Postpartum perineal injuries can cause pain and dysfunction for a short or an extended period of time. Pelvic rehab providers are in a position to educate women about the immediate and long-term management of perineal pain. A 2015 study by Manfre et al. assessed the response of cortisone cream application to the perineum in the immediate postpartum period. The study was a randomized controlled trial involving 27 subjects with each subject serving as her own control. Three different treatments were given over a 12 hour period: corticosteroid, placebo, and no treatment. (The hydrocortisone cream was at 1% in an alcohol-based cream, the placebo was a non-medicated acetyl alcohol-based cream.) The cream was applied by an investigator who placed the cream on a Witch Hazel pad. The participants and the researchers were blinded to the type of cream applied, and the applications were randomized and took place within the first 12.5 hours after birth. Perineal pain levels were assessed immediately before cream application, and at 30 and 60 minutes after application. Using a visual analog scale (VAS), the symptom of pain was assessed and compared to baseline. In the study, the authors report that in the immediate postpartum period, women in their institution were often prescribed medication ranging from ibuprofen to hydrocodone. Topical medications, ice packs, heat packs are also mentioned as available treatments. Other pain medications or cold packs were available during the study; no other topical creams were utilized.

Results indicated that the participants responded positively to both creams with significantly more pain reduction than the no treatment group. The authors propose that both creams provided a soothing effect by providing moisture to the tissues, creating a protective barrier, and preventing friction and irritation. Because the placebo emollient cream was not significantly more expensive than the hydrocortisone cream, the article suggests using hydrocortisone on the postpartum perineum due to the medication’s potential beneficial anti-inflammatory effects. Also of note was that ice packs were used by less than half of the women in the study, and when ice was used, it was only during the first four hours after birth. One reason for the low frequency use of ice was thought to be the difficulty in maintaining ice application on the perineum.^{Manfre 2015}

Because the pelvic rehab provider is in an optimal role as educator for pain reduction strategies, this study provides some interesting information to share with other birth providers and with patients. Learn more about postpartum patient care at Care of the Postpartum Patient, available in Seattle this March.

Manfre, M., Adams, D., Callahan, G., Gould, P., Lang, S., McCubbins, H., ... & Chulay, M. (2015). Hydrocortisone Cream to Reduce Perineal Pain after Vaginal Birth: A Randomized Controlled Trial. MCN: The American Journal of Maternal/Child Nursing, 40(5), 306-312.

Diastasis of the Rectus Abdominis Muscle (DRAM) is the separation of the two rectus abdominis muscles along the linea alba and is very common during and after pregnancy as the rectus abdominis and linea alba stretches and thins. Patients with DRAM are often sent to seek non-surgical management for DRAM from a physical therapist (PT). Typically these patients are either at the end of their pregnancy or adjusting to round the clock care of an infant. They can be sleep deprived, and have a full schedule of doctor’s appointments, having difficulty finding childcare, making attending PT somewhat challenging. Furthermore, they may have difficulty finding the time for a home exercise program (HEP). As PT’s we often struggle with making sure to give the patient exercises that will accomplish the goal of improving DRAM, however, making sure the HEP is not so extensive or time consuming that it becomes unmanageable. Is something as easy as abdominal bracing with exercise effective for reducing DRAM in post-partum women? A recent study published in 2015 in the International Journal of Physiotherapy and Research explores just this topic^(Acharry).

Why is Diastasis of the Rectus Abdominis Muscle (DRAM) important?

Women with DRAM tend to have a higher degree of abdominal and pelvic region pain^(Parker). Also women with DRAM may be more likely to have support related pelvic floor problem such stress urinary incontinence, fecal incontinence, or pelvic organ prolapse. The linea alba and rectus abdominis play an integral role in maintaining the anterior support of the trunk, these structures work together with pelvic girdle, posterior trunk muscles, and hips in maintaining stability when we shift weight (or transfer load) such as with standing, squatting, walking, carrying, and lifting. Therefore postural stability may be impaired with these daily tasks. Lastly, the abdominal muscles and fascia protect and support our organs so women with DRAM may have compromised support and protection of visceral structures.

Is DRAM common?

