clinical decision making for the evaluation and management of coccydynia… · 2018. 3. 26. ·...
TRANSCRIPT
journal of orthopaedic & sports physical therapy | volume 44 | number 8 | august 2014 | 615
[ case report ]
Coccydynia is a painful and potentially debilitating condition that may be related to trauma, obesity, or other unidentifiable causes.11 The coccyx is variable in size and consists of 3 to 5 vertebral units that are usually fused, with the exception of the
first segment, which articulates with the distal end of the sacrum and is referred to as the sacrococcygeal joint. In general, the dorsal surface
of the coccyx is convex, so that its inferior aspect is sloping anteriorly. The sacro-coccygeal joint has a limited amount of movement in flexion and extension, rang-ing from approximately 5° to 15° in either direction.18 A posterior rotation (flexion) motion occurs when moving from a standing to a sitting position, which is thought to enable optimal force absorp-tion in the seated position. The reverse occurs when moving from a seated to a standing position. Movement also occurs during defecation, where flexion controls descent of feces and extension allows release.4,14,18
Women are 4 times more likely to have symptoms consistent with coccydynia, and individuals with increased body mass index are 3 times more likely to develop this painful disorder.6 Coccydynia is as-sociated with posterior sacrococcygeal subluxation from repeated or prolonged sitting loads.9 Diagnosis of this condition is based on clinical presentation and, often, static-view radiological imaging to identify displacement of the coccyx. Dynamic imaging can also be performed to assess abnormal mobility by compar-ing the position of the coccyx in stand-ing versus a seated position. Instability of the coccyx has been defined as a flexion movement that exceeds 25° or exten-sion that exceeds 20°; however, recent dynamic magnetic resonance imaging
TT STUDY DESIGN: Case report.
TT BACKGROUND: Coccydynia is a painful condi-tion of the sacrococcygeal region, with symptoms associated with sitting and rising from a seated position. There is no gold standard for diagnosis of this condition; however, coccyx mobility as-sessment, pain provocation testing, and imaging have been proposed as reasonable diagnostic approaches. Once correctly diagnosed, treatment options for coccydynia include conservative man-agement and surgical excision. The purpose of this report is to describe the different but successful clinical management strategies of 2 patients with coccydynia.
TT CASE DESCRIPTION: Two women, 26 and 31 years of age, presented to physical therapy with persistent coccygeal pain that increased with prolonged sitting and intensified when transitioning from sit to stand. One patient had a traumatic onset of symptoms, in contrast to the other patient, for whom prolonged sitting was the precipitating factor. Both individuals were consid-ered to have hypomobility of the sacrococcygeal joint, as assessed through intrarectal mobility testing, which also reproduced their symptoms. In both patients, examination of the lumbar spine was negative for alleviation or reproduction of symptoms. The patient with a traumatic onset
of symptoms was referred to physical therapy at the onset of her symptoms, whereas the patient with a nontraumatic onset of symptoms was initially treated with a cortisone injection and, when symptoms returned 1 year later, was referred to physical therapy. Both individuals underwent manual therapy to the sacrococcygeal joint over 3 treatment sessions.
TT OUTCOMES: The patient with traumatic onset of symptoms had almost complete resolution of symptoms, whereas the patient with a nontrau-matic onset only had temporary relief. This patient required further diagnostic examination and surgical excision.
TT DISCUSSION: Although the mechanisms of injury were different, both patients presented with similar clinical symptoms, and both were consid-ered to have coccydynia through coccyx mobility assessment and pain provocation testing. Suc-cessful clinical outcomes were achieved in both cases; however, the interventions were significantly different.
TT LEVEL OF EVIDENCE: Therapy, level 4. J Orthop Sports Phys Ther 2014;44(8):615-621. Epub 23 June 2014. doi:10.2519/jospt.2014.4850
TT KEY WORDS: coccyx, manual therapy, musculoskeletal imaging, physical therapy
1Department of Physical Therapy and Athletic Training, Boston University, Boston, MA. 2Muir Orthopaedic Specialists, Walnut Creek, CA. These cases were seen at Boston University Physical Therapy Center, Ryan Center for Sports Medicine, Boston University. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Lee N. Marinko, 635 Commonwealth Avenue, Boston, MA 02215. E-mail: [email protected] T Copyright ©2014 Journal of Orthopaedic & Sports Physical Therapy®
LEE N. MARINKO, PT, ScD, OCS1 • MATTHEW PECCI, MD2
Clinical Decision Making for the Evaluation and Management
of Coccydynia: 2 Case Reports
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[ case report ]findings have demonstrated excursion up to 31° of flexion in asymptomatic indi-viduals.4,18 There is, therefore, no imaging gold standard for the diagnosis of coccy-dynia, and to date there are no reliability studies of manual assessment of mobility abnormalities, which leaves the clinician to rely primarily on the history and physi-cal examination for diagnosis.
