File
Sabbahi M.1, Badghaish M.2, Ovak Bittar F.3, Sabbahi W.3,4, Al-Malki A.2
1Texas Woman's University, Physical Therapy, Houston, United States, 2Medical Physical Therapy Clinic, Physical Therapy, Jeddah, Saudi Arabia, 3Texas Physical Therapy and Electrophysiology Services, Research, Houston, United States, 4Kowa Inc., CEO & President, Houston, TX, United States
Background: Coccyx pain (coccydynia) has been a nagging clinical problem defying effective treatment. Evaluation using clinical evaluation or imaging lacks the pathophysiology of the disorder. Electrophysiologic testing procedure could identify the origin of such pain. During clinical testing we recorded a strong association between lower back pain (LBP) and coccyx pain.
Purpose: This presentation is to discuss a new procedure to identify the origin of coccyx pain and to provide an effective treatment for such disorder.
Methods: Patients with LBP with or without radiculopathy (N= 200) were tested, out of those patients 20 suffers coccyx pain. Soleus H-reflexes were tested, during our routine clinical evaluation, in both legs during lying (unloading) and standing (loading) as well as during dynamic postural tests (in standing) to identify the decompression posture (Optimum Spinal Posture) and compression posture (Unwanted Spinal Posture, USP). H-reflexes were tested using our method using surface electrodes. Tibial nerve was electrically stimulated (1 ms, 0.2pps at H-max) while recording soleus muscle action potentials (M and H). Five representative traces were recorded in each trial (lying, standing and dynamics postures). H/H value (H-amplitude of the symptomatic/non-symptomatic) was measured before and after the treatment program. Pain intensity was using VAS, straight leg raising and tiptoe/ heel walking was also tested. Descriptive statistics were used for signal and data analyses.
Results: The results showed significant reduction in the peak-to-peak amplitude of the soleus H-reflex in one or both lower limbs during lying more than standing, in all patients, indicating S1 nerve root compromise of one or both lower limbs. H/H value ranged from 57-76% during lying-standing. Dynamic postural testing was completed, while recording the compromised soleus H-reflex in forward bending, backward bending, side bending, rotations, side bending and right or left rotation. The trunk posture causing maximum reflex recovery (decompression posture, OSP) and maximum reflex depression (compression posture, USP) were identified. Treatment (including exercise and postural education) were developed for each patients promoting the OSP and avoiding the USP. Male patients with coccyx pain reported substantial erection disorder while female patients reported stress incontinence. Patients reported centralization of the coccyx pain toward the lumbar segment after the 3rd. session, and was at 50% of the initial value. Lack of protocol compliance resulted in peripheralization of the pain to the coccyx. By the end of the 6th session LBP was eliminated, SLR was symmetric at both lower limbs at 90 degrees and gait showed normal tiptoes and heel walking. H/H ratio showed a range of 80-90% value indicating improved spinal functions/control. Erection function was not tested post treatment. The results for the H-reflex, VAS, SLR were statistically significant (p=0.05).
Conclusion(s): It appears that coccyx pain is primarily a neural disorder originating from S1 nerve root radiating to the coccyx and it should be treated accordingly using direction-sensitive exercise therapy protocol.
Implications: Clinical relevance: Coccydynia associated with erectile dysfunction in males and stress incontinence in female appears to be due to neural dysfunction affecting S1 nerve root and could be treated with direction sensitive exercise therapy.
Funding acknowledgements: No funding.
Topic: Orthopaedics
Ethics approval: IRB of Texas Woman´s University
All authors, affiliations and abstracts have been published as submitted.
