FACTS ABOUT A SPECIFIC PHYSIOTHERAPY FOR PROSTATITIS:
A KEY TO RECOVERY

WHAT WE HAVE LEARNED IN THE PAST 18 YEARS IN THE WISE-ANDERSON PROTOCOL

SUMMARY

The Wise-Anderson Protocol, first developed at Stanford University in the Department of Urology, has been the pioneer protocol in treating symptoms of men diagnosed with pelvic pain caused by spastic pelvic muscles. Understanding that the distressing symptoms of what continues to be called chronic prostatitis, prostatodynia, chronic pelvic pain syndrome, interstitial cystitis, may not be the result of infection or inflammation of organs, has been a major turning point in the treatment of the debilitating problem of prostatitis in the past almost 2 decades.  Most importantly, it has enabled a large majority of both men diagnosed with prostatitis to be able to significantly reduce or resolve their pain and symptoms.  In this article, we review the importance of using a researched protocol whose success has been documented in published studies for men who have been diagnosed with prostatitis.

Recognizing the diagnosis of prostatitis as a muscle dysfunction and not a prostate problem

Most men diagnosed with prostatitis do not immediately understand that for most cases, what is diagnosed as pelvic pain is a problem of the muscles of the pelvis and not a problem of the prostate glandPut simply,  a growing body of  research continues to confirm that  the cause of the symptoms in a large majority of men diagnosed with prostatitis is not an infected or inflamed prostate gland, but rather muscles of the pelvic floor that have gone into a kind of spasm.  Symptoms include urinary frequency and urgency, increased discomfort with sitting, discomfort during or hours after ejaculation, discomfort in the penis, testicles, perineum or anus, discomfort or relief after a bowel movement. The chronic muscle contraction in the pelvic muscles, typically diagnosed as pelvic pain, can bring about the formation of trigger points or tight, painful bands of muscles inside the pelvis that can refer pain to the genitals, testicles, perineum, groin or inner thighs, and can make it very uncomfortable to sit down. One essential method for this condition is a specific physiotherapy to release the tension of the muscles of the pelvis.

Key differences in physiotherapy for men diagnosed pelvic pain

Even doctors who understand the central role of the muscle tension in the pelvis as the central problem in most diagnoses of prostatitis, and understand the need for pelvic floor physiotherapy, often do not appear to understand the critical differences in techniques for releasing the pelvic muscles of its constrictions.  In this article, we want to clarify the new muscle-releasing treatment for men diagnosed with prostatitis (more properly now called urologic chronic pelvic pain syndrome) that we  developed in our early work at Stanford and now teach to our patients.  Here we explain what is diagnosed as pelvic pain as a muscle dysfunction.  We discuss the methods of myofascial release, trigger point release, physiotherapy self-treatment, the physical and psychological impact of patient self-treatment and the use of our Internal Trigger Point Wand for treating symptoms of what is diagnosed as pelvic pain, among other subjects.

NOTE: Please see end of this essay about the definition of prostatitis

USING A PROTOCOL FOR TREATING PROSTATITIS AND UROLOGIC PELVIC PAIN SYNDROME

The Wise-Anderson Protocol

Webster’s Medical Dictionary defines protocol as: “A detailed plan of a scientific or medical experiment, treatment, or procedure.”  Said in another way, a medical protocol is series steps that practitioners or patients follow that has proven to help patients with the same condition.

The Wise-Anderson Protocol (popularly called the Stanford Protocol), began to be used with patients with pelvic pain at Stanford University in the Department of Urology 18 years ago.  Since that time a number of  studies on a 6 day immersion clinic using this protocol  have been published in the Journal of Urology.  This protocol has been described in detail in the popular book,  A Headache in the Pelvis, now in its 6th edition.

Importance of Medical Protocols

  • REASONS FOR PROTOCOLS:  There is an important reason why there are medical protocols for dealing with infection, cancer, heart disease and many other medical conditions.
  • PROTOCOLS CAN BE EVALUATED AND IMPROVED:  As a protocol is uniformly administered to many patients and more information is collected about what works and what does not, medical protocols can be improved.
  • WITHOUT A PROTOCOL, ONE IS RELIANT ON WHATEVER THE DEGREE OF TRAINING AND SKILL OF A PARTICULAR  PRACTITIONER:  Without evaluated treatment protocols, treatment of a particular condition can only rely  on the skill, tools, training and experience of a particular practitioner.  
  • WITHOUT A PROTOCOL THAT HAS BEEN RESEARCHED, PATIENTS THERE IS LITTLE OBJECTIVE EVIDENCE ABOUT RESULTS OF A CERTAIN KIND OF TREATMENT: Without evaluated treatment protocols, the methods and results of the individual practitioners, who use their own regimens, are not subject to evaluation.
  • WITHOUT A PROTOCOL, THERE IS LITTLE OBJECTIVE EVIDENCE TO BASE A DECISION ABOUT TREATMENT:  Without following a protocol and documenting the results from it, the patient has little basis to evaluate it.
  • THE GOLD STANDARD EVALUATING A MEDICAL TREATMENT PROTOCOL IS A DOUBLE BLINDED PLACEBO-CONTROLLED INVESTIGATION.