Currently, there is a paucity of re-search for the role of conservative treat-ment in the management of coccydynia. Treatment descriptions vary but consist of nonsteroidal anti-inflammatory drugs, manual therapy, and local cortisone in-jections.2,5,7,10,12-14 Compared with placebo intervention, Maigne et al8 found that manual therapy in the form of intrarec-tal manipulation for 3 treatment sessions resulted in better outcomes for pain and function at both 1 and 6 months.8 Fur-thermore, Maigne and Chatellier7 found that intrarectal manual therapy in the form of massage, mobilization, and stretching resulted in a positive success rate of 43% of those treated at 2-year follow-up. Treatment success varied by cause of coccydynia and classification of mobility by plain-film radiography.7 Although both of these studies support the use of mobilization in the presence of chronic coccydynia, effectiveness may vary based on the underlying cause of the painful condition and individual patient characteristics.
The evidence to support the use of corticosteroid injections is also limited but favorable. Wray et al19 compared the outcomes of 120 individuals with coc-cydynia who were treated with physical therapy consisting of therapeutic ultra-sound and shortwave diathermy, local cortisone injection, or cortisone injection and manipulation. They found that the combination of injection and manipu-lation was successful in 85% of cases, compared to local injection, which had a 60% success rate. Those positive data are in contrast to the use of ultrasound and shortwave diathermy, which had a success rate of 16%. In a study by Mitra et al12 of individuals treated with fluo-
roscopic-guided injection, patients with pain of less than 6 months in duration were more likely to have significant pain relief at 3-year follow-up than those with longer pain duration, suggesting that early injection may be a viable interven-tion for this condition. Local injection in this area carries the risk of infection, skin irritation, or, worse, perforation into the rectum, so guided techniques may be the better option for safety.
Coccygectomy, or surgical extraction of the coccyx, has been recommended in cases of acute trauma, including unstable fractures or recalcitrant pain, when con-servative management has been deemed unsuccessful or has not provided suf-ficient relief.1,3,6,13-17 In a retrospective analysis of 32 individuals treated by an orthopaedic spine surgeon over a 5-year period, Hodges et al5 reported that 13% of the patients were treated with nonste-roidal anti-inflammatory drugs alone, 53% were treated with both nonsteroidal anti-inflammatory drugs and local injec-tions, and 34% underwent coccygectomy. In their study, those who underwent coc-cygectomy had significantly greater pain scores and slightly greater Oswestry Dis-
ability Index scores pretreatment than those who were treated conservatively.5 The primary complications of the surgi-cal approach were wound infections that required treatment with antibiotics. Oth-er complications included poor wound healing, hematoma, and wound dehis-cence that resulted in reoperation. These findings suggest that surgery may result in positive outcomes, although there are potential complications.
Current evidence is limited for both conservative and nonconservative man-agement of coccydynia, and clinical tri-als are lacking to establish the relative benefits of conservative versus surgical approaches. Therefore, conservative versus surgical interventions should be considered. This case report describes 2 different clinical presentations and out-comes of coccydynia, both diagnosed through clinical examination that in-cluded intrarectal coccyx mobility and pain provocation testing. The cases described are intended to help guide clinicians in the diagnostic testing and clinical decision making for both con-servative and surgical management of coccydynia.
TABLE Patient Characteristics
Abbreviations: BMI, body mass index; FABQ-PA, Fear-Avoidance Beliefs Questionnaire physical activity subscale; FABQ-W, Fear-Avoidance Beliefs Questionnaire work subscale; ODI, Oswestry Disability Index; VAS, visual analog scale.
