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When pelvic pain goes away, the sore pelvic tissue heals

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.

MUSCLE SORENESS/TENSION AND URINARY FREQUENCY AND URGENCY

In our experience, and that reported by other centers and physicians who have worked in this field, it is quite common for both men and women who develop a chronic pelvic pain condition also exhibit urinary dysfunction.  Urinary frequency and urgency is one of the most common symptoms of patients who come to our 6 day immersion clinics. It has been well reported that approximately 71% of men experience symptoms such as urinary frequency, urgency, nocturia, poor urinary flow and even pain in the bladder upon filling.  In most of the male patients, there is little to no laboratory or imaging evidence to incriminate the prostate as the source of this pain and urinary symptomatology.

There are women as well suffering chronic pelvic pain with no bladder or organ pathology who have symptoms of urinary frequency and urgency. Both women and men typically have sore and painful anterior (which means located toward the front) musculature within the pelvis floor that refer sensations of urinary frequency and urgency when certain trigger points in the front of the pelvic are palpated. With almost all of the men and women with urinary frequency and urgency and no evidence of organ or related physical pathology, we find trigger points in the pelvic floor and related areas that tend to refer sensations of urinary frequency.

The relationship between sore, painful pelvic floor muscles and urinary frequency is not intuitively clear. Indeed how is it that one has urinary frequency and urgency but with no pathology, infection in or of the organs of the urogenital tract.

When I first had pelvic symptoms, I just had urinary frequency with no pain other than the uncomfortable symptoms you have with urinary frequency and urgency. As time went on, I had most of the symptoms we describe in our book including urinary frequency and urgency, sometimes in the extreme. The doctor could find no physical pathology. Nevertheless I suffered with sometimes extreme urgency, voiding little, never feeling emptied or relaxed the way urination feels in someone without pelvic pain. As I recovered, I went from sometimes feeling that I had to void every 15- 30 minutes to feeling normal in this area and noticing I went 3-5 hours with no undue distress. When I had urinary symptoms, I remember when I went to a movie, I always sat in an aisle seat at in a movie theatre because I could never sit through a whole movie without having to get up to go to the bathroom in the middle of the movie. I experienced a difficult to describe, gnawing, aching irritated feeling in and around the bladder. After my recovery, my urinary frequency and urgency disappeared and urination disappeared.

When someone is suffering from urinary frequency and urgency with no known physical pathology, they feel uncomfortable in and around the bladder, they feel like they need to urinate, often urinating small amounts which don’t resolve the feeling of having to urinate the way one normally feels resolved after a trip to the bathroom. When you have urinary symptoms related to pelvic floor pain and dysfunction, the sensation in and around the bladder simply doesn’t feel normal. So what is going on here? This is a question I believe some people suffering from pelvic pain are baffled by. Being able to easily wait to go to the bathroom is important in many situations in modern life including work, social and recreation related situations. That there is gnawing, uncomfortable feeling in the bladder and urinary tract can be very distressing as it persists without resolution.

So here are thoughts I share with you about the phenomenon of urinary frequency and urgency arising when someone has pelvic pain and subsiding or disappearing with the subsidence of pelvic pain. I would like to propose that afferent (sensory) nerves associated with the bladder or a neighboring receptor in the pelvic neural network may be affected by the tension, discomfort and anxiety originating within the pelvic muscles.  This afferent plexus, or branching network of intersecting nerves of the lower urinary tract is complex and responsive to a variety of different kinds of stimulation including stress and anxiety and pain. Many of us have experienced the need to urinary under circumstances of extreme anxiety or stress.  The theory I propose is that pain and anxiety triggers the branch of the autonomic nervous system related to bladder relaxation – bladder relaxation that is felt as the need to urinate. Absent pain in the pelvis using our protocol, we have often seen someone’s urinary frequency and urgency reduce or entirely go away without any drugs or other interventions.

