“The goal of the Stanford Protocol is to enable the patients to reduce and/or resolve their symptoms without dependency on drugs or others to do so for them.”

David Wise, Ph.D.
Plenary address to the
National Institutes of Health (NIH)
Scientific Workshop on Prostatitis/Chronic Pelvic Pain Syndromes
Baltimore, Maryland
October 21, 2005

Introduction
Thank you for giving me the opportunity to discuss the Stanford Protocol at this National Institutes of Health sponsored scientific meeting on Prostatitis/Chronic Pelvic Pain Syndrome.

How I became involved in treating chronic pelvic pain syndrome
I happened to have had the unusual experience of the slow motion nightmare of chronic pelvic pain for a period of over twenty years– at one time or another having had almost all of the symptoms you typically hear from patients, and then unrelieved, unrelenting pain 24 hours a day 7 days a week …and no one to talk to or no one to help me --- and then around ten years ago, I had the fortune of experiencing the resolution of my own symptoms by finding and implementing the elements of what is now called the Stanford Protocol that I am going to discuss. I gratefully remain pain and symptom free. So I speak to you both someone who understands this problem as a clinician who has seen many, many patients with pelvic pain over the past years, and as someone who has had the direct experience of pelvic pain of long duration and then the experience of the resolution of the pain.

The development of the Stanford Protocol
I have also have the unusual fortune of meeting and collaborating with Rodney Anderson at Stanford University, director of the Stanford Pelvic Pain Clinic, a remarkable physician to whom I have great gratitude for his big mind and willingness to think outside of the box, as well as collaborating with Tim Sawyer, an extraordinary physical therapist. My purpose in the few minutes I have, is to as clearly as I can, explain the methodology we developed at Stanford over an eight-year period and which we continue to study and refine.

Paradigm shift: From seeing chronic pelvic pain as an infection to seeing it as tension disorder
The question you ask determines the answer you get. The paradigm you hold about pelvic pain determines what you look for and how you treat it.

I am aware that the Stanford Protocol represents a significant paradigm shift. We don’t believe the vast majority of those diagnosed with prostatitis/chronic pelvic pain syndrome suffer from a prostate infection or occult bacteria, an autoimmune disorder or compressed pelvic nerves.

We see the overwhelming majority of cases diagnosed as the result of the overuse of the human reflex to tighten the genitals, rectum, and contents of the pelvis in response to anxiety, pain, or trauma by chronically contracting the pelvic muscles. This tendency becomes exaggerated in predisposed individuals, particularly those with a tendency toward anxiety who respond to stress by habitually and unconsciously tightening their pelvic floor. Such a tendency is invisible. No one can see it. Usually the person who has such a tendency is unaware of it. And the consequences of this tendency are also invisible except for the complaints of discomfort, pain and urinary dysfunction that the sufferer eventually expresses.

This state of chronic constriction creates pain-referring trigger points in and around the pelvis, which in turn, as simply as I can express, creates an inhospitable environment for the nerves, muscles, blood vessels, and structures within the pelvic basin. This results in a self-feeding cycle of tension, anxiety, and pain, which has been previously unrecognized and untreated. It is a kind of short circuit. Patients with pelvic pain often wind up in the emergency room when this short circuit gets out of control.

The havoc of chronic tension in the pelvis and the tension-anxiety-pain cycle
Most people neither appreciate nor understand the havoc that chronic tension plays in the pelvic floor. It is the same havoc that chronic neck and shoulder tension plays in headache, chronic back tension plays in low back pain, or chronic jaw clenching plays in temperomandibular disorder.

There can be psychological, physical, or social triggers to the chronic tightening of the pelvic floor. Once this cycle of tension, anxiety, and pain begins, it tends to have a life of its own, and carries on even when the initiating triggers have passed.