Characteristic Case 1 Case 2
Age, y 26 31
Height, cm 157 160
Weight, kg 56.7 61.2
BMI, kg/m2 22.9 23.9
Occupation Graduate student Editor
Activity level Aerobic activity, including elliptical, running 5 d per wk, and yoga occasionally
Aerobic activity, primarily running, 5 d per wk for 30 min, weight training
Symptom duration 5 mo Newest onset, 2 mo (initial onset, 1.5 y ago)
Average time sitting per d 8-10 h between classes, teaching assistant, and studying
8 h at work; avoids outside of work
VAS worst (24-h period) 8/10 10/10
VAS best (24-h period) 2/10 0/10
ODI, % 24 28
FABQ-PA 6 6
FABQ-W 3 11
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journal of orthopaedic & sports physical therapy | volume 44 | number 8 | august 2014 | 617
CASE DESCRIPTIONS
Patient 1
A 26-year-old female doctoral student was referred to physical therapy with pain in the sacrococ-
cygeal region. She reported that her pain was primarily intensified immediately by sitting directly on her tailbone in any type of chair. The pain also significantly increased during transitions from sit to stand and completely resolved when standing upright or lying supine. The patient reported being in a motor vehicle accident approximately 6 months prior to the current examination. Immediately after the accident, she had neck and low back pain, which was treated and re-solved within 8 physical therapy sessions at another clinical facility. She reported that her current pain in the sacrococ-cygeal region began to hurt at about 1 month after her accident, but she thought it would resolve on its own. At 6 months post–car accident, she had persistent pain in her coccyx that began to interfere with her current activities as a graduate student. Initial examination of the lum-
bar and sacral region did not reproduce any of her reported symptoms and was normal for all neurological examinations, including the straight leg raise and seated slump tests, and all lumbar spine seg-mental motion testing. The patient was also asked to complete an 11-point (0, no pain; 10, maximum pain) visual analog scale for pain and the modified Oswes-try Disability Index to assess function (TABLE).
As her primary symptom was pain with sitting and transitioning from sit to stand and the remainder of the clini-cal examination was essentially normal, a potential diagnosis of coccydynia was considered. At this point, after discussion with the patient, a second opinion from a fellowship-trained manual physical therapist was sought.
Because mobility assessment of the sa-crococcygeal joint requires grasping the coccyx through the anal canal with the thumb and index finger (FIGURE 1), the in-trarectal nature of the examination was carefully explained and verbal consent obtained prior to performing the exami-nation. Examination of the sacrococ-
cygeal joint revealed perceived reduced mobility in the anterior-to-posterior (AP) direction. Simultaneous to resistance to motion, movement of the coccyx in the anterior direction reproduced the pa-tient’s symptoms.
Based on examination findings, the patient was treated with mobilization in the AP direction (FIGURE 2), utilizing a stretching and oscillating force for 10 to 15 seconds each application. Initial mobilization was done within the tissue slack to facilitate pain mediation. Once tolerated, mobilization at the end range of motion was performed to facilitate tis-sue stretching. The stretching technique was repeated 4 times on the initial visit and immediately resulted in 100% re-duction of the pain perceived when mov-ing from a sitting to a standing position, and 80% reduction of the pain perceived when seated.
Following the treatment session, the patient was instructed to resume regular activities, maintain a pain log, and return to physical therapy in 7 to 10 days. On the second treatment session, 12 days af-ter the initial examination and treatment, the patient reported that the sit-to-stand pain remained resolved but that she was still noticing pain after sitting longer than 1 hour on any surface.
Re-examination revealed residual hypomobility of the sacrococcygeal joint in the AP direction, along with contin-ued reproduction of pain when moving in the anterior direction. Relief of pain was noted when a traction mobilization technique was performed (FIGURE 3). The patient was treated this visit with trac-tion mobilization and AP glides consist-ing of end-range techniques for 10- to 15-second holds and 4 repetitions in each direction. After this treatment session, it was recommended that the patient resume all activities and reschedule for a subsequent physical therapy ap-pointment within 2 weeks if sitting pain continued to interfere with her daily activities.
The patient returned for a third visit after 17 days and underwent intervention
FIGURE 1. Joint play assessment of the sacrococcygeal joint. A posteriorly directed force is applied to the coccyx on its anterior surface via the intrarectal digit of the examiner. The anteriorly directed force is applied with the thumb externally. Copyright © Kara Moore. Reproduced with permission.
