10/13/2014
Coccygeal Internal Mobilization: Clinical Reasoning and Treatment for Diagnoses Beyond the Pelvic Floor
Brian Weber PT, DPT, FFMT, FAFS, NG360 GPS, FAAOMPT Gregory S. Johnson PT, FFFMT, FAAOMPT
Thank You My wife, Julie, for all her support Michelle Nesin: expertise on internal mobilization and editing Brent Yamashita: presentation development and editing Ryan Johnson presentation development and editing Gregg and Vicky Johnson: Developers of FMT AAOMPT for the opportunity to present this material
Outline
History Associated Diagnosis/Dysfunctions Anatomy/Biomechanics Why the Coccyx Treatment ◦ Precautions ◦ Patient Education ◦ Set Up ◦ Treatment procedure
1 10/13/2014
History The first record of internal work on the coccyx was in 1859 by J. Y. Simpson M.D.
◦ For treatment he separated the coccyx from all the surrounding muscles, tendons, and ligaments, which was done subcutaneously, with a tenotomy knife
In 1937 Thiele described internal coccyx mobilization extending up to the piriformis in JAMA
A randomized single-blinded study in 2005 by Maigne evaluated intrarectal manipulation to treat coccydynia
◦ Good results were twice as frequent (borderline significant) in the treatment group compared to the control
Associated Diagnosis/Dysfunctions
Coccydynia Visceral dysfunction (slow transit times) Sacroiliac Pain Pelvic floor dysfunction Lumbar pain Bowel or Bladder Dysfunction Pain with sitting Dural Tension (Cervical retraction Sciatica test, Johnson) Neurotension Shin splints ◦ Flexion slump (Maitland) Chronic hamstring strains, especially Bilateral ◦ Extension slump (Johnson) Chronic plantar fasciitis Upper Extremity Nerve Tension Trigger points not accessible externally Decreased Cervical Rotation Coccyx Decreased Shoulder elevation ◦ Not treatable Decreased Trunk Rotation externally Decreased Hip Rotator Strength Sexual Dysfunctions Decreased Trunk Forward Flexion Headaches Scoliosis Patellofemoral Pain Syndrome (PFPS)
Consists of three to five coccygeal vertebrae (Woon 2013) ◦ 3 (13%) ◦ 4 segments (76%) ◦ 5 segments (11%)
Overall mean length ◦ Women: 3.7 ± 0.7 cm ◦ Men and 4.2 ± 0.8 cm
The first coccygeal ◦ Largest segment ◦ Articulates with the sacrum via a symphysial or synovial joint (Saluja, 1988)
2 10/13/2014
Intercoccygeal Joints Balain B, et al. (2006); A. Fused joints Maigne JY, et al. (1994) B. Intact Disks (similar to Lumbar Spine) C. Synovial Joints D. Symphysial joint
http://www.gustrength.com/anatomy:bones‐of‐the‐adult‐skeleton
Coccyx Angulations A radiographic classification of the Coccyx: Potacchini et al
◦ Type I :(~70%) : the coccyx is curved slightly forward, apex pointing caudally
◦ Type II : (~15%) : the coccyx is curved more markedly anteriorly, apex pointing straight forward
◦ Type III : (~5%) : the coccyx is sharply angulated forward between the first and second or the second and third segments
◦ Type IV : (~10%) : the coccyx is subluxed anteriorly at the level of the sacrococcygeal joint or at the level of the first or second segment
◦ Type V: A coccyx with a retroverted tip (Woon et al. 2013)
• Flexed • Extended • Rotated • Side Bent • Anterior/Posterior Shear • Lateral Shear • Compressed
3 10/13/2014
Coccyx Mobility
Coccyx mobility in sitting: flexion (Maigne,1994) ◦ Coccyx flexion: between 5 and 22 degrees
◦ During straining/ bowel movement, coccyx extension: between 5 and 15 degrees
Postacchini: 120 asymptomatic subjects ◦ Sacrococcygeal joint was mobile in 53 (63%)
◦ First intercoccygeal joint was mobile in 75 (90%)
◦ Second intercoccygeal joint was mobile in 47 (57%)
◦ Only 7% had completely fused coccygeal segments
Woon and Maigne:101 Patients with Coccydynia
Sacrococcygeal joint: 27% Fused
Intercoccygeal joint ◦ C1/2 (first) 17% Fused
◦ C2/3 (second) 47% Fused
◦ C3/4 (third) 78% Fused
Tip of the coccyx demonstrate minimal side bend (mean of 6 degrees) ◦ (Woon 2013)
