David Wise, Ph.D.
Director, National Center for Pelvic Pain Research, Telephone: 707 874 2225, Fax: 707 874 2335. Website: www.pelvicpainhelp.com and www.pelvicpainhelpforwomen.com
Coccygodynia, Coccydynia, or tail bone pain is a distressing and often chronic condition that has a number of presumed causes. Trauma, childbirth and anxiety triggered chronic tension in the pelvic floor are among the events associated with this condition. In this essay, we will discuss tail bone pain that is understood to be muscle-based and is often successfully treated by the Wise-Anderson Protocol (www.pelvicpainhelp.com) a treatment involves rehabilitating the muscles in the pelvic floor related to tail bone pain used for many cases of tail bone pain developed at Stanford University in the Department of Urology. We have discussed this subject as it also relates to other diagnostic categories. Below we discuss a proposed origin of tail bone pain that takes on a life of its own after the initial physical or psychological trauma has resolved because of a self feeding cycle of tension, anxiety, pain and protective guarding. Again this essay discusses chronic tail bone pain that is based in painful chronically contracted muscles of the pelvic floor.
It is common knowledge that a dog will pull his tail between his legs when he is fearful. Other emotions have been attributed to this tail-pulled-between-the-legs behavior, including shame, submission, dread, defeat or shyness. For the present discussion we propose here that the common denominator running through the various emotions associated with the tail-pulled-between-the-legs behavior in vertebrates and significantly, including humans with pelvic pain, is fear.
In the typology of Walter Cannon, the great Harvard physiologist of the early 20th century who introduced the phrase "fight, flight, freeze" to describe the varieties of survival behavior in mammals, a tail-pulled-between-the-legs is an expression of the survival behavior that he termed, "freeze". This freeze behavior expresses the organism’s attempt to self-protectively hold fast, while waiting for danger to pass. The behavior of a waving tail has been associated among animal watchers with the emotions of excitement or aggression, contrasting sharply to the tail-pulled-between-the-legs behavior. Most cat and dog owners, for example, intuitively read their animals’ emotional states, in large part, by what the tail is doing.
In humans, the tailbone is commonly understood to be what remains of the tail inherited from our humanoid ancestors. This tailbone (coccyx) is sometimes called the vestigial tail. In humans, the coccygeal, iliococcygeal and pubococcygeal muscles of the pelvic basin are attached to the coccyx or tailbone and are responsible for its movement. in conjunction with other pelvic floor muscles.
The phrase, 'a tail between the legs' exists in the vernacular in many languages to describe behaviors of fear, shame, submission, cowardice or defeat. In English, we describe someone who withdraws in fear, shame or defeat as "pulling his tail between his legs". For example, in French, the term, "la queue entre les jambes" is commonly used and is identical in meaning. In modern Greek, the transliterated phrase “"Autos einai san to skylo pou vazi tin oura mes ta skelia tou" which translates as "he is like the dog who puts his tail deep down below" Greeks use this phrase all the time to describe someone who is fearful, anxious, nervous, ashamed, or beaten down by life. This Greek phrase is often used to describe someone who can't make a decision, who is "frozen" by choices before him, who obsesses over which decision to make.
The phenomenon of pulling the tail between the legs requires that specific pelvic floor muscles, particularly involving the coccygeal muscles, participate in this muscular event. In this act of muscle contraction, this set of pelvic muscles contract, causing the tail (tailbone) to pull in. We offer the insight here that in terms of evolution, the tail- pulled-between-the-legs is an active behavior associated with the experience of fear, and whose aim is likely to protect the anorectal area and genitals of the organism as well as signaling to a predator or competitor that it is no longer a threat.
To our knowledge, in the scientific discussion of pelvic pain, there is little discussion of what we believe to be the intimate relationship between tail-pulled-between-the-legs behavior, anxiety and pelvic pain. Here we introduce this idea and the therapeutic implications of this unlikely and yet clinically important relationship.
From the beginning of our research we have known that pelvic pain was related to chronic self protective muscle tension that formed a self-feeding cycle of tension-anxiety-pain and protective guarding. In the original publication of our book, A Headache in the Pelvis, we summarized our understanding as follows:
We have identified a group of chronic pelvic pain syndromes that we believe is caused by the overuse of the human instinct to protect the genitals, rectum, and contents of the pelvis from injury or pain by contracting the pelvic muscles. This tendency becomes exaggerated in predisposed individuals and over time results in chronic pelvic pain and dysfunction. The state of chronic constriction creates pain-referring trigger points, reduced blood flow, and an inhospitable environment for the nerves, blood vessels, and structures throughout the pelvic basin. This results in a cycle of tension, anxiety, and pain, which has previously been unrecognized and untreated.