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[ case report ]
consistent with the second session. At the completion of this third treatment ses-sion, the patient reported 95% improve-ment in sitting pain on both soft and firm surfaces, so she was instructed to contact the therapist if any subsequent problems
arose. In follow-up communication with the patient at 6 and 12 weeks and 1 year via e-mail, the patient reported contin-ued relief from sit-to-stand pain and only mild pain after prolonged sitting, without any reported disability.
Patient 2A 31-year-old female editor was referred for consultation with a fellowship-trained manual physical therapist for pain in the buttocks region that initially began 1.5 years prior (TABLE). There was no trau-matic event leading to the onset of pain; however, she indicated that the pain began following a week at work during which she had to sit 4 extra hours per day for mandatory training. Approximately 4 months after the initial onset of pain, the patient was treated by her primary care physician with a cortisone injection, per-formed without imaging guidance, to the painful region of her sacrococcygeal joint. At that time, it was also recommended that she use a custom donut pillow for work, which resulted in complete resolu-tion of her symptoms.
After almost 1 year of pain relief from this initial intervention, her symptoms returned, for which she sought medical attention and was referred to physical therapy for examination and treatment. Examination was inconclusive for re-production of her symptoms with lum-bopelvic testing, and coccydynia was considered the primary cause. The pa-tient was referred to a fellowship-trained manual physical therapist for assessment of the sacrococcygeal joint. Prior to the examination, an explanation of the po-tential diagnosis and the details of the intrarectal examination procedure were provided to the patient, and her verbal consent was obtained for examination and potential intervention. The mobility assessment of the sacrococcygeal joint in the AP direction revealed perceived hypomobility and reproduction of her symptoms in both anterior and posterior directions. Also, the shape of the distal coccyx was prominent, and a small mass was palpable externally on the dorsal sur-face of the coccyx and tender to touch.
Following the examination, an initial intervention of sacrococcygeal traction (FIGURE 3) at end range of motion, held 10 to 20 seconds and repeated 4 times, was performed. Immediately following treatment, the patient reported between
FIGURE 2. Joint mobilization in the anterior-to-posterior direction. The external hand stabilizes the sacrum while the internal digit applies a force in the posterior direction. Copyright © Kara Moore. Reproduced with permission.
FIGURE 3. Traction mobilization: traction is performed using intrarectal and external fixation of the coccyx via the second digit and thumb. Stabilization of the sacrum is achieved through manual fixation with the opposite hand. Copyright © Kara Moore. Reproduced with permission.
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60% and 70% relief of sit-to-stand pain, and she was able to sit pain free on both soft and firm surfaces for a short time. The patient was instructed to return to usual activities, resume use of the pillow at work, and return to physical therapy within 10 to 14 days.
At the second visit, the patient reported no change (increase or decrease) in pain when going from sit to stand but return of pain with sitting at work, even when using the donut pillow. Upon re-examination, mobility of the sacrococcygeal joint was perceived to be normal, but pain was still present in the anterior direction and could be relieved with traction. The superficial mass initially perceived with external palpation of the dorsum of the coccyx re-mained present and tender to palpation. The patient was treated with manual trac-tion to the sacrococcygeal joint, similar to the first treatment, along with AP mo-bilization with a sustained stretch. This intervention resulted in an immediate improvement in pain-free sitting, with no real change in the sit-to-stand pain. She was again instructed to return to usual ac-tivities and to return to physical therapy in 2 weeks. At the third visit, the symptoms with sit-to-stand were slightly improved, but sitting pain returned and there was no change in the palpable mass. The patient underwent 1 more treatment of manual therapy, consisting of both traction and AP mobilization, and again had improved sitting tolerance and slightly better sit-to-stand pain, but only temporarily, as her pain returned with sitting once she re-turned to work.
Due to conservative management only providing partial and temporary reduc-tion in pain and the presence of a palpable mass over the coccyx, imaging tests were recommended and ordered by a sports medicine physician. The patient initially had static images of her coccyx that were considered normal. Subsequently, given that she previously had complete relief of her symptoms with a corticosteroid injection, she was referred to a physician trained in the utilization of musculoskel-etal ultrasound imaging for another in-
jection. Ultrasound examination revealed an abnormal bony spur at the distal tip of her coccyx (FIGURE 4), which seemed to be her most tender area when the coccyx was palpated under ultrasound guidance. This spur was not visualized on previous plain-film radiography but was consis-tent with the palpable mass felt during the physical therapy examination. Based on these findings, the decision was made to inject corticosteroid, under ultrasound guidance, around this bony spur with a peppering technique. One week after the injection, the patient reported 50% relief of her pain; however, over the subsequent 4 weeks, her pain seemed to return to the prior level, prompting a discussion of sur-gical options.