Pregnancy is the most common cause of DRAM and studies widely range from 50-100% of women experiencing DRAM at end stage pregnancy. Natural reduction and greatest recovery of DRAM usually occurs between day 1 and week 8 after delivery. Various ways exist to diagnose DRAM. The gold standard for diagnosis is computed tomography but is sometimes considered impractical due to expense. Clinically a separation of 2.0-2.7cm or “two finger widths” of horizontal separation at the umbilicus or 4.5cm above or below while performing a hooklying (supine with knees bent) abdominal curl up is considered pathological separation.

What can be done for DRAM?

Current guidelines for conservative treatment of DRAM are sparse with little established recommendations. The earlier referenced recent cross sectional study^(Acharry) explores efficacy of abdominal bracing as a treatment for reduction of DRAM in post-partum females. The study included 30 females that were one month post-partum or more who had vaginal delivery with or without episiotomy. The average distance of the diastasis was measured before and after treatment using the finger width technique. The treatment included teaching the subject four abdominal exercises, and the subjects were encouraged to complete abdominal bracing while carrying out daily activities. The four exercises included 1) static abdominal bracing exercise, lying supine with arms crossed over the diastasis for support and then pulling abdominals inwards with an isometric contraction of abdominal muscles. 2) Head lift with bracing, in hooklying with arms crossed over diastasis, exhale, lift head and use hands (or a towel/sheet) to approximate diastasis towards midline. 3) Head lift and pelvic tilt with bracing, is the same as previous exercise only adding a posterior pelvic tilt. 4) Pelvic clock exercise with bracing, visualize a clock on the lower abdominals and complete gentle movements from 12-6 o’clock, 3-9 o’clock, 12-3-6-9-12 o’clock, in a clockwise fashion and then reverse the pattern in a counter clockwise pattern. All exercises were performed twice daily, with a repetition of 5-6 days per week, for 2 weeks duration. After completing the program for two weeks the distance of the diastasis was re-measured and the average DRAM distance decreased from 3.5 to 2.5 finger widths which was considered significant. The results of this study show abdominal exercise with bracing is effective for reducing DRAM in early post partal females.

As PT’s who treat DRAM we should encourage our patients to use abdominal exercises with bracing as well as encourage our patients to use abdominal bracing with their daily tasks such as standing, lifting, weight shifting, and carrying. A home exercise program such as the one in this study proved to be effective for reducing DRAM and included only four exercises making this a manageable home exercise program for our post-partum patients.

Herman & Wallace offers a full series of peripartum courses called the "Pregnancy Series". To learn more about diastasis of the rectus abdominis muscle, join Holly Tanner, PT, DPT, MA, OCS, WCS, PRPC, LMP, BCB-PMB, CCI at Care of the Postpartum Patient in Seattle, WA this March 12-13, 2016!

Acharry, N., & Kutty, R. K. (2015). ABDOMINAL EXERCISE WITH BRACING, A THERAPEUTIC EFFICACY IN REDUCING DIASTASIS-RECTI AMONG POSTPARTAL FEMALES. Int J Physiother Res, 3(2), 999-05.

Parker, M. A., Millar, L. A., & Dugan, S. A. (2009). Diastasis Rectus Abdominis and Lumbo‐Pelvic Pain and Dysfunction‐Are They Related?. Journal of Women’s Health Physical Therapy, 33(2), 15-22.

Sexual dysfunction is a common negative consequence of Multiple Sclerosis, and may be influenced by neurologic and physical changes, or by psychological changes associated with the disease progression. Because pelvic floor muscle health can contribute to sexual health, the relationship between the two has been the subject of research studies for patients with and without neurologic disease. Researchers in Brazil assessed the effects of treating sexual dysfunction with pelvic floor muscle training with or without electrical stimulation in women diagnosed with multiple sclerosis (MS.) Thirty women were allocated randomly into 3 treatment groups; 20 women completed the study. All participants were evaluated before and after treatment for pelvic floor muscle (PFM) function, PFM tone, flexibility of the vaginal opening, ability to relax the PFM’s, and with the Female Sexual Function Index (FSFI). Rehabilitation interventions included pelvic floor muscle training (PFMT) using surface electromyographic (EMG) biofeedback, neuromuscular electrostimulation (NMES), sham NMES, or transcutaneous tibial nerve stimulation (TTNS). The treatments offered to each group are shown below.

