding; you guard to protect. This means the muscles tighten up to protect and this is instinctive. You notice you are doing this self-protective guarding without even being conscious of it, it just happens out of awareness. It’s just a reflex of the body to protect itself from being hurt more, when a certain part of the body has been injured or hurt.

If you keep it protected over time, it heals. If you don’t protect it, it likely will continue to hurt. If you do take care of it, you stop being so guarded, and eventually you forget about it and you go back to the way you’ve been in the world, not thinking about your shoulder, not tightening it up, not protecting it, not pulling it away from what might hurt it. So the sore arm and shoulder that got hurt, then got better.

Comparing the painful pelvis to the sore arm

Now I want to talk about a situation in which the pelvis hurts and is sore, irritated, and increases in pain when you do certain things that are just normal, everyday activities that everyone does. For some people with muscle-based pelvic pain, sitting down hurts. Other people aggravate the pain in the pelvis when they have a bowel movement. Or conversely, sometimes a bowel movement helps. Sometimes urination makes it feel better, sometimes it makes it feel worse. Or when trigger points, which we have extensively discussed elsewhere are in a certain location, for some people orgasm can irritate pelvic pain and make it feel worse. Stresses in life and anxiety can make the pelvis hurt a lot more. Again, all of these things we have explained elsewhere. But these are things that are not a the normal kind of bump, like the bump against your sore shoulder or arm. There are these other things in life that flare up pain in a sore pelvis but they are distressing because they don’t seem to make sense and don’t feel normal.

Unlike a shoulder and wrist that were injured when you fell on them, then healed when you rested and took care of them, chronic pelvic pain most simply called pelvic floor dysfunction doesn’t heal up. Why?

The relationship between protective guarding in the sore pelvic and the sore arm

In the pelvis something different occurs in response to pain that doesn’t seem to occur in other parts of the body quite like it does in the pelvis. What occurs in the pelvis, different from what occurs in the sore arm, is an instinctive, very sensitive reflexive tightening against anything that feels strange or uncomfortable. This is what I refer to as the reflex-guarding of the pelvic tissue against its own sensation of pain. In other words, when you tighten up the pelvis when you’re anxious, and it stays tight for a long period of time and the muscles become sore, that sore irritated tissue in the pelvis tightens up protectively as a defense against its own pain. It’s not a very good design. Where the instinct to protect a sore arm and shoulder helps healing and is protective, I’ve often thought the reflex guarding of the pelvis against soreness generated by its own chronic tightening is a kind of flaw in the human design because the guarding against the pain makes it worse.

Physical bumps cause protective guarding in the arm; anxiety and an aroused nervous system ‘bumps’ the sore pelvis

So, either through chronic anxiety and worry (which again, we have discussed elsewhere) or through injury, the tissue of the pelvis involves the tightening up of certain kinds of muscles and parts of the pelvic floor. It involves a tightening up of the muscles around the genitals and anus, often including the internal pelvic floor muscles called the piriformis, the obturator internus, the levator ani muscles, the coccygeal, levator ani, puborectalis and related internal muscles. The muscles of the lower abdomen are often also involved including the rectus abdominus, and suprapubic muscles. Other muscles including the quadratus lumborum, the iliacus, the psoas get into the act. Many of these muscles can tighten up in concert and remain tight and can feed into the internal muscle hypertonicity and pain. In our experience, when you have pelvic pain all of these muscles have to be dealt with when they are part of the ‘fist’ of muscles that has chronically tightened up if you want to heal the sore pelvis. These muscles tighten up and become painful. They often refer pain and sensation back inside the pelvis and are all part of a complex of tightening and protective guarding against the pain in the pelvis.

Unlike the arm, pelvic pain and protective guarding is strongly provoked and perpetuated by anxiety and the arousal of your nervous system. Anxiety and nervous arousal that irritate, perpetuate and increases pelvic pain are equivalent to ‘bumping the arm’ when the pelvic floor muscles are irritated and tight, except you don’t even have to move or be bumped to have the pain in the pelvis exacerbated by anxiety. Anxiety and nervous arousal are themselves the bump. While anxiety and nervous arousal may slightly increase the discomfort of a sore arm or shoulder, anxiety and nervous arousal strongly increase the pain, protective guarding and tightening in the pelvis. And people who chronic pelvic pain often catastrophize and worry constantly. The relationship between anxiety and pelvic pain is not at first intuitively obvious.