This individual was referred for a sur-gical consult with an orthopaedic physi-cian who specialized in coccygectomy, and the decision to excise the coccyx was made. She underwent successful surgical coccygectomy without complication and, at 8 weeks following the surgery, returned to full level of activity and full-time work pain free. When contacted via e-mail at follow-ups of 6 months, 9 months, and 1
year, the patient reported complete relief of symptoms for all activities and only mild pain with prolonged sitting.
DISCUSSION
This case report highlights 2 in-dividuals with similar pain presen-tation examined and treated by a
fellowship-trained manual physical ther-apist utilizing manual therapy techniques to assess and treat coccyx mobility. Both patients were women of an age consistent with the demographics of individuals with coccydynia reported in the literature and would have been classified as having chronic somatic pain.2,13 Neither woman had a body mass index greater than 27.9 kg/m2, which would have placed them in a higher risk category.9 Both cases pre-sented with similar clinical presentation regarding their symptoms, and both had successful outcomes but with different interventions.
Patient 1 was in a motor vehicle ac-cident shortly prior to her initial symp-toms, which is not a common source of coccyx injury but cannot be ruled out as
FIGURE 4. Bony anomaly (spur) visualized at dorsal tip of coccyx. Normal-appearing intercoccygeal joint.
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[ case report ]the initiating factor, as she had never had symptoms of coccydynia prior to the ac-cident. The symptoms for patient 2 were attributed to an increase in the amount of time spent sitting over a 5-day period, which may be considered microtraumatic in nature. Neither woman had ever given birth or had a recent history of fall di-rectly on their buttocks.
Both individuals presented with per-ceived reduced mobility of the sacrococ-cygeal joint with mobility assessment and pain with sitting, as well as move-ment from sit to stand, that responded positively to manual intervention on the first visit. Although symptoms continued to improve in patient 1, she returned to physical therapy with reduced mobility in the sacrococcygeal joint at visits 2 and 3. These deficits improved after mobi-lization, and her symptoms completely resolved and had yet to return 1 year post-intervention, similar to the outcomes re-ported by Maigne et al.8 Patient 2, on the other hand, had perceived normal mobil-ity after the initial intervention, and her painful symptoms did not progressively improve with interventions 2 and 3. Her outcomes were similar to the variable responses to manual therapy reported by Maigne and Chatellier.7 Given these conflicting outcomes in our patients, we propose that after a thorough history and clinical examination that has ruled out red flags and competing diagnoses, an assessment and immediate response to treatment of joint dysfunction may be used to help guide the clinician in deci-sions for subsequent consultation, exami-nation, and treatment options (FIGURE 5).
Patient 2 also highlights the use of corticosteroid injection in the treatment of coccydynia. There is no uniform agree-ment in the literature on the location of the injection. Previously, the injection was often performed blind; however, since the advent of musculoskeletal ultra-sound, it has been more often performed with guidance. Patient 2’s initial injec-tion with cortisone resulted in 1 full year of pain-free sitting and sit-to-stand. This is consistent with the findings by Wray et
al19 of a 60% success rate in individuals treated with local injection as first-line intervention. However, in their review of 120 individuals with coccydynia, they found a much greater success rate (up to 85%) when the cortisone injection was combined with manipulation to the sa-crococcygeal joint. The lack of long-term success from the local injection in patient 2 might have been due to the lack of other interventions to address coccyx mobility in the early onset of her symptoms.