We all know of the colloquial term to be so scared you pee in your pants. This colloquialism refers to a moment of urinary urgency occurring under conditions of extreme fear or stress. In my personal journey with pelvic pain, I thought that the pain in my pelvis was something that my brain confused with the discomfort of a full bladder that urination would relieve. In a person without pelvic pain, you feel relaxed after urination. My sense when I was symptomatic was that somehow my brain confused the discomfort in my pelvis with the discomfort of a full bladder that is relieved with urination. What is clear is that urinary frequency and urgency is often present when someone has pelvic floor pain and no other physical findings, and the urinary frequency and urgency can disappear once the pelvic pain resolves.

I hope this is a helpful essay about this interesting subject.

Escaping the fight, flight, freeze cycle in the healing of pelvic pain

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.

Cause and Effect In Muscle Based Pelvic Pain

What makes a difference in the journey of healing pelvic pain is seeing when you are doing something that reliably helps your symptoms. When I was symptomatic, I tried all kinds of things: acupuncture, supplements, reflexology, medications, considered surgical procedures which I gratefully didn’t pursue. My symptoms waxed and waned, often inexplicably. At that time, if you asked me if those things helped, I’d have said I didn’t really know. I’ve come to understand that if the answer to the question “Is something helping your symptoms?” is, “I don’t really know,” then it probably is not helping. Anyone with chronic pelvic pain really does know when something is reliably helping.

When I was in pain, I dreaded trying something new to help myself because I had had the experience of trying new things and being disappointed when they ultimately failed to help me, which was most things I tried. I think that disappointment is an underrated suffering. In myself and in my patients, I see that feeling hope of help and then being disappointed at the failure of what you have hoped would help you is a feeling that many people avoid after a number of failures, by being very reluctant to do new treatments and be hopeful about them. Often that reluctance to be hopeful about a new treatment is justified.

When our patients experience improvement, they dance; they say ‘Wow. Gosh. Amazing!” They are genuinely surprised that something worked. Their energy changes. And they move around and exclaim, ‘I feel better’. You know when something helps. The mental and emotional space around someone who has had pelvic pain and experiences something they have done has helped them resolve it is wonderful to be around.

Our patients tend to be intelligent, conscientious and accomplished, keen to find the relationship between their symptoms and the real cause of their symptoms. Not infrequently our patients are scientifically inclined, who sometimes keep charts and records of any relationship between their symptoms and what they eat, when they void, when they go to sleep and a variety of different things. Yet most people fail to helpfully identify the factors that really move the needle in improving the problem. They will look for some kind of food, activity, supplement or something that correlates to their flare-up of symptoms.   Most importantly, they find little that really helps in the direction of resolving their condition.

Not being able to see cause and effect has large consequence psychologically. It is greatly distressing not being able to find a relationship between what really helps a condition that goes on and on. A large part of the suffering of pelvic floor dysfunction comes out of this uncertainty of and helplessness about what the problem is, of often not being able to see a relationship between something that makes it worse or makes it better. In a word the distress comes from the helplessness of really understanding why the problem exists or what to do about it.

It is from this helplessness and inability to see the cause and effect that people catastrophize, that they feel lost, worrying that they will never get better, that their pain is out of their control.

But when you do find a relationship between cause and effect, especially when you see yourself being able to do something that routinely helps you, it’s a game-changer in your life. Not surprisingly, such a discovery tends to stops the catastrophic thinking. I’ve always said that being able to help yourself is the great antidote to catastrophic thinking.

What is the cause and remedy for pelvic pain in the view of those of us who train patients in the Wise-Anderson Protocol? We know it isn’t drugs, or surgery or procedures or supplements. We published an article in the Gold Journal of Urology stating that prostatitis in men, which we are clear is mostly pelvic floor dysfunction, a psychoneuromuscular disorder, involving sore an irritated pelvic floor tissue, the result of anxiety related chronic guarding in the pelvic muscles, held in the grip of chronic reflex guarding that prevents the sore tissue from healing. Our view is that supporting the healing of the pelvic tissue is the answer to this disorder.

