Internal Trigger Point Wand
A central part of our program, has recently been FDA Approved.
Internal Trigger Point WandSince we began the Wise-Anderson Protocol at Stanford University Medical Center in the department of Urology in the mid 1990’s, we recognized the need for a special device to do internal trigger point release self-treatment for those with muscle based pelvic pain. Hundreds of patients in our clinic have used an Internal Trigger Point Wand (Wand) that we designed and the Wand has recently received FDA approval.
Our Internal Trigger Point Wand is the first scientifically designed device for internal myofascial/trigger point release that has been in a clinical trial, whose results have been published by a peer-reviewed journal and presented in scientific meetings. In our study published in 2011 in the Clinical Journal of Pain, after 6 months the median reduction in sensitivity/pain of trigger points after 6 months of self-treatment reported by patients with pelvic pain moved from 7.5 to 4 on a 1-10 scale. This is a remarkable result. In our experience, we have observed that there is a continual drop in trigger point sensitivity/pain beyond 6 months.
We have presented the Wand at the International Continence Society in San Francisco, in 2009, at the American Physical Therapy Association Meetings in New Orleans in 2011 and the results of our Wand study were presented at the American Urological Association meetings in Washington in May, 2011. The abstract on our Internal Trigger Point Wand won an award at the American Urological Association meetings, was presented to the public in a press conference sponsored by the AUA and was nominated for presentation in the AUA meetings in Tokyo.
The Internal Trigger Point Wand has recently been approved by the FDA. The Wand and the required training for its use is available in our 6 day immersion clinic.
When we first began seeing patients from out of town at Stanford University Medical Center, like other practitioners, we thought conventionally about treatment of pelvic pain. Patients came to us for treatment and the participation of the patient in the essential internal trigger point release part of our program, aside from the relaxation protocol, in large part was passive. We referred our local patients to physiotherapists for weekly or bi weekly internal trigger point treatment and the physiotherapists would do physiotherapy on them. We found some therapists seemed to be of little help and a very few seemed to have excellent results. At this time we saw that we got the best results from patients seeing Tim Sawyer who is now our senior physical therapist. We eventually asked Tim to join our team and design a protocol for the physiotherapy part of our protocol. Even back then, although we weren’t sure exactly how to do it, we were considering options for patient internal trigger point self-treatment.
Before the Wand, we attempted to help patients who lived far away to find physiotherapists and coach the physiotherapist in internal trigger point release. When it was possible, we attempted to teach the partners/spouses of our patients how to do internal physiotherapy. This sometimes seemed a better option than referring them to physiotherapy because we could train the partner in exactly how to do the internal trigger point release we found was most effective, because there was no cost in partner administered internal trigger point release and because treatment could be done more frequently and more conveniently. Partner administered internal trigger point release however was not perfect. It tended to be hit or miss as to whether a patient had a partner, not to speak of a willing partner to do pelvic floor physiotherapy on him/her. As important, it was not uncommon for a patient to be very reluctant to have an intimate person do something so bold as internal trigger point release. Finally we could only teach a partner rudimentary skills and the patient and partner were limited by the narrow competence of the partner.
Understanding the rehabilitation of painful pelvic floor muscles.
When we teach our patients to use the Wand, we consider it critical for them to understand the practice of internal trigger point release and internal myofascial release (myofascial release focuses on the general loosening of the constricted fascia or connective tissue where there are no specific trigger points present). If one does not understand what the point of trigger point release is, both internally and externally, and if one is not instructed in the proper method of identifying trigger points and areas of restriction, the frequency of use and the proper pressure to use on them, self-treatment will probably flounder.
The area inside the pelvis is foreign territory to most people. Quite understandably, most people have never put their own finger up inside their anus or vagina as you must to do internal trigger point release. It is not surprising that there can be shame, fear and bewilderment about doing what would appear to most people as a very strange thing to do. When our patients begin to feel the pain reduction and relief of symptoms that accompanies this activity when done for the purpose of releasing trigger points and painfully constricted tissue, any feelings of aversion to this activity quickly disappear. Our patients soon realize that the inside of the pelvis is just another part of the body that can hurt and whatever relieves the pain in the pelvis is welcomed as a gift and a blessing.