When treatment for prostatitis/pelvic pain for instance is left up to the individual practitioner and an unevaluated treatment is used, the following typically occurs:

Doctors and other practitioners can diagnose and treat the same condition very differently with little or no evidence of efficacy

One doctor or therapist prescribes one course of treatment, while another doctor or therapist might prescribe a different course of treatment for the same problem.  The variety of treatments we have observed and heard that physicians and therapists use to treat men diagnosed with prostatitis/urologic chronic pelvic pain syndrome include: 

  • antibiotics, anti-inflammatory drugs, alpha blockers
  • pain medications including drugs that focus on nerves, striated and smooth muscle
  • narcotic pain medication
  • trans urethral resection of the prostate
  •  injection of the prostate with various drugs and antibiotics
  • Prostatectomy
  • pudendal nerve entrapment surgery
  • surgical removal of testicles
  • sphincterotomy (cutting the anal sphincter)
  • cutting of the psoas muscle
  • botox injections internally and externally
  • pelvic muscle alignment,
  • leg length correction,
  • core strengthening exercises
  • stretches
  • kegel exercises
  • electrical stimulation,
  • avoidance of gluten containing foods
  • botox injections
  • vitamins and minerals
  • biofeedback
  • Thiele massage
  • chiropractic adjustment
  • adjusting the bones of the cranium and sacrum.  

Symptoms, prior surgeries, treatments and of our patients

Below are the symptoms that our patients reported at the time we saw them, and below we list the  details of the different failed treatments that our patients have reported to us that they underwent.  These are patients whom we examined and in whom which we found painful trigger points and areas of myofascial restriction associated with their pain.  Trigger points and myofascial pain associated with symptoms are major criteria we use in determining that a patient has symptoms that may be helped by our protocol.

Symptoms of our patients typically diagnosed with prostatitis

  • Discomfort/aching/pain in the rectum (often described as a “golf ball” in the rectum)
  • Discomfort/pain/symptoms triggered or exaggerated by sitting
  • Pain or discomfort during or after sexual activity
  • Reduced libido (reduced interest in sex)
  • Anxiety about sexual activity
  • Urinary frequency (more than every two hours)
  • Urinary urgency (hard to hold urination once urge occurs)
  • Discomfort/pain in the genitals
  • Ache/pain/sensitivity of testicles
  • Suprapubic discomfort or pain (above the pubic bone)
  • Perineal discomfort or pain (between the scrotum and anus or vagina and anus)
  • Coccygeal (tailbone pain or discomfort)
  • Low back discomfort or pain (on one side or both)
  • Groin discomfort or pain (on one side or both)
  • Dysuria (pain or burning during or after urination)
  • Nocturia (frequent urination at night)
  • Reduced urinary stream
  • Sense of incomplete urinating
  • Hesitancy before or during urination
  • Discomfort or relief after a bowel movement
  • Anxiety especially in the early morning
  • Depression, catastrophic thinking that the condition will never go away
  • Social withdrawal and impairment of intimate relations
  • Impairment of self-esteem 

Prior failed surgeries, procedures, medications and treatments used by our patients before coming to see us

Other procedures/treatments patients underwent prior to coming to treatment with the W-A Protocol

 (click here to read our scientific publications)

 The various physiotherapy methods used for men typically diagnosed with prostatitis are not all the same

Trigger point release is one key physiotherapy method, among other methods, we use to treat men with trigger points who were diagnosed with pelvic pain.  From early on in our work in the Department of Urology at Stanford University, we have been struck by the large differences in physiotherapy treatment methods undertaken for pelvic pain in patients who have come to see us.  When men diagnosed with  prostatitis in whom we found trigger points described the physiotherapy they went through prior to coming to us for treatment, they variously reported that many of the key pelvic pain-related trigger points that we found were not identified or treated.  Many told us that their therapy consisted of stretching, biofeedback, kegel exercises or unremarkable massage inside the pelvic floor, methods we mostly do not endorse.  While many patients reported that their physiotherapy involved internal treatment, some patients said that the physical therapist they saw did not work internally.  Most patients reported that very little time or instruction was given in self-treatment.