The following factors made up the inclusion criteria for the study: age at least 18 years, diagnosis of relapsing-remitting MS, and a 4 month history of stable symptoms. All of the participants were sexually active and were found to be able to contract pelvic floor muscles correctly. Group 1 patients were treated with “sham” electrical stimulation using surface electrodes placed over the sacrum at a pulse width of 50 ms and a frequency of 2 Hz. Patients in Group 2 used an internal (vaginal) electrode at 200 ms at 10 Hz. Group 3 were given transcutaneous tibial nerve stimulation at 200 ms and 10 Hz. All groups followed these treatments with pelvic floor muscle exercises using a vaginal sensor and biofeedback.

The authors concluded that pelvic floor muscle training alone or in combination with intravaginal neuromuscular electrostimulation or transcutaneous tibial nerve stimulation is effective in treating sexual dysfunction in women who have MS. Improvements were noted in these groups in sexual arousal, vaginal lubrication, satisfaction, and in the Female Sexual Function Index. While the numbers in the respective intervention groups is not large enough to determine the best option for patients who have multiple sclerosis, the research reminds us that neurostimulation in conjunction with pelvic muscle training may be very valuable.

As pelvic rehab practitioners, it is common for our patients to ask us dietary questions pertaining to their unique pelvic floor symptoms. We often counsel on fluid consumption, bladder irritants, and fiber intake. At times, we even give our patients a bladder or bowel diary to better monitor nutritional status and habits. However, how often do we ask about vitamin D status? It is common knowledge that vitamin D deficiency contributes to osteoporosis, fractures, and muscle pain and weakness, but what is the role of vitamin D in overall health of the female pelvic floor. Is vitamin D supplementation something we as health care providers need to at least discuss? An article published in the International Urogynecology Journal ^{(Parker-Autry)} explores this topic. This interesting paper reviews current knowledge regarding vitamin D nutritional status, the importance of vitamin D in muscle function, and how vitamin D deficiency may play a role in the function of the female pelvic floor.

How may vitamin D play a role in the function of the pelvic floor?

Vitamin D affects skeletal muscle strength and function, and insufficiency is associated with notable muscle weakness. Vitamin D has been shown to increase skeletal muscle efficiency at adequate levels. The levator ani muscles and coccygeus pelvic floor muscles are skeletal muscle that are crucial supporting structures to the pelvic floor. Pelvic floor musculature weakness can contribute to pelvic floor disorders such as urinary or fecal incontinence and pelvic organ prolapse. Pelvic floor muscle training for strengthening, endurance, and coordination, are first line treatment for both stress and urge urinary incontinence, fecal incontinence, pelvic organ prolapse, and overactive bladder syndrome. The pelvic floor muscles are thought to be affected by vitamin D nutrition status. Additionally, as women age, they are more prone to vitamin D deficiency and pelvic floor disorders.

This article reviews several studies, including small case and observational, that show an association between insufficient vitamin D and pelvic floor disorder symptoms and severity of symptoms. The recommendation from this review is that more studies of high quality evidence are needed to fully understand and demonstrate this relationship between vitamin D deficiency and pelvic floor disorders. However, the authors feel that vitamin D supplementation may be a helpful adjunct to treatment by helping to optimize our physiological response to pelvic floor muscle training and improving the overall quality of life for women suffering from pelvic floor disorders.

How much vitamin D?

The Institute of Medicine has only made recommendations for dietary allowance for vitamin D and calcium for bone health. There is no consensus for adequate vitamin D levels for a condition specific goal (other than bone health), and the levels of vitamin D varied throughout the reviewed studies. It has been shown that very high levels of vitamin D are tolerated well, so supplementation of vitamin D seems to be very safe in low and very high doses.

Food for thought?

