BIOFEEDBACK - disappointing results - David Wise Comments

[faceinthecrowd]

Today at the physical therapist I had biofeedback done to measure the tension of my pelvic muscles. Some measurements were a little abnormal, but nothing spectacular was recorded - certainly there didn't appear to be enough dysfunction to cause my now horrendous symptoms. I'm running out of options here, guys.

[webslave]

I'm not sure that's an entirely valid way to ascertain the state of pelvic floor spasm. I'll ask David Wise to comment.

[faceinthecrowd]

I'd aprreciate that, Weblsave. Thank you. Just to clarify, this biofeedback procedure (which I had never heard of before) was done through a rectal probe.

[webslave]

I've spoken to him on the phone, and he confirmed that biofeedback just isn't the right way to assess spasm. He will send more data soon. Meantime, relax

[scotsman]

My physio did an external and internal pelvic assessment and found lots of triggerpoints without a biofeedback machine in sight - infact, we're only now starting to look at using a biofeedback machine after 6 months of treatment.

As webslave says, it's not the way to assess spasm.

[webslave]

Dr Wise has commented on this discussion:

Dear Mark,

I am responding to your request for a comment about the usefulness of biofeedback measurements in determining if pelvic pain is a tension disorder and appropriate for the Stanford/Wise-Anderson Protocol. My short answer is that electromyographic measurement of the anal sphincter with a biofeedback anal probe, used alone, is an unreliable measure of what is going on inside the pelvic floor. Unremarkable readings of the anal sphincter should not be used to rule out tension disorder prostatitis and pelvic pain nor to dismiss the appropriateness of a treatment like the Stanford/Wise-Anderson Protocol.

Here is the longer answer. In my own case, when I was symptomatic, I did an hour or two of pelvic floor biofeedback on a daily basis for a year. After many months of diligent practice, my resting anal sphincter tone was a remarkable zero after about 15 minutes of relaxation. And I was very dismayed, like the person whose comment you sent to me, to find that I was still in pain at the moment that the anal probe registered zero. I was also disappointed as a clinician experienced in the successful use of biofeedback for other problems to find that the biofeedback measurement seemed to indicate (erroneously) that tension was not a central problem in my pelvic pain.

I didn't understand then what I understand now which is that the electrical activity in the anal sphincter is, for the most part, the only area that the anal biofeedback sensor measures, and often says very little about what is going on with the other 20 some odd other muscles within the pelvic floor. Furthermore, the biofeedback sensor measures dynamic muscle tension, but not chronically shortened tissue without elevated tone. It is possible to have a relaxed anal sphincter and have pelvic floor trigger points. In this case elevated tone and active trigger points inside the pelvic floor are not reflected in the anal sphincter measurements.

Shortened contracted tissue inside the pelvic floor, symptom- recreating trigger points when palpated and a tension-anxiety-pain cycle are the culprits in most people with pelvic pain that we successfully treat (which can sometimes includes a chronically tight anal sphincter as well in some) and we consider these factors criteria for diagnosis.. For example, in my experience at Stanford, people with levator ani syndrome almost always have an entirely normal resting anal sphincter tone while palpating the painful trigger points on the levator ani muscle is excruciatingly painful... resolving those trigger points and relaxing the inside of the pelvic floor can resolve this pain without much change in the measurement of the tone of the anal sphincter before or after treatment.

On our small website, http://www.pelvicpainhelp.com, we have video clips of a important study, replicated many times, demonstrating that at rest, the electrical activity inside a trigger point in the trapezius, monitored by an a needle electromyographic electrode is quite high while the electrical activity of the tissue less than an inch away from the this elevated electrical activity is essentially electrically silent. If you used a regular biofeedback sensor to measure the general tone of the trapezius, you may well find nothing remarkable and yet to rely on this information is entirely misleading and would incline you to miss the treatment that could substantially reduce or abate the pain and dysfunction coming from the active trigger point.