One way to understand pelvic pain is to look at, for instance, a frightened dog who pulls its tail in. The pelvic floor tightens up in a dog to pull the tail in. Similarly, when a certain group people are chronically anxious, their ‘tail’ pulls in.

Pelvis pain can be seen as a condition of a tail chronically pulled between the legs

In the case of a human being, pulling the tail in means the tailbone is pulled forward when the pelvic floor tightens. The arm heals relatively quickly when more or less left alone. What is important to understand is that pelvic floor muscles don’t get a chance to heal up because they are continually irritated and held in a guarded, tense and protected state, by all kinds of activities that are just normal activities of life; activities like defecation, urination, sexual activity, sitting, the normal stresses of life, and sometimes even certain kinds of physical activities. Intimately involved, in addition to the activities of life, the formation of knots inside the muscles called trigger points. These knots form and remain irritated and perpetuating pain until they release and go away. Once formed however, for the most part, they stick around unless they’re specifically treated to release.

The self feeding cycle of protective muscle guarding and a sore pelvis

So, you have a whole series of factors that bear down on the poor, painful pelvis and stop the painful tissue from healing. What needs to heal is not serious or pathological. But it is sore and painful. In our book at A Headache in the Pelvis and in our other writings, we have talked about the self-perpetuating pelvic pain cycle; a cycle that once it gets going, takes on a life of its own. Sore pelvic tissue triggers its own tightening and protective guarding, which triggers more pain, which triggers anxiety and worry about whether it will ever go away, which is variously aggravated by going to the bathroom, not being able to sleep through the night, sitting down, sex and the stresses of life. These stresses represent an onslaught of perpetuating factors that keep pelvic pain going and give it a life of its own.

When you have pelvic pain, like I did for over 20 years, there’s not a lot more to do sometimes than to try and figure this out, and I don’t think that most people don’t figure it out. How you deal with pelvic pain is daunting. If you search the internet, and look at the research on it, there are a lot of ideas about what pelvic pain is how you treat it. But most of what I read on the internet is off the mark. Pelvic floor pain i hard to understand if you have never had it and watched the process of it resolving.

Temporarily loosening the sore pelvic contraction vs. healing the sore pelvic contraction

Our protocol was formed by my own experience in conjunction with the remarkable expertise of the folks I work. We have developed a careful, skillful program to physically loosen the tightened tissue in the pelvis. But, as we have said in our book and in a number of podcasts, physical therapy (though we are pioneers in using it and are strong proponents of necessity teaching patients how to self-treat all aspects of it) is a temporary fix for pelvic pain. Unless the tissue is healed to a state of normal tissue like the sore arm or shoulder, even if its loosened in one moment, and the pain is temporarily absent, the tissue s ready to be aggravated, irritated and tightened up again in the next moment by the activities and stresses of life.

Putting a sore arm in a ‘sling’ to help it heal; putting the sore pelvis in a sling to help it heal

That is why I suggest here that, like the sore arm, the pelvis needs to be put into a kind of ‘sling’ to prevent aggravation and irritation and allow the healing mechanisms of the body to heal the tissue. Unless you do that, temporarily loosening the tissue through physical therapy and other physical methods, is a temporary (though critical and necessary) intervention and usually not sufficient to heal the pelvic floor. We’ve come to see that the physical loosening of the sore pelvis has to be done repetitively and as we’ve learned, it is best done by the person with pelvic pain themselves. If you have pelvic pain, you really need to learn how to do the loosening yourself.

Extended Paradoxical Relaxation is the ‘Sling’ that Allows Tissue of the Pelvis to Heal

We teach our patients how to loosen all of this tissue (from the knees to the sternum) themselves physically, and then we teach them how to put this loosened, relaxed tissue into a sort of ‘sling’ to allow its healing.

What does it mean to put the pelvis in a sling? It means resting the pelvis in a way wherein it is not being assaulted by anything that tightens it up, so that the mechanisms of the body can heal it and allow it to operate it and work the way it is meant to. In our protocol, the ‘sling’ for the pelvis is called Extended Paradoxical Relaxation. I have written a book about this method and we talk about it extensively in A Headache in the Pelvis.