Understanding this tension, anxiety, and pain cycle has allowed us to create an effective treatment. Our program breaks the cycle by rehabilitating the shortened pelvic muscles and connective tissue supporting the pelvic organs while simultaneously using a specific methodology to modify the tendency to tighten the muscles of the pelvic floor under stress.
We have been impressed by the pervasiveness of pelvic pain internationally. Every month our website is visited by individuals from over 90 countries. The biological instinct for animals to pull the tail between the legs exemplifies why pelvic pain to one degree or another, exists in human beings regardless of race, gender or country of origin.
The insight that pelvic pain is related to tail-pulled-between-the-legs behavior has both theoretical as well as practical applications. The practical application more clearly identifies what we believe is the therapeutic strategy necessary to treat posterior symptoms like sitting pain, coccygeal pain and post-bowel movement pain in particular, along with associated pelvic pain and dysfunction in general.
In summary, we propose that pulling the tail between the legs is a mammalian self-protective reflex which occurs in vertebrates with tails and humans, with vestigial tails, otherwise known as tailbones. Furthermore, we are proposing here that pelvic pain in humans occurs when, in states of intense or ongoing anxiety, individuals chronically pull their ‘tail’ between their legs. In fact, the muscular activity of pulling the ‘tail’ between the legs, if done chronically, causes painful shortening and contraction of the coccygeal muscles as well as other muscles associated with puling the tailbone (tail) in.
Upon examination, the muscles involved in the tail-pulled-between-the-legs behavior are among the most common with trigger-pointed, shortened and painful muscles in patients with pelvic pain. Specifically, in the data we have collected from patients who have visited us for treatment of their pelvic pain, we have very often been able to recreate pain associated with sitting, coccygeal pain and post bowel movement pain by palpating the ileococcygeus, pubococcygeus, sphincter ani, and piriformis muscles.
It is also important to say, that physical trauma or injury to the pelvis can also trigger this protective tail-pulled-between-the-legs behavior. In other words, the tail-pulled-between-the-legs behavior can occur outside of states of chronic anxiety or fear.
The tail-pulled-between-the-legs phenomenon is essentially invisible to our fellow humans because we do not have a visible tail to inform each other of our states of fear and anxiety. Because muscle related pelvic pain has its origin in the biological instinct to protectively pull the tail between the legs in states of fear or trauma, it makes sense why this disorder consists of various spastic or chronically contracted muscles that tighten the entire pelvic floor, and are fed by tension, anxiety, pain and protective guarding. Once set in motion, this syndrome takes on a life of its own and forms a self-feeding cycle, even when the fearful event or trauma has passed. Additionally, the act of sitting on sore muscles reinforces a protective contraction that perpetuates sitting pain and makes it difficult to treat.
We draw a relationship here between sitting pain and tail bone pain in humans and the animal behavior of pulling the tail between the legs related to states of fear. Pulling the tail between the legs is a muscular event primarily involving contraction of the puborectalis, pubococcygeus, ileococcygeus, sphincter ani, gluteus maximus and related muscles. From the data of patients that we have treated over the last several years in our Wise-Anderson Protocol clinics, we found in a large number of cases of patients with sitting pain, trigger points in the muscles listed above were able to recreate sitting pain symptoms. These muscles are involved in pulling-the-tail-between-the-legs behavior. The rehabilitation of these muscles and the modification of the tendency to chronically pull the tail in under stress are essential to the amelioration of sitting pain.
Beyond the necessity of softening the taut, chronically tensed muscles involved in pulling in the tail, the notion that pelvic pain comes from a biological impulse to pull in the tail between the legs in states of fear confirms the necessity of lowering the default level of nervous system arousal that keeps the tail chronically pulled in.
Lowering the default level of nervous system arousal requires ongoing practice in reversing the thinking process representing the world as a dangerous place in which we must remain protectively guarded. We train our patients in Paradoxical Relaxation which provides a regular time during the day, when you can release your protective guarding, free yourself from fear and inwardly rest. In the moments of being free from anxiety, the biological reflex to keep the tail pulled is interrupted and the pelvic floor can get accustomed to being relaxed.
