UPDATE: “Pelvic Floor paradox” (original post early 2008)
Since then there has been an enormous amount of additional research, and together with Dr Ruth Jones, I have co-edited/authored the book “Chronic Pelvic Pain & Dysfunction” a textbook for therapists and practitioners (Elsevier 2012).One major shift since then has been the increasing awareness, and research, into male pelvic floor pain. This is often mis-diagnosed as being of prostate origin, when in fact it may derive directly from trigger-point activity in the pelvic floor, and abdominal and pelvic musculature. (Anderson et al 2005)
For example Prendergast & Rummer, writing in Chapter 8.2 of the Chronic pelvic pain book note that:
“Due to the varied symptoms, patients may seek the help of primary care physicians, gynaecologists, urologists, colorectal surgeons, orthopedists, neurologists and/or psychiatrists. It is reported that 85–90% of patients with CPP have musculoskeletal dysfunction that has been identified as either a primary cause of pain and dysfunction or a secondary consequence of vulvodynia, painful bladder syndrome/interstitial cystitis, chronic pelvic pain syndrome/non-bacterial chronic prostatitis, irritable bowel syndrome, pudendal neuralgia and endometriosis (Tu et al. 2006, Butrick 2009).”
Anderson (in Chapter 18 of the pelvic pain book)observes that – having ruled out pathology as a source of CPP:
“Many investigators believe that the source of pain and dysfunction in men and women with CPP, includingchronic testicular pain, relates to chronically tensemyofascial tissue in and around the pelvic floor(Anderson et al. 2005, Berger et al. 2007, Plankenet al. 2010).
In simple and broad terms we candescribe the neuromuscular disorder as pelvic myoneuropathy.
Traditionally, the diagnosis of urologic chronic pelvic painsyndromes (UCPPS)depends upon a descriptive symptom complex.
However, it is now clear that UCPPS is multifacetedand not all patients have the same constellation
of symptoms, or respond in the same way tosingle treatment modalities. Because the pathogenic
mechanisms associated with the development ofpelvic genitourinary symptoms are unknown, it
remains difficult to explain the role of painful myofascialtissue. One of the phenotypes proposed for
UCPPS includes a domain of tenderness of skeletal muscle and this has been the focus of a growing numberof clinical research trials and publications. Arecent NIH-sponsored, multicentre study demonstratedthe feasibility of performing clinical therapeutictrials utilizing muscle and connective tissuephysiotherapy (myofascial physical therapy) to treatUCPPS (Fitzgerald et al. 2009). A comparator groupof subjects was randomized to receive total-body traditionalWestern massage with no myofascial releaseor internal pelvic therapy.
In the NIH trial the originalphysician investigators quantified the degree oftenderness in muscle groups prior to corroborationby physical therapists trained in such techniques. Aclear discrepancy existed between what physiciansscored for subjective pain on examination and whatthe physical therapists reported; physicians found28% less tenderness on their examination (P < 0.01).
Patients randomizedtothemyofascialphysical therapygroup underwent connective tissue manipulation to allbodywall tissues of the abdominalwall, back, buttocksand thighs as well as internal pelvic muscles clinicallyfound to contain connective tissue abnormalities and/
or myofascial TrP release to painful myofascial TrPs.
This was done until a texture change was noted inthe treated tissue layer. Manual techniques such as
TrP barrier release with or without active contractionor reciprocal inhibition, manual stretching of the TrPregion and myofascial release were used on the identifiedTrPs. A secondary outcome of the pilot studyrevealed good patient response to the internal andexternal myofascial physical therapy as compared togeneralized external Western massage only (57% versus28%, respectively). This form of therapy wasexpanded to a larger trial in women suffering fromIC/PBS and the results show an equally impressiveresponse to the manual physical therapy.”
Hopefully these observations by Prendergast, Rummer and Anderson add to the general information in my earlier postings?
The remainer of this post is a copy of the 2008 ‘paradoxical blog:
The Problem ?
Let’s start with a clinical trend I have become aware of, but have been unable to explain until recently. Over the past five to ten years, more and more of my younger, mainly but not exclusively, female patients have reported symptoms ranging from variable to acute pelvic pain, to stress incontinence, and interstitial (i.e., nonbacterial) cystitis.
Many of these patients had seen appropriate experts in genitourinary medicine and/or physical medicine, and most had been prescribed what can best be described as “toning” (Kegel-type) exercises for presumed laxity in their pelvic floor muscles, along with various forms of medication.
