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.

A treatment to stop pelvic pain must cooperate with the body’s healing system

With all the discoveries of modern medicine, there remains a certain arrogance in the idea that medicine is the source of health and longevity. Yes, we live longer, and illnesses and conditions that killed our ancestors are cured by the remedies of modern treatments. But we also often forget that the healing of the human body requires the services of the body’s natural ability to heal itself.

The body’s ability to heal itself is essential for the efficacy of any man-made remedy. We cut ourselves and observe over a week or two that the torn tissue heals. How amazing would it be if a car with a crushed fender could spontaneously fix itself when left alone for a few weeks? But this is what the human body does, and we tend to take it for granted when admiring all the modern methods to support that healing system.

Modern medicine depends on the body’s innate ability to heal

The focus in modern medicine on miracle drugs and new technologies leaves out a fundamental reality: without the body’s ability to heal itself, no medicine heals anything. In our work with pelvic pain, I see that the only use for any medical intervention is to honor, cooperate with, and enable the healing mechanisms of the body to work on what is injured or troubled. What we often consider remedies for illnesses and disorders are really only support mechanisms for the body’s natural ability to heal itself.

Any successful treatment of pelvic pain must cooperate with the body’s intrinsic ability to heal the sore tissue of the pelvic floor

This insight is crucial in the resolution of pelvic pain. Many patients with pelvic pain hanker for a miracle drug or procedure to relieve their suffering. Most have been deeply disappointed in finding such a remedy.

When I myself suffered from pelvic pain, I forgot a very important thing: no medicines or procedures or technologies are necessary for people who don’t have pelvic pain to remain out of pain. People who have no pelvic pain have a body in which the pelvis is not sore or painful, and the body continues to maintain the pelvis in an easy and pain-free state without interventions of any sort. This kind of body is what we need when we have pelvic pain, and it is attainable.

Our bodies want to heal themselves of pain and disease

The pelvis does not want to hurt. The question is how to help the body in its biological intention to be without pain. It has become clear to me over the years how anything that helps pelvic pain must cooperate with the natural healing mechanisms in our own body.

This raises two important questions. First, can pelvic pain heal even when it has gone on for a long time? The answer is yes. I recovered after 22 years, and I am one of many whose pelvic pain resolved. And second, how can we help the body’s innate healing mechanism restore health and stop the pelvic pain? In order to answer this question, you have to understand what gets in the way of the body healing the sore pelvis.

It is possible for pelvic pain to heal and go away. This is often forgotten by the patient because the most distressing aspect of chronic pelvic pain is its chronicity – how it seems to stubbornly hang around no matter what a patient or doctor does. For most of those years I suffered from chronic pelvic pain, I doubted anything would help. I didn’t understand why the pain and symptoms wouldn’t go away like other aches and pains. Like many pelvic pain patients, I worried that I was a goner, that somehow my pelvis was beyond reach of getting better. Only after many years did it become clear to me what was necessary for me to heal.

There is an approach that cooperates with the healing mechanism of the body

When I recovered from pelvic pain, a key component of my path to health was regularly loosening my sore, irritated pelvic muscles. I created an environment where loosening and easing of my sore pelvis was not disturbed by the stresses that normal life can impose. I achieved this through a method of becoming both physically and mentally quiet, as we teach patients in our six-day immersion clinics on what is now known as the Wise-Anderson Protocol.

So, why doesn’t pelvic pain spontaneously heal?

Sore pelvic tissue is typically caused by chronic, anxiety-related tightening of the pelvis. The irritated tissue triggers a reflex in the pelvic floor to tighten up against the pain already there. This reflexive tightening imprisons the pelvic tissue in a chronic constriction, preventing it from healing – much like a broken leg that is continually walked on. Chronically irritated and tightened pelvic muscle tissue can throw a wrench into the normal functions of life, like urination, defecation, sexual activity, or even just sitting. But then, catastrophic thinking that the pain will never go away leads to worry and stress, which contributes to tightening the tissue to keep it in an ongoing sore and irritated state. As the diagram below illustrates, anxiety first leads to chronic tightening of the pelvic floor.

[caption id="attachment_1853" align="aligncenter" width="617"] The Pelvic Pain Cycle[/caption]

There is an effective treatment

We teach our patients to do pelvic floor physical therapy three or four times per week, with the goal of temporarily freeing the sore tissue from reflexive guarding. As pioneers in using pelvic floor physical therapy for the treatment of pelvic pain, we have treated thousands of patients. We developed the only FDA-approved internal trigger-point wand, and established clear instruction for patients to do their own internal trigger point release.

While essential, simply loosening painful pelvic tissue isn’t enough for it to heal. Pelvic floor physical therapy can help temporarily loosen the reflexive guarding that occurs in a sore pelvis, but the stresses of life tend to return the pelvis to its tightened state. It is simply incorrect to think that you can physically loosen the irritated, tightened pelvic floor without resolving the stress-related habit of chronic guarding that contributed to the problem in the first place.

One of our key insights is that loosening the pelvic floor with physical therapy helps in the long term only when this loosening is accompanied by sufficient time and inner quiet to allow the loosened pelvic tissue to heal.

In a way, the Wise-Anderson Protocol is like putting a broken bone in a cast and then allowing it to heal properly by removing it from activity that worsens the injury. Learning to profoundly relax to enable the healing of sore pelvic tissue takes time and practice, but the mind and the body are intertwined in pelvic floor dysfunction – treating the physical, mental, and behavioral dimensions of pelvic pain together is essential to any real possibility of resolution.

There is no quick fix for pelvic pain but there is a slow fix. Healing is a slow dance of physically loosening chronically contracted sore pelvic tissue and bringing it into the healing chamber of a quiet, relaxed body. Day after day. As the saying goes, God cures and the doctor collects the fee. Only when we give our body the support it needs can the real healing of pelvic pain begin.

Pelvic Floor Healing Occurs Within an Environment of Inner Quiet

There is a deep insight in a book called the Course in Miracles that says: “ In my defenselessness my safety lies”.  This means that we only feel safe when we are not tightening up in self-defense and self-protection. Protective guarding typically reflects a state of fear, a state of not feeling safe.  Only after one is willing to trust that there is no threat and one let’s down one’s guard, anticipating nothing threatening, can we feel the relief of feeling safe. Only then can the muscles relax, the nervous system ease and the systems of the body can rest.

Most of us intuitively understand that there are groups of people who respond to stress in different parts of their body.  We all know people who under stress get headaches, or who suffer with gastrointestinal symptoms, have high blood pressure or non-cardiac chest pain among other physical reactions.   I am clear that there is a group of patients who can be called pelvic responders, people who have symptoms of pelvic floor pain. I know this group very well as I was a member of this group.  I have treated many people who are pelvic responders over the years as well.

Just like cars that respond to wear and tear in different places… some cars are known to variously have problems with the fuel system, charging system, electrical system, among others — all of these different problematic mechanisms, are brought about by the stresses and aging of a car.  So it is with people. In another podcast I have discussed pelvic pain as a local and systemic problem. It is local in that the local area of the pelvic floor becomes sore, irritated and contracted. It is systemic in that it is the stress on the car by virtue of simply driving it, that can trigger the various local reactions.

Understanding this, the reduction of stress and reduction in nervous arousal is helpful for many what could be called functional disorders.  There is a significant, published scientific literature documenting the relationship between the reduction of stress and the resolution of stress related disorders.  In the Wise-Anderson Protocol for pelvic floor pain, we treat both the local and systemic dysfunction. We train our patients to do all of their internal and external myofascial/trigger point release, which is the focus on the local component of the disorder.  In training our patients in Extended Paradoxical Relaxation, we train our patients in addressing the systemic aspect of pelvic floor related pain.

Just like it is recommended to change the oil the oil in a car every 3000 or 5000 miles allows the car to last much longer and to not break down, so the regular practice of reducing anxiety and autonomic arousal is critical in helping to heal a painful pelvis.  While what I am describing may feel like a huge and onerous burden, in fact it is one of the most pleasurable, soothing and healing of practices. While it takes several months of daily practice to begin to gain some skill in it, the practice of reducing anxiety and nervous arousal, in which the practitioner struggles to learn the method, once learned it is a life long practice of inestimable value.  It was a huge revelation to me that giving up my guarding was the only way I could finally feel safe.