Bringing an attitude of kindness to internal self-treatment.
Many people with pelvic pain regard and treat their hurting pelvis like a piece of meat that simply pains and offends them. Often they are angry at this part of their body. Acting out any feelings of anger or resentment while doing internal treatment can ultimately make their symptoms worse. Without an understanding that the pelvis wants to heal and not hurt, and without clarity about the proper attitude to have toward the pelvis when doing internal trigger point release with the finger or the Wand, most people who attempt internal trigger point release can unwittingly flare up their symptoms and abandon self treatment.
What helps internal self-treatment.
The phenomenon of muscle based pelvic pain occurs when the tissue of the pelvic floor has been squeezed, hurt and unwittingly abused by the squeezing. Often this squeezing and inadvertent abuse has gone on for thousands of hours over a period of years. Healing this tissue in our view, requires gently and gradually stretching and lengthening and space to heal and normalize.
Helping to heal pelvic tissue takes kindness and gentleness. All attempts at punishing the tissue, pushing it beyond what it is capable of easily accepting will make it afraid of trigger point release, will cause it to hurt more, and is counter-productive. When someone is doing internal trigger point release, as our physiotherapist Tim Sawyer has often said, the tissue should be treated with the care and kindness you would bring to helping to heal a wounded bird. When patients don’t pay attention to their negative or anxious attitude and the way it influences their self-treatment, and flare-ups from self-treatment, they can give up on self-treatment. They don’t understand that their attitude and the accompanying roughness and overzealous contact with their pelvis during self-treatment is primarily the source of their discomfort with self-treatment.
Using sex toys for internal trigger point release.
There has never been an FDA or CE approved device for doing internal trigger point release. It is a common practice for many physical therapists to prescribe sex toys for their patients because they want to give them something to use to help their condition at home. While devices are sometimes prescribed for patients, there is no control over the materials of the devices prescribed, no oversight as to adverse events occurring with them (a colleague of ours had a patient ‘lose’ a acrylic dildo inside the rectum who had to go to an emergency room to have it removed), no instruction in the use of the device or any study as to the effectiveness of the devices.
Safety issues and limitations of sex toys, dildos, dilators and other devices used for internal trigger point release
The anterior trigger points, those most commonly associated with anterior related symptoms like urinary frequency, urgency, hesitancy, genital pain, pain with sex, supra pubic pain etc. are best accessed while the patient is lying on his/her back. The ‘dildo’ shape of sex toys sometimes used for internal trigger point release make it very difficult to reach and properly palpate both anterior and posterior trigger points and raise significant safety issues. In order to exert pressure on a trigger point, sex toys that are used require that someone rotate the hand inward while pushing the top part of the device away from the body. This requires strength in the hand that hands are typically not used to having and any kind of excessive pressure here can cause tissue irritation or flare up of symptoms.
Exerting pressure on the pelvic floor trigger point with this kind of product requires direct pressure rather than using leveraged pressure that the Internal Trigger Point Wand is designed to provide In trying to do trigger point release anorectally, straight shaft or bent shaft requires that someone contort the body sagittally and posteriorly requiring the quadratus lumborum, pectoralis and trapezius to uncharacteristically rotate. This requirement of using direct force that requires an unnatural contortion of the body is often not possible with someone who is overweight or who has a bad back. The requirement that the tip of a sex toy be directed inward toward a trigger point typically will press on tissue that is not trigger pointed. This extraneous and unnecessary pressure can typically dilute the pointed pressure required on the trigger point. It can exert pressure on the opening of anal sphincter or vagina as the sex toy is pressed in different parts of the pelvic floor. In doing so, it can interfere with the sensation of pointed pressure on a trigger point that allows for the release of the trigger point.
