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Working with a sensitized nervous system

By Erik Dalton

Using modalities such as massage, manual manipulation, psychotherapy, and pelvic floor rehabilitation, pain management researchers at the Ochsner Clinic Foundation discovered that conservative treatment was successful in 90 percent of coccydynia cases.1 In some people with coccyx dysfunction, the brain’s alarm system is triggered, warning of the possibility of tissue damage, whereas others with the same condition feel no pain. In the extreme, a person’s nervous system “volume” may be turned up due to prolonged exposure to painful stimuli. This sensitization process causes buttock and pelvic pain to linger long after the problem has been resolved.

Image 1. Sidebent coccyx and pelvic floor

Researchers are uncertain why some people with coccyx dysfunction are symptomatic and others are not, but it’s likely linked to pain gating malfunction and coccyx hypersensitivity. Here, we’ll focus on assessing and correcting the most commonly seen coccyx disorders — sacrococcygeal joint misalignment and accompanying pelvic floor muscle spasm (Image 1). To begin, let’s review possible causes and symptoms in clients suffering coccydynia pain.

Pratfalls and direct blows to the coccyx from contact sports are obvious culprits, but what about the strenuous compressive forces cyclist, rowers, and desk jockeys place on the tailbone? In this “overuse and abuse” population, spastic pelvic floor muscles over-engage and bind down the coccyx and surrounding neural structures. When noxious input from strained connective tissues overloads the spinal cord’s neuronal pool, the brain gets involved and may decide to splint the area with protective muscle spasm. Thus begins the vicious cycle of muscle overuse causing brain irritation causing more layering of protective spasm.

Overuse injuries and direct blows are not the only contributors to coccyx pain — consider the potential insult the coccyx experiences during pregnancy. At the end of the third trimester, hormonal changes enable the synchondrosis between the sacrum and the coccyx (sacrococcygeal joint) to soften and become more mobile. This increases coccygeal segmental mobility, allowing for more sidebending, flexion, and extension, which is a good thing. However, in some mothers, the resting tension of surrounding musculoligamentous connective tissues is altered as secretion of the hormone relaxin decreases.

Unlike fractures, which can remodel, sacrococcygeal joint injuries can last indefinitely if an inflamed joint is repeatedly forced from its normal position. In cases where inflammatory waste products trigger chemoreceptors and altered sacrococcygeal joint alignment hyper-excites mechanoreceptors, the brain often decides to lock the area up to prevent further insult. This is where myoskeletal therapy may help.

Symptoms and corrections

In a fully functioning body, the coccyx acts as a shock absorber by flexing forward during sitting. Together, the coccyx and bilateral ischial tuberosities form a weight-bearing tripod that houses the pelvic floor muscles and ligaments. The coccyx bears more weight when a seated person leans back, so we often see coccydynia clients flex at the hips to shift more weight to the sitz bones (Image 2). They usually report dull, aching pain emanating from the gluteal cleft just superior of the anus and sometimes stabbing pain when rising from prolonged sitting.

Image 2. Coccydynia clients flex at the hips to shift weight to sitz bones

Physical examination through underwear or a sheet includes gentle palpation of the coccyx and surrounding connective tissues for tenderness (Image 3). Hypertonus and protective guarding may be felt when palpating adjacent pelvic floor muscles, such as the coccygeus and levator ani. The sacrococcygeal, sacrotuberous, and sacrospinous must also be individually evaluated for tenderness. Ask the client to report any palpation maneuver that reproduces the tailbone pain. In true coccydynia cases, the coccygeal region is typically very sensitive, so first seek permission, and then carefully explain what you intend to do. Always keep an open dialog with the client, as this can be an emotionally charged area, and err on the side of modesty when working the buttock and hip areas.

Myoskeletal techniques such as those demonstrated in Images 4 and 5 may be helpful as a conservative treatment for sacrococcygeal dysfunction. Once alignment and mobility are restored to the pelvic bowl, the therapist uses ligaments as levers to help decompress hooked and sidebent coccyges. This can be performed with the client seated, sidelying, or prone. As pain decreases, home exercise assignments, such as diaphragmatic breathing and mini-trampoline rebounding can help restore optimal pelvic floor function.

Image 3. Therapist’s thumb hooks and lifts soft tissue attachments at coccyx Image 4. Therapist’s thumbs hook and lift contralateral sacrotuberus ligament Image 5. Therapist’s forearm gently scrubs adductor fascial attachments to pelvic floor

Discussion

Pain is a symptom all healthy human beings experience at some point in their lives. In fact, pain sensation is necessary for survival — without it, we would not know if we were injured or unwell. However, in our sensitized clients, the degree of pain does not always match the degree of injury, and this is where proper manual therapy and corrective exercise can help. Working together in a comfortable, safe environment, we can identify specific movements that reduce a client’s coccydynia symptoms and help eliminate areas of bind. Getting the client moving and exercising is always a great strategy for easing the pain of coccyx dysfunction.

Notes

1. Lirette, L.S., Chaiban, G., Tolba, R., & Eissa, H. (2014). Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner Journal, 14(1), 84-87.

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