Effortlessness as the Unlikely Medicine for Pelvic Floor Pain

In an earlier podcast I discussed ‘letting go’ as the medicine of the Wise-Anderson Protocol. By letting go, I mean the release of muscle tension inside and outside the body and daily reduction of nervous arousal enabling the healing of sore pelvic tissue. By letting go I mean ceasing to hold the sore, irritated pelvic tissue captive in the reflex tightening that the pelvic floor does when it feels pain or intrusion.

The methods we use to help patients let go of a painful, contracted pelvic floor in the Wise-Anderson Protocol are both physical and mental/behavioral. The physical way we help patients learn to relax is by self-treatment doing myofascial release and trigger point release using our internal and external trigger point release devices. The physical release of chronically sore and tightened tissue using these methods is essential in helping someone to reach a level of relaxation and ease of the pelvic floor that relaxation alone cannot reach. When muscles have shortened and trigger points form, the muscle can only loosen to a certain point, just like a rubber band cannot extend to its full length if there is a knot tied in it.

In a daily protocol, after the tissue is repetitively loosened physical, a specific relaxation method, when done skillfully and in conjunction with the physical self-treatment, can help the pelvic pain patient reach areas of profound relaxation that are not able to be reached otherwise. This profound relaxation is what I think of as a healing chamber for the sore and irritated tissue of the pelvic floor.

Learning to let go, is the practice of being effortless. One of the central instruction of my relaxation teacher, Dr. Edmund Jacobson, was to discontinue effort.  Babies are the best at being effortless and do not need any training to help them relax. In fact no one needs to learn how to relax.  The ability to relax is hard wired in us. ……. The obstacles to relaxation are what must be overcome to be able to engage our natural ability to profoundly relax. These obstacles centrally involve anxiety, reflex guarding against pain and an upregulated nervous system. The relaxation method we use and have done research on over the years in the Wise-Anderson Protocol,addresses the real-life, moment-to-moment inner obstacles to lying down to do a relaxation session and calm down a nervous system. Over the years we have honed this practice, which we call Extended Paradoxical Relaxation, to help someone who is anxious, chronically clenched and in pain.  Anxiety and chronically tightened core muscles are often-overwhelming and defeating barriers to relaxation.  The goal of our relaxation method is to enable one to enter into a state of profound relaxation. The practice of relaxation can also be  called the practice of conscious effortlessness. In this state the body’s healing mechanisms are called forth.

It takes courage to do learn to deeply relax. To profoundly relax, you are asked to lie down, stay awake, rest your attention in sensation, and allow anxiety, discomfort and protective guarding against pain to come and go as a strategy of moving past them. When you’re anxious or in pain, it’s hard and often scary and unpleasant to lie down for a relaxation session, because it means being alone with your anxiety, discomfort, and uncertainty. Our aversion to these feelings typically sidetracks many people’s attempts to put an end to their anxious state and to enter a state of inner quiet.

Many of our patients have been told to breath deeply or do certain exercises to relax the pelvic floor.  It is my view that such instructions are of little use and usually suggested by someone who is not able to profoundly relax themselves.  There is no quick and dirty way to relax the pelvic floor. Relaxing the pelvis floor and permitting the sore tissue of the pelvic floor to heal by bringing it into an regular environment of daily equanimity is not achieved by a breathing maneuver and can take up to several hours.  Attention must be trained to rest in sensation in an extended period of time, outside of the reach of the discursive, anxious narrative that runs through most people’s minds who are anxious and in pain.

The method we use of Extended Paradoxical Relaxation specifically address what to do with the subtle psychological resistances to lying down with anxiety and discomfort. The method addresses the issue of attention and how central it is to be committed to developing what you can call the ‘muscle’ attention.

When you’re motivated to learn relaxation, you’re often upset emotionally in some way. These feelings are usually unexpressed; they remain inside and are felt as a kind of pressure, anxiety, constriction, or deadness. When unresolved, they are obstacles to your nervous system calming down. Fear, sadness, grief, anger and frustration are among the emotions that may arise. What we train our patient to do with them is critical to learning how to deeply relax.

Anxiety and chronic tension are states of self-defense and concern about survival. When you’re anxious or chronically tense, some deep part of you, usually unspoken, feels like you need to protect yourself. In a kind of unconscious reasoning, some part of your mind believes that tension and anxiety are helping you stay safe. We discuss this in our book as pleasure anxiety, catastrophic thinking, and the desire to avoid disappointment by rejecting the experience of feeling safe.

Pleasure anxiety and the fear of feeling safe and undefended are not just concepts. They are the engine the drives people to compulsive working and workaholism, and we must address them with the aim of overcoming their influence or they remain obstacles to our relaxation.

Extended Paradoxical Relaxation is the Practice of Un-defending Yourself

If tension is part of how you defend yourself, our relaxation protocol is the practice of letting go of defending yourself. When people who are anxious or who suffer from the symptoms associated with pelvic pain and its accompanying anxiety begin to learn relaxation, they usually feel fear about letting go. Sometimes people are uneasy about what they’ll find inside, or afraid that they might lose control, or that something bad will happen if they let down.

Underneath Tension and Anxiety is Peace

I have learned that under all anxiety is peace. It is difficult to discover this on your own.  I had Edmund Jacobson, the father relaxation training in the United States as a teacher. His example and instruction gave me the courage to dare to let go in the way that he taught me.  Underneath suffering, tension, anxiety, and pain, lies serenity. I tell our patients that they only need only trust my words up until they have the experience of this themselves. Then it’s theirs, and they don’t have to rely on what I or anyone else says anymore. When you practice Extended Paradoxical Relaxation in the safety of knowing that someone else has been there, it is far easier to trust that you are safe in resting even when anxiety, fear, sorrow, and uncertainty are present,  because underneath these disturbing emotions is the ease we all want.

What is unconscious controls us. If difficult emotions are not acknowledged during relaxation, they typically remain huge obstacles in entering into the healing state that relaxation provides.

Learning to relax requires a commitment of daily practice. Without real earnestness, reliable ongoing ability to relax in my experience is not possible.

In our protocol, Extended Paradoxical Relaxation is best done in conjunction with loosening the body with trigger point release and its related practices. This combination is found in the practices of types of yoga and meditation that have withstood the test of time over millennia. In the yogic traditions, the body is stretched through the asanas or yoga postures and then meditation is done.  In fact practicing effortlessness – which is commonly called relaxation is both a mental and physical event. Practicing the physical methods of releasing the body’s deep tensions followed by the practice of focusing attention within, in my view is the best way to practice conscious effortlessness in order to provide a healing chamber for the sore pelvic tissue at the heart of pelvic floor pain.

Reducing Anxiety to Heal Pelvic Pain: The Wise-Anderson Protocol

PART 1 – INTRODUCTION: PELVIC PAIN IS A PSYCHO-PHYSICAL EVENT TO REDUCE ANXIETY

Learn the importance to reduce Psycho-Physical events to help reduce Anxiety. During the writing of the fourth edition of our book, a physical therapy colleague of ours reported an important story that occurred with one of her patients. The patient was a woman with pelvic pain who had experienced an intense flare-up of her symptoms, and she had started seeing our colleague in an attempt to reverse the flare-up. In one of their physical therapy sessions a remarkable event occurred. It was remarkable not because it was uncommon (indeed we see it often in our patients) but because the event was witnessed in a therapeutic setting and the relationship between cause and effect was so clear. While the therapist was pressing on trigger points inside the vagina of her patient, the patient began to talk about a politician she despised. As the woman shared her anger, the therapist felt her finger being crushed in a vise-like grip of the woman’s pelvic muscle contraction.

Emotional upset, anxiety and sympathetic nervous system arousal can trigger clenching, contraction, and spasm in the pelvic muscles

The patient was middle-aged and the physical therapist was amazed at the strength of contraction of the muscles of this woman’s pelvic floor while she shared her upset feelings. The vice-like pelvic contraction appeared suddenly in this patient and the strength of the contraction was intense. The physical therapist shared with us that it felt like her finger was about to be crushed and she felt frightened that she might be injured.

“Did you feel that?” the physical therapist asked her patient.
“Did I feel what?” replied the patient.
“Can’t you feel the spasm that your pelvis has gone into right now while you are talking about your hatred of this man?” asked the physical therapist.
The patient was dumbfounded. “Feel what? I don’t feel anything,” replied the patient.

Almost unbelievably, the patient had no sense of the relationship between her emotions and the reaction of her pelvic muscles. And while this particular example was striking given the setting and acute cause/effect detection of our colleague, we have seen this psycho-physical inner behavior in all of our patients over the last 21 years and believe it to be the primary causative and perpetuating factor in chronic pelvic pain syndromes.