4 10/13/2014
Nervous System ◦ Dural attachment
Ligaments ◦ 7 attach to the coccyx
Fascia
Muscles ◦ 6 attach directly to the coccyx
http://www.backandneck.ca/tail-bone-injuries/
Rufus Weaver, anatomist, 1892
Proposal
Positional Mal-alignments and motion fixations of the coccyx from trauma places sustained tension through the Filum Terminale and Dura, simulating Tethered Cord Syndrome in the general population (Wardlaw)
5 10/13/2014
Signs and Symptoms ◦ Intermittent pain in the back of one or both legs and in the lower back ◦ Pain in a radicular distribution, elicited by a straight leg raise ◦ Increased abnormal sensations in the feet (numbness, tingling, burning) ◦ Sensory loss in a root distribution ◦ Muscle stiffness, weakness, or atrophy ◦ Progressive scoliosis ◦ Abnormal lower extremity reflexes ◦ Bladder problems
http://childrenshospital.org/az/Site1705/Images/Final_TetheredCord_lrg.gif
Filum Terminale Sometimes erroneously referred to as the coccygeal ligament
Anchor for the spinal cord
Distally, fuses with the periosteum of the dorsal aspect of the coccyx or sacrum (Tubbs, 2005)
Consists largely of fibrous tissue containing smooth muscle, blood vessels, and peripheral nerves (Tubbs, 2005) http://www.ktif.info/coccyx_illustrations.asp
Spinal Motion
Spinal Cord ◦ Lengthen approximately 30% from spinal extension to spinal flexion (Troup 1986)
Filum Terminale ◦ Stretches to allow cranial movement of the spinal cord with flexion
◦ Pulls the spinal cord to normal position when returning from a flexion
◦ Decreased mobility leads to increased stretch to the spinal cord instead of the filum
http://www.ktif.info/coccyx_illustrations.asp
6 10/13/2014
Myodural Bridge A connective tissue link between the rectus capitis posterior minor muscle (RCPMi) and the cervical dura mater (Hack 1995)
◦ High density of muscle spindle (Peck 1984)
Action ◦ Active when the head is translated forward at the AO joint (McPartland and Brodeur 1997)
◦ May prevent in-folding of the dura mater during cervical extension (Hack et al.1995)
Testing ◦ Cervical Retraction Test (Johnson)
http://www.massagetoday.com/archives/2005/07/06.html
Gentle traction at occiput
Drop Legs to one side than other Positive Test Head will be drawn inferior with leg rotation Increase tension on the dura by extending the knees
Dural Connection
KAHKESHANI AND WARD 2012
7 10/13/2014
Kemper and Wooley (1998) ◦ 50 Patients with or without coccydynia ◦ Treatment: Internal coccyx manipulation
Results ◦ Average treatment Duration 3.1 visits for females 4.3 visits for males
◦ 7.38 inch improvement in lumbar flexion
◦ Visual analogue Pain Scale (0-10) Pre: (4.66/10) Post (0.66/10)
http://www.ktif.info/_documents/patients_before_after.pdf
Ligaments
Anterior Longitudinal
Sacroccygeal ligaments ◦ Extension of the ALL ◦ Insertion first and sometimes the second coccygeal vertebrae ◦ Thicker over the sacrococcygeal joint
Anococcygeal Extends between the coccyx and the external anal sphincter
Posterior Sacrococcygeal Ligament Superficial ◦ Sacral hiatus to dorsal surface of the coccyx ◦ Corresponds to the ligamentum flava
Deep ◦ Continuation of the posterior longitudinal ligament ◦ Originates on the posterior fifth sacral segment ◦ Inserts on the dorsal surface of the coccyx
Lateral ◦ Up to 3 separate ligaments ◦ ILA to first coccygeal transverse processes ◦ Attachments to the sacrotuberous and sacrospinous ligament
8 10/13/2014
Sacrospinous Ligaments
Attachments ◦ Lateral margins of the sacrum and coccyx
◦ Entire length is covered by the coccygeus muscle
◦ Laxity allows for excessive posterior innominate rotation (Woodley 2005) ◦ Increased tension can pull the innominate into anterior rotation
Sacrotuberous Ligaments
Attachments ◦ Posterior portion of the iliac crest, the lower three sacral vertebrae and the coccyx
Associated Ligaments ◦ Dorsal sacroiliac ligaments