As pelvic rehabilitation providers, it is our job to assess the whole person, however, we are not dieticians. As physical therapists we are musculoskeletal specialists and vitamin D affects muscle function. What our patients put in their bodies (wholesome nutritious food vs nutrient lacking artificial food) affects the quality of the cells they produce and tissues that are made, which can influence their healing. When reviewing health history, maybe consider discussing vitamin D status and possible supplementation with the patient, or with the patients’ primary care provider or naturopathic doctor. This team approach may provide more comprehensive health care, hopefully yielding more successful outcomes.

Parker-Autry, C. Y., Burgio, K. L., & Richter, H. E. (2012). Vitamin D status: a review with implications for the pelvic floor. International urogynecology journal, 23(11), 1517-1526.

With age, many of our patients may be at higher risk of developing dementia. Dementia has a wide range of causes and symptoms, and is most often associated with Alzheimer’s disease. Memory loss, difficulty in communicating, in organizing complex tasks and in coordinating motor functions can add to the challenge of participating in rehabilitation. In pelvic rehabilitation, we are already faced with the importance task of effectively communicating about sensitive topics, obtaining clear consent, and instructing in exercise that may be difficult for the patient to “see” or appreciate in the same way as with a biceps curl or leg raise. How can we set ourselves and our patients up for success when working with a patient who has dementia or other cognitive issues?

An article with a focus on communication with older people who have dementia ^{de Vries, 2013} summarizes practical information that can positively affect our skills in communication with patients who have cognitive dysfunction. From the impact of hearing loss on orientation and sense of vulnerability, to the types of listening skills recognized as means to improve communication, the article integrates a wide range of valuable information.

Some of the suggestions for enhancing interactions with patients who have dementia come from the work of Wilson et al., 2012, and include the following:

• slow the rate of your speech
• use verbatim repetition
• ask questions that can be answered with a “yes” or “no”
• decrease the complexity of your sentences
• ask one question at a time give instructions for one idea or concept at a time
• avoid use of pronouns when able (can be confusing, refer instead to the person)

Other research-based advice given in the article includes eliminating distraction, such as turning off a radio or television, and avoid interrupting the person who has dementia. Sitting face to face is recommended, as is using non-verbal communication such as facial expressions and gestures. Also very interesting is the idea that using a more controlling tone of voice can lead to increased resistance to care. A terrific strategy that is recommended in the article is this “Ask a colleague to observe your practice…and make notes on how you communicate…” Although being critiqued may feel intimidating, learning how others perceive our use of the above skills can help to optimize communication with patients who have dementia.

Providing optimal communication strategies during rehabilitation is just one of the topics that is discussed in the Institute’s new Geriatric Pelvic Floor Rehab continuing education course. The first opportunity to take this new course is Tampa, Florida this January. The course is taught by Heather Rader who immerses herself in the care of people in the geriatric age range. Her expertise not only in pelvic rehab, but also in adaptations for the geriatric population, billing practices, and marketing will be shared.

De Vries, K. (2013). Communicating with older people with dementia. Nursing older people, (25), 30-7.

Wilson, R., Rochon, E., Mihailidis, A., & Leonard, C. (2012). Examining success of communication strategies used by formal caregivers assisting individuals with Alzheimer’s disease during an activity of daily living. Journal of Speech, Language, and Hearing Research, 55(2), 328-341.

Mindful awareness has been defined as “the awareness that emerges through paying attention on purpose, in the present moment and non-judgmentally, to the unfolding experience, moment by moment.” ^Kabat Mindful awareness can be cultivated through training in sitting meditation, mindful body scan, walking meditation and mindful movement. Over the past 3 decades, a growing body of research has identified multiple health benefits from training in mindful awareness. ^{Keng, Lakhan, La Cour} One pilot study evaluated the feasibility and efficacy of an 8-week mindfulness program for patients with chronic pelvic pain. ^Fox Pre- and post-assessments included daily pain scores, the Short Form-36 Health Status Inventory, Kentucky Inventory of Mindfulness Score and the Inventory of Depressive Symptomatology. Upon program completion, participants reported significant improvement in daily maximum pain scores, physical function, mental health, social function and mindfulness scores. These pilot results are positive and promising.