The purpose of the Stanford Protocol is to break this tension, anxiety, pain cycle and to help patients prevent its reoccurrence. The methodology is low tech. The aim is to get patients off of all drugs and to end patient dependency on professional help. The responsibility for the success of the treatment is largely up to the patient’s compliance with the protocol. Patients who look for a quick external fix to their condition tend to lack the motivation that the Stanford Protocol demands. Such individual tend not to be good candidates for our protocol.

The problem in the great quest to restore the pelvis to a relaxed and symptom-free state is that pain and tension and trigger point activity in the pelvis turns out to be intimately tied up with emotional reactivity and autonomic arousal. They feed each other. Anxiety is the gasoline on the fire of pelvic pain. This is also why placebo is so influential in this condition. This intimate tie-up with autonomic arousal and pelvic pain has never been effectively addressed in treatment and is essential to any effective treatment.

How to understand pelvic pain if you don’t have it
I want to take a moment to help those of you who have never had pelvic pain to experientially understand it from my viewpoint. In this way, you may have more of an intuitive sense of what we are doing. If I were to ask you to tighten your pelvic muscles for the next ten seconds as though you were stopping yourself from urinating, most of you would probably be willing to do this. If I ask you to tighten your pelvic muscles for one minute, probably few of you would be willing.

Now imagine you were to continually tighten up your pelvic muscles for a half an hour, one hour, twelve hours, twenty-four hours, one month, six months, one year, two years, five years, ten years. Most people would consider it inconceivable to be stuck in an activity of such self-abuse and self-inflicted pain, and into a realm, no one here would dare venture voluntarily. I suggest that the consequences of this kind of chronic tension leads to the symptoms from which most patients diagnosed with prostatitis/cpps suffer.

I want to talk about the relationship between anxiety and trigger point activity.

Anxiety makes trigger points hurt more
Here are pictures of electrical activity in a trigger points at baseline , during relaxation and under stress, a study done by Gevirtz and Hubbard in San Diego. On the left we see trigger point activity at baseline… notice that the electrical activity in the trigger point is significantly elevated from the electrical activity of the non-tender tissue just 1/4 inch away. Notice now the center reading after the subject has begun relaxation. The electrical activity of the trigger point normalizes. Notice now the electrical activity of the trigger point during a stressor. The electrical activity of the trigger point is significantly activated well beyond baseline readings. These studies have been duplicated hundreds of times and clearly show the strong impact of autonomic arousal on trigger point activity.

The Stanford Protocol represents an effective and safe non drug, non surgical treatment for pelvic pain, and provides far better outcomes than conventional therapies for most patients with no long term side effects. I will briefly summarize the results of our study published this year in the July issue of Journal of Urology. At Stanford, we studied 138 patients who were referred to us, usually by physicians who could no longer help these patients because they had failed all conventional therapy. We were the court of last resort. After treatment, using the Stanford Protocol, 72% of these refractory patients reported that that they had marked or moderate improvements in their symptoms as reported on the Global Response Assessment. These responses reported as marked and moderate improvements by patients were commensurate with appreciable (10.5% decrease in marked and a 6.5 % decrease) decreases in the NIH-CPSI scores.

Although we have not systematically studied the numbers, it is my observation that positive results from our protocol improve with the increased competence of the patient in our methodology over time. In other words, in my experience, patients’ symptoms appear to improve the longer they follow our protocol.

The Stanford Protocol methodology consists of two essential elements: Paradoxical Relaxation and pelvic floor trigger point release.
Let me touch on the Stanford Protocol trigger point release. Time does not permit any detailed discussion of the trigger point release we use and have developed. Suffice it to say that we work with approximately 40 trigger points related to pelvic pain. We apply the same principles of trigger point release pioneered by Travell and Simons for external muscles, to the release of the internal muscles. A comprehensive list and detailed illustrations of trigger points related to male pelvic pain and a detailed description of our method are found in the 3rd edition of our book, A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes.

Stanford Protocol Trigger Point Release.
Here are some notable aspects of the trigger point release protocol we use.

• We use primarily trigger point release oriented therapy and not myofascial release therapy … they are not the same.
  
