Chronic Pelvic Pain is one of the most elusive and perplexing areas of human suffering, made all the worse by the cultural taboos and traditions which are associated with that part of the body, "down there". On the one hand, patients don't like to admit that they suffer pain in an area of the body better known for its association with pleasure. And therapists don't like to hear complaints about an area in which many of them feel powerless to practice their best professional skills.
When the focus of pain is in the lower posterior spinal region, many patients are eager to describe their pain as "low back pain", rather than "coccyx pain" or "crotch pain". In a famous clinical chart (and series of publications) designed to assist therapists in systematically assessing structural muscle irregularities, my good friend and teacher Jeff Cram drew our attention to all of the major muscle groups except the pelvic region! Imagine a left-side-view of the torso, with a giant "question mark" superimposed: ? From the frontalis, over the head and down the spine to the tailbone, the famous Cram Scan presented normal and deviant EMG levels for analysis and comparison. In the extended version, a couple of disconnected abdominal sites are also listed. But the Scan Stops at the Tailbone!
Obviously we are not faulting Cram for failing to suggest that the manual "scan" be continued past the tailbone, under the pelvic floor, and around to the pubic synthesis in the front. It is difficult to decide whether we, or our patients, would be more uncomfortable if it did! Nevertheless, candor compels us to admit that our assessment of muscular-structural abnormalities is defined more by social constraints than medical wisdom. We know that muscular conditions of the pelvic floor cause a variety of medical complaints, but we are ill-equipped to provide our patients with the technological armaments to diagnose and treat them when the terrain becomes "personal". That is, until now!
ASIDE: In 1979, soon after the first professional presentations on vaginal myography had been made at the Biofeedback Society of New England, I attended a convention of the "other" national biofeedback society in Chicago. I was especially interested in a two-hour workshop in which a nationally-prominent Physical Therapist presented, in 14 Xeroxed pages, her best understanding of the major muscle groups of the human body, indicating in great detail what biofeedback clinicians ought to know about them all. I dutifully waited through the first round of Questions from the audience. When my turn finally came, I gently inquired about the large "white area" on her charts, "between the navel and the two thighs", and asked if there were not any major muscle groups in that region as well? "Oh, yes," she sighed, "There are important muscles there; but we Physical Therapists just haven't figured out how to deal with them yet." At that point I became convinced that my new invention, the vaginal myograph (later to be known as the EMG perineometer), had a promising future in helping therapists to "be there" without violating patient's privacy.
I am pleased to note that the first fruits of that new capacity -- the ability to help patients deal with chronic pelvic pain without invading their privacy -- are now appearing, as evidenced on this "pain" page. First, we are pleased to present a reprint of Howard Glazer (et al)'s article on the Treatment of Vulvar Vestibulitis by EMG biofeedback, which appeared in the Journal of Reproductive Medicine last year. Howard's excellent results (most patients resumed sexual relations after their pain diminished significantly) are all the more remarkable when you noted that, like most biofeedback therapists, he was only referred the most intractable cases, who had failed to improve after more traditional treatments. Vulvar Vestibulitis, which has a 40% overlap with Interstitial Cystitis, is not a widespread condition, but is extremely debilitating to those who suffer from it.
The same can be said for Levator Syndrome, which is also known as "Prostatitis" when diagnosed by a Urologist. It consists of chronic tension, often accompanied with muscle spasms, of the "Levator Ani" muscle (which impinges directly on the prostate gland). Levator Syndrome, which has along resisted treatment by electrical stimulation devices and pharmacologic weapons as well, in very easily treated with EMG Biofeedback using a PerryAnal™ rectal EMG sensor. It is common to find men (especially) who have suffered from this condition for 10 or 20 years, with significant impingement on their creative energy. One West Coast Psychologist was recently treated for LS by Dr. Glazer in New York City. He was so impressed with his own cure that he has himself now offered the same therapy to over a hundred patients in the Bay Area in the past year. (For referral information, click here.)
The EMG Perineometer permits evaluation and training of the pelvic muscles, but it remains unquestionably true that biofeedback alone cannot treat all pelvic muscle problems. As a psychologist, I have applied the "Brief Therapy" model to pelvic muscle dysfunctions, including pain. Succinctly stated, this model requires that the patient's problem be first assumed to be "simple"; it is treated by the basic therapy, and if the problem goes away, it was a simple problem; the patient is happy, the insurance company is happy, and the national deficit hasn't been exacerbated. However, if the first-line therapy is not successful, the model calls for progressively higher levels of intervention until a cure is obtained.
Fortunately for pelvic pain patients, not all Physical Therapists are so timid as to limit their services to their own comfort level. Our Incontinence Clinic was located in Paoli, Pennsylvania, and we were fortunate to have access to the John F. Barnes Myofascial Release Treatment Center in Paoli (now also in Sedona!) Barnes is well known for his MFR Seminars, held around the country for many years; he has personally trained over 20,000 therapists in his "Myofascial Release" techniques. Barnes teaches his advanced students not to avoid the "blank area" between the navel and the thighs. (His "Fascial- Pelvis Myofascial/Osseous Integration" seminar will be offered 13 times in 1996.)
We have referred three kinds of patients to Barnes' MFR center with excellent results.
(1) One patient was given an EMG home trainer and pelvic muscle sensor by a Texas PT and told to practice "on her own" -- despite the fact that unsupervised practice is contrary to FDA regulations! A year later, she had developed "fantastic" muscles -- 20+ microvolts EMG -- but there was no change at all in her incontinence symptoms (accidents). A manual evaluation by a Barnes' therapist revealed that -- whatever muscles the patient was contracting, NONE of them were part of the pelvic floor!
(2) A number of patients have traced vaginal pain to scar tissue from one or more episiotomies. Whereas many therapists avoid sensitive scar tissue, Barnes teaches therapists to "break up" and soften scar tissue, usually with excellent results. It is difficult, even with biofeedback, to teach patients to relax the pelvic muscles when provoked by persistent irritation.
(3) Finally, in patients whose coccyx bone has been broken, the slightest tension of the pelvic floor can sometimes cause it to swing forward, even to impinge the rectum and cause constipation. If the bone is actually pivoted forward, no mere relaxation of the levator ani will cause it to move back; manual manipulation is the best alternative.
If the incontinence nurse, biofeedback psychologist, or social worker is not licensed and trained to do direct vaginal and rectal manipulation, an appropriate MFR-trained therapist should be consulted when "simple therapy" doesn't completely resolve the problem in the normal time frame.
© 1996 by John D. Perry
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