Many doctors and patients have little understanding of the different physiotherapy methods now used for what is often diagnosed as prostatitis/urologic chronic pelvic pain syndrome

Over the years we have paid very close attention to what has helped our patients and what has not.  We have noticed that both our patients and most of their doctors tend to see all physiotherapy for pelvic pain as all the same. This is not our experience.  Trigger point release and other physiotherapy methods for pelvic pain vary widely.  Effective trigger point release inside and outside the pelvis can make the difference between someone remaining in pain or coming out of pain, yet all physiotherapy methods for urologic pelvic pain syndrome tend to be lumped into one category by both doctors and patients.  This is particularly unfortunate when it leads a patient with trigger points diagnosed with pelvic pain to give up on physiotherapy because one method failed, whereas that patient may have been greatly helped by another method.

Men diagnosed with prostatitis/urologic chronic pelvic pain syndrome can give up looking for help from physical methods when a particular physiotherapy method does not help them. In fact one method may help where another one did not.

Many men diagnosed with prostatitis who have trigger points often give up pursuing trigger point release and physiotherapy to treat their pelvic pain symptoms when a particular physiotherapy method did not help them. It is important for these men to know that not all physiotherapy methods are effective for muscle-based pelvic pain.  A certain methodology of doing pelvic floor physiotherapy in fact may be a turning point in someone getting better.  Because one experience with a certain kind of physiotherapy for pelvic pain did not help someone does not necessarily mean that another form will not.  

We were surprised to find that in reviewing consecutive patients with pelvic floor pain whom we have treated in the last four years, many of whom were diagnosed with prostatitis, almost one quarter of them (97 patients) had undergone previous physiotherapy.  We found that between those who had physiotherapy and those who had no physiotherapy prior to coming to see us, there was no difference in the baseline scores of symptoms or trigger point tenderness.  Of those who did our protocol for six months, the degree of improvement of those who had physiotherapy prior to coming to us was the same as the improvement of those who had no physiotherapy. 

In accounting for these findings, it may well be the case that patients who came to see us having had prior physiotherapy that did not help them simply were a group that could not be helped by any pelvic floor physiotherapy, while those who did not come to see us did well in the physiotherapy they undertook.  Whatever the reason, our patients represent a group who were not helped by prior physiotherapy, then were trained in and self administered the physiotherapy protocol we recommend and most experienced significant improvement in their symptoms.

At the beginning of our treatment, patients had prior physiotherapy were no better off than patients who had no physiotherapy

chart3.pngPrior physiotherapy in patients we have seen did not reduce Trigger Point Sensitivity measured at the beginning 

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There are a number of methods that are commonly used to treat men diagnosed with pelvic pain

While there are a variety of physical methods used to treat pelvic pain, we have found that a specific protocol for physiotherapy is most effective in treating patients who come to see us.  The large category into which physiotherapy methods for pelvic pain fit is soft tissue mobilization in which the soft tissue (as opposed to bony tissue) is massaged, stretched and compressed in various ways to lengthen the muscle fibers, releasing constricted connective tissue and releasing trigger points in order to relieve pain and dysfunction.  Major soft tissue mobilization methods include:

  • Trigger point release developed by Dr. Janet Travell
  • Rolfing developed by Ida Rolf
  • Thiele massage developed by George Thiele, a colorectal surgeon in the 1930’s-1960’s who treated coccygodynia or tailbone pain by massaging certain muscles of the pelvic floor along the length of their fibers
  • Bindegewebsmassage/skin rolling/connective tissue manipulation developed by Elizabeth Dicke
  • Shiatsu (Japanese acupuncture point massage)
  • Swedish massage (massage of superficial musculature used by many massage therapists)
  • Reflexology (massage of acupuncture points in the feet)
  • Craniosacral massage developed by William Sutherland, Upledger et. al.
  • Myofascial release (Thiele, Rolf, Barnes)

Skin rolling and connective tissue manipulation is a myofascial release method widely used in the treatment of muscle-based pelvic pain

skinrolling.png(From A Headache in the Pelvis, 6th edition)

Myofascial release becomes necessary when fascia becomes problematic and tightens, constricts and squeezes the tissue which it surrounds

Fascia is generally thought of as a sheathing or band of fibrous connective tissue forming a framework and support structure of the body tissues, enveloping, separating, or binding together muscles, organs, and other soft structures of the body.  It can be thought of as a fibrous sheath surrounding muscles and muscle fiber.

