Confusion about internal trigger points

[Viking]

Having been to see PT Bill Taylor in Scotland, who has treated Scotsman and I believe Alprost as well, and reading what DR. Wise and DR. Anderson has said about internal trigger points, I feel that there is some confusion here.

Bill found basically one TP just inside my rectum and I have later on found and treated another myself. These have just been about 1 inch inside. Bill told me that most people go too far in where there is only the anal canal and no muscles. I feel that the slight progress I have made though, can not be contributed to these two TPs being treated, but the fact that I am now able to relax the pelvis pretty much all day. Scotsman has said that he basically treats the sphincter or opening and as little as 1-2 inches inside.

Then, when you read what Wise and Anderson say, they keep referring to TPs located more infront of the pelvis where the muscles attach to the prostate. Wise has said that if the fingers are not longe enough, you will miss this connection.

Based on this, can we conclude that Bill and probably lots of other PTs do not have enough skills and knowledge to properly treat us?

It would be nice to see a diagram or even better, a real picture of the pelvic floor where you see the prostate and surrounding muscles and where typical TP locations were marked.

Any thoughts?

[Paso]

I have seen both Bill and Tim Sawyer (Who works with David Wise). As a matter of fact I see Tim on a somewhat regular basis, when my job takes me to San Fransisco, every third month or so. In my view, Bills treatment is very similar to the one being performed by Tim. I am lucky to have been under the treatment of the 2 of the leading PT:s in chronic prostatitis / chronic pelvic pain syndrome in the world. In my opinion, either one is a hard core pro, that knows what they are doing. If I were to pick one, I would go with Bill however

/Paso

[scotsman]

...Scotsman has said that he basically treats the sphincter or opening and as little as 1-2 inches inside...

I do deeper internal treatment heading up underneath my perinum as well - this seems to be my main troublespot.

Richard.

[alprost]

Having seen both Bill and Tim Sawyer I feel I really need to comment here. Firstly, I'm really grateful to Bill. He correctly diagnosed me, treated some trigger points which gave me a noticable improvement in my symptoms, and gave me hope at one of the lowest points in my condition - I'll always extremely be grateful to him for that.

Ultimately however, Bill only got me so far as he missed many (around 15) trigger points, both externally and internally, which were later found by both my partner and Tim Sawyer. I've also spoken to other patients of his who have had a similar experience. I want to emphasise that I'm not 'bad mouthing' Bill behind his back - I've told him this in a face to face conversation, and he mentioned that he was planning to go over to Stanford at some point to spend some time learning from Tim Sawyer. This is a very difficult post for me to write, but I feel I need to be completely honest for the sake of chronic prostatitis / chronic pelvic pain syndrome patients. Absolutely nothing matters more than the truth - only this can lead to lessening their suffering. As such, Physiotherapists also need to look deep inside themselves and be truly honest with themselves regarding the extent of their training and experience in treating chronic prostatitis / chronic pelvic pain syndrome if they are to get outside their comfort zone and acquire real skills.

There are three types of PT's who treat CPPS:
Type 1 - Have talent, training, experience and a proven track record in successfully treating CPPS.
Type 2 - Know that chronic prostatitis / chronic pelvic pain syndrome is caused by trigger points and try their best to treat it, but do not have extensive training and experience.
Type 3 - Have absolutely no knowledge of chronic prostatitis / chronic pelvic pain syndrome or the fact that it is caused by myofascial trigger points.

Of these, type 2 are not part of the solution - they are part of the problem - as they can send you down the wrong treatment path. If you go to see one of these (I've seen 2 Physios in this category who missed numerous trigger points), and they tell you that you have no more trigger points when you do have, you start to think that something else must be wrong with you, and then you start pursuing other treatment options for your remaining symptoms. I've been told this twice with a pelvic floor and abdomen full of trigger points! These physios can send you off-track from the only treatment which can help you!!!

Getting access to a trained and experienced PT is the biggest difficulty we all face. This causes the type of confusion about treatment/symptoms seen in the original post.

Read the section on Physical Therapy in the 3rd edition of AHIP - believe me, all of the answers are in there.

[inflamed]

I personally think in some cases when you are getting treated internally, Tps can go away but unfortunately new Tps can form as well. I can know exactly what alprost is saying when I worked in States I saw 2 physios.

1. Tim Sawyer who basically you can tell knows exactly what he is doing

2. lady who was surprised when I showed her trigger points on my abdomen, and was quite tentative with internal trigger points, but still helped me a great deal.

1 of the problems basically is who wants to stick their finger up some else's ass as part of their job.

[scotsman]

A fair post Alan.

I've had around 50 sessions with Bill but my last one was well over a year ago. Bill is a really nice guy and does know a fair amount but I did find his ability to help me reached a certain point and I took the treatment forward myself.