The methods of the Wise-Anderson Protocol for pelvic floor related pain are, and are not intuitively obvious. We teach our patients treat how to repetitively loosen the sore, tightened tissue between the breast bone and the knees while practicing daily a method to allow the sore tissue to rest and heal. One of our early patients said that the most memorable moment in his recovery from pelvic pain was not when every little sensation of discomfort finally disappeared but when the pain would flare up and he would not be at all concerned about it because he knew he had the ability to calm down the flare up. Having the ability to do something that regularly is able to reduce or stop symptoms and move in the direction of no symptoms is a major moment in life for the patients we have treated who have such an experience.

It is hard to see the relationship between cause and effect until you practice a method that allows the sore pelvic tissue to heal. I came upon it after many years of experimentation and failure. This method is not intuitively obvious and confidence in it is really only available by practicing it and seeing the results. Our method has helped many of our patients (not everyone) out of pain. It is what I did to resolve my own pain when I was lost in the wilderness of chronic pelvic pain – the wilderness that most pelvic pain patients find themselves in. While our mantra is self-treatment, the methods of self-treatment require in person training. Our 6 day program is not an easy one and at the same time we consider by far it offers the best chance, when done competently and practiced earnestly, when done competently and practiced earnestly to help end chronic muscle based pain.

Cause and Effect In Muscle Based Pelvic Pain

What makes a difference in the journey of healing pelvic pain is seeing when you are doing something that reliably helps your symptoms. When I was symptomatic, I tried all kinds of things: acupuncture, supplements, reflexology, medications, considered surgical procedures which I gratefully didn’t pursue.  My symptoms waxed and waned, often inexplicably.  At that time, if you asked me if those things helped, I’d have said I didn’t really know. I’ve come to understand that if the answer to the question “Is something helping your symptoms?” is, “I don’t really know,” then it probably is not helping. Anyone with chronic pelvic pain really does know when something is reliably helping.

When I was in pain, I dreaded trying something new to help myself because I had had the experience of trying new things and being disappointed when they ultimately failed to help me, which was most things I tried.  I think that disappointment is an underrated suffering. In myself and in my patients, I see that feeling hope of help and then being disappointed at the failure of what you have hoped would help you is a feeling that many people avoid after a number of failures,  by being very reluctant to do new treatments and  be hopeful about them.  Often that reluctance to be hopeful about a new treatment is justified.

When our patients experience improvement, they dance; they say ‘Wow. Gosh. Amazing!” They are genuinely surprised that something worked.  Their energy changes.  And they move around and exclaim, ‘I feel better’. You know when something helps. The mental and emotional space around someone who has had pelvic pain and experiences something they have done has helped them resolve it is wonderful to be around.

Our patients tend to be intelligent, conscientious and accomplished, keen to find the relationship between their symptoms and the real cause of their symptoms. Not infrequently our patients are scientifically inclined, who sometimes keep charts and records of any relationship between their symptoms and what they eat, when they void, when they go to sleep and a variety of different things. Yet most people fail to helpfully identify the factors that really move the needle in improving the problem. They will look for some kind of food, activity, supplement or something that correlates to their flare-up of symptoms.   Most importantly, they find little that really helps in the direction of resolving their condition.

Not being able to see cause and effect has large consequence psychologically. It is greatly distressing not being able to find a relationship between what really helps a condition that goes on and on.  A large part of the suffering of pelvic floor dysfunction comes out of this uncertainty of and helplessness about what the problem is, of often not being able to see a relationship between something that makes it worse or makes it better. In a word the distress comes from the helplessness of really understanding why the problem exists or what to do about it.

It is from this helplessness and inability to see the cause and effect that people catastrophize, that they feel lost, worrying that they will never get better, that their pain is out of their control.

 

But when you do find a relationship between cause and effect, especially when you see yourself being able to do something that routinely helps you, it’s a game-changer in your life. Not surprisingly, such a discovery tends to stops the catastrophic thinking.  I’ve always said that being able to help yourself is the great antidote to catastrophic thinking.

