Uncontrollable spasms or chronic tension of the pelvic floor musculature is described by several different names by the several medical specialties which encounter them. Regardless of the name, the symptoms are clear: intense rectal or genital pain usually during or after any physical activity involving the lower extremities. We have encountered many patients, usually professional males, who have been partially debilitated by this condition for 10, 15 or 20 years. Invariably they have been told there is no treatment for it.
In females the pain may be associated with the vagina, and may or may not be worse with sexual activity. In males, the pain may focus on the corresponding area, the prostate, with similar results. Such pain is often debilitating and interferes with many normal activity.
In the past, therapists were limited to electrical stimulation methods or manual manipulation techniques to treat Levator Syndrome (LS). Unfortunately, such approaches only relieve the symptoms (at best), and fail to treat the underlying problem. The patient either returned regularly for therapy, or learned to live with the condition.
The underlying problem can best be described as a combination of two elements: (1) muscular tension often triggered by injury or surgery and (2) a learned, habitual coping mechanism of "denial" or "dissociation".
Objectively, the patient exhibits usually intense muscular spasms (spikes) which may or may not be superimposed on a significant elevation of the resting EMG levels of either the vaginal or rectal muscles, or both. This is readily ascertained using a Perryvaginal or Perryanal sensor and a computerized videographic EMG instrument capable of displaying spikes. [Note that some EMGs are too heavily filtered to display spikes, and may therefore give false-negative readings.] Resting levels of 2 to 4 microvolts (RMS) may be associated with pain. Resting levels of 4 to 10 or even 20 microvolts are quite common in LS patients.
Clinical Tip: Some patients show excellent resting levels when seated for a period of time; spasms appear only after the patient moves to a standing posture. In others, even standing does not produce observable spasms, but any attempt to lift either leg off the floor will do so. In addition, the "resting" level should go up as the patient moves to upright (or lifts and lowers the leg) [actually this is artifact from the strong distant muscles employed in the movement], but it should return to a low level quickly when the movement ends. If it takes four or five seconds to quiet down after every movement, it is clear that it never has a chance to do so during a series of discrete movements, such as walking.
Objective spasms as described above are probably never seen except in patients who additionally employ a coping strategy which involves denial of their pain, through mental tactics of disassociation. These coping skills fail because, when the "mind" is detached from the "body", there is no one left in control! The muscles literally become "free-running"; i.e., fibrillating, like an unruly high school cafeteria. In interviewing such patients, there are some "red flag" conditions to watch for:
(1) Out-of-Body techniques. Some patients attempt to mentally "leave" their body through esoteric, eastern, or idiosyncratic methods. They seek to view their bodies from "above" or as if standing outside their own skin. Often they can become very "successful" at doing this---but there is no one minding the shop! Once outside, they cannot feel any pain. Unfortunately, neither can they feel any bodily pleasures. (Such patients often complain of diminished sexual response---or even its total absence.)
(2) Will-Power Techniques. Some patients cope with muscular pain by mustering massive amounts of determination---sheer will power---to pretend that their pain really isn't there. As a short-term solution, this is sometimes helpful; as a major personality habit, it is deadly. Watch out for patients who habitually deal with pain by will power; for example, they actively avoid use of common pain killers, including aspirin and alcohol. They allow their teeth to be drilled without Novocain. They are often proud of their learned skill---and it never occurs to them that it should not be applied in this situation.
LS is relatively easy to treat with EMG biofeedback, at least in uncomplicated patients. The first part is common to all patients with elevated resting levels; teach relaxation of the pelvic floor and sphincter(s). But since very few people can discriminate between (say) 1 and 5 microVolts initially, graphic video biofeedback is essential. Also, few people can spontaneously "relax", but almost everyone can use an adaptation of Jacobsonian technique: we teach them pelvic floor contractions, but we stress the "letting go" during "REST" periods, rather than the height of the contractions during "WORK" periods. Most patients can learn some skill at this in one or two sessions, and master the skill in four or five.
The second technique for eliminating this pain is paradoxical; one must ask the patient to pay attention to the area whose sensations they are trying so hard to deny. With rectal or vaginal EMG graphically displayed on the computer screen, the patient is instructed to notice and report the internal sensations that accompany the spikes on the screen. (Sometimes spikes only appear after a few contractions, or after attempting to lift the leg a bit.) In any case, when a spike appears, ask the patient "Did you feel that one?" With relaxation and encouragement, they can soon learn to feel what is going on in the pelvic region. Unless the patient is spinal cord injured, it is safe to assume that the anesthesia is entirely learned_and is equally unlearnable.
As with any pelvic muscle restoration problem, patients who have an EMG home training instrument for daily practice show the fastest improvement in symptoms.
THE CLINICAL GUIDE SERIES is published by PerryMeter Systems
Copyright 1990 by John D. Perry, Ph.D., Psychologist