◦ Posterior sacrococcygeal ligament Direct attachment to the dura (Barral)
◦ Blends/fuses with the sacrospinous ligament
Nerves/Arteries ◦ Cutaneous nerve and filaments of the coccygeal plexus
Anatomy Trains
Muscle attachments ◦ Gluteus maximus Most direct connection
◦ Biceps femoris Hypothesized to stabilize the sacroiliac joint via the sacrotuberous ligament
◦ Piriformis
◦ Obturator internus
◦ Semitendinosus/Semimembranosus (Woodley 2005)
9 10/13/2014
Woon, 2012
http://www.tlcschool.com/the-enlightened-body- Anatomy Trains blog/thoracolumbar-fascia-and-back-pain/
Muscles
1. Puborectalis 2. Pubococcygeus 3. Iliococcygeus 4. Coccygeus 5. Piriformis 6. Obturator Internus
10 10/13/2014
Puborectalis
U-shaped
Most medially levator ani muscle
Defecation ◦ Relaxation of the puborectalis ◦ Extension of the coccyx
Treatment indications ◦ Problems with defecation ◦ Pubic Symphysis Dysfunction
Muscles of the Hip and Pelvis
Gluteus Minimus
Piriformis Superior gemellus Greater sciatic Obturator foramen Internus
Lesser sciatic Inferior gemellus foramen Obturator Externus Obturator Internus Quadratus Femoris
So why coccyx? ◦ Nerve and Dural Tension ◦ Muscle length-tension relationship ◦ Ligament length-tension relationship ◦ Fascial Connections
Why Internal Mobilization? ◦ Structures not assessable or treatable externally ◦ Nerve tension with strong pull to coccyx (especially flexion) ◦ Patient who has not been successfully with other treatments
11 10/13/2014
Theile 1937
Precautions Verify that this procedure is within the scope of your state’s practice act
This procedure requires explanation, permission, and tact
Be sure to give clear explanation of the procedure
Parents should always be present during examination and treatment of children
Avoid rectal examination during menstrual period
DO NOT force or pressure a reluctant patient
Bleeding Hemorrhoids
Patients who have been sexual abused
Be aware of patients with osteopenia and osteoporosis
Complications
The most likely risk is irritation of the rectal lining ◦ May cause mild, temporary bleeding
The more severe risk is that you tear the rectal lining
Increased pain or nerve symptoms
Autonomic Symptoms: Ganglion Pars ◦ Instruct the patient on autonomic symptoms ◦ They need to inform you if symptoms occur Change in temperature
Increased heart rate
Clamminess/feeling flush
Increased breathing rate
Increased sweating
12 10/13/2014
Patient Preparation Request that the patient to empties their bladder prior to treatment
Verbal/nominal consent must be obtained from the patient
An informed-consent form for the patient to sign should be standard practice
Many clinicians choose to have an assistant in the room ◦ Assistance with neurotension ◦ Patient comfort and help them relax during the procedure ◦ To avoid/decrease likelihood of any possible liability issues
Patient Position Side lying ◦ Bilateral hip flexion to 70-90 degrees ◦ Top leg flexed and bottom leg extended ◦ Patients placed with most involved side on top
Set Up
Gloves and lubrication ◦ Make sure to use enough lubrication Apply to glove and may also apply to rectal area Warm up lubricate: improves patient comfort and relaxation
Finger Choice ◦ Use your index finger
◦ 3rd digit is the longest, but other fingers limit you depth of palpation
Sanitation ◦ Have a waste basket, tissues and hand sanitizer next to you
◦ Have tissues and waste basket for the patient to clean themselves
13 10/13/2014
Set Up and Draping
Patient comfort is First and Foremost ◦ If the patient feel uncomfortable at any time let them know they need to let you know
◦ Tell them that you will stop treatment and slowly remove your finger
Draping ◦ Sheet should be placed on the table and another sheet to cover the patient
Treatment Techniques
Soft Tissue Mobilization ◦ Boney contours ◦ Muscle belly/trigger points