Fascia becomes a problem and a source of pain and dysfunction when it pressures, constricts, tightens, chokes and squeezes the tissue it connects.  Myofascial release involves the sustained pressure to loosen connective tissue or fascia that has tightened and caused pain particularly around muscle tissue.  Skin rolling, deep tissue massage, Rolfing, Thiele massage, connective tissue manipulation are among the more well known forms of myofascial release methods.

In the Wise-Anderson Protocol, we have found that myofascial release without trigger point release is not adequate when a patient has pelvic pain referring trigger points

Most soft tissue mobilization used in physiotherapy for muscle-based pelvic pain is called myofascial release or myofascial trigger point release.  Men whom we have seen who have been diagnosed with pelvic pain also have pelvic floor-related trigger points.  We have found that myofascial release methods like skin rolling and other myofascial release methods are necessary but not sufficient for patients with specific pelvic pain referring trigger points.  Trigger points must be identified and worked with patients over time to help resolve muscle-based pain.  The methods of pressure release, strumming, stroking and contract/relax on trigger points are particularly important techniques in doing trigger point release.

Other aspects of trigger point release for muscle-based symptoms diagnosed as pelvic pain are important.  It is essential to understand that trigger points can exist in the insertion as well as deep or superficially in the belly of the muscle.  Using the correct range of pressure and holding the trigger points for a certain period of time are all necessary to do effective treatment.  Also, the stretching of a muscle should not be done when the trigger point is in the insertion of the muscle. Finally, teaching men to repetitively do their own trigger point release and myofascial release has been a major component in significantly helping men we have seen who have been diagnosed with pelvic pain.

A therapy emphasizing trigger point release has the best results with our patients diagnosed with prostatitis

The methodology we recommend in our protocol adheres closely to the methodology introduced to medicine by Dr. Janet Travell.  In their medical texts on myofascial pain and trigger point release, Dr. Travell and Dr. David Simons discuss how anyone doing trigger point evaluation or treatment must be both experienced and trained in the correct method of trigger point evaluation and treatment.  In their medical text, Myofascial Pain and Dysfunction, they state (p. 31): “Clearly, a clinical or experimental research study of human myofascial trigger points, to obtain the most meaningful results, should employ both experienced and trained examiners (my emphasis) who have been tested for inter-rater reliability before the study is conducted.  The necessary skill can be learned.”  At Stanford, with the recommendation of Dr. Simons, we invited Tim Sawyer PT to join us.  He was specifically trained in trigger point therapy in the mid-1980s by Dr. Travell and Dr. Simons.

Travell and Simons reported that when experienced physicians examined the same patients, they found that unless the physicians were trained in the correct method, their findings did not agree with each other.  This was perplexing because these physicians had significant experience in treating patients with myofascial pain, and one would assume that they all were doing and looking for the same things.  When these trained physicians underwent a three-hour training in the correct method of trigger point identification, they all found the same trigger points and their inter-rater reliability significantly improved. 

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Textbooks on trigger point release authored by Janet Travell, MD and David Simons, MD

Doing Trigger Point release requires training and experience

The challenge of doing trigger point release is generally not understood, especially for treating pelvic pain.  Here are some of the requirements:

  1. You first have to be able to find the trigger points.  If you don’t find them, you can’t release them.  If you can’t find them, you can’t teach your patient how to find them and release them themselves. 
  2. Finding trigger points on the outside of the body is not easy and requires study of the trigger point locations and their relationship to someone’s symptoms.  Being able to locate trigger points and properly release them requires experience and training. Trigger point education is generally not taught in medical school and often not taught in any detail even in current physiotherapy curricula.  While this is slowly changing, trigger point treatment on the outside of the body is a whole field of specialization that often requires years to master. 
  3. Trigger points, as we discuss elsewhere in this essay, are not easy to find.  It is necessary to have to have a finger that is sensitive and can feel the trigger point among other adjacent tissue.  In doing trigger point release inside the pelvic floor for someone with pelvic pain, it is necessary to find the trigger point in and around the pelvic floor inside the anus or vagina of someone who is usually in pain. 
  4. One must know how hard to press on the point while reassuring the patient to tolerate the discomfort of the pressure on the trigger point.  They need to understand that trigger points release gradually and can come back with stress.  They should understand that trigger points must be repetitively treated.  The therapist who is experienced in trigger point release as well as in internal trigger point release is a treasure.      

