Sunkyoung Kaylen Lee. Clinical Case Report Competition. West Coast College of Massage Therapy. New Westminster. First Place Winner

Transcription

1 Massage Therapists Association of British Columbia Clinical Case Report Competition West Coast College of Massage Therapy New Westminster April 2013 First Place Winner Sunkyoung Kaylen Lee The efficacy of soft-tissue-tension release treatment to relieve the pain of coccygodynia from birthing trauma P: F: massagetherapy.bc.ca MTABC 2013

2 Abstract Objectives. To determine the efficacy of the soft tissue tension release technique of massage therapy for relieving the sacrococcygeal pain from coccygodynia relating to birthing trauma. The goals of this study are to address the trigger points around the coccyx, to decrease the sacrococcygeal pain with prolonged sitting, and to address the soft tissue restriction to increase the nutritional metabolic circulation on the sacrococcygeal region. Background. A 34 year-old female presented the severe tailbone pain with sitting after her first delivery approximately two years ago. Diagnostic radiography revealed that her bone had no indications of a pathological condition, and her medical doctor diagnosed her condition as coccygodynia. The subject had no other medical intervention. Methods. The subject received a series of ten massage therapy sessions over one and a half month. As the main modalities, trigger point release, active myofascial release on the hip extensors and pelvic floor muscles, and the grade 1 to 2 of the joint mobilization on the hip and sacroiliac joints are selected. Daily pain journal and Guided assessment protocols are used as baseline measurement. Results. The severity of the coccygeal pain is decreased; Similar improvements to the possible maximum sitting time without pain is increased from 7-8 minutes to minutes. The subject also showed decreased myofascial restriction and increased soft tissue mobility. Although the myofascial restriction relapsed as noted in the follow up session a month later, the subject described reduced coccygeal pain. Conclusion. The soft tension release treatment with the combination of three different modalities was effective to relieve the pain on the subject s coccyx. There is a need for treatment consistency and modification for intensity of treatment to improve the effects of the massage treatment. Keywords. Coccygodynia, Tailbone pain, Massage therapy, Trigger point release, Active myofascial release. i P age

3 Table of Contents Abstract... i 1. Introduction Research Findings Case History Assessment Treatment Plan and Method Treatment goals and Management Plan Modalities Used and Procedure Hydrotherapy and Remedial Exercise Results A One-Month Follow Up Treatment Discussion and Conclusion Works Cited Appendix.26 1 P age

4 1. Introduction Coccygodynia or coccydynia is defined as pain in and around the coccyx that does not significantly radiate, which is made worse by sitting or by standing up from the sitting position (Maigne & Chatellier, 2001). It is rare form of pelvic disorder, as the cause of less than 1% of all reported back pain and is five times more common in females (Mathews, 2010). This condition has been reported since 1600s, however it was only first designated by Simpson in 1859 (Dolin & Padfield, 2004). According to Dolin and Padfield (2004), most common etiology of coccygodynia is trauma from a fall, such as a slip going down stairs, a fall from a horse or during contact sports. Repetitive trauma also leads to coccygodynia by over-stretching the muscles and the ligaments attached to the coccyx. This causes pain and soreness for the patients when sitting due to the inflammation of the soft tissue around the coccyx. They also mentioned childbirth as one of the less common cause of coccygodynia; the hypermobile sacrococcygeal joints during pregnancy due to relaxin results in permanent change in the resting tension of the ligaments and muscles surrounding and attaching to the coccyx (Dolin & Padfiled, 2004, p.183.) Overall, the direct cause of the condition is unknown in one third of the patients suffering from coccygodynia. (Dolin & Padfield, 2004). 2 P age