• Trigger points that refer pelvic pain exist both inside and outside the pelvic floor
  
• The most common trigger points in male pelvic pain are found in the anterior levator ani, the obturator internus, adductors and surprisingly in the quadratus lumborum and the psoas I don’t expect you to take in this list but only to know that we have found there are specific trigger points related to specific pelvic pain symptoms.
  
• Trigger points tend to be found anteriorly in patients with more urinary symptoms and posteriorly in patients complaining more of rectal pain.
  
• We use a method called pressure release on a trigger point, holding it for 60-90 seconds– this length of time, which is usually difficult for many therapists to routinely hold, is critical to the release of the trigger point.
  
• We rarely do trigger point injection, and then only with stubborn external trigger points and even then we never advise the use of botox in such injections. We never do or advise internal injections.
  
• The number of treatments vary between 5-40 sessions.
  
• We generally discourage kegel exercises and do not use pelvic floor biofeedback or electrical stimulation.
  
• Patients are taught external and internal trigger point self-treatment. We have found that patients can do the majority of the Stanford Protocol physical therapy themselves once they are shown how to do it.
  
• We continue to develop an internal wand which we sometimes prescribe for patients when a patient has no partner or other resources to work with the internal trigger points at home. This has to be used carefully and only after the patient has been thoroughly instructed in its use.
  
• In the Stanford Protocol, trigger point release is done concomitantly with Paradoxical Relaxation

A word about simply using only physical therapy or Paradoxical Relaxation in treating pelvic pain
Both Paradoxical Relaxation and Stanford Protocol physical therapy aim to rehabilitate the patient’s pelvic floor and to stop the habit of chronically tightening the pelvic muscles under stress. For most patients each method is necessary but not sufficient in restoring the pelvis to a symptom free state. The intrapelvic trigger point release we use aims to rehabilitate the pelvic muscles and allow them to relax. The focus of Paradoxical Relaxation is to allow a rehabilitated pelvis to profoundly relax and to support the healing mechanism of the body with respect to a chronically sore and contracted pelvic floor. Importantly, a central purpose of Paradoxical Relaxation is to modify the habit to unconsciously and habitually tighten the pelvis.

It is tempting to look for a quick fix to the problem of Prostatitis/CPPS. As we know, there are no drugs or surgical procedures that satisfactorily help the pain and dysfunction of Prostatitis/CPPS. There is no quick fix. While physical therapy is essential to our protocol, it is insufficient to resolve the problem. Most patients who have suffered with this problem and simply do physical therapy discover this.

Generally, if patients do not learn to voluntarily and regularly relax the pelvic floor and reduce their own nervous system arousal, in the long term, manual physical therapy efforts at rehabilitating the pelvic floor tend to be short lived. Patients easily go back to the old habits that brought about the condition in the first place. A stressful hour in traffic or a fight with one’s partner after the best of physical therapy session can easily reactivate the trigger points that the therapist has just deactivated. I have seen this with many patients and know it personally.

Paradoxical Relaxation in the Stanford Protocol
Few would disagree with the value of profoundly relaxing a painful pelvis. The question is, how is it done. Consider how difficult it is to relax even you neck muscles in the middle of an ordinary upset in your life. Relaxing tension associated with pelvic pain and anxiety is orders of magnitude more difficult.

Tightening against pelvic pain worsens it
Paradoxical Relaxation addresses and seeks to reverse the dysfunctional reflex to tighten against pelvic pain and fear associated with it. We can call this chronic tension dysfunctional protective guarding. This reflexive tightening is dysfunctional because it exacerbates rather than protects against pain and anxiety.

The reflexive reaction to tighten the pelvis in response to pain paradoxically exacerbates it. Pain is a stimulus that triggers fight or flight. Pain does not reflexively trigger repose and rest, which is in fact what we ask patients to do. Accepting tension as a way to relax it, which is what we ask patients to do, is counter- intuitive. Paradoxically it is this counter-intuitive strategy that can reduce the pain or take it away, and thus, we name our method Paradoxical Relaxation.