In my experience, mindfulness gives patients the skillful awareness necessary to self-regulate their reactions to pain and stress. Many of these reactions are maladaptive and amplify distress and pain. With training in mindfulness, patients are able to observe physical, cognitive and emotional reactions to pain and stress and adopt healthy choices that de-escalate suffering. I am excited to share my 30 years of experience and training in mindful awareness and its application to patient care and provider self-care through my 2-day course with Herman & Wallace. Join me at "Mindfulness Based Pain Treatment: A Biopsychosocial Approach to the Treatment of Chronic Pain" on January 16-17, 2016 in Silverdale, WA.

1. Kabat Zinn, J.Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. 2013, 2nd ed. New York: Bantam.
2. Keng, S.L., Smoski M.J., Robins, C.J. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev, 2011;31(6), pp. 1041-56.
3. Lakhan, S.E., Schofield, K.L. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One, 2013;8(8), e71834.
4. La Cour, P., Petersen, M., 2014. Effects of mindfulness meditation on chronic pain: A randomized controlled trial. Pain Med, Nov 7. doi: 10.1111/pme.12605.
5. Fox, SD, Flynn E, Allen RH. Mindfulness meditation for women with chronic pelvic pain: a pilot study. J Reprod Med, 2011;56(3-4):158-62.

Pelvic Floor Muscles: To Strengthen or Not to Strengthen? 

If that is the question, then who should provide the answer? As I was reading yet another article about how women should strengthen the pelvic floor muscles to have a better orgasm, I can't help but think about the unfortunate women for whom this is a bad idea. Yes, having healthy awareness of and strength in the pelvic floor muscles is important for healthy sexual function, but healthy muscles and building of awareness is challenging to achieve from viewing a few images. 

If you clicked on the link above about the article in question, you will see that the recommendation is for activating the pelvic floor muscles and engaging in pelvic strengthening exercises for up to a couple minutes per exercise, with several exercises prescribed up to 2x/day for a period of weeks. And that if you visualize stopping the flow of urine, you will surely feel the muscles activate. Based on clinical experience, we know that this is not the case for most women. One verbal cue may not be enough. The woman may not feel the muscle activation. She may have tight, painful pelvic muscles that are limiting healthy sexual function. These are issues that pelvic rehab providers face on a daily basis: when and how to strengthen the muscles. 

Rhonda Kotarinos and Mary Pat Fitzgerald did the world of pelvic rehab an immense good with their promotion of the concept of the "short pelvic floor."  If a patient presents with pelvic muscle tension, shortening of the muscle, and poor ability to generate a contraction, a relaxation phase, or a bearing down of the pelvic muscles, how in the world will trying to tighten those overactive muscles bring progress? This concept is further described in a 2012 article from the Mayo Clinic by Dr. Faubion and colleagues. The article explains the cluster of symptoms commonly seen with non-relaxing pelvic floor muscles including pain and dysfunction in bowel, bladder, and sexual function. Medical providers and rehab clinicians should look for this cluster of symptoms and combine this knowledge with a pelvic muscle assessment to decide if pelvic muscle strengthening is warranted. 

If this has not been a part of your current practice, please consider ruling out a shortened or non-relaxing pelvic floor prior to suggesting any "Kegels" or pelvic muscle strengthening. If you are well aware of this issue, then it is our responsibility and opportunity to educate the public and the medical community to STOP! strengthening when it is not appropriate. The way I often explain this to patients or students is to pretend that a patient has walked in to the clinic with the shoulders elevated maximally, complaining of headaches or shoulder dysfunction. Then I say, "Great! Let's hit the weights- you just need to strengthen your upper traps." This always gets a giggle or a smirk, but the point is this: that is exactly what providers are doing to patients who walk in with bowel, bladder, pain, or sexual dysfunction when the announcement is made that "you just need to do your Kegels." 

While we do not want to villainize Kegels or strengthening of the pelvic muscles, we do want our colleagues, our patients, and the valued referring providers to know that there is way more to pelvic health than strengthening. The abundance of bad advice available to our patients may leave them in worse condition and with less hope about finding relief. While well-intentioned, advice that only describes strengthening as the cure is misleading and potentially harmful.