5 According to Sir James Y. Simpson, with the injured coccyx or the coccygeal joints, or inflammation on the surrounding structure, any contraction of the muscles connected with the coccyx would provoke the characteristic pain of coccygodynia. He added that due to the origin of a portion of the gluteus maximus from the side of the coccyx, any contraction of these muscles such as in walking, sitting down or arising from a sitting position would move the sacrococcygeal joint. (Thiele, 1950). The gluteus maximus, piriformis, coccygeus, obturator internus, gemelli and levator ani have intimate anatomical relation with the sacrospinous and sacrotuberous ligaments. The hypertonicity of these muscles compress these ligaments and nearby structures such as the internal pudendal artery and pudendal nerve (Appendix 1), which in turn deprives the surrounding structures of blood supply (Alimohammadi, M., personal communication, 2013). This case study experiments on the efficacy of soft tissue tension release techniques on the sacrococcygeal and pelvic floor muscles to decrease the soft tissue restriction and to restore or improve the blood supply and innervation of the area. All of them factors which can contribute to significant pain relief on the sacrococcygeal region. 3 P age

6 2. Research Findings Coccygodynia due to birthing trauma is rare, and not many of the patients seek massage therapy to relieve the symptoms. As a result, there was no established massage therapy protocol or research available to treat coccygodynia caused by birthing trauma. However, there are several studies regarding physiotherapy and chiropractic treatments, which have demonstrated effectiveness for pain relief. According to the study of Maigne and Chatellier in 2001, the three different approaches of manual treatments to treat coccygodynia had varying levels of treatment efficacy. 74 patients with the coccygeal pain were randomly divided into three groups. Each group of patients received three to four sessions of one treatment approach: levator anus massage through the rectum, or sacrococcygeal joint mobilization, or mild levator anus stretch (Appendix ). A two year follow-up revealed that the group of patients who received the massage as well as the stretching of the levator anus reported more successful results than the sacrococcygeal mobilization group (Appendix 3). Heller D.C., introduced a chiropractic coccygodynia treatments the coccyx bone readjustment; the technique is applied through the rectum on the internal posterior mobilization or adjustment of coccyx (Heller, 2010). He also mentioned this procedure could trigger mild discomfort to excruciating pain on the tender spot when the coccyx is corrected. 4 P age

7 Guerineau, Bensignor, Labat and Robert demonstrated a physiotherapy treatment for coccygodynia in their study in The treatment mainly focuses on stretching the group of perineal muscles and aims to decrease the perineal pain by releasing their myofascial restriction and possible pudendal plexus entrapment. There is a partial internal massage or joint manipulation through the rectum to address the hard and painful cord of the levator ani. This study reported that more than 60% of the feedback from the 36 randomly selected patients was positive (Guerineau, Bensignor, Labat, & Robert, 2002) (Appendix 4). The studies above demonstrate the trigger points and the myofascial restriction are the main cause of the coccyx pain. The objective of this case study is to determine the efficacy of the soft tissue tension release techniques in relieving coccygodynia related pain. Thus, as the main modalities for this case study, trigger point release, myofascial release techniques, and grade 1 to 2 joint mobilization are selected. According to Travell and Simons, trigger point pressure release technique over the tensed muscle fibers can eventually eliminate the tissue tenderness and help to flush metabolites from the tissue (Travell & Simons, 1999). This technique also helps to relieve the coccyx pain along the sacrococcygeal region, mainly on the gluteal maximus s insertion. Travell mentioned, Gluteus maximus trigger point is located in the most medial and inferior muscle fibers. These fibers lie close to the coccyx, to which this TrP refers pain. Therefore, TrP, is a source of coccygodynia (Travell & Simons, 1999, p.133). According to 5 P age

8 Rattray, myofascial release technique can also address the trigger points by inducing tissue relaxation (Rattray, Ludwig, & Belgin, 2000). Dixon also stressed the importance of the myofascial release and the joint mobilization to increase the muscular tissue mobility (Dixon, 2006). Based on these factors, this case study focused on the soft tissue tension release modalities described above, to determine its efficacy to decrease the pain of coccygodynia from birthing trauma. 3. Case History The subject of this study is a 34-year-old female, a full-time mother. She had her first vaginal delivery in July 2010 and soon after birthing she started experiencing pain near her coccyx. Her medical doctor diagnosed her condition as coccygodynia in August 2010 and recommended the use of a donut cushion when sitting. He informed her that the symptoms would mostly be relieved in six months. She underwent diagnostic radiography (X-ray) in August 2010, which determined that her coccyx had no abnormality such as fracture or misalignment. She does not have any history of injury on this area, or any other spinal related issues. The quality of pain is usually tight and aching with any contact on her tailbone, and becomes excruciating on the moment of standing up after five to seven minutes of sitting, which is slightly reduced with the use of the donut 6 P age

