To begin, this blog as with all of our blogs and podcasts do not represent medical advice but simply a report of our experience and opinions in treating pelvic pain.
I want to discuss the role of how much pressure our physical therapist instructs our patients to use on trigger points both internally and externally when we are treating those with pelvic pain.
The issue of how much pressure to use on trigger points related to pelvic pain is not a subject that is very much discussed in the research on pelvic pain. There is no objective way for the pelvic pain therapist practitioner to compute amount of pressure exerted. The therapist will simply use pressure that he/she deems appropriate.
Also, there is no internal trigger point release device other than our own that offers readings on a display of the pressure being exerted on the internal tissue.
We have been concerned about how much pressure to use inside and outside the pelvis because we have regularly seen that the flare up of symptoms after self-treatment comes from too great pressure exerted on the trigger pointed tissue. Too much pressure or too vigorous stretching on or of skeletal muscle can trigger the what is called the stretch reflex. This reflex acts as a protective mechanism that cause the muscle to tightening up to guard against injury.
We have long experience doing myofascial/trigger point release for pelvic pain. In our experience, muscle based pelvic pain does not heal up unless the internal and external trigger points related to someone’s symptoms significantly or entirely resolve. This involves first accurately locating the trigger points and then exerting careful pressure on the trigger point for a specific duration. Simply, in our experience, if you press on a trigger point too hard or too lightly, the trigger point likely will not release and the pain and symptoms will remain. The problems and lack of results often tend to come from not being able to locate the trigger points, which requires study and training, or exerting too much pressure on them causing regular flareup of symptoms when they are found.
In our experience, the gentle pressure on a trigger point of not more than 2 on a 0-10 subjective scale of pressure on an internal trigger point, and the gentle pressure of no more than 3 on the subjective experience on an external trigger point makes it most likely that the trigger point will release over time.
Said differently, over the years, we have seen that that the most effective way to resolve pelvic pain related trigger points is to press on them to elicit a modest degree of discomfort that ‘hurts so good’ — to repeat, a modest degree of pressure and then hold pressure on the trigger point until there is a modest release and reduction of discomfort. To repeat, trigger points first have to be accurately identified. When accurately identified, they respond badly to getting beaten up with too much pressure.
Typically, the slight release of trigger point pain after modestly pressing on a trigger point often doesn’t feel like much. But over time there we have seen a cumulative effect of reducing the trigger point sensitivity. The over-riding principle here is that occurs myofascial trigger point release for pelvic pain is like running a marathon and not a sprint. The gentle, regular and repetitive release of long standing trigger points occurs over an extended period of time.
Patience, knowledge and practice with the correct instruction is key here. In our experience, regular flare up of symptoms after trigger point release with no improvement in symptoms is going in the wrong direction and is likely not to be therapeutic.
We have a long experience with myofascial trigger point release for pelvic pain.
Trigger point release, in my view is an essential practice in helping to heal muscle based pelvic pain. Unfortunately this is too often not understood and is typically absent in conventional medical treatment (except for trigger point injections of which we are generally not supportive).
While trigger point release is not rocket science, it requires a certain level skill and experience that will allow it to work its magic.
We are among the first who introduced trigger point release for male pelvic pain beginning when we saw patients who came into the Urology department at Stanford beginning in 30 years ago in 1995.
I want to explain what trigger points are, why we believe properly releasing them is central to resolving muscle based pelvic pain. Myofascial/trigger point release is one of the two prongs of our protocol. In other podcasts I discuss how the other essential method we use, the behavioral and psychological/behavioral intervention.
What are trigger points? Trigger points, are experienced as tender, painful spots in the skeletal muscle that cause pain and other symptoms when pressed on. You can feel trigger points with your finger as tight or taut bands of muscle fibers. They often feel like knots.
You can think of trigger points as small spasms within a chronically tight muscle that are the sources of pain and related symptoms. If you don’t release the trigger point, the pain and symptoms in the chronically tightened muscle in our experience generally don’t go away.