What is the cause and remedy for pelvic pain in the view of those of us who train patients in the Wise-Anderson Protocol?  We know it isn’t drugs, or surgery or procedures or supplements.  We published an article in the Gold Journal of Urology stating that prostatitis in men, which we are clear is mostly pelvic floor dysfunction, a psychoneuromuscular disorder, involving  sore an irritated pelvic floor tissue, the result of anxiety related chronic guarding in the pelvic muscles, held in the grip of chronic reflex guarding that prevents the sore tissue from healing.  Our view is that supporting the healing of the pelvic tissue is the answer to this disorder.

The methods of the Wise-Anderson Protocol for pelvic floor related pain are, and are not intuitively obvious.  We teach our patients treat how to repetitively loosen the sore, tightened tissue between the breast bone and the knees while practicing daily a method to allow the sore tissue to rest and heal.  One of our early patients said that the most memorable moment in his recovery from pelvic pain was not when every little sensation of discomfort finally disappeared but when the pain would flare up and he would not be at all concerned about it because he knew he had the ability to calm down the flare up.  Having the ability to do something that regularly is able to reduce or stop symptoms and move in the direction of no symptoms is a major moment in life for the patients we have treated who have such an experience.

It is hard to see the relationship between cause and effect until you practice a method that allows the sore pelvic tissue to heal. I came upon it after many years of experimentation and failure.   This method is not intuitively obvious and confidence in it is really only available by practicing it and seeing the results.  Our method has helped many of our patients (not everyone) out of pain.  It is what I did to resolve my own pain when I was lost in the wilderness of chronic pelvic pain – the wilderness that most pelvic pain patients find themselves in. While our mantra is self-treatment, the methods of self-treatment require in person training.   Our 6 day program is not an easy one and at the same time we consider by far it offers the best chance, when done competently and practiced earnestly, when done competently and practiced earnestly to help end chronic muscle based pain.

Symptoms and Treatments in Pelvic Pain: Using Modern Terms to Explain Nervous System Arousal

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:

  1. Setting aside enough sacrosanct, uninterrupted time and space for Paradoxical Relaxation sessions (which we discuss as carving out 2-3 hours a day);
  2. 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.

Successfully Treating the Stress Dimension of Pelvic Pain Syndromes

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.

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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.

Being “on”.

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.

Taking Hot Baths to Alleviate Chronic Pain in the Pelvis

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.

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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.

Paradoxical Relaxation and the Treatment of Chronic Pelvic Pain Syndrome

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.

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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.

…But mindfulness goes beyond improving emotion regulation.”

Read the rest of the article here.

Rectal Pain, Anal Fissures, Hemorrhoids, Constipation and Other Manifestations of Headaches in the Pelvis

Are you experiencing the symptoms of rectal pain, anal fissures, hemorrhoids, or constipation?

It is important to have a clear understanding on symptoms for hemorrhoids, rectal pain, anal fissures and constipation. At some time or another, many people find a little blood in their stool usually after a particularly hard bowel movement and can become confused and upset at such an event. At other times, alarmed individuals go to the doctor complaining of rectal pain after a bowel movement with no apparent blood in the stool. Often the doctor gives the diagnosis of anal fissure or hemorrhoid to these complaints. To most, this can sound foreboding. In fact, an anal fissure is like a paper cut in the internal anal sphincter. Hemorrhoids constitute another condition that is painful and sometimes the source of blood in the stool. A hemorrhoid is a kind of varicose vein in the anus.

One French study showed that one-third of women had hemorrhoids or anal fissures after childbirth. One to ten million people in North America suffers from hemorrhoids symptoms. Both of these conditions are common in both men and women. These conditions are often related to constipation and diarrhea. Constipation has been related to chronic tension in the pelvic muscles in adults and recently in a study at the Mayo Clinic in refractory constipation in children.