9 cushion. She does not exercise and her activity level is low since she had her second birthing in August Because she is still breastfeeding, she does not take any medication to relieve her pain. The pain experienced by the subject has remained essentially the same for the past two years. She did not experience any neurological symptoms on her coccygeal region, however, there was a random tingling sensation on her right pelvic region which transmits to her right thigh (near the tensor fascia lata) and to her right ankle. Her stress level was moderate five to six on the stress scale where ten is the maximum. Her sleeping pattern was mostly disrupted by breastfeeding. She had no problem sleeping on her back, but she did not feel rested in the morning. Her goals for this treatment were to reduce her coccyx pain down to one or two on the pain scale and to have her own relaxation time away from her family to decrease her stress level. 4. Assessment Initially, a soft eye scan exam with the plum line assessment was performed the subject to observe overall body posture and any possible structural compensation. The subject showed a minor degree of rounded right shoulder with slight head forward posture and lumbar hyperlordosis with slight outflare on her right side of the pelvis ( 7 P age

10 Table 1). The spinous processes of all vertebrae were aligned, and the tip of her coccyx was slightly deviated (about 1 mm) to the right from the plum line. Palpation corroborated with the visual assessment of the symptoms of coccygodynia. The subject presented major hypertonicity on the gluteal region with the right side being relatively more severe. The sacral region exhibited minor swelling and the tip of the coccyx responded with excruciating pain with slight pressure. The restriction of the thoracolumbar fascia that connected along the posterior iliac crest on the right side was remarkable. The subject s skin was well hydrated and smooth overall. The range of motion assessment and the functional tests of the lumbar spine, pelvis, and acetabulofemoral joints were performed to observe any restriction related to the pain on the coccygeal region. The subject exhibited decreased pelvic rotation anteriorly and posteriorly on the right side without any pain provocation. However, she did not experience difficulties with functional movements such as squat and rise, toe walk, heel walk and touch toe. The subject reported experiencing a minor tingling sensation along the right side of her lower limb, therefore it was critical to perform neurological tests. 8 P age

11 However, the subject did not show any abnormality on the tests, including myotome, dermatome and deep tendon reflex for the lower limbs. Although referred pain is not present, special tests such as sacral apex pressure, squish test and prone gapping test provoked the pain on the right side of the coccyx, referring to the left side. To discriminate the osseous factor contributed to the sacrococcygeal condition, leg length discrepancy, pelvic outflare and inflare were measured and long-sit test was performed (Table 1.) In conclusion, the right ilium of the subject presented the anterior rotation with slight outflare with the normal range of leg length discrepancy. A daily pain journal was given to the subject before the first day of treatment (Appendix 5). The subject was instructed to record her daily pain scale with her activity level, especially the duration of her sitting and sitting posture. Another baseline measurement, the Guided Assessment Protocol ( GAPS ) for low back and pelvis, was used to compare the pain scale and the subject s pelvis and low back structural changes before and after the treatment (Appendix 6). 9 P age

12 Table 1. Précis of the Pelvis Assessment (Magee, 2008) 10 P age

13 5. Treatment Plan and Method 5.1 Treatment goals and Management Plan On November 1 st 2012, the first treatment was initiated by establishing the four main goals based on the general assessment and the subject s feedback; First, to address the trigger points on the sacrococcygeal region in order to decrease the pain with prolonged sitting (pain scale 4-5 to 1-2). Secondly, to increase the sitting duration to more than 10 minutes without excruciating pain. Thirdly, to decrease the soft tissue restriction on the right side of the low back and lower limb; And lastly to increase the nutritional exchange on sacrococcygeal region in order to promote the healing process of the soft tissue. Since the subject s condition is chronic, it was reasonable to plan for ten treatment sessions over 8 weeks and 65 minutes for each session. In the first week, the subject receives three treatments to facilitate the correctional tissue mobility, and then two treatments in the next two consecutive weeks to promote the tissue healing process. Finally, once a week for the last two weeks to maintained the tissue mobility. The subject is instructed to continue the remedial exercise daily basis for the next three months after the entire session to prevent the soft tissue restriction and maintain the tissue mobility. The subject recorded the result of the each treatment, including any inflammation response or discomfort after the treatment, on her daily pain journal. 11 P age