Functional Movement Patterns (FMP) ◦ Active patient movements Breathing Unilateral or bilateral hip rotation Pelvic Tilts Pelvic floor contractions Hip Motion Knee Motion
Treatment Techniques
Functional Mobilization (FM) ◦ Resisted movements
Nerve Mobilization (Direct treatment to the nerve) ◦ Lateral mobility ◦ Longitudinal mobility Nerve place on tension with Lower extremity motion Block segment being pulled/shifted by the nerve tension
14 10/13/2014
Initiation of Mobilization Prior to initiation ◦ Visual confirmation of the rectum is recommended
Gently spread the buttocks with your free hand
Finger facing posterior towards coccyx
There are 2 anal sphincters ◦ Voluntary external sphincter muscles
◦ Involuntary internal sphincter muscles
Initiation of Mobilization
If trigger points (TrPs) are present, insertion of the finger can be distressful even when done very carefully
Entering the rectum ◦ Have patient gently bear down ◦ As they relax enter deeper into the rectum ◦ May also have patient initiate posterior depression of the pelvis
DO NOT use force to enter deeper
Internal hemorrhoids can perpetuate TrPs
◦ Perform a 360 degree assessment and treatment
Puborectalis
Located inferior to tip of the coccyx at the level of the external anal sphincter
Restrictions will resist ability to move to higher structures
Treatment ◦ 360 degree STM
Key structure ◦ Constipation ◦ Pubic symphysis dysfunctions
15 10/13/2014
Red Flag Rectal Cancer ◦ Signs and Symptoms Diarrhea Constipation Not being able to completely empty the bowel Change in the size or shape of stools (narrower) Bloody stool (either bright red or very dark)
• The symptoms of rectal cancer are similar to other bowel diseases, like ulcerative colitis, Crohn's disease
• These diseases usually demonstrate periods of symptom remission
• If you feel a hard button like area over the tissues of the rectum refer the patient to their primary physician to rule out the presence of cancer
Levels of Palpation
In 2012 Joguet et al looked at the anatomy of the digital rectal examination to improved teaching methods and consistency with palpation for medical students
These bone landmarks are less consistent for internal organ palpation
We will utilize the palpation guidelines as a general rule ◦ Remember Coccyx length is variable
Coccyx angulations does vary Index finger length is variable Patient size and structure can influence palpation
Level One Palpation The first level (the tip of the index on the tip of the coccyx)
Assess tip of coccyx Flexion Extension Side bend Pelvic Floor
16 10/13/2014
Levator Ani Assess Pelvic Active ◦ Have your patient actively squeeze their rectum around your finger Assess along the margin of the coccyx ◦ Lateral ◦ Inferior Levator ani may feel like a firm sheet of muscle Soft tissue mobilization of these structures very helpful prior to positional corrections of the coccyx Treatment STM FMP FM
Coccyx Flexion
Type III : (~5%) coccyx is sharply angulated forward
Only the rectal wall between finger and coccyx
Spring test to the coccyx to check mobility
Flexion may occur at any of the mobile joints
Treatment
Anterior to posterior mobilization
May apply traction
FMP and FM
If no motion is present proceed to the next structure
Level Two Palpation
Distal inter-phalangeal articulation placed on the tip of coccyx
Sacrococcygeal Joint
Anterior Longitudinal Ligament
Sacroccygeal ligaments
Anterior
Lateral
17 10/13/2014
Palpation ◦ Mainly at level 2 ◦ Most of the muscle lies anterior to the sacrospinous ligament ◦ Gluteus maximus coccyx attachment similar to the cocccygeus
Treatment STM FMP FM
Sacroccygeal ◦ All cross sacrococcygeal joint
Treatment ◦ Lateral Mobility ◦ Longitudinal mobility ◦ STM ◦ FMP ◦ FM
Shears
Anterior shears ◦ Sacrococcygeal ◦ Individual vertebrae of the Coccyx
Lateral shear ◦ Sacrococcygeal ◦ Individual vertebrae of the Coccyx