Sleep difficulties are a common problem among women in the menopausal period, with hot flashes and night sweats commonly interfering with a restful night’s sleep. According to Baker and colleagues^{Baker, 2015} , disturbed sleep is present in 40-60% of women in the menopausal transition. The authors also point out that insomnia is not well characterized, with poor identification of a physiologic basis for the sleep disturbances. In the research linked above, perimenopausal women diagnosed with clinical insomnia (n=38) were compared to women who did not have insomnia (n=34). Outcome measures included the Beck Depression Inventory, the Greene Climacteric Scale, sleep diaries, sleep studies, and nocturnal hot flashes via dermal conductance meters.

Results of the study concluded that women with insomnia, compared with controls, had higher levels of psychologic, somatic, vasomotor symptoms, and had higher scores on the depression inventory, shorter sleep duration, and lower sleep efficiency. Women with insomnia were also more likely to have hot flashes, with number of hot flashes predicting awakenings during the sleep study. Episodes of wakefulness after sleep onset, and decreased time of sleep were noted in the women who were diagnosed with new-onset insomnia.

Because untreated insomnia is associated with negative consequences including hypertension, stroke, diabetes, and depression, the authors suggest that women who are diagnosed with insomnia should be treated for their insomnia. If you are interested in learning about natural methods to manage and reduce hot flashes, among many other interesting topics, you will likely enjoy Herman & Wallace faculty Michelle Lyons and her newer course: Special Topics in Women’s Health. The next chance to hear Michelle discuss these topics is in Denver in January. Bring your skis!

Baker, Fiona C. et al. "Insomnia in women approaching menopause: Beyond perception" Psychoneuroendocrinology, Volume 60, 96-104 October 2015

Today we get to hear from Ramona Horton, MPT, who teaches several courses with the Herman & Wallace Institute. Her upcoming course, Visceral Mobilization Level 1: Mobilization of Visceral Fascia for the Treatment of Pelvic Dysfunction in the Urologic System, will be taking place November 6-8, 2015 in Salt Lake City, UT.

This spring I reached a milestone in my career. I have been working as a licensed physical therapist for 30 years, of which the past 22 have been in the field of pelvic dysfunction. Other than some waitressing stents and a job tending bar while in college this is the only profession I have known. When I entered the US Army-Baylor program in Physical Therapy in the fall of 1983 nowhere was it on my radar screen that I would be dealing with the nether regions of men, women and children, let alone teaching others to do so. As time marches on, I find myself visiting my hair dresser a bit more frequently to deal with that ever progressive grey hair that marks the passage of these years…translation: I am an old dog and I have been forced to learn some new tricks.

Like many aspects of our modern life, the profession of physical therapy is under a constant state of evolution. The best example of this is the way we look at pain and physical dysfunction. I was educated under the Cartesian model, one that believed pain is a response to tissue damage. Through quality research and better understanding of neuroscience we now know that this simplistic model is, in a word, too simple. We have come to recognize that pain is an output from the brain, which is acting as an early warning system in response to a threat real or perceived. I wholeheartedly embrace the concept that pain is a biopsychosocial phenomenon; however I am not willing to give up my treatment table for a counselors couch when dealing with persistent pain patients.

As a physical therapist, I still believe that we need to educate, strengthen and yes, touch our patients. Given that paradigm, ultimately I am a musculoskeletal therapist and I believe that when a clinician is designing a treatment program for any patient, applying sound clinical reasoning skills means the clinician needs to take into consideration that there are three primary areas in the individuals life in which they may be encountering a barrier to optimal function: neuro-motor, somatic and psycho-social. After many years of developing and refining my clinical reasoning model, I have chosen to adopt the image of the Penrose triangle. My goal was to provide the clinician with a visual on which to focus their problem solving skills and a reminder to encompass the person as a whole. The goal is to convey the understanding that the barriers which present themselves rarely do so in isolation, and that the source to resolve of all barriers that impede human function, regardless of origin, is ultimately found within the brain.