A New Study on Targeted physiotherapy self-treatment for Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) for women

We were heartened to see that in the April 2012 Journal of Urology, a new multi-center study about the use of physiotherapy for the distressing chronic pelvic pain syndrome of interstitial cystitis/painful bladder syndrome recently came out.  This study shows the effectiveness of targeted internal and external physiotherapy on Interstitial Cystitis/Painful Bladder Syndrome.  In conclusion the authors state:

Fifty-nine percent who received myofascial physiotherapy reported a moderate or marked improvement according to global response assessment at 12 weeks compared to 26% in the massage group (p=0.0012).  Only 18% of patients receiving myofascial physiotherapy reported no improvement, whereas 43% of patients reported no improvement with massage.

One of the authors states:  "The physical therapists who participated (in the study) were experienced and had undergone training in the past to learn how to do this kind of therapy well," said Dr. Clemens. "It remains to be seen if the therapy works as well if it's administered by a group that isn't as experienced" (our emphasis).

The targeted physiotherapy of the new study involved  “the physical therapist's use of hands and fingers to target specific muscles and tissues located within your pelvis, rectum, and/or vagina (the pelvic floor) as well as muscles and layers of tissue in your abdomen and legs….. Targeted internal and external Connective Tissue Manipulation focusing on the muscles and connective tissues of the pelvic floor, hip girdle, and abdomen.”

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The Wise-Anderson Protocol and targeted internal physiotherapy for muscle-based pelvic pain, often diagnosed as prostatitis

We can discuss our protocol using the language of the new above study that has come out in terms of our physiotherapy also being targeted physiotherapy.  We published a study in 2009 in the Journal of Urology identifying specific locations of trigger points related to pelvic pain and dysfunction in men with pelvic pain (click here to read article).  We discovered throughout our work with pelvic pain that targeted physiotherapy identifying both restricted connective tissue and trigger points within the muscles is central for reducing pelvic pain and dysfunction in the vast majority of our patients who have trigger points.  The targeted physiotherapy we have used for years (and have published about in various research articles) identifies specific pelvic trigger points and areas of myofascial restriction, and stresses the importance of palpating these areas with a certain range of pressure and for a certain duration until they resolve.

The Journal of Urology 2009
Painful Myofascial Trigger Points and Pain Sites in Men with
Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Anderson RU, Sawyer T, Wise, D Morey A. Nathanson BH
Department of Urology, School of Medicine, Stanford University, Stanford, California

(Click here to read article)

Physiotherapy of the Wise-Anderson Protocol involves both trigger point release and myofascial release

The targeted physiotherapy methodology in the Wise-Anderson Protocol, involving both connective tissue restriction and pain referring trigger points in muscle, has been essential in helping our patients.  Our focus is primarily on trigger point release as well as the release of connective tissue restriction.  The most effective pelvic pain relief comes from a combination of trigger point release and myofascial release.  While trigger point release a form of myofascial release, it is a very specific in terms of where to palpate and many of our patients who have had physiotherapy have come with untreated trigger points that were essential to their pain.  In the Wise-Anderson Protocol physiotherapy, we are clear that effective treatment must focus primarily on the identification and release of trigger points that recreate someone’s symptoms when palpated, the myofascial release of relevant muscles, and the identification of any perpetuating factors that may keep the trigger points active.  Travell and Simons wrote about perpetuating factors in their textbooks. 

What does it mean to release a trigger point?

Releasing a trigger point means locating it, and pressing it, stretching it or using other methods to release the trigger point so that it is no longer painful and no longer refers pain or symptoms.  Releasing trigger points is not a small feat when trigger points are inside the pelvic floor, and have been there for years.  The challenge of internal trigger point release is also heightened because the internal trigger points must be accessed either vaginally or rectally.  The trigger point is the source of the pain and releasing it resolves the referral of the pain to the area where the pain is felt.  It is most effective to do connective tissue manipulation along with trigger point release.  If we draw an analogy to a car, we consider trigger point release three wheels of a car and connective tissue manipulation to be one of the wheels.  All are necessary. 

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Locating and treating all internal and external trigger points and areas of myofascial restriction is essential

At this time in history, there is no medical technology that is able to locate the internal trigger points responsible for pelvic pain and dysfunction.  Locating and successfully releasing internal trigger points must come from experience, knowledge, training and an educated and sensitive finger that has palpated many trigger points in the pelvic floors of those with pelvic pain.  It also takes a certain kind of person to be able and willing to do this kind of treatment and such individuals are uncommon.  These requirements often make it difficult to find a physical therapist who does internal trigger point release.  This is one of the reasons why we so strongly believe in training patients to do their own internal trigger point release.