18 10/13/2014
Sacrococcygeal joint ◦ Traction is applied with the internal hand and also the external hand ◦ Anterior to posterior mobilization ◦ Dysfunction may be central (pure shear) or lateral (rotation) Treatment ◦ FMP ◦ FM
If no motion is present proceed to the next structure
Level Three Palpation
Proximal interphalangeal articulation placed on the tip of the coccyx ◦ Sacrospinous Ligament ◦ Sacrotuberous ligament ◦ Obturator internus muscle ◦ Ischial spine ◦ Pudendal nerve
Sacrospinous Ligaments Attachment ◦ Superior and lateral to sacrococcygeal joint
◦ Fibers run medial to lateral with slight inferior angulations to the ischial spine
◦ Majority covered by the fibers of the coccygeus muscle
Motion restrictions and tenderness if dysfunctional
Important to treat at ischial tuberosity ◦ STM ◦ FMP ◦ FM
19 10/13/2014
Palpation ◦ Posterior to the sacrospinous ligament ◦ Vertical Fibers ◦ Easiest to palpated superior and inferior to the sacrospinous ligament ◦ Often tender and demonstrate restricted mobility
Treatment ◦ STM ◦ FMP ◦ FM
Pudendal Nerve Palpation ◦ Round and string-like ◦ Always keep same diameter with palpation ◦ Landmarks Cocccygeus muscle Sacrospinous Ligament Ischial tuberosity
Treatment ◦ STM Medial to lateral mobility Longitudinal mobility
AA First Labs
Formed by folding of the obturator internus fascia
Follow the nerve anterior and inferior
Just superior to ischial tuberosity
Treatment ◦ STM Medial to lateral mobility Longitudinal mobility
http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2028_%20Pelvis%20and%20Perineum.htm
20 10/13/2014
Oburator Internus Palpation ◦ Level 3 ◦ Turn finger to face anterior lateral to anteriolateral wall of the lesser pelvis ◦ Inferior to the pubic bone ◦ Verify by resisting external rotation of the hip
http://lucy.stanford.edu/img/img7.jpg
Treatment STM Critical to examine just caudal to the tip of the ischial spine Most likely place for trigger points according to Travell and Simons
Level Four Palpation • Metacarpophalangeal articulation comes into contact with the tip of the coccyx
• Piriformis
21 10/13/2014
Sacral Nerves Anterior to the coccygeus muscle Anterior aspect of the piriformis Round and string-like Always keep same diameter with palpation ◦ STM Medial to lateral mobility Longitudinal mobility
Piriformis Palpation ◦ Cranial to the sacrospinous ◦ Usually can palpate inferior/medial edge of the muscle ◦ Verify palpation with resisted hip abduct ◦ If tender will often reproduce patient’s pain in a sciatic distribution
Treatment ◦ STM ◦ FMP ◦ FM
http://www.pudendal.com/
Review of Palpation
Travell and Simons
22 10/13/2014
Following mechanical treatment assess nerve tension
Nerve consist of 50- 90% connective tissue
Beware of being too aggressive
Clear out nerve restrictions distal prior to performing nerve mobilization at the coccyx
Decreased likelihood of exacerbation
Very powerful treatment in decreasing pain, improving function and preventing recidivism
Pressure placed on coccyx
Assistant brings hip into flexion until tension is perceived in the leg or coccyx
Block coccyx movement ◦ Flexion ◦ Anterior shear
Perform flossing
Assistant resists hip extension
Nerve manipulation
Blocking for Nerve Tension
23 10/13/2014
Uterus
The uterus is located immediately dorsal (and usually somewhat anterior/superior) to the urinary bladder
When assessing the ovaries and uterus if you feel masses and growths must make a referral to an OBGYN
Uterus Treatment ◦ Level 2 ◦ Turn finger to face anterior If the uterus is retroverted you will feel a hard round mass which prevents your finger from moving forward ◦ When in a normal position the uterus give little resistance to digital pressure ◦ Treatment ◦ Assess mobility in all directions
Prostate Inserted finger in a downwards angle as if pointing to the umbilicus
