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Intrarectal manipulation was the first published modality for the treatment of coccydynia. The technique was
mentioned in 1634, by Ambroise Pare (cited by Sugar1).
The object was to reduce a presumed fracture. In the
20th century, coccygeal pain was successively attributed
to a painful spasm of the intrapelvic muscles,2 loss of
From the *Department of Physical Medicine, Hopital Hotel-Dieu,
Paris, France; Unite dEpidemiologie Clinique, Paris, France; Faculte
de Medecine Rene Descartes Paris 5, Paris, France; and Hopital Europeen Georges Pompidou, Paris, France.
Acknowledgment date: February 14, 2006. Acceptance date: March
30, 2006.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Jean-Yves Maigne,
MD, Department of Physical Medicine, Hotel-Dieu University Hospital, Place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France;
E-mail: jy.maigne@htd.aphp.fr
Gender (female/male)
Age (yr)
Duration of complaints (mo)*
Etiologic trauma (%)
BMI (kg/m2)
Stable coccyx (%)
Unstable coccyx (%)
VAS 100 mm (maximum 100 points)*
MPQ (maximum 60 points)*
Paris (maximum 100 points)*
DPQ (modified) (maximum 100
points)*
Individual global score (maximum
360 points)
Manipulation
(n 51)
Controls
(n 51)
46/5
45.2 (11.5)
15 (2120)
18 (35.3)
24.4 (4.2)
26 (51)
25 (49)
62 (2595)
18 (452)
50 (2080)
37 (1161)
46/5
44.6 (13)
11 (260)
22 (43.1)
24.5 (4.7)
22 (43)
29 (57)
68 (2295)
19.5 (552)
50 (3090)
41.5 (1085)
168 48
186 41.2
BMI body mass index; VAS visual analog scale; MPQ (modified) McGill
Pain Questionnaire; Paris Paris Questionnaire; DPQ (modified) Dallas Pain
Questionnaire.
Data are mean (SD) or % (n).
*Data are median (range).
Results
Patient Baseline Characteristics
A total of 102 patients were enrolled. Two were lost to
follow-up (1 after the first manipulation session; the other,
a Control group patient, after the 1-month follow-up visit,
which had shown 50% improvement). Thus, in each
group, 50 patients were available for review. At enrollment,
the 2 groups were well matched for the parameters studied
(Table 1).
One-Month Results
At 1 month, all the VAS and questionnaire results differed statistically between the 2 groups, with the manipulation group showing the better outcomes (Table 2).
The mean individual global score had improved by 26%
in the manipulation group, as against 14% in the control
group. Equal to or greater than 50% improvement in the
individual global score at 1 month was seen in 36% of
the manipulation group patients and in 20% of the control group patients.
M0
M1
62 (2595)
40.5 (0100)
34.7%
68 (2295)
55 (0100)
19.1%
MPQ (P 0.03)
M0
M1
18 (452)
11.5 (041)
36%
19.5 (552)
18 (154)
7.7%
Paris (P 0.02)
M0
M1
50 (2080)
40 (090)
20%
50 (3090)
60 (0100)
20%
DPQ (P 0.02)
M0
M1
37 (1161)
24.5 (071)
33.8%
41.5 (1085)
35 (087)
15.7%
VAS visual analog scale; MPQ (modified) McGill Pain Questionnaire; Paris Paris Questionnaire; DPQ (modified) Dallas Pain Questionnaire.
Data are median (range). Data were compared using a Mann-Whitney test.
Six-Month Results
The patients who at 1 month had had a good outcome
(50% improvement in the individual global score) continued in the study out to 6 months. In the manipulation
group, 34 patients were observed up for that period; in
the control group, there were 24. At 6 months, there
were 11 good outcomes (50% improvement in the individual global score at 1 month and 60% at 6 months)
in the manipulation group (22% of the patients); in the
control group, there were six good outcomes (12% of the
patients), a 10% absolute rate of improvement (95%
confidence interval, 6.5% to 22.2%). If a more stringent definition of a good outcome (e.g., 50% improvement at 1 month and 90% at 6 months) had been applied, the respective numbers and percentages would
have been 4 (8%) and 2 (4%), a 4% absolute rate of
improvement (95% confidence interval, 7.1% to
11.6%).