Principles of our physiotherapy protocol

Teaching our patients to clear pelvis of pain referring trigger points and areas of myofascial restriction is a central focus of both our physical and psychological treatment

Over the years we have concluded that trigger points must be identified and released in the pelvis for someone diagnosed with pelvic pain/chronic pelvic pain to get better.  Here are details of what we have learned:

  1. There are many potential trigger points found inside and outside the pelvic floor.  We have illustrated them and discussed them at length in A Headache in the Pelvis.  Without the identification and release of trigger points that refer pain and recreate symptoms upon palpation, patient symptoms tend not to improve.  
  2. Relevant trigger points typically do not release in one visit.  They must be repetitively released typically over an extended period of time.  Even when trigger points fade into the background and are not tender and do not refer symptoms, the trigger points can re-emerge in periods of stress and must be re-released.  In our long-term strategy of helping our patients with pelvic pain, we have come to see that these trigger points are best released by the patient him/herself. 
  3. When first treated, these trigger points can be exquisitely tender and produce all of the characteristics of trigger points (jump response, twitch response, referral of pain, exquisite tenderness, pain mitigating upon sustained or ‘strumming’ palpation).  When patients come to see us, we make a comprehensive map of our patients’ trigger points on the first day we see them and give it to them at the end of our treatment so that they can locate them when doing self treatment.
  4. We instruct our patients to use pressure on the trigger point within a range of no less or more than 3-7 on a 0-10 scale of pain.
  5. When someone learns how to do internal and external trigger point release themselves, they inevitably flare themselves up.  We believe it is important to educate patients about the common phenomenon of flare-up of symptoms coming both from self-treatment and from the natural course of the condition.  Flare-ups need to be constructively worked with and learned from.  It is important to address catastrophic thinking often triggered by flare-ups to help our patients manage flare-ups without the catastrophic thinking anxiety that usually attends such flare-ups.
  6. Pressure release, strumming, stroking, skin rolling, stretching are all a part of our comprehensive program aimed at freeing the pelvis of pain.  These are methods in which patients are taught and supervised on.
  7. We typically suggest that our patients do internal trigger point release 2-4 times per week, usually for many months after we carefully instruct them.  Patients are encouraged to do external trigger point work in the gluteal muscles, adductors, abdominals and quadratus lumborum. These muscles must be released of trigger points and stretched daily for many months.
  8. Our goal in our clinic is to teach our patients to self-administer all aspects of their physiotherapy treatment so they become able to repetitively do all physiotherapy treatment on themselves internally and externally, and no longer have to rely on professional help.
  9. The relationship of trigger points to each other must be understood.  For instance, gluteal trigger point release is often critical in releasing coccygeal trigger points internally.  One can work on the internal trigger points and if the external ones remain active, symptoms tend to persist.
  10. Perpetuating factors are factors that interfere with the release of trigger points and myofascial restriction.  Mechanical perpetuating factors must also be treated when relevant.  The most common and difficult factor that perpetuates the maintenance of painful trigger points is anxiety and an aroused nervous system.
  11. We do not believe that injecting trigger points, especially inside the pelvis, is a helpful method. We occasionally refer someone with very stubborn trigger points for ‘dry needling’ of the trigger points in which the doctor ‘peppers’ the area of a trigger point by inserting  a very thin needle (like an acupuncture needle) superficially in the area of a trigger point over and over again.    Most trigger points, however can be released manually through persistent self-treatment.
  12. Biofeedback for pelvic pain, in which a sensor is inserted vaginally or rectally, and kegel exercises are done by contracting the pelvic muscles and then relaxing the pelvic muscles in ten second intervals is of little help for myofascial pelvic pain.  Biofeedback was originally introduced to treat women with vulvar pain.  There is little evidence that biofeedback helps men diagnosed with pelvic pain.

You can press on a section of tissue 1/2” from a trigger point and miss the trigger point

Trigger points as well as areas of myofascial restriction are specific and can be easily missed – if one misses locating specific pain referring trigger points/myofascially restricted tissue or does not deactivate them properly, and they remain active, the pain and symptoms associated with them typically will not resolve.  Finding trigger points comes with experience and can be taught to patients.

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In other words, it is not helpful to guess where to press inside the pelvis and expect a therapeutic result.  We appreciate the authors of the April 12 Journal of Urology article understanding the skill required by the physical therapist in implementing this kind of targeted physiotherapy of fascial restriction.

triggerpoint.jpg triggerpoint2.jpg triggerpoint3.jpg

 

It is not well known that the sensation of trigger points changes as treatment progresses in men diagnosed with prostatitis/chronic pelvic pain syndrome

Understanding the progression of the sensation of an active trigger point release from the sensation when initially palpated to the time when, often months later, it is no longer sensitive when palpated, is essential, especially when doing self-treatment.  If you think that the trigger point or myofascial restriction will feel the same each time you palpate it rather than changing as it is worked with, you can become confused as to where to focus and how to treat the tissue.  The trigger point can feel exquisitely tender when first palpated and then the sensation of it can morph into a sore, tender sensation that typically diminishes and resolves with proper treatment.