Bottom line here is that in my experience, electrical measurement of the anal sphincter, (or the opening of the vagina) used alone, is often poor measure of what is going on inside the pelvic floor. While I believe biofeedback is remarkably successful for many other disorders, and is one of the treatments of choice for urinary incontinence, vulvar pain, I am unimpressed with the usefulness of biofeedback in treating most male pelvic pain

The best gauge of the usefulness of our protocol that treats pelvic pain of neuromuscular origin is a thorough examination of the pelvic floor for trigger points that recreate symptoms and palpating for tightened and restricted muscles inside the pelvic floor. This must be done by someone with a significant amount of experience in working with pelvic pain and with the kind of myofascial trigger point release that we use. An inexperienced person will miss all this and I have seen many times that even physical therapists who specialize in treating pelvic pain miss trigger points referring the symptoms to and inside the pelvis. This is one reason why we have offered trainings for physical therapists who treat male pelvic pain.

We sometimes find it useful when there is a high pelvic floor resting tone, because it provides an objective marker that we can compare readings to after the patient has used our protocol. The idea that pelvic floor biofeedback measurements are a reliable test of whether pelvic pain is a tension disorder represents a misunderstanding of the problem and should not be relied on, especially when the readings are normal. Pelvic floor electromyographic measurement monitoring the anal sphincter is one of those medical tests where a positive finding may mean something and point toward the proper therapy and a negative result doesn't prove anything.

[alprost]

Very Interesting! - Thanks Dr Wise & Mark.

[scotsman]

Very Interesting! - Thanks Dr Wise & Mark.

Completely agree - very interesting response from Dr Wise.

[MS]

Very Interesting! - Thanks Dr Wise & Mark.

Completely agree - very interesting response from Dr Wise.

Ditto...

Faceinthecrowd: I think what Dr. Wise commented is very relevant:

"...the electrical activity in the anal sphincter is, for the most part, the only area that the anal biofeedback sensor measures, and often says very little about what is going on with the other 20 some odd other muscles within the pelvic floor."

Does your PT do internal myofascial release? I had a lot of success with release of other pelvic floor muscles, especially the obturator internus.

I think you still have a lot of options.

[lrm]

What is the range for a "postive" electromyographic measurement of the anal sphincter? If your readings are positve, can you use this method as a reference to work on biofeedback of the pelvic floor? Can it be useful or successful, or since it isn't measuring many of your other muscle areas is it not really relevant

[alprost]

Today at the physical therapist I had biofeedback done to measure the tension of my pelvic muscles. Some measurements were a little abnormal, but nothing spectacular was recorded - certainly there didn't appear to be enough dysfunction to cause my now horrendous symptoms. I'm running out of options here, guys.

Make sure you check out this post - It is very important in relation to this point: viewtopic.php?t=1626

[Bill in NH]

Today at the physical therapist I had biofeedback done to measure the tension of my pelvic muscles. Some measurements were a little abnormal, but nothing spectacular was recorded - certainly there didn't appear to be enough dysfunction to cause my now horrendous symptoms. I'm running out of options here, guys.

Have you had any relief yet?

I just read your post and can very much relate! I've had chronic prostatitis / chronic pelvic pain syndrome now for 15 months. Although my symptoms started with severe pain, my pain now is minimal. What I have instead is a near constant irritation/hypersensitivity in my bladder and urethra associated with varying degrees of needing to void. I am in the middle of a flare now and this sensation is really bothersome.

I think in my case and others, the urgency is due to two factors. One is simply the irritation of the bladder lining and the other is a high rate of urine production. I have keep accurate records of my urine frequency and volumes for over one year and have noticed that I will often pee up to 400cc an hour during flares, even when I haven't been drinking anything. I suspect that the irritation in the bladder signals the brain to produce more urine (via hormonal control of the kidneys).

I have had more than 25 PTs sessions by 4 different PTs. My pelvic muscles now feel nearly normal to myself and to the two PTs that I have recently seen. One of those PTs is recommending that I have an EMG probe placed into my bladder neck to see if the sphincter muscle is tight, and if so, to relax the muscle using biofeedback. In light of my recent flare and my already having tried almost everything else, I am seriously considering this recommendation. I'll keep you posted.