Virgin trigger points that have not been treated share several characteristics;
• They often refer sensation felt in a place that is remote from them
• They elicit a ‘jump response’ when pressed on
• They are exquisitely painful when pressed on
• You often feel a ‘twitch’ when you press on them
• They can disappear and resolve back into the muscle if treated properly so that they no longer refer pain/symptom
The sensation of trigger points can cause what is often referred to as unexplained pain frequently radiating from these points of local tenderness. The fact that the source of someone’s symptoms are often found in a place remote from where the symptoms are felt is what has fooled many doctors in treating muscle based pelvic pain. We have seen men who complained of testicular pain that the doctor, not understanding trigger points and their referral patterns, decided to surgically remove. While not all testicular pain is muscle based, trigger points remote from the testicles can refer pain to the testicles and is typically the source of pain when no other physical cause is found.
The same has been true for patients reporting tailbone pain. More than a few of our patients have had their tailbone removed to find that no relief of pain occurred because it was not the tailbone that was the source of the pain.
In our article in the Journal of Urology in 2009, we found that patterns of pain referral in patients with front or anterior symptoms were came from trigger points located in the front or anterior portion of the pelvic floor. For instance in those with pelvic floor dysfunction, we have found that genital pain, urinary frequency/urgency, pain above the public bone, pain with sexual activity, pain with urination, were typically related to trigger points in anterior or the front of the pelvis.
Similarly, we have found that symptoms located in the back or posterior of the body were produced by trigger points in the back or posterior portion of the pelvic floor when palpated. These include symptoms sitting pain, post bowel movement pain, rectal pain, low back pain
In summarizing our experience, releasing pelvic floor related trigger points, along with reliably lowering anxiety, is essential for the pain and symptoms of chronic pelvic pain to go away. In our view no drug, surgery or procedure or other methods can do this.
In our experience, our patients whom we teach to treat themselves, have to be educated how to locate trigger points and need to understand the level of pressure being exerted on their trigger point when doing trigger point release. This involves understanding how to determine how much discomfort self-treatment pressure elicits. In the Wise-Anderson Protocol, we have found how hard they press on a trigger point is clearly related to whether they are helped.
We strongly recommend different levels of pressure be use on trigger points inside the pelvic floor and outside the pelvic floor. We instruct patients doing internal trigger point release with our Internal Trigger Point Wand to press no more than 2 on a 0-10 scale of discomfort.
We instruct patients doing external trigger point release to press to create discomfort of no more 3 on a scale of 0-10
Over time, if pressure is too low, nothing happens to the trigger point and its related symptoms. If pressure is too great, then a flare up of symptoms typically occurs and progress can be impeded.
When a skilled practitioner does an initial evaluation, pressure on the trigger point is often more than 2 or 3 on a 0-10 scale as the trigger points need to be identified and pressing harder is often necessary to do this. Temporary flare up of symptoms may occur during this evaluation session. But going forward with internal and external trigger point release self-treatment requires a lower level of pressure on trigger points.
We tell our patients to pay close attention to how the pressure feels when they are doing trigger point release self-treatment from moment to moment. A rule of thumb is that if you can’t relax while the pressure is being exerted, it is too much pressure and the likelihood that the pressure will be therapeutic is doubtful. We call the correct amount of pressure the ‘sweet spot’ So paying attention to the sensation of the pressure on the trigger point and controlling the pressure is essential.
The key to trigger point release self treatment is to be patient, persistent and attentive and press gently to simply ‘greet the pain’ as our physical therapist instructs. It can take many months of self-treatment to help resolve chronic, long standing trigger points and long standing tightened tissue.
In our view, the best person to do internal and external trigger point release is the patient him/herself as long as they have the proper tools and instruction.
In our experience, trigger point release self-treatment is the best way to be able to regulate pressure on the trigger points because the patient is both pressing on the trigger points and then determining how much pressure to use. The feedback from the patient pressing on their own trigger point immediately informs them as to what the correct pressure should be. In this way, when someone is trained to do your own trigger point release, they can easily determine the appropriate pressure to exert and the length of time to hold it.
In summary, careful use of specific levels of pressure on trigger points within a specific duration can make the difference between helping to reduce/resolve pelvic floor pain or not.