The method we train our patients to do is basically a method to askes us to say to all the stresses that interfere with the healing of the pelvic floor, “Stay out of the room and leave me alone for now. Let me rest.” It’s a method of allowing the pelvic floor to be quiet and be free of the stresses that irritate it and interfere with its healing. Extended Paradoxical Relaxation requires daily practice and we ask our patients to do both the physical loosening and the relaxation components together for at least 2 hours a day. This is a big thing to ask of anyone but most of the people who agree to do this do it because they feel the possibility of their condition healing up. When you suffer from \ pelvic pain for a long time, you often reach a point (as I did) where you say “If I have to go to Mongolia and eat cow dung, tell me when the next plane is.” When you are suffering from pelvic pain that doesn’t heal, it becomes the bane of your existence and you become willing to do whatever it takes to get it to go away.

Healing a sore pelvis requires an inner environment in which it can heal

Pelvic pain is peculiar in that we have to deal with the reflex that tightens the pelvis in response to the slightest amount of pain. Many different factors have caused the pelvis to tighten and hurt, and the normal stresses of life trigger the reflex guarding of the sore pelvis which keeps it in pain and not able to heal the way a sore arm will when it’s put in a protected healing environment. I hope that this metaphor is helpful. Like a sore shoulder, you need to provide an environment in which the body can heal itself and return itself to normal. The ‘sling’ for pelvic pain that allows this healing is just a bit different from that of a sore arm and wrist. The sling involves regular physical loosening , inner quiet, and a psycho physical internal environment free from the bumps of everyday life.

The word commodity comes originally from the Latin commodus meaning ‘a useful or valuable thing’. By the early 15^th century commodity was being used in English to refer to “an article of merchandise, anything movable of value that can be bought or sold.” Implicit in this definition is that a commodity is the same anywhere it is found. A commodity is something of value that is the same everywhere. It is like a package of M&Ms: if you buy a package of M&Ms in New York, or San Francisco or Hong Kong, the M&Ms will taste the same. M&Ms are the same everywhere and you can expect and count on that same flavor, shape, quality, size, no matter where they are bought. Similarly, in medicine, some procedures and treatments have been standardized and could be called commodities.

In the world of pelvic pain, only in the last 10-20 years, some physicians treating patients with pelvic pain refer them to physical therapists. I believe these physicians assume that physical therapy for pelvic pain is a commodity…. the same everywhere and any physical therapist will be able to treat the pelvic pain patient in some standardized and successful manner.

In our experience of treating many patients with pelvic pain and hearing their reports , this is simply not so. There is a very wide variety of what is done in the name of physical therapy in the treatment for pelvic pain. There is no standardize physical therapy for pelvic pain. In fact there are a number of treatments done in the world of physical therapy that our patients undergone. Those treatments that were not successful tended not include trigger point therapy. The point here is that physical therapy for pelvic pain is not standardized from therapist to therapist.

We are very specific in terms of what physical therapy for pelvic pain is therapeutic and offers the best chance of helping pelvic pain. In our experience, a physical therapy treatment for pelvic pain in which both myofascial release and trigger point release is done, is the most effective treatment. In another essay, I have discussed the difference between myofascial release and trigger point release and the necessity of doing both. We propose that external as well as internal myofascial trigger point release should be done. In our book we discuss why pelvic floor biofeedback, pilates or kegel exercises are not helpful, nor have we found much use in electrical stimulation either inside or outside of the pelvis.

Self-Treatment vs. Treatment by Others

Then there is the subject of self-treatment vs. treatment from a therapist or physician. Over the years, for a number of reasons, we have come to see that self-treatment (externally and internally) in the treatment of muscle based pelvic pain, is far superior and effective in offering the possibility of reduction or resolution of this kind of pelvic pain.

We are strong advocates of teaching our patients how to do their own trigger point release to become their own best therapist. They learn what is going on in their body and tissue, they learn how hard to press and how to locate trigger points easily and certainly they can do treatment far more frequently and conveniently than one could do it if having to go to a physical therapist for treatment. Being able to treat oneself allows for trigger point release to be done more often, at the exact time/location that is most convenient for the person, and after being trained in self-treatment with the proper tools, without the need to travel to and from a physical therapist’s office with the advantage of not cost for a self-treatment.  Physical therapy treatment can be hugely important in conjunction with and in supervising self treatment. 