Neuro-motor barriers include issues of muscle function to include motor strength, length, endurance, timing and coordination. These barriers are improved through therapeutic exercise training. Somatic barriers are those that are addressed through any number of manual therapy interventions which address issues found within multiple structures to include the fascia, osseous/articular tissue, lymphatic congestion, restrictions within the visceral connective tissue, neural/dural restrictions and challenges of the dermal/integumentary system. All of these barriers can contribute to nociceptive afferent activity. Lastly would be the psychosocial barriers which include history of trauma, clear behavior of hypervigilance, catastrophization, current life stressors, perceived threat which includes kinesiophobia (back to neuro-motor) ANS issues which present as autonomic dysregulation and lastly pain model misconceptions.

I suggest that we remember that the body is a self-righting mechanism. If we cut our skin, given the wound is kept free from infection (a barrier), the human body will heal the wound. As clinicians, I believe that we need to come to the realization that we don’t fix anything, we simply remove the barrier to healing and trust the body to do the rest. Our challenge is to recognize and address the barriers.

How many of us have heard a subjective report from a patient that clearly implicates the coccyx as the problem but quickly think, “I’m sure as heck not going there!”? We cross our fingers, hoping the patient will get better anyway by treating around the issue. That is like trying to get a splinter out of a finger by massaging the hand. As nice as the treatment may feel, the tip of the finger still has a sharp, throbbing pain at the end of the day, because the splinter, the source of the pain, has not been touched directly. For most therapists, the coccyx is an overlooked (and even ignored) splinter in the buttocks.

A colleague of mine had a patient with relentless coccyx pain for 7 years and was about to lose a relationship, as well as his mind, if someone did not help him. He had therapy for his lumbar spine with “core stabilization,” and he had pain medicine, anti-inflammatory drugs, and inflatable donuts to sit upon to relieve pressure, but his underlying pain remained unchanged. Luckily for this man, his “last resort” was trained in manual therapy and assessed the need for internal coccyx mobilization to resolve his symptoms. The patient’s desperation for relief overrode any embarrassment or hesitation to receive the treatment. After a few treatments, the man’s life was changed because someone literally dug into the source of pain and skillfully remedied the dysfunction.

Marinko and Pecci (2014) presented 2 case reports of patients with coccydynia and discussed clinical decision making for the evaluation and management of the patients. The patient with a traumatic onset of pain had almost complete relief of pain and symptoms after 3 treatment sessions of manual therapy to the sacrococcygeal joint. The patient who experienced pain from too much sitting did not respond with any long term relief from the manual therapy and had to undergo surgical excision. The first patient was treated in the acute stage of injury, but the second patient had a cortisone injection initially and then the manual treatment in this study 1 year after onset of pain. Both patients experienced positive outcomes in the end, but at least 1 patient was spared the removal of her coccyx secondary to manual work performed in what some therapists consider “uncharted territory.”

A systematic literature review was published in 2013 by Howard et al. on the efficacy of conservative treatment on coccydinia. The search spanned 10 years and produced 7 articles, which clearly makes this a not-so-popular area of research. No conclusions could be made on how effective the various treatments of manual therapy, injections, or radiofrequency interventions were because of the insufficient amount of research performed on the topic.

In an evidence-based era for physical therapy intervention, sometimes we limit ourselves in our treatment approaches. What if the best interventions just have yet to be oozing with clinical trials and published outcomes? The first person to pull a splinter out of a finger did not have a peer-reviewed guide instructing one to use 2 fingers to wrap around the splinter and pull it out of the skin. Coccyx mobilization internally and externally is a legitimate treatment without a lot of notoriety. The Coccyx Pain, Evaluation, and Treatment course uses the most current evidence to expand your knowledge of anatomy and pathology and hone your palpation skills to evaluate and treat an area where you never thought you’d go.

References: Howard, P. D., Dolan, A. N., Falco, A. N., Holland, B. M., Wilkinson, C. F., & Zink, A. M. (2013). A comparison of conservative interventions and their effectiveness for coccydynia: a systematic review. The Journal of Manual & Manipulative Therapy, 21(4), 213–219. http://doi.org/10.1179/2042618613Y.0000000040
Marinko LN, Pecci M. (2014). Clinical decision making for the evaluation and management of coccydynia: 2 case reports. J Orthop Sports Phys Ther, 44(8):615-21. doi: 10.2519/jospt.2014.4850