Hopefully Bill will follow through with his plans on going to Stanford to continue his learning.

Richard.

[robertpagen]

Alprosts observations (Type 2 PT's ) are applicable to what I encountered with PT's in New York. I got the feeling that some were just poking around and hoping for the best.

[webslave]

Bill is a member here and may wish to comment.

I tend to support those who say that the Stanford team is still cutting edge, and until the knowledge they have is more widely applied and studied, this situation is unlikely to change.

[GS]

Tim Sawyer is the man plain and simple when it comes to treating trigger points related to CPPS. I live on the east coast and get treatment in NYC on a regular basis, but I try to go out to California every 6 months to see Tim and get a checkup and make sure the local PT's are doing a good job. He is very accesible to other PT's who may need some guidance. One of my NY PTs went with me to see Tim on one trip. The other 2 PTs took Tim's course when he was in NYC a couple years back.

[robertpagen]

I had gone to sessions at EMH physivcal therapy on 3rd ave in November 2003 and found them ineffective at that time.

I had gone to sessions with Ann Duffy in 2004 and found them good up to a point. They were also very good with insurance issues.

Marilyn Friedman is in her own league when it comes to PT for chronic prostatitis / chronic pelvic pain syndrome in men.
She is excellent but expensive.

It is my view that we are a resource for those on this site looking for information and direction. For this reason we ought to be specific when mentioning who we have consulted with. It is not helpful to say "someone in NYC".

[alprost]

It is my view that we are a resource for those on this site looking for information and direction. For this reason we ought to be specific when mentioning who we have consulted with. It is not helpful to say "someone in NYC".

Fair Point. The other PT I saw was Marcy Dyan whilst I was on Holiday in Vancouver 3 years ago. She was very helpful and went out of her way to give me advice about a range of issues related to chronic prostatitis / chronic pelvic pain syndrome and even gave me extra time for free.

However, she was completely ineffective at assessing and identifying trigger points.

[physiobil]

Thanks for the opportunity to reply to the discussion regarding the assessment and treatment of trigger points.

Firstly let me say that I am a physiotherapist with over twenty years experience of treating chronic pelvic pain in many groups of patients. My interest in chronic prostatitis / chronic pelvic pain syndrome developed through treating patients over a number of years with unremitting and unusual symptoms which id not fit conventional diagnostic categories and had proved unresponsive to conventional therapy. As a result I have been seeing chronic prostatitis / chronic pelvic pain syndrome clients in my clinic for over 5 years now. The success I have had has been encouraging and has pushed me as a physiotherapist and an individual. However, to say that I'm not still learning and will continue to learn about chronic prostatitis / chronic pelvic pain syndrome and my clients would less than truthful.

My knowledge of the treatment of chronic prostatitis / chronic pelvic pain syndrome comes from a mixture of sources. My previous knowledge and experience in the treatment of pelvic pain and a significant amount of self directed study of the published work of The Stanford Group and Ruth Sapsford who has contributed significant information to the function of the pelvic floor. The work by the Dr David Wise and the Stanford Group is cutting edge and has inspired me in my work with chronic prostatitis / chronic pelvic pain syndrome patients.

Assessment and treatment of trigger points is paramount in the treatment of chronic prostatitis / chronic pelvic pain syndrome and this is obviously a skill which has to be learned. It is a palpatory skill, which I have refined to a considerable degree over my twenty years as a Certified Manual Therapist. It is though, a skill which can be taught effectively to the partners of chronic prostatitis / chronic pelvic pain syndrome clients.

The assessment and treatment of trigger points is on the surface a straight forward task. However TPs can be elusive and whilst existing TPs can disappear new points can arise daily. As we are all aware symptoms can be made worse by many different activities and flare ups can occur for no apparent reason. This can make the mapping of TPs in the pelvic floor a challenge in a dynamically changing landscape.

It behoves each physiotherapist who is treating patients with chronic prostatitis / chronic pelvic pain syndrome to critically evaluate their practise and ensure they are following a scientifically based assessment and treatment procedure. They should become as knowledgeable and skilled in the assessment of the function of the pelvic floor and the location of TPs both internally and externally as they can. At present this can prove to be difficult as there are few, if any formal training courses available. In this environment it is responsibility of each physiotherapist to wok within his scope of practise while continuing to refine his knowledge of chronic prostatitis / chronic pelvic pain syndrome treatment. Spending time in California with Dr Wise and his team is one of the few opportunities available to develop and refine your skills. It has been difficult for me to get time away from my busy practise to do this, but hopefully this is something I will get the opportunity do sometime soon.

Each client I see is an individual who receives a very specific assessment of the mechanical function of the pelvis, the global and local muscular system, the neural system and a specific assessment of the pelvic floor musculature including assessment of TPs. I take a holistic approach to the function of the body and treatment, for me, must take all of these systems into account, even if at the end of the assessment there is a bias towards the treatment of TPs, both internal and external.