When examined with musculoskeletal ultrasound in preparation for injection, the tissue abnormality palpated by the physical therapist on the dorsal surface of the coccyx in patient 2 was visualized, although not previously visualized with
plain-film radiography. In a study by Maigne et al10 of 208 consecutive patients presenting with chronic coccydynia, the authors described a morphological ab-normality of bony excrescence on the dor-sal surface of the coccyx that they termed a spicule. Thirty of the 208 patients pre-sented with this tissue abnormality and, of those, 22 were associated with immo-bile coccyges that would cause the great-est irritation in sitting. The abnormality found on patient 2 was consistent with this study, as it seemed to be the point of maximum pain and was palpable on the dorsal surface of her coccyx, though she appeared to have normal mobility after joint mobilization. In their study, Maigne et al10 found that a positive anesthetic
Step 1: physical therapy• Examination utilizing intrarectal
assessment• Mobilization
Step 3A: pain relief
• Follow-up for symptoms
• Patient education
Step 3B: pain remains
• Static and dynamic radiography
• Referral for surgical consult
Step 2B: referral for diagnostic imaging
• Musculoskeletal ultrasound• Guided corticosteroid injection
Step 2A: physical therapy intervention
• Follow-up: 2 to 3 more sessions of mobilization over a 3- to 4-week period of time, with resumption of daily activities and monitoring of response
• Patient education3 visits are standard for resolution
of symptoms, and if pain returns or persists, recommend referral for subsequent examination as in step 2B
Pain relief: proceed with treatment Pain remains or abnormal tissue noted on examination
Coccydynia pain: pain in the region of the rectum that is exacerbated by sitting, sit-to-stand, and/or bowel movements and not reproduced by any lumbar or sacral testing
FIGURE 5. Clinical decision-making algorithm in the presence of coccydynia.
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block test to the spicule was diagnostic for the lesion producing the coccydynia. This is consistent with the positive but temporary response to direct injection of corticosteroids into the tissue abnormal-ity and provided the examining clinician with evidence that surgical consult for removal may be recommended.
Although the success rate for surgi-cal excision is variable (54%-85%),13 the positive outcomes found after coccygec-tomy in patient 2 are consistent with the results of a recent systematic review by Karadimas et al6 that included 24 manu-scripts published between 1980 and Jan-uary 2010, for a total of 671 individuals treated with coccygectomy. Based on an average 2-year follow-up, 504 (75.1%) of the cases had good to excellent results, which was defined as mild occasional discomfort.6 Furthermore, Balain et al,1 in a retrospective analysis of 38 patients undergoing coccygectomy, demonstrated greater long-term success in those indi-viduals with degenerative changes in the coccygeal joints. Given the association with joint abnormalities and reported success with surgical excision, we rec-ommend plain-film radiography and surgical consultation if there is no im-provement with intrarectal mobilization or if abnormal tissue findings or mobility disorders such as luxated or hypermobile sacrococcygeal joints are perceived dur-ing examination (FIGURE 5).
Plain-film radiography assessment was used in both of our patients and deemed to be normal, and therefore was not consistent with the literature in assisting in diagnosis of coccyx ab-normalities. Mobility assessment us-ing intrarectal techniques reproduced both patients’ symptoms, and the use of manual intervention provided immedi-ate relief, suggesting a mechanical origin of the painful symptoms. But, based on our patients’ response and limitations in current research, we propose that manual therapy be considered a reasonable initial option of care, as it poses minimal risk
of complications and may be associated with positive outcomes.
CONCLUSION
Conservative and surgical inter-vention for sacrococcygeal pain may be successful management
strategies, but there are no clear guide-lines allowing the identification of which patients will benefit from which inter-vention. We presented 2 patients with relatively similar symptoms and findings for coccydynia. Although one patient responded to manual therapy, the other did not and required surgery. We propose that a short-term course of manual ther-apy may be a safe, viable first option to consider for coccydynia when there is no indication of significant injury and there is a possibility of mechanical aggravating factors. More invasive procedures like injections and/or surgery might then be considered in the presence of trauma or significant injury and/or the absence of improvement with short-term applica-tion of manual therapy. t
REFERENCES
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5. Hodges SD, Eck JC, Humphreys SC. A treatment and outcomes analysis of patients with coc-cydynia. Spine J. 2004;4:138-140. http://dx.doi.org/10.1016/j.spinee.2003.07.011
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analytic review of the literature. Eur Spine J. 2011;20:698-705. http://dx.doi.org/10.1007/s00586-010-1617-1
7. Maigne JY, Chatellier G. Comparison of three manual coccydynia treatments: a pilot study. Spine (Phila Pa 1976). 2001;26:E479-E483; dis-cussion E484.
8. Maigne JY, Chatellier G, Faou ML, Archambeau M. The treatment of chronic coccydynia with in-trarectal manipulation: a randomized controlled study. Spine (Phila Pa 1976). 2006;31:E621-E627. http://dx.doi.org/10.1097/01.brs.0000231895.72380.64
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