[scotsman]

What I have instead is a near constant irritation/hypersensitivity in my bladder and urethra associated with varying degrees of needing to void. I am in the middle of a flare now and this sensation is really bothersome.

Bill - worth trying Prelief - I've been taking them recently and have found they have taken away all my irritation and hypersensitivity in my urethra (I didn't have it that bad - but it has taken away what was there).

Richard.

[Bill in NH]

Bill - worth trying Prelief - I've been taking them recently and have found they have taken away all my irritation and hypersensitivity in my urethra (I didn't have it that bad - but it has taken away what was there).

Richard-thanks for the advice. Fortunately, that very bothersome irritation/hypersensitivity abruptly disappeared about 3 hours after I posted my message and my last 3 days have been my best since this problem started in Jan 2003.

Apropos to one of your earlier posts about negative feelings, I go on a downward spiral about once every 2 weeks when my symptoms gets very bothersome. A PT recently suggested that I try a SSRI (selective serotonin reuptake inhibitor) antidepressant to help block the pain signals as well as treat the depression. However, I got depressed just reading about all the potential side-effects of these drugs and decided to markedly increase my daily dose of omega3 fish oil instead (high dose omega3s have been shown to reduce depression by increasing the production of serotonin in the brain). About 12 hours into this last flare, I increased my daily dose to 10g (15 capsules) and 12 hours later the flare abruptly stopped. Whether the fish oil had anything to do with my improvement I don't know. Another theory is that there is a cycle that runs its course: something precipitates the release of histamine from mast cells in the urinary tract which stimulates nerves endings that in turn cause more release of histamine until all the histamine is used up. Then there is a relatively symptom free period until the histamine builds up to a critical level again. Regardless, I'll keep up with the fish oil for the time being and keep you posted.

BTW, I did use Prelief last year when my symptoms first started and I really didn't notice any great effect. Admittedly, though, it's hard to figure what works a little and what doesn't at all when the underlying problem waxes and wanes so much.

[scotsman]

Richard-thanks for the advice. Fortunately, that very bothersome irritation/hypersensitivity abruptly disappeared about 3 hours after I posted my message and my last 3 days have been my best since this problem started in Jan 2003.

Apropos to one of your earlier posts about negative feelings, I go on a downward spiral about once every 2 weeks when my symptoms gets very bothersome. A PT recently suggested that I try a SSRI (selective serotonin reuptake inhibitor) antidepressant to help block the pain signals as well as treat the depression. However, I got depressed just reading about all the potential side-effects of these drugs and decided to markedly increase my daily dose of omega3 fish oil instead (high dose omega3s have been shown to reduce depression by increasing the production of serotonin in the brain). About 12 hours into this last flare, I increased my daily dose to 10g (15 capsules) and 12 hours later the flare abruptly stopped. Whether the fish oil had anything to do with my improvement I don't know. Another theory is that there is a cycle that runs its course: something precipitates the release of histamine from mast cells in the urinary tract which stimulates nerves endings that in turn cause more release of histamine until all the histamine is used up. Then there is a relatively symptom free period until the histamine builds up to a critical level again. Regardless, I'll keep up with the fish oil for the time being and keep you posted.

BTW, I did use Prelief last year when my symptoms first started and I really didn't notice any great effect. Admittedly, though, it's hard to figure what works a little and what doesn't at all when the underlying problem waxes and wanes so much.

Great news about the last 3 days - long may the improvement continue!

I'd avoid the SSRI approach if you can. I took Paxil (seroxate) for a number of years and came off it 5 months before my chronic prostatitis / chronic pelvic pain syndrome started. Coming off it was horrendous and I felt it didn't do anything for me when I was on it. Everyone is different though and such drugs have helped others.

Interesting that you're getting good omega3 results - I've just started taking them myself.

Richard.