Treatment of coccygodynia: physical rehabilitation

The complex of conservative treatment of coccygodynia includes, first of all, a large volume of physiotherapeutic procedures: darsonvalization by inserting an electrode into the rectum; ultrasound with an analgesic mixture or hydrocortisone, paraffin applications, therapeutic mud, ozokerite.

The leading role in the rehabilitation of patients with coccygodynia belongs to the means of exercise therapy, which should solve the following problems:

1. Improve trophic processes of the pelvic organs.
2. Strengthen the muscular-ligamentous apparatus of the pelvic floor, pelvic girdle, abdominal muscles and back.
3. To promote the restoration of the anatomical and topographic relationships of the pelvic organs.
4. To promote the removal of pathological dominance in the cerebral cortex.
5. Provide a general strengthening effect on the patient's body. When including exercise therapy in the complex therapy of the disease, along with the general principles of physical training, it is necessary to take into account the following guidelines:
   • Differentiate the methods of using exercise therapy depending on the severity (mild, moderate, severe), age and tolerance to physical activity of the patient.
     
   • Use different starting positions when performing physical exercises: a) for mild cases - lying down, standing, and only from the second half of the course of treatment - sitting; b) for moderate cases - the same, excluding the initial position - sitting; c) for severe cases - standing on all fours, antiorthostatic (lying on your back on an inclined plane with a raised foot end, the angle of which can be changed up to 30° depending on the tolerance of the negative gravitational load), lying on your side.
   • Use special isotonic exercises and isometric (static) tension in your classes to maximally strengthen the muscular-ligamentous apparatus of the pelvic floor, pelvic girdle, back muscles and abdominal muscles.

An approximate set of physical exercises

1. I.p. - standing, feet together, arms down. Slowly raise your arms up, move your leg back, bend - inhale, return to I.p. - exhale. Repeat with each leg 2-3 times.
2. I.P. - the same. Raise the bent leg, pull the knee to the chest with your hands three times, tilt your head - exhale, return to I.P. - inhale. Try not to bend the supporting leg. Repeat with each leg 4-6 times.
3. I.P. - standing, legs apart, hands on the waist. Circular movements of the pelvis. Repeat 8-12 times in each direction.
4. I.p. - standing, feet together, arms down. Springy squats with simultaneous lifting of arms through the sides upwards. Repeat 12-16 times.
5. I.p. - standing, legs apart, arms to the sides. Turn your hands with your palms up, move your head back, bend - inhale, count to three, then return to I.p. Repeat 8-12 times.
6. I.p. - sitting, legs bent, knees pulled to chest with hands, head down, back round. Rolling on your back, touch the floor with your head, return to I.p. Repeat 8-12 times.
7. I.P. - lying on your back, legs bent and spread, arms along the body. Raise your pelvis, spread your knees to the sides, tighten your gluteal muscles, hold this position for 3-5 seconds. Repeat with short intervals 8-12 times.
8. I.P. - the same, but legs are spread wide. Bend one leg as far inward as possible, the other - as far outward as possible. Then - vice versa. Repeat 4-6 times.
9. I.P. - the same. For 5-7 seconds, forcefully connect your knees. Repeat 8-12 times with 7-10 second rest intervals.
10. I.P. - lying on your back, bent legs slightly raised. Perform the "bicycle" exercise for 10-15 seconds. Repeat 4-6 times with 10-15 second rest intervals.
11. I.P. - lying on your back, arms along your body. Sit up without using your arms and do three springy forward bends, trying to touch your knees with your forehead. Repeat 12-16 times.
12. I.p. - lying on your back, bend your legs slightly raised. Turn both legs to the left, trying to touch the floor with your left knee. Do the same in the other direction. Repeat 12-16 times.
13. I.P. - lying on your back, along your body. Raise your bent legs, holding them together, and try to touch the floor behind your head with your toes. Repeat 8-12 times.
14. I.P. - sitting and leaning on your hands behind you, pelvis slightly raised. Perform alternate leg swings forward and up. Repeat 8-12 times with each leg.
15. I.p. - kneeling, hands on waist. Bend backwards, then return to I.p. Repeat 6-8 times.
16. I.p. - the same. Sit on the floor - to the left, return to I.p. Repeat 8-12 times in each direction.
17. I.p. - lying on your stomach, fir-hands on the back of your head. Raise your head and shoulders, hold this position for 3-5 seconds, return to I.p. Repeat 8-12 times.
18. I.p. - lying on your stomach, hands on the floor near your shoulders. Bend your leg, move your knee to the side and look at it. Repeat ~ 8-12 times with each leg.
19. I.P. - standing on all fours. Arch your back, pull your stomach in and hold this position for 3-5 seconds. Repeat 6-8 times with 5-6 second rest intervals.
20. I.p. - standing, feet together, arms down. Step left with left foot, move arms to the sides, bend - inhale, return to I.p., clasp chest with hands - exhale. Same with the other leg. Repeat 3-4 times.

Most special physical exercises should be performed in alternating contractions and relaxations of the perineal muscles, which is carried out in the inhalation and exhalation phases, respectively. For a full contraction of all perineal muscles, the patient should simultaneously "pull in" the anus, squeeze the vagina and try to close the external opening of the urethra.

• Isometric muscle tensions must be performed each time with the maximum possible intensity. Depending on the period of the exercise therapy course, the number of such muscle tensions varies from 1 to 4, the duration (exposure) of the tension is 3-7 sec.