I continue to learn from my own study but especially from my clients, who never stop amazing me with their courage in dealing with and frequent insights into this condition. I cannot post this without thanking alprost who was the force behind my interest in the treatment of chronic prostatitis / chronic pelvic pain syndrome and scotsman who taught me so much about how to listen and to hear what chronic prostatitis / chronic pelvic pain syndrome patients have to say.

I continue to improve my skills in the assessment and treatment of my patients and continue to be challenged by this condition - Someone has to step up to the plate and I am glad it's me.

[boudreaux]

this is a fascinating thread because it is so honest, and the key to overcoming this condition is being honest with yourself, even if that means admitting your mortality and that there are more sustainable ways to live life. long term trigger point treatment and maintenance is absolutely crucial to healing but it must be combined with a lowering of your default autonomic central nervous system arousal level through deep relaxation/meditation as well as dealing with long suppressed emotional rationalizations, delusions, and suppressions through the use of cognitive therapy (like other posters on this forum, I think byron katie's work is the best).

this is a wonderful and honest thread about how few PTs there are that "really" know about trigger point phenomena. I concur that tim sawyer is the best in the world, I have seen him multiple times. however, even tim can miss trigger points not because he doesn't know all the muscles, but because he is literally "not in your body." You are the only one in your body, and therefore it is your responsibility, not a therapists', to learn your trigger points, how they feel, the type of pain they refer (stinging, cold, throbbing, shooting), the best way to release them (tennis ball, Theracane, knobber, pencil eraser, wife, girlfriend, or a therapist if you are having trouble finding the right angle to treat it) -- even if this means sticking your thumb up your butt in the shower and feeling around to find the spots of tenderness and pain (study AHIP third edition). Also, touching on what Bill Taylor said about other trigger points "arising", it is undeniable that releasing a major trigger point can allow a whole new problem area to arise -- this is because the myofascial system is one, and you can have areas of restriction that are so knotted and suppressed that other distant trigger points have to be treated before you are even aware of them. Trigger points is a fascinating science, and though chronic prostatitis / chronic pelvic pain syndrome was hell for a while, I feel blessed to know about and how to identify trigger points.

i am not a physical therapist (in fact I'm a lawyer, but don't hold that against me), but I am confident that I could teach a class on trigger points to urologists. in fact, I have a group of friends that come to me when they hurt and I do trigger point work on them. I have read travell's medical textbooks cover to cover. I do not tell all this to toot my own horn -- I tell it because I want to encourage all of you to take responsibility for your condition, to become an expert of your body. Trigger point work to me is like art, it becomes fun -- rolling around on tennis balls, getting in creative positions with the Theracane. I have gone from being someone who could not think about touching his toes to being able to lay my forehead on my knees with straight legs. I cannot recommend yoga enough. Each yoga posture shows you where you have myofascial restriction, and where you need to focus your trigger point massage efforts. Also, I cannot recommend Davies' book enough.

As Dr. Wise says, chronic prostatitis / chronic pelvic pain syndrome cannot be overcome if you look at it as a distraction to your "real" life. chronic prostatitis / chronic pelvic pain syndrome is the main curriculum, it is your "real" life right now. You have to get into it and learn just like you would something that was making you money. I know it sounds crazy, but chronic prostatitis / chronic pelvic pain syndrome can be a "gift" if you break out of your old separating, rationalizing mindsets. chronic prostatitis / chronic pelvic pain syndrome can teach you the value in just being alive, being present, being conscious. But it takes times -- years, maybe one, maybe two, maybe four -- do not give up. as dr. wise says, if you have been chronically contracting your pelvic floor for 30 years, it's not that big of a suprise that it will take 2-3 years of stretching it out and relaxing it for it to heal. in fact, that's a pretty good ratio.

this is an amazing forum, absolutely amazing. grown men bearing their souls is a beautiful thing -- it's a shame society teaches that we are not supposed to. My best to everyone.

[scotsman]

As Dr. Wise says, chronic prostatitis / chronic pelvic pain syndrome cannot be overcome if you look at it as a distraction to your "real" life. chronic prostatitis / chronic pelvic pain syndrome is the main curriculum, it is your "real" life right now. You have to get into it and learn just like you would something that was making you money. I know it sounds crazy, but chronic prostatitis / chronic pelvic pain syndrome can be a "gift" if you break out of your old separating, rationalizing mindsets. chronic prostatitis / chronic pelvic pain syndrome can teach you the value in just being alive, being present, being conscious. But it takes times -- years, maybe one, maybe two, maybe four -- do not give up. as dr. wise says, if you have been chronically contracting your pelvic floor for 30 years, it's not that big of a suprise that it will take 2-3 years of stretching it out and relaxing it for it to heal. in fact, that's a pretty good ratio.