The Internal Trigger Point Wand

The Wise-Anderson Protocol developed the only FDA approved Internal Trigger Point Wand that has been vetted through a rigorous clinical trial for safety and efficacy. But just like a Stradivarius violin, unless you know how to play it, it doesn’t matter if it’s the greatest violin in the world or not. In the same way, if you have the greatest tool for doing trigger point release unless you know how to use it, its not going to help you which is why the focus of our treatment is in the careful training and supervision of our patients doing internal and external physical therapy self treatment.

The Issue Of How Hard And Long To Press And How To Find The Trigger Points

A number of years ago we articulated what we call the Wise-Anderson Pressure Principle which has to do with how much pressure one should exert on a trigger point. If one exerts too much pressure and there is jumping-out-of-your-skin pain, the whole area can tighten up protectively and cancel anything therapeutic you are trying to accomplish. It is like putting on the gas and the brake pedal at the same time. Too vigorous pressure can actually aggravate the situation. We don’t believe in doing trigger point release that simply flares up symptoms. Of course, there are times where one will be sore after trigger point release and even stay sore for a day or so, but the whole point of doing trigger point release is to loosen the tissue and not cause it to protectively guard. The idea of no pain, no gain does not apply to trigger point release. The idea that if some is good, more is better is the wrong idea with trigger point release.

Our Internal Trigger Point Wand is the only device I know of that can measure pressure exerted on trigger points internally. It is very important for the user to be able to have a sense of pressure objectively so that they can pair their internal pressure and the sensation of the pressure on trigger points, and an objective measure.

Physical therapists cannot objectively measure the pressure they exert on trigger points internally (and externally) unless they use an algometer, of which none to my knowledge, other than on our device, currently exists in conventional pelvic floor trigger point release. We have had many patients complain that before they came to see us, physical therapy was tortuous, painful, and ultimately unhelpful. It is my guess that especially less experienced physical therapists overdo the amount of pressure they exert on trigger points internally because they want to have an impact on someone’s symptoms. They do not understand that the process of deactivating trigger points is a long one and pressure internally needs to be carefully and sensitively applied so as not to flare up someone’s symptoms unduly. Working internally requires an especially sensitive and delicate hand. Again, if too much pressure is used, symptoms can flare up and the pelvic floor can reflexively tighten up, detracting from instead of promoting the healing of the sore tissue. Internally trigger point release is an art and requires an extensive knowledge of trigger point behavior, of the appropriate pressure to be exerted especially inside and importantly, an understanding of the slow arc of improvement that occurs when a sore pelvic heals. Additionally, as I discuss, trigger point release done skillfully must be paired with regular time for the tissue to recover and heal. And in our view this is all best done by the patient him/herself.

Trigger Point Genie

In the last number of years, we have developed and are now using a remarkable tool for external trigger point release called the trigger point Genie. You can find more information about this device at www.triggerpointgenie.com. The trigger point Genie allows someone to comfortably, on a soft surface to perform external trigger point release on almost every part of the body, including the gluteal muscles, TFL muscles, iliotibial band, the adductors on the inside of the thigh, the abdominals, the quadratus lumborum, the rectus abdominus and other places that are implicated in pelvic floor dysfunction. The trigger point Genie, along with the Internal Trigger Point Wand, gives a patient the freedom to treat themselves and to seek out professional help when they need consultation in their self-treatment.

To summarize, physical therapy for pelvic pain is not a commodity. All physical therapy done for pelvic pain is not the same. In our view one way of doing pelvic pain physical therapy can offer little help, can flare up symptoms, or can move the pelvic pain patient in the direction of healing and resolution of symptoms.

In our protocol we have seen people for whom therapists have not been able to even locate trigger points, then we have examined them and found a treasure trove of trigger points. There have also been many people who have just been flared up by physical therapy and had no release of tension or pain prior to doing our protocol, but once they have learned to do their own therapy it has opened the door to their own healing.

