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.
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]
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.
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
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. [email protected]
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.
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.
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)
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.
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