Chronic pelvic pain syndromes represent a psycho-physical event

Indeed, the chronic pelvic pain that we treat is a psycho-physical event. Unfortunately, the historical treatment of pelvic pain has almost entirely been a misdirected physical treatment of the organs of the pelvis such as the prostate or bladder. Indeed, the conventional medical establishment unfortunately continues to place most of the blame for pelvic pain on the pelvic organs, and attempts to throw various pharmaceuticals at the condition, including antibiotics, anti-inflammatories, botox, and other classes of medications, as well as procedures such as nerve blocks and even surgery, all of which have had, at best, mixed results. And, when physical therapy for the pelvic muscles is prescribed, it is almost always prescribed alone, that is, with no accompanying psychological/cognitive support, relaxation training, or self-treatment training.

In our experience, a limited course of solitary physical therapy produces mediocre to poor results in the pelvic pain patient. In our FDA study that led to the approval of our internal trigger point wand, approximately ¼ of our patients had previously undergone some physical therapy and their baseline level of symptoms was no different than those who had received no previous physical therapy. It has been our strong collective experience over the years that simply treating pelvic pain as a physical event and trying to rehabilitate the pelvic muscles to a supple and pain-free state without addressing the psychological environment and inner behavior of the patient is ultimately not helpful and can often result in the patient abandoning his/her treatment regimen.

Of course, we are not saying that the physical therapy aspects of our protocol are not important in recovering from chronic pelvic pain and dysfunction. It is essential to understand, diagnose, evaluate and treat the myofascial trigger points and muscular restriction that has developed inside and around the pelvic floor in muscle based chronic pelvic pain syndromes. We consider ourselves disciples and champions of the work of Drs. Janet Travel and David Simon and their seminal medical textbook Myofascial Pain & Dysfunction. We comprehensively treat our patients for myofascial trigger points, conducting what we believe to be the gold standard evaluation and identification of trigger points, and then we treat them over multiple sessions in our immersion retreats with specific manual trigger point release, myofascial release, skin rolling, and other myofascial trigger techniques. We train our patients extensively in self-treatment of trigger points using our FDA-approved internal trigger point wand, the theracane, trigger point balls, and other tools, and teach specific yoga-type stretches following trigger point self-treatment. We have developed an unrivaled 300 plus page manual regarding physical therapy self-treatment that our patients take home with them, which includes our “Pressure Principle” concept that details how to determine the level of pressure to use in trigger point self-treatment. Thus, as one can see, we have a world class physical aspect of our protocol and continue to enhance and improve it. What sets us apart from most providers, however, is our deep understanding of chronic pelvic pain syndromes as a psycho-physical disorder and that we pair with our physical protocol with a comprehensive and continuing relaxation/behavioral protocol.

Ignoring the psychological environment of muscle based pelvic pain means that it typically sticks around

The psychological environment that perpetuates the physical contraction, irritability, pain and dysfunction of the pelvic floor has simply not been fully addressed in conventional medicine. When the psychological/anxiety environment that regularly tightens up the pelvis is ignored, pelvic pain typically remains a gnawing and ongoing problem. Even if the relationship between anxiety and pelvic floor pain is acknowledged, and drugs, psychotherapy, mindfulness, or breathing exercises are casually or partially suggested, these mechanisms still usually fail, in our opinion, because the practitioner fails in adequately advising and informing the patient of how significant the intervention needs to be in order to profoundly and reliably down-regulate the patient’s sympathetic nervous system and anxiety.

Over the last 20 years of enhancing the Wise-Anderson protocol, we have developed both a strong and substantial behavioral and psychological protocol of intervention to help patients stop their pain and dysfunction. In the psychological area, we have come to an understanding and treatment of anxiety and the nervous environment of the pelvic pain patient that we believe is remarkable and unparalleled. In this essay, we describe in more detail our method of teaching patients to reduce their anxiety and sympathetic nervous system arousal.

PART 2 – THE TENSION-ANXIETY-PAIN-PROTECTIVE GUARDING CYCLE AND THE METHOD OF EXTENDED PARADOXICAL RELAXATION TO BREAK IT

How anxiety keeps the pelvic muscles tight and painful

The typical etiology (the manner of causation) in chronic pelvic pain syndromes we treat is that the muscles of the pelvis in someone with a tendency toward anxiety tighten up in response to their daily anxiety over a long period of time, often months or even years and decades. During this extended period of anxiety-related pelvic muscle contraction, myofascial trigger points form in the chronically contracted muscle tissue and then, often with an intense period of acute stress, these tightened and restricted muscles get pushed over a certain threshold, become painful and produce a variety of physical dysfunctions and pain. When pelvic muscles remain in this chronically squeezed and contracted posture, they become very sore, painful (including all types of pain such as burning, stinging, aching, shooting, piercing, etc), and irritated. In this constricted state blood flow becomes inhibited, range of motion is restricted, and interference occurs with the neurological relationships that allow for normal and symptom-free life functions: urination, defecation, sexual activity, sitting, exercising, and any other movement or function that involves the pelvis.

The Tension-Anxiety-Pain-Protective Guarding Cycle is the heart of the self-feeding vicious cycle of chronic muscle based pelvic pain

The major concept we introduced in the early editions of our book, A Headache in the Pelvis, is the self-feeding vicious cycle of tension-anxiety-pain-protective guarding. This cycle is the causative and perpetuating heart of muscle based chronic pelvic pain disorders, and is the reason why the sore, irritated and painful pelvic muscles cannot achieve the environmental space to heal like other conditions the body heals on its own. The reason for this is the significant multitasking required by the pelvic floor and the normally inaccessible environment of the internal pelvic floor (vs. the shoulder, for example). Immediately below is a helpful graphic demonstrating this vicious cycle:

pelvic pain

The pelvic floor muscles are like a hub of many highways

help with pelvic painThe pelvic floor is like a hub in which many freeways converge and the pelvic floor, like the heart, is almost always moving and called upon for different tasks including key life functions like urination, defecation, sexual function and structural support. Even breathing in and out moves the pelvic floor. Even the most basic full body movements involve the pelvic floor muscles because of their intimate support of the body’s core.

Once the pelvis becomes sore and painful, and normal life functions are disturbed, the pelvis becomes hyper-sensitive to anxiety and/or nervous system arousal, which we refer to herein interchangeably. Indeed, the onset of anxiety can immediately aggravate hyper-irritable pelvic tissue and directly result in the further tightening or “guarding” of the muscles. Beyond this initial reflexive protective clenching that occurs in response to anxiety and nervousness, an additional layer of reflexive tightening can occur in the pelvic pain patient in response to the actual pain, and all of this inner behavior usually occurs outside of a person’s awareness if the patient does not understand and comprehend this cycle.

 

Pelvic pain as a tail-pulled-between-the-legs phenomenon

We have discussed in several previous writings how pelvic pain can be understood biologically and psychologically as a tail-pulled-between-the-legs phenomenon where fear causes a contraction of the pelvic muscles that pull in the mammalian tail as an evolutionary reflexive response to stress and anxiety. There are a number of ways to comprehend the fact that the pelvic floor muscles, once they have become painful and dysfunctional, fail to heal in a way that normally occurs in other, less complex, more easily treatable parts of the body. Indeed, the reflexive and ongoing engagement and clenching in the pelvis interferes with and prevents the kind of rest, relaxation, blood flow and protection from stress that is required to restore the pelvic tissue back to a supple, relaxed, functional, pain-free state.

Anxiety is the fuel to the fire of chronic pelvic pain syndromes

Some level of anxiety or sympathetic nervous system up-regulation is what almost all patients with chronic pelvic pain syndromes live with day in and day out. Anxiety can trigger pelvic contraction and, as Gevirtz and Hubbard demonstrated in their 1995 experiments, electrical activity strongly increases in trigger points with increased anxiety. Anxiety regularly exacerbates the condition and this mental state is further fed by the patient’s catastrophic thinking, the isolation of often being unable to share the feelings and experiences of pelvic pain, and a conventional medical establishment unequipped to provide any significant help or relief to the sufferer. Most pelvic pain patients who have not been trained in our protocol have no way to reduce their level of nervous upset and anxiety other than with drugs, which of course, have their own significant side effects and problems.