Treatment Results
Despite its limitations (see below), the current study
broke new ground by comparing the outcomes, in
chronic coccydynia, of intrarectal coccygeal manipulation versus those obtained with a noneffective control
treatment. Under the study conditions, manipulation
was more effective than the control treatment. Improvement was definite using questionnaire results (the primary outcome measure), but only modest using the rate
of good outcomes (the secondary outcome measure). The
6-month rate of good results was 22%, which compares
favorably with the outcomes of 2 earlier, uncontrolled
studies, but meant that the efficacy was modest. The effectiveness observed appears to be less than that of intradiscal injections,15 or of coccygectomy, which is, however, performed in unstable coccyges only. 16 It is
conceivable that the various treatment methods are specific to different types of coccydynia, with manipulation
particularly suited to patients who are not relieved by
intradiscal injections (i.e., patients who do not have intradiscal inflammation). However, this hypothesis re-
Clinical Factors
A short time interval between the onset of the complaints
and initiation of treatment, and etiologic trauma, were
predictive of a good outcome following manipulation.
These factors were not found in the patients with a good
outcome following the control treatment, which suggests
that the improvement observed in the manipulation
group was attributable to the manipulation. Normal (undiminished) pelvic muscle tone was predictive of a good
outcome at 1 month, but not at 6 months (Table 3).
Radiographic Factors
Patients with a stable coccyx had a 30.8% chance of obtaining relief from manipulation, as against a 13.6%
chance of relief from the control treatment. On the other
hand, unstable coccyges did not respond any better to manipulation than they did to the control treatment. The angles measured on the stress radiographs (coccygeal inci-
Table 3. Association of Some Clinical and Radiographic Factors With Outcome in the 2 Groups
Clinical factors
Median time to treatment (mo)
Etiologic trauma (%)
Pain on getting up from sitting (%)
Diminished pelvic muscle tone (%)
BMI (mean)
Radiographic factors
Stable coccyx
Coccygeal incidence angle ()
Pelvic sagittal rotation angle ()
Sacrococcygeal angle ()
Patients With a
God Outcome*
Following Manipulation
(n 11)
Patients With a
Poor Outcome*
Following Manipulation
(n 39)
Patients With a
Good Outcome*
Following the
Control Treatment
(n 7)
Patients With a
Poor Outcome*
Following the
Control Treatment
(n 43)
5
55
73
45
23.4
18
28
64
44
24.6
19.8
0
43
NA
23.4
16.2
46.5
58
NA
24.5
8 (73%)
38.8
35.7
147
18 (46.2%)
22.9
39.8
138.7
3 (43%)
20
33
136
19 (44.2%)
24
37
130
NA not applicable (not measured in this group); BMI body mass index.
*A good outcome was defined as at least 50% improvement at 1 month, and at least 60% improvement at 6 months.
Table 4. Association of Baseline Pain Intensity and Pain Impact, and Psychosocial Factors, With Outcome
in the 2 Groups
Patients With
a Good Outcome*
Following Manipulation
(n 11)
Pain intensity and pain impact
VAS (median)
Paris Questionnaire (median)
DPQ Section IX: How much
does pain interfere with
traveling in a car?
DPQ Section X: How much
does pain interfere with
your job? (median)
Psychosocial factors
MPQ affective items (max 28
points) (median)
DPQ Section VIII: How much
does pain interfere with
your social life? (median)
DPQ Section XI: How much
control do you feel you
have over demands made
on you? (median)
DPQ Section XII: How much
control do you feel you
have over your emotions?
(median)
DPQ Section XIII: How
depressed have you been
since the onset of pain?
(median)
DPQ Section XIV: How much
do you think your pain
has changed your
relationship with others?
(median)
DPQ Section XV: How much
support do you need from
others to help you?
(median)
DPQ Section XVI: How much
do you think others
express irritation,
frustration, or anger
toward you because of
your pain? (median)
Patients With a
Poor Outcome
Following Manipulation
(n 39)
Patients With a
Good Outcome
Following the
Control Treatment
(n 7)
Patients With a
Poor Outcome
Following the
Control Treatment
(n 43)
50
50
60
62
50
70
66
50
60
71
50
65
50
50
70
55
12
12
43
54
60
50
30
30
25
40
18
24
31.5
40
10
23
23
35
16.5
10
14
8.5
8.5
10
4.5
8.5
10
VAS visual analog scale; DPQ (modified) Dallas Pain Questionnaire; MPQ (modified) McGill Pain Questionnaire; max maximum score (Unless otherwise
indicated, the maximum score that could be obtained in any one test was 100 points).