Hyperirritable trigger points must be treated with extra care

Understanding how to treat trigger points that are hyperirritable and flare-up with the slightest palpation is central to the successful resolution of muscle-based pelvic pain in many individuals.  Teaching patients to do internal trigger point release and myofascial release, unless internal trigger points are found at the opening of the pelvic floor, requires a device to be able to reach and release trigger points not otherwise accessible.  Our Internal Trigger Point Wand is a focus in training our patients in self-treatment.

The central importance of self-treatment: men can do internal and external physiotherapy at home with the Internal Trigger Point Wand

We consider the most important factor in our physiotherapy protocol is teaching patients the lifelong skill of doing all internal and external physiotherapy on themselves so that they can treat themselves with the number of treatments sufficient to help calm down the constriction and pain in the pelvis. 

Pelvic floor trigger points tend to be reactivated under stress

Pelvic floor pain and dysfunction tends to recur under stress in someone's life.  In our clinical experience, patients who have developed experience in successfully treating themselves tend not to fall into despair at the occurrence of symptom flare-ups.  The ability to reduce or resolve the flare-ups that typically occur with chronic pelvic pain syndrome empowers patients who formerly felt helpless in the face of their pain. 

Giving patients this ability is a huge psychological and therapeutic boon especially when someone’s symptoms with pelvic pain flare-up.  When someone knows how to calm down his or her own flare-up, the problem of pelvic pain can become a minor problem that can be well dealt with.  Our goal is to free our patients from dependency on others and empower them to take care of themselves.  For this purpose we have designed and developed the Internal Trigger Point Wand that we train patients to use in an ongoing clinical trial. 

Instructing patients in the use of the Internal Trigger Point Wand

We published a paper in 2011 in the Clinical Journal of Pain (click here to view the abstract) showing how training patients in the use of the Internal Trigger Point Wand allowed patients who used the Wand for six months to significantly reduce the tenderness of their internal trigger points and fascially restricted tissue.  This reduction in trigger point sensitivity after six months was correlated to a dramatic reduction in total symptoms and emotional distress in our patients.

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Internal Trigger Point Wand
(click here to read about the Internal Trigger Point Wand)

Advantages of self-administered physiotherapy self treatment for what is often diagnosed as prostatitis but now is called urologic chronic pelvic pain syndromes, using the Wand

Our patients diagnosed with pelvic pain/chronic pelvic pain syndrome learn to self-administer a standardized physiotherapy protocol

A major advantage to patients using our Wand is that they are taught a specific, standardized physiotherapy protocol that has been shaped and honed over the years with many patients.  Patients then become their own therapists.  The aim of our instruction is to allow patients to deactivate all internal trigger points and areas of myofascial restriction responsible for pelvic pain in the pelvic floor.  Our goal is to help our patients do self-treatment so they no longer have painful areas in the pelvis.  Our data of trigger point sensitivity, pain, emotional distress, total symptoms all point in the direction of the efficacy of such targeted physiotherapy self-treatment.

The Internal Trigger Point Wand has not been cleared by FDA.  Patients who come to our clinic may participate in a clinic trial in which they can be given the Wand and instructed in its use.

Reduction in the use of drugs for pelvic pain associated with using the Wand

One of the unanticipated results we observed in those using the Internal Trigger Point Wand over a period of 6 months was a significant reduction in those using medications for their symptoms.

Reduction in medication use over time after doing the Wand for 6 months

63.64% of patients were using at least one drug before enrolling in our protocol.

39.71%  of patients were using at least one drug after 6 months of self-treatment using our protocol.

Self-treatment makes frequent physiotherapy treatments possible financially and logistically

Patients describe the stress of how, before coming to see us, they often had to travel (sometimes for hours) to seek pelvic pain physiotherapy and how having to get back in the car and sit uncomfortably for long periods of time, often undid the gains made in physiotherapy.  Other patients have described the disruption to their productivity at work and negative impacts on relationships with co-workers.

One of the clear advantages of a patient doing physiotherapy at home is that after self-treatment, the softened, lengthened tissue in their pelvic floor muscles could be rested and the tissue could have a good period of time to be disengaged.  We believe this period of time of resting after physiotherapy self-treatment is very important in the reversing the tissue memory and central sensitization to normalize.  In our clinics where we train our patients in self-treatment, we advise our patients to do our relaxation protocol after every physiotherapy self-treatment session. 