Finally, when physical therapy for pelvic pain is done without a dedicated program to reduce anxiety and nervous arousal, in our view the likelihood of real resolution of symptoms is remote. Physical therapy does not offer a permanent rehabilitation of the sore pelvis. The pelvic tissue that is painful and chronically tightened, is human tissue that needs time to heal after it is released and an environment in which it is not tightened in the way that got it in trouble in the first place. Physical therapy is a temporary release of the tissue that can easily return to its pre-treatment state upon leaving the therapists office and getting into traffic.

Being able to do external and internal physical therapy in the comfort of your own home and then putting the pelvis in the healing mode of a long relaxation session to allow the released tissue to recover and rest, in our view is critically important. We have had patients who drove 5 hours to a physical therapist for pelvic floor physical therapy and then found their symptoms flaring back up and whatever therapeutic effect of the physical therapy being undone by having to get into a car and drive back 5 hours. Pelvic floor related pain is essentially a stress related condition that comes about in the body as the result of dealing with the stresses of life. Healing a painful pelvis is an inside job. In our view, when someone has pelvic pain, they must regularly loosen and release the sore pelvis physically, regularly lower anxiety and the arousal of the nervous system in order to have a chance for the sore pelvis to heal and the pain and symptoms to go away.

I hope this discussion about the physical treatment of pelvic pain is helpful

In the 1920s, a well-known physiologist at Harvard named Walter Cannon introduced the concept of fight, flight, freeze. Coincidentally, Walter Cannon was a teacher of my relaxation teacher, Edmund Jacobsen. Commonly, the term Cannon coined is called “fight or flight.” This means that in the presence of something threatening, you either fight it to get rid of it or run away from it. However, the full term is actually “fight, flight, or freeze,” because the biological response to a threat can also be to freeze up, as a way of hiding from the threat, or indicating you offer no threat to what is chasing you. The phrase a deer in the headlights is an example of freeze. Fight, flight, and freeze are terms that make intuitive sense – we all easily understand how we either run away from, fight against, or freeze up in the presence of a threat. How the freeze response is centrally related to pelvic floor pain is a bit less obvious, but I’d like to explain it now.

Pelvic floor pain is associated with muscles in the pelvic floor being overly tightened on an ongoing basis. I’ve described this previously as a charley horse in the pelvic floor perpetuated by anxiety and protective guarding, and unhealing, sore pelvic tissue. Pelvic floor pain takes on a life of its own and remains painfully present on an ongoing basis.

Once we understand that pelvic pain represents a condition of biological “freeze” in the center of the body, we have a path to the solution: unfreezing the chronically frozen pelvis, I suggest, is the remedy for the disorder. While easier said than done, I can tell you from my own personal and professional experience that it is possible.

So, the question is, “How do you unfreeze a chronically tightened pelvic floor?” In the Wise-Anderson Protocol, we recognize that doing this is a psycho-physical task. It requires intervention in both mind and body.

Over the past 25 years we have carefully developed a method to release painful, frozen pelvic tissue. Our FDA approved Internal Trigger Point Wand, in our protocol, is a necessary tool that can enable the unfreezing the pelvis, because it centrally assists internal trigger point release. Trigger point release is a manual method of skillfully pressing on tight bands that form when muscles are held in an extended or intensely contracted state. We teach our patients to use this wand alongside our new external Trigger Point Genie, specific stretches, and other physical methods to loosen the inside of the body.

However, it is also necessary to provide an environment in which the sore tissue of a chronically tight pelvis can heal up from its tendency to freeze (hypertonia). Loosening the inside of the body without this, in our experience, will not provide long-lasting relief, because whatever triggers reflexive muscle freezing will simply cause the pelvic floor to freeze again even if the tightening has been temporarily released physically. Tissue that is sore and irritated is primed to tighten back up with little provocation. This is why most physical intervention that does not reduce nervous arousal at best provides only temporary relief for pelvic floor pain – the state of freeze prevents the healing of the sore tissue in the pelvic floor. Healing this sore tissue is essential to any real, lasting resolution

The pelvic floor in its normal state is soft and responsive, able to easily relax and tighten as the body needs. In the Wise-Anderson Protocol, we teach our patients how to physically loosen the external and internal tissue, interrupting the frozen state of the pelvic floor while reducing the nervous arousal that keeps the pelvic floor irritated and ready to jump back into a state of freeze.