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Why all physical treatment for pelvic pain is not the same

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

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

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

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

 

Self-Treatment vs. Treatment by Others

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

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

The Internal Trigger Point Wand

 

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

 

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

 

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

 

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

 

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

Trigger Point Genie

 

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

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

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

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

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

 

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

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