The range of cost of the average physiotherapy visit ranges from approximately $100-$250+.  Being trained to do internal physiotherapy self treatment, especially given the fact that pelvic pain tends to flare up at time of stress, makes being able to do your own physiotherapy in the comfort of your own home may make effective treatment  possible financially for many men who cannot afford  physiotherapy treatment.

Self-administered targeted internal trigger point release can be done consistently over an extended period of time

In the latest review of our data, we noticed that our patients were able to have a far greater number of internal treatments through self-administration than those who had received conventional physiotherapy before coming to see us.  Our data shows that the longer the patients used the Wand over time (six months vs. one month), the greater their improvement in reduction of trigger point sensitivity, emotional distress and total symptoms.   

The Wand Allowed Patients to do Internal Physiotherapy(PT) More Frequently

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Patients can allow their treated pelvic muscles to rest after internal trigger point self-treatment

Self-treatment of internal and external trigger points and areas of restriction allows patients to be able to rest the lengthened tissue after a treatment instead of having to re-engage in life and immediately subject the pelvic floor related tissue to the stresses of life.  The ability to rest the tissue and do Paradoxical Relaxation after physiotherapy self-treatment, in our view, helps to facilitate the tissue’s getting used to being a normal length and tone.  Not having to engage the tissue after treatment, in our view is a boon to healing a sore pelvis.

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The empowerment of self-treatment cannot be overstated: the psychological impact

Over the years it has become clear to us that the deepest suffering of our patients is the helplessness they feel in relationship to their chronic pain.  This helplessness is the breeding ground of catastrophic thinking and nervous system arousal connected to their condition, which actually makes the symptoms worse and forms the self-feeding cycle of tension-anxiety-pain-protective guarding.  We have been unimpressed with the use of traditional psychological methods to deal with the suffering of pelvic pain when they are not connected to actually empowering patients to reduce their own physical symptoms themselves.

The best remedy for the anxiety, depression and catastrophic thinking related to pelvic pain/chronic pelvic pain syndrome is to empower the patient to reduce or stop his own physical symptoms

Men diagnosed with muscle-based pelvic pain typically deal with the greatly distressing negative and catastrophic thought that they will always be in pain and that they have no control over their condition.  When a patient who is in pain can do a self-treatment session in which they are able to reduce or stop pain, it can meaningfully reduce or stop catastrophic thinking and depression related to their condition.  In the review of reports from our patients over the last four years, we have found that emotional distress reduces as physical symptoms reduce.  Empowering patients to help themselves to reduce their physical symptoms and to become free of dependency on others is akin to teaching someone how to fish instead of giving someone a fish.  Giving our patients the tools to reduce or stop their own pain is the most powerful intervention we can offer them.

 

NOTE: The term prostatitis in this essay refers to prostatitis as a muscle based problem requiring physiotherapy and relaxation training.

  • While the term prostatitis refers to an inflammation/infection in the prostate gland, the facts in many studies and the most credible research have found that only a fraction of men diagnosed with prostatitis have an infection/inflammation of the prostate that accounts for their symptoms.
  • Chronic nonbacterial prostatitis/CPPS accounts for 90%-95% of cases of  men diagnosed with prostatitis and has not been scientifically demonstrated to be primarily either a disease of the prostate or the result of an inflammatory process In our experience over the last 18 years of treating this problem, we have observed from our patient reports that most physicians give antibiotics without demonstrating infection in the prostate gland.
  • What is commonly diagnosed as called prostatitis is also  called prostatodynia, non bacterial prostatitis, abacterial prostatitis, urologic chronic pelvic pain syndrome, chronic pelvic pain syndrome, pelvic floor dysfunction, levator ani syndrome and none of these categories refer to inflammation or infection in the prostate gland as the cause of their distressing and debilitating symptoms
  • In this essay, when we refer to prostatitis, we do not refer to a condition in which inflammation or infection of the prostate (which is a tiny fraction of the cases given the diagnosis) is the cause of symptoms. 

In this essay we use the term prostatitis to refer to symptoms including many but not all of the following: chronic or intermittent penile, testicular, anal or lower abdominal pain, urinary frequency urgency, pain with orgasm, pain or relief with bowel movements, pain or discomfort with sitting,  and other symptoms that doctors typically diagnose in men as prostatitis and routinely given antibiotics that fail to relieve symptoms. We list these symptoms in detail in this essay.  In our extensive clinical experience most of these men have demonstrable trigger points and areas of myofascial restriction in the muscles of the pelvic floor that recreate symptoms when palpated and relieve symptoms when trigger points and myofascial restriction are resolved.