In the presence of anxiety and reflexive protective guarding, the sore contracted pelvis cannot find the healing space and environment to restore to a normal, non-symptomatic state. Added to an individual’s anxiety is the puzzlement of the doctors. The doctor is often frustrated about his inability to help the problem and is not infrequently worried that perhaps he has missed something. Doctors are problem solvers. As we have discussed in our book and other essays, certain doctors do not respond well to their own helplessness to solve the problem of chronic pelvic pain syndromes. Any anxiety, uncertainty or helplessness felt by the doctor is almost always communicated to the patient – a communication whose impact can be overwhelmingly upsetting to the patient.

That pelvic pain is hugely affected and perpetuated by anxiety is why the placebo effect reduces the anxiety that helps fuel the condition. This is also why many people have a reduction in symptoms after they read our book. Many of our patients whose symptoms reduce after reading A Headache in the Pelvis report their emotional relief after finally finding something that makes sense about what is going on and offers some intuitively viable solution.

Anxiety, sympathetic nervous system arousal, and reflex guarding is the environment that keep the pelvis painful; the concept of a stopping anxiety and protective guarding to create a “healing environment” for pelvic pain and dysfunction

During our 21 years of treating muscle-based chronic pelvic pain syndromes with the Wise-Anderson Protocol, we have often said that the challenge of healing and rehabilitating the pelvis would be much easier if we could send the pelvis on a long island vacation where it had nothing to do but relax and heal its chronically tightened, sore, irritable and painful state. While meant comically, our saying this acknowledges a very important question in the understanding and treatment of pelvic pain, and one that is rarely discussed in the realm of conventional treatment for pelvic pain: namely, how can we create a healing environment that allows for the sore, contracted and painful pelvic muscles to heal? How can we interrupt the tension-anxiety-pain-protective guarding cycle in a profound enough way to fully permit the pelvic floor muscle irritability to heal, just like other muscle conditions heal?

The inner healing environment of Extended Paradoxical Relaxation

This idea of a “healing environment” to allow physical healing both in terms of an external environment and a “local or internal” environment, is intuitively understandable and practiced in a multitude of medical conditions and treatments, including the following very familiar ones –

  • a cast for a broken bone to ensure bone immobilization and a reliable healing environment for the process of bone healing;
  • a neck brace for the neck after certain types of neck injuries;
  • band-aids and tourniquets along with antiseptic ointments for cuts and wounds to heal;
  • stroke and brain rehabilitation centers for the regaining of function lost in stroke and brain damage disorders;
  • in-patient addiction retreat centers for drug and alcohol users that remove the abuser from the aspects of his/her life that make it difficult to abstain from drugs or alcohol.

As one can see, these examples include both external, social-psychological healing environments (addiction retreat centers, stroke rehab centers, etc.) and local, body-focused healing environments (cast for a broken bone, wound healing, neck brace, etc.). Both of these aspects of the healing environment are crucial in chronic pelvic pain syndromes because the factors of the external, social-psychological healing environment (anxiety, work and family stresses) are so inextricably intertwined with the local function and state of the muscles in and around the pelvis. It is unfortunate that we could prepare an exhaustive and long list of healing environments like those listed above for myriad conditions in conventional medicine yet a similar concept for chronic pelvic pain syndromes has hardly ever been discussed.

When we get a cold, we don’t have to change our environment in order to recover; perhaps we get some extra sleep and stay home for a few days but otherwise we maintain our normal lifestyles of work and relationships. Healing from pelvic pain and other conditions similar to the above examples, however, requires a heightened and more intentional intervention to our normal schedule. Drug rehabilitation is an obvious and well known example where “time away” is almost universally accepted and supported by the entire medical community as well as a patient’s family and friends. This type of caregiver and social support is exactly what the pelvic pain patient needs in attending to his/her recovery as well.

The Wise-Anderson Protocol helps patients create a daily “healing environment”

In our view, when the symptoms of the pelvic pain patient get routinely better, like in the morning, on week-ends, on vacation or in a hot bath, they are in an “inner healing environment.” The muscle tension has eased, the nervous system is quieter. We are convinced that chronically contracted and dysfunctional pelvic muscles need a “healing environment” in order to optimize recovery potential in the patient. In this healing environment the pelvic muscles are not caught in the tension-anxiety-pain-protective guarding cycle. The Wise-Anderson Protocol is focused on helping the patient create this healing environment regularly in order to interrupt the self-feeding cycle that keeps the pelvic muscles sore, irritated and painful.

While we cannot place a literal “cast” on the pelvic muscles, like you can on a broken leg, or send it to a tropical island for an extended healing vacation free from the onslaught of a vigilant and aroused nervous system, we have developed a 2-4 hour daily practice that can help turn off the relentless self-feeling cycle of tension-anxiety-pain-protective guarding. We do this by using the practice of daily Extended Paradoxical Relaxation (EPR). The practice of EPR allows for a profound down-regulation of our sympathetic nervous systems, which in turns stops fueling the fire of pelvic pain and allows the pelvic muscles time to heal.

The concept of taking a significant and continuous 2-4 hour daily break from your normal life in order to heal from pelvic pain (which we mean to include the variety of diagnoses given to pelvic pain including prostatitis, pelvic floor dysfunction, interstitial cystitis, chronic proctalgia, levator ani syndrome, among others) is not something that is part of the current conversation among professionals who treat pelvic pain. While certain conditions like stroke and drug rehabilitation have been treated in month long immersive formats, it is rare for a patient of a functional somatic disorder to be encouraged to do this. In a recent essay we wrote for our blog comparing a locked up computer to the state of a dysfunctional, up-regulated nervous system, we stated:

With regard to people who have chronic pelvic pain, their bodies can be said to be experiencing a similar overwhelm to that of the frozen, locked-up computer. Too many tasks, stresses, demands, and pressures have accumulated over time and the body has found itself in a distant place from its homeostatic, healthy, default mode. In response to the demands of our hectic lives, the muscles of the pelvic region have engaged in a pattern of chronic, unyielding protective guarding as a method of coping with and getting through these stresses. These pelvic muscles, normally supple and pain-free and able to relax and contract easily, are rigid and chronically contracted and dysfunctional. In other words, the pelvis has become part of the body’s lock up, just like the locked up computer.

Using an Extended Paradoxical Relaxation retreat to train the patient in EPR and “Kick-Start” their recovery journey

What Extended Paradoxical Relaxation provides is a regular daily hiatus from the tasks, stresses, demands, and pressures that have played a causative and perpetuating role in a patient’s symptoms. When a soldier returns injured from war, or a patient survives a stroke, usually all of the caregivers and family support a comprehensive, immersive, long term treatment program. The physicians, physical therapists, psychologists/counselors, and loved ones of the patient are all on the same team and understand that a sustained, repetitive healing environment will be required for many months or years for the patient to reach his/her full potential of recovery.

We are studying a similar methodology for the functional somatic disorder of chronic pelvic pain where treatment begins with a multi-week, (9-30 days) immersion, in-patient clinic, in which the patient receives all of the training in the physical therapy aspects of our protocol and engages in 4-7 hours of our Extended Paradoxical Relaxation method in order to profoundly intervene in and break the vicious cycle causing and perpetuating their pelvic pain and dysfunction.

This extended, intensive immersion retreat sets the patient on the path to recovery by helping patients regularly turn off the ongoing mental narrative and regular experience of being ‘on’ in order to respond to personal and work demands, and by spending enough sustained hours in a state of Extended Paradoxical Relaxation in order to create the healing cast for the pelvic muscles to return to a supple, relaxed, functional pain free state. Indeed, our goal in conducting research into this extended EPR retreat is to place the patient into an almost permanent “airplane mode” for several weeks and essentially bring the ancient practice of the meditation retreat into the 21st Century as medical treatment for functional somatic disorders like chronic pelvic pain.

PART 3 – BRINING THE TRADITIONAL MEDITATION RETREAT INTO THE 21ST CENTURY TO DOWN-REGULATE THE NERVOUS SYSTEM AND HEAL THE PELVIC FLOOR

For thousands of years, in most spiritual or wisdom traditions, it has been common for those seeking deep inner understanding to spend long periods of time in meditation and contemplation. Innumerable books and texts over the centuries have extensively documented and profiled the concept of the meditation retreat in the Buddhist, Hindu, Judeo-Christian, and Muslim traditions.