14 The therapist then modified the intensity or duration of the treatment based on her feedback. On each session, the therapist utilized the clinic log sheet to record the change of the pain severity on the sacrococcygeal region and the soft tissue restriction before and after the treatment. 5.2 Modalities Used and Procedure The first main technique used in this study is the trigger point release technique to reduce the coccygeal pain. During the palpation assessment, the gluteus maximus was slightly slackened with the hip external rotation. The subject indicated familiarity with several tender spots near coccyx especially on the right side along the sacral border with the hypertoned muscular structure. The palpation on the point of tenderness is shown in the Figure 1. Within three to five minutes of applying the gentle trigger point release technique on each tender spot during the first day of treatment, the subject reported that the pain had decreased remarkably (from a rating of nine down to two on the pain scale). This modality is applied for five to seven minutes bilaterally following the trigger points along the sacral borders. Each treatment session finishes with longitudinal stroking to increase the circulation and to minimize the risk of inflammation. 12 P age

15 Figure 1. Palpation at the Point of Tenderness (Photo by Author) Acetabulofemoral joint ( AC joint ) distraction and the sacral compression in the level of grade one to two were applied at the beginning of the treatment to induce the increase of nutritional metabolism in the affected area. The purpose of this modality was to stimulate the production of the synovial fluid, and decrease the potential joint restriction or muscular restriction of the surrounding structures on the pelvis towards the lower limbs (Dixon, M,. Personal communication, 2013.) Because the subject still produces relaxin due to breastfeeding, only grade one or two of the joint mobilization is applied to minimize the risk of potential harm on the ligaments. Sacral compression was performed in prone position for about seven to eight minutes or until the sacral movement became more bouncy. Eight 13 P age

16 to ten seconds of gentle compression was followed by five seconds of release. AC joint distraction was performed for about two to three minutes on each side in supine position. Active myofascial release ( AMFR ) is followed by stretching to the hip extensor muscles, especially focusing on the obturator internus. After the sacrotuberous ligament and sacroiliac joint release (Dixon, 2006), AMFR was performed in prone position with the hip internal and external rotation for three to five minutes; intensity is limited by the subject s endurance of pain. It was followed by the hip extensor muscles stretch for another three to five minutes. The obturator internus with its tendon, the pudendal nerve and the internal pudendal vessels pass through the foramen, and if the muscle develops trigger points or tightness, it can easily compress the pudendal nerve and vessels (Travell & Simons, 1999). This technique is utilized to resolve the trigger point and release any tension around this muscle to create more space for the nerve and vessels. AMFR was also applied to the pelvic floor muscles, especially levator ani muscles. In supine position, the subject pointed the tip of the coccyx for the therapist to palpate the levator ani. The therapist then followed the coccyx and moves inferiorly and laterally. To confirm the levator ani, the subject performed the kegel exercise to contract the muscles. The therapist explored the trigger points and applied gentle compression to locate the excruciating tender spot. The 14 P age

17 subject then continued the gentle muscle contraction within her pain tolerance until the tenderness is decreased. The subject position, draping and progress of the levator ani palpation are shown in Figure 2. Cold compression is applied within the subject s tolerance to decrease any potential inflammation on this area. Figure 2. Position and Progress of the Levator Ani Palpation (Photo by Author) 5.3 Hydrotherapy and Remedial Exercise Hydrocullator is applied on the lower back, gluteal and posterior thigh region during each treatment to decrease the fascial restriction. The subject is instructed to apply heat over the same areas for 20 minutes every day. Hydrotherapy and remedial exercise were modified based on the subject s response to each treatment. The subject was instructed to carry out hip extensor 15 P age