The colon and rectum are structures that operate together in the activity of the evacuation of stool. Normal, non constipative bowel function involves the reflex relaxation of the external anal sphincters the pelvic floor muscles (along with sufficient tone in the colon) to allow the reflex of the sense of urgency with the filling of the rectum for fecal matter in the bowel to pass through the anal canal. Chronic tension in the bowel and pelvic floor triggered by anxiety can commonly result in constipation.

It is understood by many of researchers that the anal fissure is what is called an ‘ischemic ulcer’. Ischemia is a condition in which there is a significant reduction in blood flow to an area. The current understanding about anal fissures is that because there is elevated tension, the blood flow in the anal sphincter is reduced, thereby impairing the tissue. It becomes fragile and vulnerable to injury from a hard bowel movement or from the pressure of bearing down during defecation.

Diet has clearly been implicated in the development of the anal fissure. Cow milk consumption has been associated with chronic constipation and anal fissures in infants and children. Interestingly, a shorter duration of breastfeeding and early bottle feeding of cow’s milk are also suspected to play a role in early incidences of anal fissures in infants and young children. A Danish study showed a significant relationship between the absence of raw fruits, vegetables and whole grains and anal fissures. Furthermore, frequent consumption of white bread, sauces thickened with roux, and bacon and sausages increased the risk of anal fissures. British researchers found that hemorrhoids and anal fissures were much more likely to occur when one did not eat breakfast.

While most anal fissures and hemorrhoids resolve themselves after they flare up, some colorectal surgeons lean toward a procedure or surgery. The hope is that they will treat the rectal pain associated with hemorrhoids and anal fissures. We have seen patients who are anxious about their rectal pain easily talked into an aggressive treatment of the fissure or hemorrhoid involving surgery.

It is generally agreed that the source of the anal fissure in large part involves a chronically tightened internal anal sphincter. Surgery, the procedure of stretching or dilating the anal sphincter under anesthesia, and the application of topical agents are all aimed at relaxing the anal sphincter. The concept of surgery for anal fissures is based on the peculiar idea that cutting the sphincter is the best way to reduce the tone, tension, and spasm in the anal sphincter. While surgery is often successful, there is a risk of short term and sometimes long term fecal incontinence.

This conventional medical treatment of rectal pain, anal fissures, hemorrhoids, and constipation tends to ignore the relationship between mind and body. Like the conventional treatment of prostatitis, the relationship of a person’s mindset, level of relaxation during bowel movements, and management of stress is almost entirely ignored in the literature on the anal fissure. Instead, there is a narrow focus on immediately reducing symptoms. Procedures, surgery, laxatives and other medications are the usual options for patients suffering from rectal pain and other conditions. Like in the treatment of prostatitis, there is little literature on the connection or treatment of body and mind in the anal fissure, hemorrhoid or in problems of constipation.

The focus on a surgical intervention for rectal pain, anal fissures, or hemorrhoids is an expression of a viewpoint that sees no value and sees no intelligence in the symptoms of someone with such a condition. Instead of seeing the symptom of an anal fissure, for example, as the way in which one’s body is complaining of the diet, stress, bowel habits and anxiety, conventional treatment sees the symptom of blood in the stool, rectal pain, or abdominal pain as something that needs to be stopped. No regard is shown in the big picture of a person’s life and how symptoms are a response to this big picture. As we have said elsewhere, it is our view that the symptom is the way our bodies are trying to communicate. If we simply try to refuse to understand the message because we don’t understand the body’s language, we needlessly suffer and don’t deal with the root problem prompting the symptom. We continue to suffer.

In the large majority of cases, it is the chronic tension in the pelvic floor, including the anal sphincter, usually combined with diet and anxiety that leads to rectal pain, anal fissures, hemorrhoids, and constipation. In a word, a person’s mind and body and lifestyle are involved in the creation and perpetuation of these conditions.