The design of the Internal Trigger Point Wand
The Internal Trigger Point Wand’s hook shape came after it became clear that the Wand had to be able to be easily navigated both for anterior trigger points (those at the front of the body) as well as posterior trigger points. The diameter of the hook is carefully designed to be inserted inside the body but clear the outside of the body so it can come far enough outside the body to be able to be easily navigated from the outside without the handle touching the outside of the abdomen or the gluteal muscles.
The diameter of a trigger point device has to be small enough so that it does not create sensation in the opening of the orifice that interferes with the sensation of the tissue upon which the tip is pressing and so we found a material that was strong and of small diameter so as not to interfere with the user feeling the sensation at the tip of the Wand. We had to design a ‘stop’ to safely limit the insertion of the Wand so that it did not get ‘lost’ up inside the pelvic floor. The disadvantages of the use of sex toys and dildos for internal treatment is that the length of the sex toy requires that you insert it deeply inside the pelvic floor. There are reports of the entire sex toy being lost inside the anus or vagina. As we have discussed above, this attempt to reach anterior and superior trigger points can result in the sex toy getting out of the user’s control and being completely inserted inside the pelvis.
As important as the design of the Wand, we had to explore and explain to the user the safe amount of pressure to be used on the internal tissue. We had to carefully explain how to insert and remove the Wand so that it did not flare up the tissue and interfere with the therapeutic effect of the Wand.
One of the biggest challenges in the design of the Wand was finding a way to remotely monitor the relative pressure on the internal tissue so that the user could make determinations of slight increases or decreases in pressure on any particular internal trigger point or area inside the pelvis. For years we discussed using an algometer with some kind of spring at the tip of the device that could give the user feedback as to what degree of relative pressure was being exerted on any particular trigger point. The concept of measuring the relative pressure by the bend in the shaft that was measured by a strain gauge came after 10 years of pondering the design and came as a revelation to us. The design of the wand fed back relative pressure and this pressure was measured remotely. This allowed for us to have no measuring device pressing on internal tissue. Below is an illustration of the Wand.
Figure 1: Detailed Sketch of the Internal Trigger Point Wand
The Internal Trigger Point Wand, consists of a “J” shaped “rod” made of Ultem. The “J” has a “T” handle attached to the long end and a nitrile ball pressure applicator attached to the short end. The curved portion is substantially semi-circular, and is defined by an arc of approximately 180 degrees. A strain gauge is attached to the long portion of the “J”. The strain gauge is connected by a wire to a readout device that displays a reading relative to the amount of relative pressure being exerted at the tip of the Wand. The readout on the device allows the user to see the relative amount of pressure being applied.
The purpose of the Wand is to provide an “extended finger” that is navigated inside the pelvic floor and used to palpate and reduce internal trigger point sensitivity for those suffering from muscle-related pelvic pain. The conventional method of doing internal trigger point release is done by a health care provider inserting a gloved and lubricated finger vaginally or rectally while the user is lying down. The health care provider locates an internal trigger point and then holds pressure on or massages the trigger point for a period of approximately 15-90 seconds. The health care provider does not however have any objective feedback as to the relative pressure exerted on a trigger point or area of internal restriction where the self-treatment with the Wand does afford the user this kind of feedback. This method of myofascial/trigger point release, either done by a health care provider or done with a self administered device is aimed at reducing or resolving the sensitivity of the trigger point and associated areas of muscle pain and restriction.
The Internal Trigger Point Wand is a game changer.
The Wand has proven to be a major event in the effectiveness of our protocol. The Wand has been the last element in allowing our patients to be able to do our protocol without the help of a partner or professional. It is our observation that when people learn how to use the Wand, they are often able to reach and properly palpate their own internal tissue and reduce or stop their pain and symptoms as well or better than any professional. The Wand helps to end the feeling of helplessness that occurs when a symptom arises because the user knows that he or she can release the flared up tissue that he/she formerly could not reach. In this way it is teaching someone to fish rather than simply bringing him/her a fish and in this way it helps to empower our patients and free them from the feeling of helplessness over their condition.