Indeed, among other Biblical examples, Jesus was purported to have spent 40 days of contemplation in the desert, and all of the other religious traditions have similar stories in their sacred texts. From Buddha to St. Francis to Hindu sadhus to contemporary meditators like Thomas Merton, quieting the body and mind through meditation has been a lofty practice. Even today, the explosion in popularity in the practice of yoga, including its brief forms of meditation at the end of most hatha yoga classes, demonstrates a collective intuition that quieting down the nervous system through meditation is good for us.

Paradoxical Relaxation practice is a secular form of meditation

My teacher Edmund Jacobson went to great lengths to make a distinction between his protocol, which he called Progressive Relaxation, and many other practices including meditation. He wanted make a distinction between Progressive Relaxation and other practices and phenomena that produced relaxation like meditation, transference in psychoanalysis, spiritualism, yoga, and hypnosis, among others.

Jacobson wanted to identify Progressive Relaxation as a scientific and medical protocol aimed at reducing nervous system arousal that only relied on practitioners following the given instructions during a session. He did numerous scientific experiments with barium and fluoroscopy to demonstrate the scientific efficacy of his method. He worked with Bell labs in the 1940s to invent the electromyography that was able to measure electrical activity in muscles that he used to document the efficacy of his method.

Despite Jacobson’s protests and attempts at drawing clear distinctions between his relaxation method and other practices and phenomena that produced relaxation, contemporary methods of relaxation and ancient methods of meditation have more similarities than differences. Relaxation methods and meditation methods all aim at controlling attention to bring about the quieting of body and mind. While relaxation teachers don’t don robes, light candles or incense, or lecture students on spiritual subjects, the basic principles apply to both the directing attention away from discursive thought and cognitions and back to a focus that allows the reduction of thinking and mental activity. These instructions are the main ingredients in helping reducing sympathetic “fight or flight” nervous system arousal.

Meditation and relaxation methods, from the largest perspective, are essentially the same and both borrow from the universal principles that allow for the nervous system to quiet down. While psycho-physiologists may call the goal of relaxation “stress reduction” and “autonomic down-regulation,” while meditation teachers may call meditation the “practice of inner peace,” there is no essential difference to them on the inside if the practitioners gains entrance to the relaxation response and gains peace and equanimity; in short, it is a healing environment whether the practitioner calls what she did meditation or relaxation.

Brief periods of regular relaxation have been shown to help certain health difficulties and reduce anxiety but the effects of longer periods of relaxation have not been studied

Conventional wisdom in the 21st century easily understands the relationship between stress and illness. In the last few decades, stress reduction has become a subject of much interest not only because the relationship between stress and illness is often reported in the popular media, but many people feel the effects of stress with the increasing non-stop computer culture that routinely bombards one with stimuli, often disturbing, from numerous portals such as email, text, instant message, Twitter, Facebook, etc. The sources of our nervous system stimulation has become endless with the explosion of communication technologies.

Much has been written about the benefits of meditation for stress reduction. As with relaxation methods, such meditation interventions are prescribed in the form of relatively short periods of time – perhaps a ½ hour to an hour a day where one is asked to sit upright and quiet, and direct attention to the breath, a sound or a visual image. Indeed, meditation has been shown to help depression, anxiety disorders, chronic fatigue syndrome, and functional somatic disorders, including irritable bowel syndrome. It has also been shown in helping reduce the symptoms related to heart disease, and in our own work and previous studies, in the reduction of pelvic pain symptoms. These studies, however, typically do not include long, extended periods of relaxation/meditation. They tend to be confined to daily, ½ hr – 1 hour periods. Thus, to be sure, meditation does have the capacity to lower nervous system arousal to some modest degree or another when done regularly and reliably in short periods of time on a once a day basis.

Like these studies, for the past 21 years of our work with pelvic pain, we have asked patients to do short periods of Paradoxical Relaxation, typically between 30 minutes to 50 minutes, twice a day. We have had excellent results with a large number of our patients with this regimen. There are certain patients, however, who seem to require several hours to calm down enough to enter into the healing state of nervous system down-regulation. In recent times, for these patients, we have been recommending significantly longer periods of Extended Paradoxical Relaxation – between 2-4 hours, if not longer, on a daily basis for those whose symptoms continue to be at a plateau.

In the ways we live now, however, long periods of meditation/relxation that range from multiple hours to days (or even weeks or months) do exist but are very uncommon. Modern life, and its demands for real-time access and constant production of content, strongly discourages us from taking that unwired, unconnected sabbatical. Busy is good the society tells us. Taking a hiatius where one is “unwired” and off the communications grid is not on the radar screen of what people think about in the 21st century. Indeed, even a two or three week vacation can cause anxiety in many people for fear that their employer will consider such a break excessive. And while meditation retreats are offered at a few centers in the world, they typically are not done as part of a treatment for a specific medical disorder, as we use in the Wise-Anderson Protocol for chronic pelvic pain syndromes.

The Meditation Retreat as specific medical treatment in the Wise-Anderson Protocol

Little scientific research has been done in terms of documenting the real physiological healing potential of long relaxation retreat periods that give the nervous system a profound rest from the ongoing stimulation of the demands of life. Because meditation retreats are typically done for spiritual reasons and not for medical reasons, and because there appears to be no economic advantage to be gained by a company in investing time and research energy into the benefits of extended periods of nervous system quieting, little reliable data is available on the true, scientific healing potential of such a practice. It may be clear to some that if you were able to calm down and be peaceful for a long period of time it would have the potential to heal your medical condition; however, many people have little exposure to scenarios of recovery outside the conventional medical system and its drugs and procedures.

In the Wise-Anderson Protocol, we are now studying a modern-day, 21st-century version of the meditation retreat done at the same time and in combination with our medical, physical therapy, and psychological protocols. We believe an extended, intensive relaxation retreat combined with our Protocol has huge undiscovered potential in helping even the most refractory chronic pelvic pain patients.

From Spiritual Focused to Medical Focused: Bringing Meditation into the 21st Century

There is little difference between meditation instructions today and meditation instruction given centuries ago. Indeed, in meditation communities there tends to be a reverence toward ancient instructions. The concept exists that somehow ancient instructions have a certain power that should be adhered to up to the present day, and it is heretical to do otherwise. It is not uncommon for meditation instructions to be relatively brief and sparse, done at the beginning of someone’s interest in meditation, and infrequently reiterated or explored as someone continues meditation over their lifetime. One is expected to remember of their own accord the instructions on how to do meditation; for example, in many traditions one is often directed to attend to one’s breath and every time one’s attention wanders away from the sensation of the breath, one should return their attention to it. The meditator, however, is charged with being responsible for these self-instructions and self-motivation themselves.

In the most popular meditation traditions still active today, there are usually some instructions given about what to do when one’s attention is distracted by thinking, but again, the instructions for bringing attention back to focus is very uncommon. The meditator is expected to coach him or herself regarding directing attention on a moment-to-moment basis after the initial instructions are given and no one has truly researched what actually goes on in the mind of the meditator over time. When I first learned meditation, the instructions were given by a relative neophyte and I struggled for many years with the instructions to keep my posture straight and to focus my attention in the lower part of my abdomen. This was often difficult for me to do and at the end of meditations I would notice that, while some inner quieting had occurred, nothing really remarkable occurred in my nervous system.

Simply put, the ancient meditation instructions suffer from the problem of not having the necessary psychological insight to support the patient within the context of the stresses and demands the patient faces in modern times and its particular relation to the patient’s medical symptoms. To sit on a pillow in a cross legged position and keep a straight spine, among other ancient instructions, prove to be very difficult to a symptomatic pelvic pain patient in 2015 in facing the terms of his/her nervous system up-regulation. We do not put counseling and psychotherapy sessions on a recorded CD nor do we rely on ancient texts to determine how we counsel psychology patients in modern times. In Paradoxical Relaxation, we bring the instructions of relaxation practice, and the relationship between instructor and student, into a modern context where all of the nuances and subtleties of a reliable relaxation practice can be addressed and enhanced.

The Evolution of Extended Paradoxical Relaxation

In our experience of teaching Paradoxical Relaxation, instructions and how to focus attention usually can be held in the mind for about 10 to 30 seconds. After that the mind will tend to wander unless someone is very practiced in focusing attention and is good at self-coaching. Paradoxical Relaxation has been informed by the work of Edmond Jacobson and the number of meditation traditions that I have studied over the years. The relaxation method of Paradoxical Relaxation has mostly been informed by my attempt over the years to down-regulate my own sympathetic nervous system, and borrowing from different teachings I have experienced has been helpful to some degree.