18 muscles stretch and pelvic floor muscles strengthening exercise (Appendix 7) at home between treatment sessions. These are described in Table 4 in Section 6 Results. 6. Results The daily pain journal showed the improvement on the pain severity of the sacrococcygeal region. After the third treatment, she reported an improvement on the pain scale at a rating of two to three for most of her sitting time. Two days before the last treatment, the subject had driven for two hours, which aggravated her pain and soft tissue restriction condition. Figure 3 charts out the subject s pain scale journal which was recorded from the end of October (before the first treatment) and through the next 41 days. Pain Scale Daily Pain Scale Measurements Si4ng Standing from si4ng Prolonged walking Day Figure 3. Daily Pain Scale Measurements Results 16 P age

19 The subject also demonstrated a moderate increase in the pelvic range of motion and a decrease in the hip musculatures restriction ( Table 2). Tenderness along the sacral borders towards the coccyx was also decreased, and eventually the subject experienced no tenderness or discomfort with the sacral apex pressure test and digital compression at the end of the treatment period. Table 2. Bilateral Soft Tissue Restriction Measured Pre and Post Treatment The right pelvic outflare with pubis upslip and the anterior rotation of the ilium decreased in conjunction with the decrease of soft tissue restriction. However, the sacroiliac joint restriction was still observed on the last day of treatment. Table 3 shows the general pelvic structural changes before and after the entire treatment. 17 P age

20 Table 3. Pelvic Region Structural Changes Measured Before and the After the Entire Treatment* Table 4. Soft Tissue Response to Treatment and Homecare Progress: Additional Modalities & Homecare Exercise Recorded 18 P age

21 19 P age

22 6.1. A One-Month Follow Up Treatment The subject visited the school clinic one month later on January 12 th, 2013 to evaluate her post-treatment condition. She reported that her pain level remained at a rating of two to three depending on her activity level. After 25 minutes of sitting, she still experienced the increased tenderness on the coccyx, albeit only occasionally. The subject had not performed the given exercise regularly, but she had noted the maximum sitting time without experiencing pain in her daily pain journal. It is shown in Figure 4 below Pain Induced Time Minute Si4ng Walking Weeks Figure 4. Pain (on the Coccyx) Induced Time with Sitting and Walking 20 P age

23 The subject did not feel any pain with digital compression along the sacral borders and coccyx, and showed no swelling on the coccygeal region. The neurological symptoms such as tingling around the right lateral side of the anterior hip and ankle have diminished. The subject did not experience a relapse of the referred pain on her coccygeal region, although slight tenderness over the deep hip extensors was noted. 7. Discussion and Conclusion Coccygodynia due to birthing trauma is rare, and most of the patients do not consider massage therapy as a treatment option to relieve the symptoms. A large number of trigger points on the hip extensors and weakened pelvic floor muscles as observed in this case study can in fact be effectively treated by massage therapy. In this study, the modalities were proven to be effective in decreasing the pain on the affected area. The most obvious result through this study is that the release of the trigger point led to a significant amount of pain relief on the coccyx, which contributed to increase the sitting and walking duration without pain. Since the blood circulation is increased, swelling on the coccygeal region and the neurological symptoms on the lower limb also diminished. However, it should be 21 P age

24 noted that a low grade of pain on the coccyx and the fascial restriction remained after the entire treatment. Two main factors have to be improved to increase the efficacy of the treatment: treatment (including homecare) consistency and the intensity of modality. In the early stage of the treatment, the treatment was delayed on three separate occasions due to the subject s family obligation, which in turn may also have delayed the continuity of the trigger points releasing effect. Since the soft tissue had reverted to the original status of hypertonicity and fascial restriction in between sessions, there was an inherent lack of accuracy to effectively determine the efficiency of the applied modality and the tissue response. The subject did not perform the remedial exercise regularly, thus, the efficacy of the pelvic floor muscle strengthening exercise was not correctly measured. The intensity of the AMFR technique on the obturator internus requires modification. These techniques caused inflammation on the muscle after the first treatment, and slightly increased the pain for the next 48 hours. During the AMFR, the subject reported a rating between three out of five on the pain scale. A two out of five on the pain scale is recommended. Trigger point release technique along the sacral border to coccyx induced the similar consequences for the first three treatment sessions. A rating of two out of five on the pain scale is also recommended for this technique. 22 P age