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Typical exercises performed in isometric mode

1. I.P. - lying on your back, legs bent at the knees and spread apart, hands on the inside of the knees. Bring your knees together, overcoming the resistance of your hands. Repeat 8-12 times, taking 10-15 second rest intervals.
2. I.P. - lying on your back, holding a volleyball or rubber ball with your bent knees. Squeeze the ball with your knees for 5-7 seconds, preventing your stomach from sticking out with your hands. Repeat 6-8 times, taking 10-15 second rest intervals.
3. I.P. - lying on your back, legs straight, ball clamped between your feet. Squeeze the ball with your feet for 5-7 seconds. Repeat 6-8 times, taking 10-15 second rest intervals.
4. I.P. - lying on your back, legs bent at the knees. Spread your knees, lift your pelvis and tense your gluteal muscles for 3-5 seconds. Repeat 6-8 times, taking 10-15 second rest intervals.

When performing isometric tension, the following features of their implementation should be taken into account: a) use mainly the patient's initial position - lying on the back (on the side) and "antiorthostasis"; b) breathing should be uniform, with some lengthening of the exhalation (holding the breath is not allowed!); c) "disperse" and alternate muscle tension with isotonic exercises; d) after each repetition of isometric tension, perform breathing exercises and exercises in voluntary muscle relaxation.

• Avoid running exercises, fast walking, jumping and hopping, jerky movements, sudden changes in the position of the torso and lower limbs, straining elements, and, at the beginning of the course of treatment, forward bending of the torso.
• All exercises should be performed at a calm pace, rhythmically. Classes are held 2-3 times daily, preferably with musical accompaniment.
• To consolidate the effect, it is advisable to use physical exercises in combination with electrical stimulation of the pelvic girdle muscles, the back of the thigh muscles and acupuncture.
• It is essential to include elements of therapeutic massage, point and segmental reflex massage in the complex of treatment measures.

Post-isometric muscle relaxation (PIR)

1. PIR of the piriformis muscle.

• The patient's initial position is lying on his stomach. The leg on the side of the relaxed muscle is bent at the knee joint and rotated inwards. The doctor's hand, which is the same as the patient's leg, is fixed on the patient's heel, the other palpates the piriformis muscle. On inhalation, the patient brings the lower leg, while exerting pressure on the doctor's hand. The position is fixed for 7-10 seconds. On exhalation, the doctor passively stretches the muscle, moving the lower leg to the opposite side. The maneuver is repeated 3-4 times;
• The patient's initial position is lying on his stomach, with his knees at the level of the edge of the couch. The legs are bent at the knee joints. The doctor's hands crosswise fix the patient's feet. On inhalation, the patient brings his knees together, the doctor provides a measured resistance to this movement. The position is fixed for 7-10 seconds. On exhalation, the patient relaxes, the doctor performs passive stretching of the muscles, increasing the abduction of the shins.

2. PIR muscles of the pelvic floor (levator ani muscle, coccygeus muscle, external depressor of the anus)

The patient's initial position is lying on his stomach, arms extended along the body. The doctor's hands crosswise fix the medial surfaces of the patient's buttocks. On inhalation, the patient tenses and brings the buttocks together, and the doctor's hands provide a measured resistance to this movement (7-10 sec). On exhalation, the doctor performs passive muscle stretching, spreading the buttocks apart. The procedure is repeated 3-4 times.

3. PIR of the gluteus maximus and medius muscles).

The patient's initial position is lying on his back, the leg on the side of the relaxed muscles is bent at the knee and hip joints. The doctor's hand, which is the same as the patient's leg, fixes the ankle joint area from above, the other - the knee joint. On inhalation, the patient tries to straighten the leg with a slight effort, and the doctor's hand provides a measured resistance to this movement (7-10 sec). On exhalation, the doctor performs passive stretching of the muscle, increasing pressure on the knee and ankle joints:

• in the direction of the same shoulder, mobilization of the sacrotubera lig occurs;
• in the direction of the opposite shoulder, lig. sacrospinale is mobilized.

The procedure is repeated 3-4 times.

4. PIR of the adductor muscles of the thigh.

• The patient's initial position is lying on his back, legs apart. The doctor's hands crosswise fix the thighs in their lower third (from the inside). On inhalation, the patient brings his legs together, and the doctor's hands provide a measured resistance to this movement (7-10 sec). On exhalation, the doctor performs passive muscle stretching, spreading the patient's legs apart. The procedure is repeated 3-4 times.
• The patient's initial position is lying on his back, the leg is bent at the knee and hip joints and abducted as much as possible to the side. One hand of the doctor fixes the knee joint from above, the other - the wing of the ilium. On inhalation, the patient tries to bring the knee without straightening the leg, and the doctor provides a measured resistance to this movement (7-10 sec). On exhalation, the doctor performs passive stretching of the muscles, abducting the knee to the couch. The maneuver is repeated 3-4 times.
• The patient's initial position is lying on his back (on the edge of the couch), legs bent at the knee and hip joints. The doctor's hands crosswise fix the patient's knees. On inhalation, the patient brings his knees together, and the doctor's hands provide a measured resistance to this movement (7-10 sec). On exhalation, the doctor passively stretches the muscles, increasing the patient's hip abduction.

5. PIR of the back group of thigh muscles.

The patient's initial position is lying on his back. One hand of the doctor fixes the foot in the area of the toes, the other - the ankle joint. On inhalation, the patient performs plantar flexion of the foot, and the doctor's hands provide a measured resistance to this movement (7-10 sec). On exhalation, the doctor's hands perform dorsal flexion of the foot, lifting the straight leg upward. Repeat the maneuver 3-4 times.

In stationary conditions, presacral blocks according to Vishnevsky and novocaine-alcohol blocks according to Aminev have a good effect. Alcohol-novocaine epidural-sacral blocks are used for the most persistent pain. A good effect is achieved by combining presacral novocaine blocks with massage of the levators and coccygeal muscle.

Surgical treatment of coccygodynia usually does not bring relief to patients. Coccygectomy is indicated only in case of a fracture or dislocation of the coccyx.