Spine 2001 Volume 26, number 20, pages E479-E484
JeanYves Maigne, MD,* and Gilles Chatellier, MD**
*Department of Physical Medicine, Hotel-Dieu University Hospital, France
**Department of Medical Statistics, Broussais Hospital, Paris, France.
This study compared three different treatments of coccydynia in which the doctor places a finger into the anus of the patient. One of the treatments was to move the coccyx about in various ways. The other two were either to massage or to stretch muscles attached to the coccyx, without moving the coccyx. These last two treatments were more successful than moving the coccyx. The treatments worked best on patients who showed up as normal on the sit/stand dynamic x-rays.
In these diagrams the patient is lying face down and the doctor's finger is inserted into the rectum. The sacrum is on the left, and the coccyx on the right. A coccyx with two segments is shown here, but coccyxes can be in 1, 2, 3 or 4 segments.
|Figure 1. Assessment of pelvic muscle tone. The internal finger is inserted following the axis of the rectum. It then is gradually pushed upward (posteriorly), stretching the pelvic floor, until contact is made with the coccyx, whereupon the pull is released. If the finger is returned immediately to its initial position in the rectum by the patient's muscle tone without any conscious effort by the patient, the muscle tone is considered abnormally high.|
|Figure 2. Thiele's technique of massage in the direction of the fibers.|
|Figure 3. R. Maigne's technique of coccygeal mobilization. The coccyx is kept in hyperextension, which stresses the sacrococcygeal and intercoccygeal joints and stretches the levator anus.|
|Figure 4. J.Y. Maigne's technique. The internal finger touches, but does not mobilize, the coccyx. The external finger checks to ensure that the coccyx is being kept still. This maneuver results in stretching of the coccygeus, the levator anus, and the external sphincter.|
Study Design. A prospective pilot study with independent assessment and a 2-year follow-up period was conducted.
Objectives. To compare and assess the efficacy of three manual coccydynia treatments, and to identify factors predictive of a good outcome.
Summary of Background Data. Various manual medicine treatments have been described in the literature. In an open study, the addition of manipulation to injection treatment produced a 25% increase in satisfactory results. Dynamic radiographs of the coccyx allow breakdown of coccydynia into four etiologic groups based on coccygeal mobility: luxation, hypermobility, immobility, and normal mobility. These groups may respond differently to manual treatments.
Methods. The patients were randomized into three groups, each of which received three to four sessions of a different treatment: levator anus massage, joint mobilization, or mild levator stretch. Assessment with a visual analog scale was performed by an independent observer at 7 days, 30 days, 6 months, and 2 years.
Results. The results of the manual treatments were satisfactory for 25.7% of the cases at 6 months, and for 24.3% of the cases at 2 years. The results varied with the cause of the coccydynia. The patients with an immobile coccyx had the poorest results, whereas those with a normally mobile coccyx fared the best. The patients with luxation or hypermobility had results somewhere between these two rates. Levator anus massage and stretch were more effective than joint mobilization, which worked only for patients with a normally mobile coccyx. Pain when patients stood up from sitting and excessive levator tone were associated with a good outcome. However, none of the results was significant because of the low success rate associated with manual treatment.
Conclusions. There is a need for a placebo-controlled study to establish conclusively whether manual treatments are effective. This placebo must be an external treatment. A sample size of 190 patients would be required for 80% confidence in detecting a difference.
Key words: coccydynia, coccygodynia, manual treatment, spinal manipulation