Extended Paradoxical Relaxation that is done over a 2-5 hour period daily has evolved over the last 21 years as a relaxation/meditation method that very particularly and specifically bring meditation into the 21st-century. As someone becomes skillful in doing Paradoxical Relaxation over this long period of time daily, we have noticed that there is a qualitative shift in the effectiveness of the methodology.

Chronic pelvic pain is a problem that is fed by nervous system arousal. If someone were able to calm down mentally and emotionally and release the chronic contraction of their pelvic muscles and related areas, their pelvic pain would resolve relatively quickly. The main problem with pelvic pain recovery comes from the pelvis not being given a rest from the onslaught of nervous system stimulation that is relentlessly delivered throughout one’s day by anxiety and the common stresses of modern life.

The purpose of Extended Paradoxical Relaxation, in the form of an “off the grid” relaxation retreat, is to give a hiatus or sabbatical to the nervous system arousal over a period of two or three weeks (or possibly longer) that can initiate the healing of the pelvic muscles from their irritable, sore, dysfunctional and painful state. During the retreat we engage the patient in 4-7 hours of Paradoxical Relaxation sessions. Often times “opening the door” is the hardest process in recovery; once the body’s momentum gets started in a healing direction, the patient usually is easily able to stay reliably committed to the protocol and the healing journey. This is the goal of the intensive, multi-week Extended Paradoxical Relaxation retreat.

Our Methodology

Here are some of the methodologies we are using in Extended Paradoxical Relaxation:

  • Noise canceling headphones to help block out any distracting noise in the environment.
  • A sophisticated, light stopping sleep mask to help keep the light out that can help calm down nervous arousal.
  • We help the patient find the ideal position to rest in during the practice, not based on ancient traditions but what works best for the patient in light of their current physical symptoms.
  • Importantly, we give detailed and optimized instructions to the real live person doing relaxation every 20 or 30 seconds to a minute and we address in our instructions the obstacles to relaxation, for example: (1) the desire to escape from discomfort that is inevitable when you sit down with a condition that involves pain; (2) the desire for pleasure and the avoidance of pain; (3) the desire to reach an ideal outcome instead of staying focused in the present moment which is paradoxically the essential ingredient in shifting a painful and uncomfortable physical state to one that is comfortably pleasurable and provides a healing environment for the pelvic tissues.

Finally, when someone goes home after their relaxation retreat with us we ask them to do what is rarely asked of any patient, which is to take 2 to 3 hours a day to create a hiatus for the nervous system. We ask them to get up early or to somehow create the time that they would take if their pain was some critical condition like a stroke recovery that demanded a certain amount of rehabilitation time. We do this for a very specific, medical reason: we have found in our 21 years of experience that this is the kind of commitment necessary to break the vicious tension-anxiety-pain-protective guarding cycle that forms the causative and perpetuating foundation of pelvic pain and dysfunction.

We have found that the length of the relaxation session is critical to the efficacy of the method in a certain sub-population of our patients. This is the same difference between taking a sub-minimal amount of a drug that doesn’t have enough traction to affect the disorder and increasing the dosage to a dosage that demonstrates efficacy. In a 14 day immersion program we just concluded we found a qualitative difference between a brief Paradoxical Relaxation session and the hours-long session. It is clear that there is a minimum dosage for the efficacy of certain drugs; likewise, we are seeing that for certain patients, there is a minimum “dosage” of relaxation in terms of the time allocated for it. For certain patients, the difference between doing Paradoxical Relaxation for ½ hr/ day and 3 hours per day makes the difference between remaining in pain and resolving the pain.

We are also excited to announce that in conjunction with our research into these longer, multi-week relaxation retreats where we do 4-7 hours a day of Extended Paradoxical Relaxation, we are developing a “take-home kit” that will include a comprehensive book, audio-visual materials, Paradoxical Relaxation recordings, and other support tools. Our goal with this kit is to provide as much environmental support as possible so that the patient can “re-create” the healing environment of the relaxation retreat at home as much as possible. Because of its personal nature with audio-visual recordings, the kit will also reinforce the teacher-student connection that occurred during the relaxation retreat. We will also be exploring the possibility of the kit as a stand-alone product for the treatment of a wide range of anxiety and functional somatic disorders.

The Invisible Patient: The Symptoms of Chronic Prostatitis and Chronic Pelvic Pain Patients

Pain Blog – The Invisible Patient: The Symptoms of Chronic Prostatitis and Chronic Pelvic Pain Patients

Our Pain Blog covers research on chronic prostatitis and chronic pelvic pain.

A recent article in the Korean Journal of Urology (see below) documented that men diagnosed with chronic prostatitis/chronic pelvic pain syndrome (chronic prostatitis, chronic pelvic pain syndrome) were significantly more stressed than control groups. The report showed that higher levels of depression, anxiety, and perceptions of stress were closely related to increased levels of pain and decreased the quality of life levels.

[embed]https://www.youtube.com/watch?v=EFryUqNCJf0[/embed]

The symptoms of chronic prostatitis, chronic pelvic pain are invisible to the eye and x-ray. 

Many of our patients have reported their distress in hearing from bosses, friends, or family members that they looked fine. The fact is that the greatly distressing symptoms of chronic prostatitis —urinary frequency and urgency, genital and rectal pain, pain associated with sex, and sitting discomfort among others—are neither visible to the eye nor any imaging technology that currently exists. It is for this reason that examining physicians will often scratch their heads and tell the patient that there is nothing wrong with him, and perhaps his problem is psychiatric. This experience has left more than a few of our patients describing their time with the doctor as one of the most upsetting in memory. To be told that there is nothing wrong with you and that you don’t look like you have a problem when you’re suffering greatly, often leaves the patient feeling frightened, lost with nowhere to go and catastrophizing about the future.

While the eye can’t see the problem, a physician or physiotherapist experienced in treating prostatitis, chronic pelvic pain can detect the disorder with an educated finger.

Many patients have undergone expensive, high-tech evaluations complete with blood, urine, and other testing that yielded no useful information. When a physician is familiar with muscle-based pelvic pain and has been trained to evaluate trigger point and myofascial constriction inside and outside the pelvis, the problem of prostatitis and most causes of pelvic pain can be easily diagnosed within the time frame of a conventional medical appointment. More important, this diagnosis can point in the direction of a real solution to the problem. Unfortunately, many urologists who are consulted for chronic pelvic pain are not trained to evaluate the presence of trigger points and myofascial constriction in the pelvic muscles. Their focus typically remains on the organs.

The Wise-Anderson Protocol has pioneered a new understanding that many cases are caused by an ongoing charley horse in the muscles of the pelvis.

The Wise-Anderson Clinical Protocol was developed and researched at Stanford University between 1995 and 2003 and continues to be offered monthly in a 6-day immersion clinic in Santa Rosa, California. A number of research articles have documented its effectiveness. This protocol represents a new and pioneering understanding of symptoms typically diagnosed as prostatitis. It focuses on teaching men to release the chronic spasm in the pelvic muscles and calm the nervous arousal that perpetuates their symptoms. A popular book called “A Headache in the Pelvis,” now in its 6th edition, offers the most detail of this new understanding and treatment.

In reviewing the data from an ongoing study we are conducting, we find that men and women who have undergone the Wise-Anderson Protocol experience a significant reduction in their emotional distress when they are able to reduce the symptoms of chronic prostatitis by virtue of their own trained self-treatment.

Korean J Urol. 2012 Sep;53(9):643-8. doi: 10.4111/kju.2012.53.9.643. Epub 2012 Sep 19.

Depression, anxiety, stress perception, and coping strategies in Korean military patients with chronic prostatitis/chronic pelvic pain syndrome.

Ahn SG, Kim SH, Chung KI, Park KS, Cho SY, Kim HW.

Source

Department of Urology, St. Paul’s Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea.

Abstract

PURPOSE:

The objective of this study was to examine the psychological features and coping strategies of patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

MATERIALS AND METHODS:

The participants consisted of 55 military personnel suffering from CP/CPPS and 58 military personnel without CP/CPPS symptoms working at the Military Capital Hospital. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) was used to assess CP/CPPS symptoms. The Responses to Hospital Anxiety and Depression (HAD) scale, Social Readjustment Rating Scale, and Global Assessment of Recent Stress (GARS) scale were compared between the two groups. The Weisman Coping Strategy Scale was used to assess coping ability with CP/CPPS.

