I’ve had a lot of great conversations since I put up my wand vlog, and I find that I’m coming back to the same areas so I decided that it’s time we talk about the wand.
1 . It’s a great tool but it’s not for everyone
In my clinic I do use them regularly with patients with difficulties reaching their pelvic floor, problems with dexterity or force through their hands, or if they’re keen to try it but don’t like the idea of self-touch. They’re also great for people who really want to own their treatment and who get a great response from manual myofascial release with me. The rest of the time with people who are comfortable with self-touch I get them using their own thumbs with one leg up supported or when reclined. For those who aren’t comfortable with self-touch I start with a deep squat breathing exercise and more generalised pelvic floor muscle down training.
Next I really want to talk about what we’re actually doing when we place our finger onto a contracted, shortened and painful pelvic floor muscle.
2. You’re not getting rid of trigger points
We’ve moved on from the idea of trigger points to a more nuanced understanding of “tension myalgia” within the tissues. I’m not disregarding your experience of palpating “nodules” which then create local or diffuse pain, and that you are able to then change, I’m just considering the physiology behind that phenomenon. There’s a wealth of articles discussing what this may be – anything by Quintner I worth reading. In fact, he puts it better than I ever could:
“We have critically examined the evidence for the existence of myofascial TrPs as putative pathological entities and for the vicious cycles that are said to maintain them. We find that both are inventions that have no scientific basis, whether from experimental approaches that interrogate the suspect tissue or empirical approaches that assess the outcome of treatments predicated on presumed pathology. Therefore, the theory of MPS caused by TrPs has been refuted. This is not to deny the existence of the clinical phenomena themselves, for which scientifically sound and logically plausible explanations based on known neurophysiological phenomena can be advanced.” (Quintner et al., 2014)
So what is happening?
We know several things about the pelvic floor of those in chronic pain:
Sensation and nociception has a reduced threshold for firing, meaning signals are sent to the brain from the vulva/vagina/pelvic floor with much less input required. This has been recorded in rats, mice and women with vulvodynia and dyspareunia. They were found to report pain to stimulation that in health controls was comfortable. They also recorded a response to stimulation that was imperceptible to healthy controls. You can read more of the work of Dr Melissa Farmer if you’re interested in this.
It’s suggested that there’s a degree of nervous oedema within the pelvic floor due to it’s constant contraction – there’s less venous drainage. This could potentially enhance the changes to sensation seen.
To support this there’s been a lot of work looking at the autonomic function of those with chronic pelvic pain, and BPS specifically. Based on their observations of a sympathetic autonomic neuropathy in BPS and pelvic pain patients Dr Chelimsky and his team propose that in myofascial pelvic pain states there’s a vascular neuropathy causing vascular hypersensitivity that reduces blood flow to the pelvic floor. And in BPS they observed impaired vagal nerve function which points to visceral hypersensitivity. It’s not difficult to see then why an ischaemic pelvic floor may hurt, or mechanisms that may lead to the body protecting itself through a constant contracted state. Also, that palpation within the area may be understood by the brain as visceral pain.
There’s oodles of brainy changes that occur – both to the motor and sensory areas, which means patients with pelvic pain have a very poor proprioception of where and what the pelvis is currently doing, and usual sensations like bladder filling or gas moving in the bowels can be misinterpreted as threatening by the brain due to the heightened stimulus it receives when everything is so hypersensitive. Dr Jason Kutch or anyone in the MAPP research network is good to follow if you want to know more about this.
The amount of attention the brain pays to the areas in pain also changes – patients are literally unable to switch off from their pain as their salience network decides that it needs to know more to potentially adapt to any threats occurring.
After a period of time where the brain has been managing a chronic threatened state, which uses a lot of energy and activity, it decides to shift the management of pain into the limbic system to free up some brain space to be open to detecting more threat. This isn’t great, now your emotional centre is managing your pain. Again, the links between psychological comorbidities such as anxiety & depression with chronic pelvic pain have been well documented and it’s not difficult to see why they may occur together.
So what are we, the physios, actually doing then?