Pressing on the prostate gland should not hurt, although it may make you feel like you need to urinate
Consistency
◦ Rubbery and firm
◦ Smooth surface
◦ Palpable sulcus between right and left lobes
◦ There should not be any tenderness
◦ There should be no nodules
24 10/13/2014
Prostate The prostate ("one who stands before", "protector“) Slightly larger than a walnut Tenderness ◦ Prostatitis, a temporary inflammation, no surface changes Prostate cancer can cause the surface of the prostate to become hard and bumpy Refer to primary physician
Females: anterior and Males: anterior and inferior to the uterus and superior to the prostate anterior to the vagina
Pubic Symphysis
Internal treatment following unsuccessful external treatment
Much easier to palpate with an empty bladder
STM: Puborectalis prior to internal pubic symphysis treatment
Posterior Shears ◦ Mobilize the posterior pubic symphysis
25 10/13/2014
Ending the Procedure
Slowly remove your finger
Ask the patient to contract the pelvic floor ◦ This prevents them from feeling like they are having a bowel movement
Educate the patient on the possibility of bleeding and that a small amount is normal
Leave the room and have tissues and waste basket close to patient for clean up
Review of Palpation
Levator Ani Muscles: Level 1/2: anterior and lateral to coccyx
Tip of the Coccyx: Level 1: posterior to rectum
Sacrococcygeal Joint Level 2: posterior to rectum
Sacrospinous and Sacrotuberous Ligaments: Level 3: lateral to rectum
Pudendal Nerve: Level 2/3: lateral to rectum
Obturator Internus: Level 2/3: anterior/lateral to rectum
Sacral nerve Root: Level 4: posterior of rectum, anterior to piriformis
Piriformis: Level 4: posterior of rectum and sacral nerves
Prostate or Uterus: Level 2 to 3: anterior to rectum
Pubic symphysis: Level: Most anterior to rectum
Case Study
26 10/13/2014
Questions
References Anatomy Trains. Second Addition. Churchill Livingston. 2009. Dissection 5. Pelvis and Perineum. www.emory.edu/ANATOMY/AnatomyManual/pelvis.html FRANTISEK T, MIROSLAV T. SHORTENING OF THE PELVIC FLOOR MUSCLES INFLUENCEST HE POSITION OF THE SACRAL BONE and CAUSES ASYMETRICAL MOVEMENT OF THE SACROILIAC JOINTS. The Journal of Orthopaedic Medicine 22(2)200O. Fisher K. Ani Muscle Overactivity Management of Dyspareunia and Associated Levator. PHYS THER. 2007; 87:935-941. Grieve, G. Modern Manual Therapy of the Vertebral Column. Churchill Livingstone. 1986. Hack GD, Hallgren RC. 2004. Chronic headache relief after section of suboccipital muscle dural connections: A case report. Headache 44:84–89. Hack GD, Koritzer RT, Robinson WL, Hallgren RC, Greenman PE. 1995. Anatomic relation between the rectus capitis posterior minor muscle and the dura mater. Spine 20:2484–2486. Heller M. The Coccyx Revisited: External and Internal Exam Correction Procedures. 2011. Coccyx.org http://www.cancercenter.com/colorectal-cancer/symptoms/tab/rectal-cancer-symptoms/ Joguet E, Robert R, Labat J, Riant T, Gue´rineau M, Hamel O, Louppe J. Anatomical basis of digital rectal examination. Surg Radiol Anat (2012) 34:73–79. Krishnan H. Anatomy of Rectum. Slideshare. May 21, 2011 Kahkeshani, K. Ward, P. Connection Between the Spinal Dura Mater and Suboccipital Musculature: Evidence for the Myodural Bridge and a Route for Its Dissection—A Review. Clinical Anatomy 25:415–422 (2012). Maigne J, Chatellier G. Comparison of Three Manual Coccydynia Treatments: A Pilot Study. SPINE Volume 26, Number 20, pp E479–E484. Marios Loukas, Robert G Louis Jr, Barry Hallner, Ankmalika A Gupta and Dorothy White. (2006) "Anatomical and surgical considerations of the sacrotuberous ligament and its relevance in pudendal nerve entrapment syndrome" Surg Radiol Anat 28(2): 163-169 McPartland JM, Brodeur RR, Hallgren RC. 1997. Chronic neck pain,standing balance, and suboccipital muscle atrophy—A pilot study. J Manipulative Physiol Ther 20:24–29.