RESULTS:

The NIH-CPSI score of the CP/CPPS group was significantly higher than that of the control group for all domains including pain, urinary symptoms, quality of life, and summed score. The Anxiety and Depression domain of the HAD showed significant differences between the two groups. There were no significant differences in the Social Readjustment Rating Scale between the two groups, but the sum of the GARS score was higher in the CP/CPPS group than in the control group. These were correlated with the pain, quality of life, and sum domains of the NIH-CPSI. The Weisman Coping Strategy Scale showed that intellectualization, redefinition, and flexibility were higher in frequency in descending order, and that fatalism, externalization, and self-pity were lower in frequency.

BLOG ABOUT PELVIC PAIN – CONCLUSIONS:

The CP/CPPS patients had depression, anxiety, and higher perception of stress. In particular, these were closely related to the pain and quality of life of the patients

The Latest CPPS and Wise-Anderson Protocol Research

The Latest CPPS and Wise-Anderson Protocol Research

 

The following are excerpts and abstracts of publications regarding the latest CPPS and Wise-Anderson Protocol research:

The following is an abridged version. For the full version, see the link at the bottom.

CPPS

Department of Urology, School of Medicine, Stanford University, Stanford, California.

PURPOSE: A combination of manual physiotherapy and specific relaxation training effectively treats patients. However, little information exists on myofascial trigger points and specific chronic pelvic pain symptoms. We documented relationships between trigger point sites and pain symptoms in men with chronic prostatitis/chronic pelvic pain syndrome.

MATERIALS AND METHODS: We randomly selected a cohort of 72 men who underwent treatment with physiotherapy and relaxation training from 2005 to 2008. Patients self-reported up to 7 pelvic pain sites before treatment and whether palpation of internal and external muscle trigger points reproduced the pain. Fisher’s exact test was used to compare palpation responses, i.e., referral pain, stratified by the reported pain site.

RESULTS: Pain sensation at each anatomical site was reproduced by palpating at least 2 of 10 designated trigger points. Furthermore, 5 of 7 painful sites could be reproduced at least 50% of the time (p <0.05). The most prevalent pain sites were the penis in 90.3% of men, the perineum in 77.8% and the rectum in 70.8%.

Puborectalis/pubococcygeus and rectus abdominis trigger points reproduced penile pain more than 75% of the time (p <0.01). External oblique muscle palpation elicited suprapubic, testicular and groin pain in at least 80% of the patients at the respective pain sites (p <0.01).

CONCLUSIONS: This report shows relationships between myofascial trigger points and reported painful sites in men with chronic prostatitis/chronic pelvic pain syndrome. Identifying the site of clusters of trigger points inside and outside the pelvic floor may assist in understanding the role of muscles in this disorder and provide focused therapeutic approaches.

PMID: 19837420 [PubMed – indexed for MEDLINE]

Chronic prostatitis chronic pelvic pain syndrome

Department of Urology, Stanford University Schoolof Medicine, Stanford, California.

PURPOSE: Chronic pelvic pain in men has a strong relationship with biopsychosocial stress and central nervous system sensitization may incite or perpetuate the pain syndrome. We evaluated patients and asymptomatic controls for psychological factors and neuroendocrine reactivity under provoked acute stress conditions.

MATERIALS AND METHODS: Men with pain (60) and asymptomatic controls (30) completed psychological questionnaires including the Perceived Stress, Beck Anxiety, Type A behavior and Brief Symptom Inventory for distress from symptoms. Hypothalamic-pituitary-adrenal axis function was measured during the Trier Social Stress Test with serum adrenocorticotropin hormone and cortisol reactivity at precise times, before and during acute stress, which consisted of a speech and mental arithmetic task in front of an audience. The Positive and Negative Affective Scale measured the state of emotions.

RESULTS: Patients with chronic pelvic pain had significantly more anxiety, perceived stress and a higher profile of global distress in all Brief Symptom Inventory domains (p <0.001), scoring in the 94th vs. the 49th percentile for controls (normal population). Patients showed a significantly blunted plasma adrenocorticotropin hormone response curve with a mean total response approximately 30% less vs. controls (p = 0.038) but no differences in any cortisol responses. Patients with pelvic pain had less emotional negativity after the test than controls, suggesting differences in cognitive appraisal.

CONCLUSIONS: Men with pelvic pain have significant disturbances in psychological profiles compared to healthy controls and evidence of altered hypothalamic-pituitary adrenal axis function in response to acute stress. These central nervous system observations may be a consequence of neuropsychological adjustments to chronic pain and modulated by personality.

Chronic prostatitis

Department of Urology, Stanford University School of Medicine, Stanford, California

PURPOSE: The impact of chronic pelvic syndrome on sexual function in men is underestimated. We quantified sexual dysfunction (ejaculatory pain, decreased libido, erectile dysfunction, and ejaculatory difficulties) in men with chronic pelvic pain syndrome assessed the effects of pelvic muscle Trigger Point Release concomitant with paradoxical relaxation training.

MATERIALS AND METHODS: We treated 146 men with a mean age of 42 years who had had refractory chronic pelvic pain syndrome for at least 1 month with Trigger Point Release/paradoxical relaxation training to release trigger points in the pelvic floor musculature. The Pelvic Pain Symptom Survey and National Institutes of Health –Chronic Prostatitis Symptom Index were used to document the severity/ frequency of pain, urinary and sexual symptoms. A global response assessment was done to record patient perceptions of overall therapeutic effects at an average 5-month follow-up.

RESULTS: At baseline 133 men (92%) had sexual dysfunction, including ejaculatory pain in 56%, decreased libido in 66%, and erectile ejaculatory dysfunction in 31%. After Trigger Point Release/paradoxical relaxation training specific Pelvic Pain Symptom survey sexual symptoms improved an average of 77% to 87% in responders that are greater than 50% improvement. Overall a global response assessment of markedly or moderately improved, indicating clinical success, was reported by 70% of patients who had a significant decrease of 9(35%) and 7 points (26%) on the National Institutes of Health- Chronic Prostatitis Symptom Index (p<0.001). Pelvic Pain Symptom Survey sexual scores improved 43% with a markedly improved global response assessment (p<0.001) but only 10% with moderate improvement (p=0.96).

CONCLUSIONS: Sexual dysfunction is common in men with refractory chronic pelvic pain syndrome but it is expected in the mid fifth decade of life. Application of the Trigger Point Release/paradoxical relaxation training protocol was associated with significant improvement in pelvic pain, urinary symptoms, libido, ejaculatory pain and erectile and ejaculatory dysfunction.

PubMed – U.S. National Library of Medicine

Journal of Urology

Abstract
J Urol. 2005 Jul;174(1):155-60.

Integration of myofascial trigger point release and Paradoxical Relaxation training treatment of chronic pelvic pain in men.

Anderson RU, Wise D, Sawyer T, Chan C.

Department of Urology, Stanford University School of Medicine, Stanford, California, USA. rua@stanford.edu

From the Department of Urology (RUA, CC), Stanford University school of Medicine, Stanford, Sebastopol (DW) and Los Gatos (TS), California.

PURPOSE: A perspective on the neurobehavioral component of the etiology of chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS) is emerging. We evaluated a new approach to the treatment of CP/CPPS with the Stanford developed protocol using myofascial trigger point assessment and release therapy (MFRT) in conjunction with paradoxical relaxation therapy (PRT).

MATERIALS AND METHODS: A total of 138 men with CP/CPPS refractory to traditional therapy were treated for at least 1 month with the MFRT/PRT protocol by a team comprising a urologist, physiotherapist and psychologist. Symptoms were assessed with pelvic pain symptom survey (PPSS) and National Institutes of Health-CP Symptom index. Patient response assessment perceptions of overall effects of therapy were documented on a global response assessment questionnaire.

RESULTS: Global response assessments of moderately improved or markedly improved, considered clinical successes, were reported by 72% of patients. More than half of patients treated with the MFRT/PRT protocol had a 25% or greater decrease in pain and urinary symptoms, respectively. The 2 scores decreased significantly by a median of 8 points when the 25% or greater improvement was first observed, that is after a median of 5 therapy sessions. PPSS and National Institutes of Health-CP Symptom Index showed similar levels of improvement after MFRT/PRT protocol therapy.