This is what I understand to be happening given the evidence we have so far:
When you place your finger on someone’s pelvic floor several things have already happened:
You have developed a therapeutic relationship with them (I hope you have!) and they’ve given consent. Therefore, their system regards you potentially as less threatening, and you’ve begun to change the “threat” narrative in their brain. If you touch them they believe you’ll be helping, not injuring. Hopefully, again not all patients are the same! But I certainly wouldn’t touch someone until I felt that their system didn’t feel I was a threat. You can do this easily by observing the flushing of skin, sweating, their unconscious responses to your questions. Getting a patient to be truly not threatened by you can go a long way to cognitively overriding the “threat” output stimulus we call pain.
By talking to them kindly and educating them about what you believe to be going on you’re improving their locus of control, known to reduce pain, and demystifying and reducing the threat of the unknown terrible awful thing attacking their insides. Reduce the catastrophising, humanise the pathology, reduce the “problem” to a manageable level.
Ok, but what about all the great physical stuff we do?
We all use different techniques to get a pelvic floor to relax. A while back I did a lit review on techniques and found that those reporting to be successful in reducing pain and visceral symptoms (such as the huge Fitzgerald trial and pilot) were using gentle pressure, “contract-relax” or “PNF style activation/release” cycles to work the muscle allowing a pre-synaptic inhibition to then allow greater relaxation of the tissues, were using an individualised approach to patients (don’t hunt the “trigger points”, treat the painful areas in the person in front of you) and didn’t create a painful sensation. Those failing to improve patients did the exact opposite, including “pressure as hard as tolerable” and “fixed points throughout the pelvis”. So what do we achieve when we do this?
Palpating the pelvic floor helps to desensitise the peripheral nerves, increasing their threshold for firing. We know this – when you first palpate someone they may have an 8/10 pain, but after you’ve done some pelvic floor work they’ll maybe have a 2 or 3/10. This isn’t because you’ve magically massaged the pain away (well, you have,..but..) you’ve altered the peripheral neural threshold, reducing it’s sensitivity, and more importantly done a really complex thing in adjusting the patient’s brain patterns in response to touch in that area. You’ve been giving constant feedback on that muscle and how it’s working, moving, and changing to the patient. You’ve helped their brain to reorganise it’s understanding of the information that’s coming in from the pelvic floor region and decide that it’s not as threatening.
There’s some really interesting work by Piche (2015) that the initial few palpations – which are noxious – create a counterirritation response which then allows for descending inhibition of the area, making it feel more comfortable. That’s going to work in a similar way to tens (or when your mum steps on your other foot to make your brain think about something else).
Getting the muscle to move flushes some of that neural oedema, reducing the hypersensitivity… but not instantly.
Getting the muscle to move and guiding it to achieve it’s full lengthened position is going to give the brain some great motor and sensory inputs that it hasn’t had in a while. You’re starting to reverse those brainy changes that have occurred.
Can I pause here and say that “stretching” the pelvic floor doesn’t happen in one session – it takes longer to change sarcomere length. What you’re doing is improving the neuromuscular control, allowing the muscle to relax to it’s lengthened state. Repeated treatment may create some stretch, or may just allow the muscle to stay in a more relaxed position daily.
And finally, if you use deep abdominal breaths alongside your myofascial release you may also be gently getting some vagal nerve stimulation to assist in reducing the overall visceral pain. I ask patients to abdominally breathe to prepare, breathe out and activate their pelvic floor, breathe back in and release, then I use abdominal breaths during my stretching to help them achieve greater lengthening. I find it helps.
It’s Not About The Wand. You’re not getting rid of knots or stretching the pelvic floor muscle, it’s more complex and beautiful than that. It’s the process the pelvic floor muscle and whole vaginal region goes through, which is overseen by the brain’s appreciation of what’s happening in the pelvis (reducing threat) that achieves a more relaxed muscle state and in the end results in reduced pain, urgency and frequency in BPS. Change the threat, change the dysfunction, change the pain.
This doesn’t make you any less of a pelvic floor badass.