The Wise-Anderson Protocol began when Dr. David Wise, a psychologist in California who had suffered from pelvic pain, including tail bone pain for many years, contacted several urologists including Dr. Rodney Anderson, a professor of Urology at Stanford University School of Medicine and a leading practitioner and expert in the field of pelvic pain. Dr. Anderson was often considered to be the court of last resort for patients with pelvic pain and prostatitis who had not been helped by any other treatment.
Through many years of suffering with pelvic pain, Dr. Wise discovered a way to become free of his symptoms. Dr. Wise reported the method he used to Dr. Anderson, who headed the chronic pelvic pain clinic in the Department of Urology at Stanford University Medical Center. After this meeting with Dr. Anderson, Dr. Wise began working as a Visiting Research Scholar at Stanford’s Department of Urology alongside Dr. Anderson, treating men and women who were referred to Dr. Anderson with a variety of diagnoses including, chronic pelvic pain, prostatitis coccygodnynia, coccydynia levator ani syndrome, pelvic floor dysfunction, pelvic floor myalgia, interstitial cystitis and other chronic pelvic pain syndromes. Dr. Wise and Dr. Anderson worked together for eight years at Stanford, treating patients with the protocol that Dr. Wise used in his own recovery. At Stanford, the protocol was administered to patient on an individual basis in a conventional medical format.
During these early years, the substance and results of the Wise-Anderson Protocol were presented at meetings for pelvic pain and prostatitis researchers at the National Institutes of Health and other scientific meetings. In 2003, Dr. Wise and Dr. Anderson published the first edition of A Headache in the Pelvis, a book for patients that described the new protocol in detail. In the first edition of A Headache in the Pelvis, this protocol was called the Wise-Anderson Protocol. As the protocol became more widely disseminated, those on the internet dubbed it the Stanford Protocol. The term Wise-Anderson Protocol is now again used to describe this protocol, although it was popularly called the Stanford Protocol for man years. The Wise-Anderson Protocol it is identical in form and substance to what has been called the Stanford Protocol in the public arena through the years.
When Dr. Wise left Stanford, he began treating patients using the Wise-Anderson Protocol in a six day comprehensive, immersion clinic in Sonoma County, California. The immersion clinics have been offered continuously in Sonoma County since 2003. Patients come from all around the world to learn the Wise-Anderson Protocol in these immersion clinics.
Competence in self-treatment has produced the best results in patients who have learned the Wise-Anderson Protocol. The focus of the Wise-Anderson Protocol has evolved over the years to train patients to be able to do the protocol without the assistance of professionals. While the immersion clinics in Sonoma County are not affiliated with Stanford, Dr. Anderson, who is currently a Professor of Urology Emeritus (active) at Stanford University School of Medicine continues to evaluate patients with pelvic pain at Stanford and refer patients to the immersion clinic. Additionally, Dr. Anderson continues conducting and publishing research on the Wise-Anderson Protocol, as well as other medical research on a variety of subjects. From 2003 to the present, Dr. Rodney Anderson, Dr. David Wise and Tim Sawyer (Physical Therapist) have actively and enthusiastically collaborated on research involving patients seen at both Stanford and the immersion clinics.
Since 2003, Anderson, Wise and Sawyer have published a number of articles in the Journal of Urology on data from patients they have collaboratively seen and treated. Abstracts of these articles can be found at http://pelvicpainhelp.com/abstractofresearch.php. In 2005, Dr. Wise was a plenary speaker at a National Institutes of Health conference on pelvic pain, presenting research results on the Wise-Anderson Protocol. Further, Dr. Wise presented the protocol to scientific meetings including those of the International Continence Society. Both Dr. Wise and Dr. Anderson have written chapters in medical textbooks describing the Wise-Anderson Protocol. At the time of writing this section, Dr. Anderson presented a clinical poster of our work at the American Urological Association. A report of Dr. Anderson’s presentation at the American Urological Association was published in Medscape Medical News, titled Intensive Therapy Regimen Helps Men With Chronic Pelvic Pain Syndrome.
Information on the Wise-Anderson Protocol for tail bone pain can be found on www.pelvicpainhelp.com or by calling 707 874 2225 in California.