25 Further studies for an approach to lessen the workload of the pelvic floor muscles by strengthening the abdominal region will be beneficial. During the later stage of the treatment program, the subject experienced sudden coccyx pain with severe coughing and sneezing due to flu. Later, abdominal strengthening exercise was given to the subject in the consideration that the internal abdominal pressure may have overloaded the pelvic floor due to the fascial restriction of the diaphragm or weakness of the abdominal muscles. If the abdominal strengthening exercise was performed in conjunction with the initial treatment, it would have enhanced the process of the perineal muscles strengthening. Another important factor, which may have affected on this case study is the subject s hormone level. Since she continues breastfeeding for her second child, relaxin is continuously produced in her body and affecting her ligament condition. Therefore, no more than grade two of the joint mobilization was utilized during the entire treatment. Further study may include the proper grade of joint mobilization to increase the nutritional metabolism and achieve the maximal ligaments healing process. 23 P age

26 Acknowledgement The author would like to express appreciation to the subject of this case study for her support, and sincere feedback. The author would also like to acknowledge the guidance of Mike Dixon, Majid Alimohamadi and the Clinic Instructors at West Coast College of Massage Therapy. 24 P age

27 8. Works Cited Alimohammadi, M., personal communication. (2013, February 8). Dixon, M. (2006). Joint Play the Right Way for the Axial Skeleton, 2nd Edition. Arthrokinetic Publishing. Dolin, S., & Padfield, N. (2004). Pain Medicine Manual, 2nd Edition. London ; Philadelphia: Butterworth-Heinemann. Guerineau, M., Bensignor, M., Labat, J., & Robert, R. (2002). Perineal Pain. Physical Therapy Treatment, Current Knowledge, 4th Trimester. Heller, M. (2010). The Coccyx Revisited: External and Internal Exam Correction Procedure. Dynamic Chiropractic, Volume 28 Issue 05. Magee, D. (2008). Orthopedic Physical Assessment, 5th Edition. Philadelphia: Sauders. Maigne, J., & Chatellier, G. (2001). Comparison of Three Manual Coccydynia Treatments: a pilot study. SPINE Volume 26, Number 20, Mathews, L. (2010). Coccydynia (Coccyx Injury). Retrieved from Morphopedics: Rattray, F. S., Ludwig, L., & Belgin, G. (2000). Clinical Massage Therapy Understanding, Assessing and Treating Over 70 Conditions. Toronto: Talus Inc. Thiele, G. (1950, January). Coccygodynia: The Mechanism of its Production and its Relationship to Anorectal Disease. American Journal of Surgery, Travell, J., & Simons, D. (1999). Myofascial Pain and Dysfunction: The Trigger Point Manual, 2nd Edition. Baltimore: Williams & Wilkins. 25 P age

28 Appendix 1- Perineal Nerve and Artery Figures Perineal Nerve and Artery (Source: Branching of the internal iliac artery supplying the pelvic floor region (Source: 26 P age

29 Appendix 2 - Assessment and Massage Techniques (Maigne & Chatellier, 2001) 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. Figure 2. Thiele s technique of massage in the direction of the fibers. Figure 3. J. 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. Maigne s technique. The internal figer touches, but does not mobilized 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. 27 P age

30 Appendix 3 - Manual Treatment Outcome Table (Maigne & Chatellier, 2001) 28 P age

31 Appendix 4 - Study Results (Guerineau, Bensignor, Labat, & Robert, 2002) 23 women (64%), 13 men (36%) average age: 51,4 years (28-74 years) average pain level 17, right 9, left 10 time since onset: 30 months (3 months to 15 years) 14 sessions (10 to 20) This study has provided the following results: aggravation:0% no benefit: 8% some improvement: 21% good improvement: 11% satisfying or very satisfying: 60% 29 P age

32 Appendix 5 - Pain Journal 30 P age

33 (Source: 31 P age

34 Appendix 6- Guided Assessment Protocols 32 P age

35 (Source: Massage Therapy Association of BC) 33 P age

36 Appendix 7 Remedial Exercise 1. Hip Extensor Stretch (Source : 2. Kegel Exercise (Source: 34 P age

37 3. Abdominal Strengthening Exercise (Source: 4. Hip Adductor Stretch (Source: 35 P age