Now, clearly, the patients I was seeing were the ones in whom such treatment had failed. However, because the practitioners prescribing these methods continued to do so, I must assume they worked for many (and research suggests this is so). But they had not worked for those distressed (mainly) young ladies consulting me, whose lives were in turmoil because of considerable and sometimes constant pain in a very intimate part of their anatomy. All too often, these women were socially incapacitated due to their incontinence; with many unable to have normal relationships. And most of these women were no older than their early 20s.
Structural evaluation often revealed very well-toned musculature. Many had a history involving athletics, gymnastics or dance, and it also was common to have a report of emphasis on Pilates toning exercises, not uncommonly with insufficient emphasis on flexibility. Frequently, there was extreme shortness of some of the muscles attaching to the pelvis, particularly the adductors, hip flexors and the (“core stability”) abdominal muscles.
The evidence is that the problems in many of these unfortunate patients was not reduced tone, but increased and excessive tone.
In recent years medical and manual therapy practitioners have also rediscovered something demonstrated many years ago (Slocumb 1984) – that trigger points can cause all of these symptoms, and that the trigger points and the symptoms frequently can be removed manually – as reported later in this post.
Diversion to Australia
Before going more deeply into the high-tone/trigger-point connection, I want to take you to Melbourne, Australia, where a part of the complex picture began to fall into place.
The 5th World Congress on Low Back and Pelvic Pain (November 2004) was held in beautiful (magnificent might be a better word) Melbourne, where I was presenting a paper on the influence of breathing pattern disorders and motor control associated with back pain. On the same panel was Diane Lee, PT, from Vancouver, B.C. In front of some 1500 delegates, she was discussing and showing video clips of paradoxical behaviour of the pelvic floor in women with stress incontinence. (Lee 2004). Ultrasound images of the pelvic floor and bladder were shown in which, when asked to “retract” or “draw the pelvic floor upward,” quite the opposite happened and the pelvic floor, along with the bladder, dropped toward the floor – and the consequence was incontinence.
In real life, such women would try to prevent from wetting themselves by the natural response of tightening and drawing up and in. But what if the muscles trying to tighten and draw up were already as tight as they could possibly be? Perhaps the better response would have been to learn to relax these clenched muscles (or to have them manually relaxed), and to be able to influence the pelvic floor via a relearned awareness of muscle control?
This was Diane’s objective.
To me, the “wow factor” was the recognition that these women were almost certainly also going to demonstrate paradoxical diaphragm behaviour and possibly unbalanced breathing (and most do), which is one of my main areas of interest.(Chaitow et al 2002).
See the earlier posting in this blog “Breathing Patterns, Connective Tissue and Soft-Shelled eggs”
It would be fair to say that, after that presentation, my area of interest moved south, to incorporate that other diaphragm, the pelvic floor.
My belief is that if normal diaphragm (breathing) function can be restored and the pelvic floor muscles relaxed, re-education can take place efficiently and relatively easily. A part of that process requires that active trigger points – in the lower abdomen, inner thigh and sometimes internally – be deactivated as the muscles are restored to their normal length and tone.
But is there evidence for any of this?
Sometime before World War II, a physician named Thiele developed a technique in which coccygeal and prostate problems were treated by means of manual stretching of specific muscles, mainly levator ani. (Thiele 1937) This approach (see description in the third bulleted item below) currently is used in major centers in the U.S. to treat prostate pain and the sort of pelvic floor problems discussed above. (Oyama et al 2004)
• Chronic prostatitis involving nonbacterial urinary difficulties in men, accompanied by chronic pelvic pain (involving the perineum and genital organs), was shown in a 2005 study at Stanford University Medical School to be capable of being treated effectively using trigger-point deactivation together with relaxation therapy. (Anderson et al 2005) The researchers pointed out that 95 percent of chronic cases of prostatitis are unrelated to bacterial infection, and that myofascial trigger points, associated with abnormal muscular tension in key muscles, commonly are responsible for the symptoms. The one-month study involved 138 men. Marked improvement was seen in 72 percent of the cases, with 69 percent showing significant pain reduction and 80 percent improvement in urinary symptoms. The study noted that “Myofascial TrPs were identified and pressure was held for about 60 seconds to release [described as myofascial trigger point release technique – MFRT]. Specific physiotherapy techniques used in conjunction with MFRT were voluntary contraction and release/hold-relax/contract-relax/reciprocal inhibition and deep tissue mobilization, including stripping, strumming, skin rolling and effleurage.”
