03/01/2023
PHYSIOTHERAPY MANAGEMENT OF COCCYDYNIA
Managerial techniques unfold under the cover of physiotherapy is now requiring a strict research based techniques with evidence or proof. Going through several information, the information below are known to be ways coccydynia is effectively managed via physiotherapy.
1. Ergonomic Adjustments:
The initial goal of treatment should be focused on providing postural education. Individuals should be taught to correct their sitting posture by sitting more erectly on a firm chair. A proper sitting posture ensures weight is taken off the coccyx and is instead loaded onto the ischial tuberosities and the thighs.Patients should be advised to avoid any positions or movements that might exacerbate their symptoms. (Ref. figure 7).
Physiotherapists may also recommend the use of cushions. Modified wedge-shaped cushions (coccygeal cushions), which can be purchased over the counter, help to relieve the pressure placed on the coccyx during sitting. Donut shaped or circular cushions may also be used. Donut shaped cushions may actually increase pressure over the coccyx, but are more beneficial for re**al pain.The use of cushions can be recommended over a 6-8 week period.Although commonly recommended, the therapeutic outcomes of these conservative recommendations have not been evaluated in the literature.(Ref Figure 1).
Manual Therapy:
The manual therapy techniques suggested in the literature range from massage, stretching, mobilization and manipulation, and may either involve internal or external contact with the coccyx.
Internal techniques may include massage of the levator ani muscle or the coccygeus muscle,joint mobilization while the coccyx is hyperextended to stretch the levator ani,or repeated mobilizations while the coccyx is rotated.
External techniques may include manipulations of either the coccyx or sacroiliac joint,mobilizations of the sacrococcygeal or intercoccygeal joints,posterior mobilizations to the thoracic spine,and stretching of the piriformis or iliopsoas.
The technique chosen will vary depending on what the originating cause of the coccygodynia is. For example, massage or stretching of the levator ani might be chosen if the underlying cause is due to spasm of the pelvic floor musculature.Mobilization techniques may be the preferred technique when the goal of treatment is to increase coccygeal mobility. Manipulation techniques are helpful when the goal of treatment is to improve extension of the coccyx.
A study by Maigne and Chatellier (2001), who compared the effectiveness of various massage, mobilization and manipulation techniques, reported that manual treatments were helpful for ~ 26% of cases with coccygodynia at 6 months and ~ 24% of the cases of coccygodynia at 2 years post treatment.The findings of this study also reported that massage and stretching techniques of the levator ani muscle were more effective than joint mobilization techniques.
In support of manipulation, Maigne and colleagues (2006)reported mild effectiveness of intrare**al manipulation in managing chronic coccygodynia when compared to shortwave diathermy. Chakraborty (2012)reported that combined manipulation and corticosteroid injection was more effective in treating coccygodynia than either technique alone.
Mohanty and Pattnaik (2017) reported that individuals with coccygodynia may benefit from stretching of the piriformis or iliopsoas muscles.In this study, piriformis and iliopsoas stretches, as well as thoracic mobilizations, had a beneficial effect in increasing pain free sitting duration and pressure pain threshold.Tightness of either the piriformis or iliopsoas can cause excessive anterior tilting of the pelvis and consequently place an excessive load on the coccyx.Stretching these muscles can help to correct the load that is placed on the coccyx.By increasing thoracic extension, thoracic mobilizations may also help to reduce the load on the coccyx.In this study, stretching was performed for 2 minutes on each side of the hip, 5 times per week.
Based on the work of Maigne and chatellier (2001) and Wray (1991),Fogel and Colleagues (2004) designed a treatment algorithm for coccygodynia. When a patient is presenting with acute coccygodynia (less than 2 months in duration), 8 weeks of rest and adjustable seating should be recommended in conjunction with stool softener and NSAIDs. When a patient presents with chronic coccygodynia (greater than 2 months in duration), massage and stretching techniques should be initiated in conjunction with corticosteroid injections.
Physical Modalities:
Lin and colleagues (2015)who compared the benefits of extracorporeal shockwave therapy (ESWT) with other physical modalities, reported that ESWT was more effective in decreasing visual analogue scale pain scores than shortwave diathermy and IFC.Patients who received ESWT reported greater subjective satisfaction scores following treatment, with ~ 70% reporting good to excellent satisfaction. In this study, 2000 shots of ESWT were applied to the coccyx area per session for 4 sessions at 5 Hz and a pressure of 3-4 bar. The findings of this study can be supported by a case report by Marwan and colleagues (2014), who reported the effectiveness of ESWT to relieve pain over 3 sessions in 2 cases of coccygodynia.[28] A quasi-experimental study by Haghighat and Mashayekhi (2016), involving 10 patients with cocycgodynia, stated that ESWT significantly decreased visual analogue scale pain scores at 4 weeks and 2 months post treatment.ESWT was delivered to the coccygeal area at 3000 shock waves per session, with a frequency of 21 Hz and pressure of 2 bar.
Although the mechanism is still being debated in the literature, it is proposed that ESWT decreases the inflammatory response and the expression of inflammatory mediators present in coccygodynia through the induction of neovascularization.
When considering the effects of other modalities, Lin and Colleagues (2015)reported that IFC and shortwave diathermy were able to decrease pain scores but not to the same extent as ESWT.Wray and colleagues (1991)reported minimal benefits with a combined treatment of ultrasound and shortwave diathermy. After receiving 2 weeks of ultrasound and 2 weeks of shortwave diathermy, only 16% of patients in the study report relief in their symptoms.Given these discrepancies, more evidence regarding which modalities provide the greatest benefit to patients with coccygodynia.