CONCLUSIONS: This case study analysis indicates that MFRT combined with PRT represents an effective therapeutic approach for the management of CP/CPPS, providing pain and urinary symptom relief superior to that of traditional therapy.

chronic pelvic pain syndrome

PURPOSE: Abnormal regulation of the hypothalamic-pituitary-adrenal-axis and diurnal cortisol rhythms are associated with several pain and chronic inflammatory conditions. Chronic stress may have a role in the disorder of chronic prostatitis/chronic pelvic pain syndrome related to initiation or exacerbation of the syndrome. We tested the hypothesis that men with chronic pelvic pain syndrome have associated disturbances in psychosocial profiles and hypothalamic-pituitary-adrenal-axis function.

MATERIALS AND METHODS: A total of 45 men with CPPS and 20 age-matched, asymptomatic controls completed psychometric self-report questionnaires including the Type A personality test, Perceived Stress Scale, Beck Anxiety Inventory and Brief Symptom Inventory for distress from physical symptoms. Saliva samples were collected on 2 consecutive days at 9 specific times with strict reference to time of morning awakening for evaluation of free cortisol variations, reflecting secretory activity of the hypothalamic-pituitary-adrenal-axis. We quantified cortisol variations as the 2-dat average slope of the awakening cortisol response and the subsequent diurnal levels.

RESULTS: Men with CPPS had more perceived stress and anxiety than controls (p<0.001). Brief Symptom Index scores were significantly increased in all scales (somatization, obsessive/compulsive behavior, depression, anxiety, hostility, interpersonal sensitivity, phobic anxiety, paranoid ideation, psychoticism) for chronic pelvic pain syndrome, and Global Severity Index rank for CPPS was 93rd vs. 48th percentile for controls (p<0.0001). Men with chronic pelvic pain syndrome had significantly increased awakening cortisol responses, mean slope of 0.85 vs. 0.59 for controls (p<0.05).

CONCLUSIONS: Men with CPPS scored exceedingly high on all psychosocial variables and showed evidence of dysfunctional hypothalamic-pituitary-adrenal-axis function reflected in augmented awakening cortisol responses. Observations suggest variables in biopsychosocial interaction that suggest opportunities for neurophysiological study of relationships of stress and chronic pelvic pain syndrome.

pelvic pain syndrome

Below is a summary of the latest research findings about the Stanford Protocol presented at the American Urological Association in San Antonio, Texas, May, 2005

RESULTS: 138 men with refractory CPPS enrolled and treated; average age 40.5 years (range 16-79). Disease duration: median 31 months (range 1-354) 59% (81/138) of patients had clinically meaningful improvements (“>25-100% decreased symptom core) in total pain as reported on Stanford PPSS(table 1)

Of these, 39% of patients achieved “>50%

Symptom improvement Total pain score 69% Urinary sc80%

After a median of five myofascial TrP release treatments , median baseline total pain scores of 13 decreased significantly by 8 points (p<0.001), Stanford PPSS (Table 2)

72% of patients reported GRAs indicating marked (46%) or moderate (26%) improvements in their symptoms.

Both symptom surveys, the NIH-CPSI and the Stanford PPSS, reflected similar levels of symptoms improvement after treatment (fig. 2)

CONCLUSION:

MFRT combined with PRT (treating these patients with the Wise-Anderson Protocol) resulted in moderate to marked improvements in symptoms in 72% of patients.

Treatment is based on the new understanding that certain chronic pelvic pain reflects a self-feeding state of tension in the sore pelvic floor perpetuated by cycles of tension, anxiety and pain. Our premise is that in addition to releasing painful myofascial trigger points, the patient needs to supply the central nervous system with information or awareness to progressively quiet the pelvic floor. The patient moves from being a passive, helpless victim to an active participant/partner in healing.

Contact us for a PDF of the Full Research.

The History of the Stanford Protocol and Wise-Anderson Protocol

https://www.youtube.com/watch?v=DCw9LCHKsys

The History of the Wise-Anderson Protocol & Prostatitis Symptoms 

The Wise-Anderson Protocol began with David Wise, PhD, a psychologist in California who had suffered from Chronic Pelvic Pain Syndrome for many years. He contacted several urologists, including Dr. Rodney Anderson, a professor of Urology at Stanford University School of Medicine and leading practitioner and expert in the field of pelvic pain. Dr. Anderson was considered to be the court of last resort for patients with pelvic pain and prostatitis who had not been helped by any other treatment.

Through many years of suffering, David Wise, PhD discovered a way to become free of symptoms.

He reported the method he used to Dr. Anderson, who headed the chronic pelvic pain clinic in the Department of Urology at Stanford University Medical Center. Dr. Wise then began working as a Visiting Research Scholar at Stanford’s Department of Urology alongside Dr. Anderson, treating men and women with a variety of diagnoses. This included chronic pelvic pain, prostatitis, levator ani syndrome, pelvic floor dysfunction, pelvic floor myalgia, interstitial cystitis, and other chronic pelvic pain syndromes. Dr. Wise and Dr. Anderson worked together for eight years at Stanford, treating patients with the protocol that Dr. Wise used in his own recovery. At Stanford, the protocol was administered to patients on an individual basis in a conventional medical format.

During these early years, the results of the Wise-Anderson Protocol were presented at meetings for pelvic pain and to prostatitis researchers at the National Institutes of Health and other scientific meetings. In 2003, Dr. Wise and Dr. Anderson published the first edition of A Headache in the Pelvis, a book that described the new protocol in detail. In the first edition of A Headache in the Pelvis, this protocol was called the Wise-Anderson Protocol. As the protocol became more widely disseminated, those on the internet dubbed it the Stanford Protocol. The term Wise-Anderson Protocol is now again used, although it was popularly called the Stanford Protocol for many years. The Wise-Anderson Protocol is identical in form and substance to what has been called the Stanford Protocol in the public arena.

When Dr. Wise left Stanford he began treating patients using the Wise-Anderson Protocol in a six-day comprehensive clinic in Sonoma County, California. The immersion clinics have been offered in Sonoma County since 2003. Patients come from all around the world to learn the Wise-Anderson Protocol and prostatitis causes.

Competence in self-treatment has produced the best results in patients who have learned the Wise-Anderson Protocol.

The focus of the Wise-Anderson Protocol has evolved over the years to train patients to do the protocol without the assistance of professionals. While the immersion clinics in Sonoma County are not affiliated with Stanford, Dr. Anderson continues to evaluate patients with pelvic pain at Stanford and refer patients to the immersion clinic. Additionally, Dr. Anderson continues conducting and publishing research on the Wise-Anderson Protocol, as well as other medical research on a variety of subjects. From 2003 to the present, Dr. Rodney Anderson, Dr. David Wise and Tim Sawyer (Physical Therapist) have actively and enthusiastically collaborated on research involving patients seen at both clinics.

Since 2003, Anderson, Wise and Sawyer have published a number of articles in the Journal of Urology on data from patients they have collaboratively seen and treated. Abstracts of these articles can be found in the “Latest Published Research” post on this blog. In 2005, Dr. Wise was a plenary speaker at a National Institutes of Health conference on pelvic pain. There he presented research results on the Wise-Anderson Protocol. Dr. Wise presented the protocol to scientific meetings, including those of the International Continence Society. Both Dr. Wise and Dr. Anderson have written chapters in medical textbooks describing the Wise-Anderson Protocol. At the time of writing this section, Dr. Anderson presented a clinical poster at the American Urological Association. A report of Dr. Anderson’s presentation at the American Urological Association was published in Medscape Medical News. It was titled Intensive Therapy Regimen Helps Men With Chronic Pelvic Pain Syndrome.

Tim Sawyer, who is the architect of the physiotherapy program, was chosen to write the pelvic floor section for the new edition of Travell and Simons. It was called Myofascial Pain and Dysfunction: The Trigger Point Manual. This is the authoritative medical textbook on myofascial trigger point therapy. Tim Sawyer trained and treated patients with Dr. Janet Travell and Dr. David Simons, the physicians who introduced trigger point therapy to medicine. Dr. Travell was the White House physician to President John F. Kennedy, and Tim Sawyer is considered one of the top pelvic floor physical therapists in the world.

Recently, Anderson, Sawyer, and Wise published a pioneering article in the Journal of Urology. The article showed the relationship of trigger point location and symptoms in patients with pelvic pain, using the data from the immersion clinics held in Sonoma County. Another article updating these results has been completed and recently submitted for publication. Currently, Anderson, Wise and Sawyer have completed a study on the effectiveness of a new internal trigger point physiotherapy device for the self-treatment of trigger points. The study data on the physiotherapy device is being prepared for publication and will hopefully be published soon.