• Using similar trigger-point deactivation methods, Weiss (2001) has reported the successful amelioration of symptoms in (mainly female) patients with interstitial cystitis using myofascial release.
• The effectiveness of the Theile manual methods has been effective in treating (Holzberg et al 2001) high-tone pelvic floor musculature in 90 percent of patients with interstitial (i.e., unexplained) cystitis.
• A link between the sort of symptoms treated in the previous examples with sacroiliac dysfunction (SI), was noted in a study conducted in Philadelphia. (Lukban et al 2001) Sixteen patients with interstitial cystitis were evaluated first for increased pelvic tone and trigger-point presence, and second for sacroiliac dysfunction. The study reported that in all 16 cases, SI joint dysfunction was identified. Treatment comprised direct myofascial release, joint mobilization, muscle energy techniques, strengthening, stretching, neuromuscular re-education and instruction in an extensive home exercise program. The outcome was a 94 percent improvement in problems associated with urination; nine of the 16 patients were able to return to pain-free intercourse. The greatest improvement related to frequency symptoms and suprapubic pain. There was a lesser improvement in urinary urgency and nocturia.
• A French osteopathic study (Riot et al 2005) investigated a new approach to the treatment of irritable bowel problems (IBS) in which there was a combination of massage of the coccygeus muscle together with physical treatment of frequently associated pelvic joint disorders. One hundred and one patients (76 female, 25 male; mean age: 54 years) with a diagnosis of levator ani syndrome (LVAS) were studied prospectively over one year following treatment. Massage was given with the patient side lying on the left. Physical treatment of the pelvic joints was given at the end of each session. Results: Forty-seven patients (46.5 percent) of the 101 patients suffered both from LVAS and IBS. On average, fewer than two sessions of treatment were necessary to alleviate symptoms. The conclusion was that the LVAS symptoms may be cured or alleviated in 72 percent of the cases at 12 months with one to two sessions, and that since most of IBS patients benefited from such treatment, it is logical to suspect a mutual etiology and to screen for LVAS in all such patients.
So, this story is not just about pelvic pain and incontinence, but possible irritable bowel disease and, in some instances, sacroiliac dysfunction. Is this not a remarkable conjunction of influences, often linked to hypertonicity and dysfunctional patterns such as breathing?
The Tennis Ball Trick
A self-help option was offered to me by a therapist (ex-dancer) at a recent workshop. She reported she had suffered many of the symptoms outlined above, and had been instructed in Kegel exercises for her incontinence. She noted that these exercises had aggravated rather than helped her. A yoga therapist had then advised her to purchase a tennis ball and sit on it with the ball (placed on a firm surface such as a carpeted floor) strategically placed under the perineum; and to allow the pressure onto the ball to deeply relax the pelvic floor muscles for five to 10 minutes daily. She reported that this procedure was somewhat uncomfortable at first, but that the effects were dramatic in terms of her symptoms. I have since recommended this to several patients for home use and all have reported benefit.
Don’t Forget the Psychological Aspect
This is a complex story, and I don’t want to leave you with the impression that it can all be solved by a tennis ball, although this might offer symptomatic relief for many.
It’s essential to note that in many such cases of clenched pelvic floor muscles, there is a background of assault or abuse (although a great many seem to be caused by nothing more than mechanically-produced, excessive tone with a background of dance, athletics and bad Pilates). Where there is a psychosocial or psychosexual element to the condition, appropriate professional support usually is needed along with bodywork.
The information offered above should at least provide a sense of what might be happening in some patient’s bodies. Those trained in neuromuscular therapy know that aspects of this work usually are a part of that training. Information on Neuromuscular approaches is provided in Clinical Applications of Neuromuscular Techniques, Volume 2 (Chapter 11). Working on relaxation of the region (adductors, etc., as a first focus!), possibly deactivating trigger points if they are readily accessible, along with breathing rehabilitation, offer practical ways forward.
And the tennis ball trick might just be an answer for some.
Anderson R, Wise D, Sawyer T, et al. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol 2005;174(1):155-160.
Berger,R.E.,Ciol,M.A.,Rothman, I., et al.,2007. Pelvic tenderness is not limitedto the prostate in chronic prostatitis/
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Butrick, C.W., 2009. Pelvic Floor Hypertonic Disorders: Identification and Management. Obstet. Gynecol.
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Lee D. “Altered Motor Control and the Pelvis: Stress Urinary Incontinence.” Fifth World Congress on Low Back Pain and Pelvic Pain, pp. 138-154. Nov. 10-13, 2004, Melbourne Australia.
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