Squatting vs. sitting during defecation as way of helping the relaxation of the pelvic floor

Most people throughout history have squatted when evacuating their bowels. The modern toilet is relatively new in the history of mankind and has been adopted as a civilized bathroom appliance. The perennial hole in the ground over which one squatted to defecate is universally considered primitive. A website devoted to promoting the advantages of squatting during defecation writes about the history of the modern toilet:

“Human beings have always used the squatting position for elimination. Infants of every culture instinctively adopt this posture to relieve themselves. Although it may seem strange to someone who has spent his entire life deprived of the experience, this is the way the body was designed to function.

The modern chair-like toilet, on the other hand, is a relatively recent innovation. It first became popular in Western Europe less than two centuries ago, largely by coincidence. Invented in England by a cabinet maker and a plumber, neither of whom had any knowledge of physiology, it was installed in the first dwellings to use indoor plumbing. The “porcelain throne” was quickly imitated, as the sitting posture seemed more “dignified” – more suited to aristocrats than the method used by the natives in the colonies.

Two other influences also favored the adoption of this new water closet. One was the headlong rush to modernize all existing sanitation facilities (which were, in fact, non-existent.) The public assumed that all the benefits of modern plumbing required the use of the seat-like toilet since it was the only one having the proper fittings to connect to the pipes. This assumption was incorrect since toilets with all the same flushing capabilities could be (and have since been) designed to be used in the squatting position.

Secondly, in nineteenth-century Britain, any open discussion of this subject was considered most improper. Those who felt uncomfortable using a posture for evacuation that had nothing to do with human anatomy were forced to keep silent. How could they denounce the toilet used by Queen Victoria herself? (Hers was gold-plated.)

So, like the Emperor’s New Clothes, the water closet was tacitly accepted. The general discomfort felt by the population was indicated by the popularity of “squatting stools” sold in the famous Harrods of London. These footstools elevated one’s feet while in the sitting position to bring the knees closer to the chest – a crude attempt to imitate squatting.

The rest of Western Europe, as well as Australia and North America, did not want to appear less civilized than Great Britain, whose vast empire at the time made it the most powerful country on Earth. So, within a few decades, most of the industrialized world had adopted ‘The Emperor’s New Throne.’

A hundred and fifty years ago, no one could have predicted the effect of this change on the health of the population. But today, many physicians blame the modern commode for the high incidence of a number of serious diseases. Compared to the rest of the world, people in westernized countries have much higher rates of appendicitis, hemorrhoids, colon cancer, prostate cancer and inflammatory bowel disease.”

There is compelling evidence that sitting on the toilet to evacuate the bowels is inferior to squatting in a number of ways. Squatting tends to relax the puborectalis muscle which is essential in defecation. It tends to reduce or eliminate the need to strain and bear down. A long study showed improvement or elimination or hemorrhoids as the result of squatting during defecation. Doing the ‘valsalva maneuver’ in which one bears down to initiate defecation while holding one’s breath have been known to cause a fatal heart attack or sometimes episodes of atrial fibrillation because such a maneuver increases pressure in the thorax and interferes with venous blood returning to the heart. The heart rate can significantly drop during this activity. Defecating while squatting can reduce the need to bear down and set this cycle in motion.

The modern toilet makes squatting during defecation a little problematic as it is made for sitting. Nevertheless, with a little innovativeness, it is possible to squat on a toilet. A device is sold that allows one to easily squat during defecation. When pelvic pain also involves rectal pain, anal fissures, hemorrhoids, or constipation, the issue of integrating squatting during defecation might well be considered.

We would like to see research on a non-invasive and self-administered treatment of both anal fissures and hemorrhoids and certain types of chronic constipation following our protocol for pelvic pain with some modifications. This would involve the rehabilitation of a very tight pelvic floor using Trigger Point Release, modifying the habit of tightening the pelvic muscles habitually under stress and during defecation and a focus on reducing anxiety producing thinking that prompts increased and habitual levels of anxiety. Squatting during defecation should strongly be considered as part of the protocol. While there is little research done on the treatment of these kinds of conditions using this perspective, we strongly support an independent study evaluating the efficacy of a modified Stanford protocol for the treatment of rectal pain, anal fissures, hemorrhoids, and certain kinds of constipation.