Dysfunctional protective guarding is at the heart of other functional disorders
This dysfunctional protective guarding exists in a number of other functional somatic disorders. They include tension headache, temperomandibular disorder, low back pain, non-cardiac chest pain and idiopathic dyspepsia among others.

I think a modified Stanford Protocol may be useful in some of these disorders as well.

The central strategy of Paradoxical Relaxation comes from the insight that accepting tension relaxes it. In Paradoxical Relaxation, the emphasis is on tension and not on pain even though pain is usually perceived peripherally during the relaxation training.

Paradoxical Relaxation is not new. The major insights of this therapeutic strategy derive from the world’s oldest wisdom traditions and practices that focus on quieting the mind and body, and from the methodology of my teacher Edmund Jacobson who developed the technique of progressive relaxation.

The paradox of Paradoxical Relaxation can be expressed in the following ways: that accepting tension relaxes it, that accepting what is, is the fastest way to change it, that what we resist persists, that the requisite for changing something is first accepting it as it is, on its own terms. This happens to apply to stubborn pelvic muscle tension. Remarkably, this insight, when practiced regularly in a pelvic floor reduced of trigger points, has the potential to allow patients to dissolve pelvic pain.

Accepting tension is both counter-intuitive and functional in terms of relaxing stubborn tension associated with functional somatic disorders I have mentioned above. Paradoxical Relaxation is a modern day method to implement this perennial wisdom for ordinary people who have pelvic pain.

In Paradoxical Relaxation, we ask patients to do an extraordinary thing: to focus on, and then rest with their tension when they are anxious and in pain. Learning to do this requires many hours of practice. For the first 3 months, patients are asked to do 1- 1 1⁄2 hours of relaxation guided by 1 of a 38 lesson sequenced recorded course. The course consists of over a year of 1-2 daily sessions of relaxation training. This can’t be learned from stand-alone relaxation tapes. Patients must receive many hours of instruction by a teacher competent in the method. The Stanford Protocol is the slow fix.

Pelvic Pain is almost always accompanied by constant level of fear

• Paradoxical Relaxation asks patients to relax while they feel pain and fear. Patients have to be reassured that it won’t hurt them to relax while they experience their fear. It is common for patients to feel that if they accept their tension and fear and pain, that they have given up and that they will never get rid of their condition. These notions are obstructions to learning and must be addressed directly. Here is the paradox again--relaxing with and accepting fear is most likely to dissolve it.

To the novice, relaxing with pelvic pain, chronic tension and chronic anxiety is scary
And so it is, in this context, that we ask people to sit still with it all. Relax with the pain, fear, helplessness, desire for distraction, fear of the method failing, fear that their life is over and that they will have to live in chronic pain until they die, and fear of getting their hopes up. This is scary territory. Teaching patients this relaxation protocol addresses all of these concerns, and takes time and many repetitions to gain some degree of competence.

The Stanford Protocol is done in a 6 day intensive immersion clinic
The format of the Stanford Protocol is unusual as it is done in a six-day intensive immersion clinic involving some 30 hours of treatment. At this clinic, patients are trained in Paradoxical Relaxation, receive daily physical therapy, are trained in self-administered Stanford Protocol Trigger Point release, specific stretches, and related physical therapy techniques. It is the goal of this clinic for the patient to be able to self-administer most of the protocol without reliance on additional treatment.

The goal of the Stanford Protocol is to enable the patients to reduce and resolve their symptoms without dependency on drugs or others to do so for them
The Stanford Protocol represents a very different paradigm from one in which a patient who feels he has no control over his symptoms comes to the doctor to be cured and submits himself passively for the remedy. Our aim is to make patients independent. It is our goal that patients trained in our protocol find themselves in a position to take care of and possibly resolve this condition themselves without dependency on drugs or others to do so for them.