References continued
PPeck D, Buxton DF, Nitz A. 1984. A comparison of spindle concentrations in large and small muscles acting in parallel combinations. J Morphol 180:243–252. Pecina, M, Krmpotic J, Markiewitz A. Tunnel Syndromes. 3rd Edition. CRC Press 2010. Prendergast S, Weiss J. PT and PNE. Advance for Physical Therapists. 2004. Vol. 15, Issue 21. Page 47. Postacchini F, Massobrio M. Radiologic Study of Asymptomatic Patients Idiopathic coccygodynia. Analysis of fifty-one operative cases and a radiographic study of the normal coccyx. The Journal of bone and joint surgery. American volume. 1983 Oct; 65(8): 1116-1124 SIMPSON J.Y. On coccyodynia, and the diseases and deformities of the coccyx: CLINICAL LECTURES ON THE DISEASES OF WOMEN, LECTURE 17. Medical Times and Gazette. 1859, 40: 1-7. THIELE, G. .COCCYGODYNIA AND PAIN IN THE SUPERIOR GLUTEAL REGION. JAMA. 1937;109(16):1271- 1275. Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual. The Lower Extremities. Williams and Wilkins 1992. Visceral Manipulation. Barral JP. Eastland Press. 1989. Vleeming, A., R. Stoeckart, et al. (1989). "The sacrotuberous ligament: a conceptual approach to its dynamic role in stabilizing the sacroiliac joint." Clinical Biomechanics 4(4): 200-203. Weiss J. Pelvic Floor Myofascial Trigger Points: Manual Therapy for Interstitial Cystisitis and the Urgency- Frequency Syndrome. Vol. 166, 2226-2231. Dec 2001. Wikipedia, the free encyclopedia Wilensky T. The levator ani, coccygeus and piriformis muscles. Agents in the causation of coccygodynia, superior gluteal pain and sciatic syndrome. American Journal of Surgery. 1943. 59: 44-9. Witmer, L. Navigating Anorectal Anatomy: Terms, Planes, Spaces, Structures. Department of Biomedical Sciences. College of Osteopathic Medicine . Ohio University. Woodley SJ, Kennedy E, Mercer SR. (2005). Anatomy in practice: the sacrotuberous ligament. New Zealand Journal ofPhysiotherapy 33(3) 91-94. All pictures contained in this presentation are from the internet unless otherwise noted.
27 10/13/2014
INFORMED CONSENT FOR ASSESSMENT OF COCCYX/PELVIC FLOOR DYSFUNCTIONS I understand that it may be beneficial for my therapist to perform a coccyx assessment and muscle assessment of the pelvic floor, initially and periodically to assess joint mobility, muscle strength, length, range of motion and scar mobility. Palpation of these muscles is most direct and accessible if done via the rectum. Coccyx/Pelvic floor dysfunctions include low back pain, SI pain, nerve tension, pelvic pain syndromes, urinary incontinence, fecal incontinence, dyspareunia, or pain with intercourse, pain from an episiotomy or scarring, vulvodynia, vestibulitis, or other similar complications. Evaluation of my condition may include observation, joint mobilization, soft tissue mobilization and nerve mobilization. I understand that I have the option to have a chaperone during evaluation & treatment that may include internal procedures. I will_____ will not_____ bring a chaperone to subsequent visits. If I opt for a chaperone, internal assessment, if allowed, will be deferred until the next visit when the chaperone is present. I understand that the benefits of the rectal assessment will be explained to me. I understand that if I am uncomfortable with the assessment or treatment procedures AT ANY TIME, I will inform my therapist and the procedure will be discussed with me. A decision will be made to either continue internal assessment/treatment or suspend it. External treatments may still be utilized. The therapist will explain all these treatment procedures to me and I may choose to not participate with all or part of the treatment plan.
I understand that no guarantees have been or can be provided to me regarding success of therapy. I have read or had read to me the foregoing and any questions, which may have occurred to me, have been answered to my satisfaction. I understand the risks, benefits, and alternatives of the treatment. Based on the information I have received from the therapist, I voluntarily agree to standard assessment and muscular treatment techniques of the pelvic area. ______Patient’s Signature Date ______Physical Therapist’s Signature Date ______(if applicable) Patient’s Legal Representative/Guardian/Parent ______Relationship to Patient
If you are pregnant, have an infection of any kind, have vaginal dryness, are less than six weeks postpartum, post surgery, have severe pelvic pain, sensitivity to KY jelly, vaginal creams or latex, please inform the therapist prior to the pelvic floor assessment.
28