*A good outcome was defined as at least 50% improvement at 1 month, and at least 60% improvement at 6 months.
signed for coccydynia. It covers, specifically, the functional aspects of the pain, which are not assessed by the
other two questionnaires. It explores the pain when sitting (and differs, in this respect, from the VAS, which
only measures the intensity of the pain), when passing
from sitting to standing (very specific of coccydynia with
radiologic findings8), when walking and at night (pain on
these occasions is frequent in severe coccydynia), and
when traveling (the most sensitive detector of coccygeal
pain). This set of three questionnaires offers a correct
representation of the pain impact in chronic coccydynia.
With the 4 scales (VAS and the questionnaires), we obtained differences between the 2 groups (P ranging from
0.09 to 0.02). This fact is explained by the interrelationship between the scales. However, it adds value to our
study: the difference due to the intervention was greater
than the variability due to random error.
Second, the control treatment (lowest-power short
waves, applied to the sacrum) was not strictly speaking a
placebo. However, the control groups success rate at 6
months was only 12%, which suggests that the effectiveness of the control treatment may be considered to have
been very slight to nonexistent.
Finally, the patients were not followed up beyond 6
months; however, in a pilot study, good results had been
seen to be maintained in the period between 6 months
and 24 months.9
Subgroup Comparison
These analyses were performed post hoc and should
therefore be interpreted with caution. Some factors were
predictive of a good outcome of manipulation. Manipulation patients with a stable coccyx did better than those
with an unstable coccyx; whereas in the control group,
stability was not a factor of good prognosis. This would
appear to derive from the mechanism of action of manipulation. The technique can make the coccyx more
supple and, in particular, relieve the painful tension of
the pelvic muscles. We think that for this relief to be
durable, the causative coccygeal disc lesion must be minimal or healing. In that case, the painful muscle tension
may be assumed to be purely reflex and to lend itself to
treatment with manipulation.9
Timing
The procedure should be performed as early as possible:
In patients with coccydynia of more than 1 years standing, the results of manipulation were markedly poorer.
In cases with etiologic trauma, the rate of good results
was twice that in nontrauma-related cases. These 2 observations suggest that a minimal coccygeal disc lesion
(especially if caused by trauma) will heal spontaneously.
If there is still pain after 1 year, the cause should be
sought elsewhere. The culprits may, for instance, be intradiscal inflammation or psychosocial factors. The current study demonstrated the role of psychosocial factors
and appears, indeed, to be the first study to show the
importance of these factors in chronic coccydynia.
References
1. Sugar O. Coccyx, the bone named for a bird. Spine 1995;20:379 83.
2. Thiele GH. Coccydynia and pain in the superior gluteal region and down the
back of the thigh: causation by tonic spasm of the levator ani, coccygeus and
piriformis muscles and relief by massage of these muscles. JAMA 1937;109:
12715.
3. Mennell JB. The Science and Art of Joint Manipulation. London: Churchill,
1949.
4. Howorth B. The painful coccyx. Clin Orthop 1959;14:145 61.
5. Maigne R. Les manipulations vertebrales, 3rd ed. Paris: Expansion Scientifique Francaise, 1961:180.
6. Maigne R. Diagnosis and Treatment of Pain of Vertebral Origin: A Manual
Medicine Approach. Baltimore: Williams & Wilkins, 1996:339 40.
7. Maigne JY, Guedj S, Straus C. Idiopathic coccygodynia: lateral roentgenograms in the sitting position and coccygeal discography. Spine 1994;19:
930 4.
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10. Maigne JY, Vautravers P. Mechanism of action of spinal manipulative
therapy. Joint Bone Spine 2003;70:336 41.
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13.
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Appendix
Annex 1. The Paris (functional coccydynia impact)
Questionnaire
Circle the number which best describes your response.
To ensure that your questionnaire will count, please answer all 5 questions.
1) When I am sitting:
I have no pain (0)
I have slight discomfort (1)
2)
3)
4)
5)