Physical therapy for poor posture and spinal stability

Dianna -

Original posting, 2004-01-25:

I came across your website as I was researching my recent diagnosis of coccydynia. I'm 27 years old - too young, I think to have to be dealing with this kind of pain!! I've been having pain in my tailbone for the last year, almost so long I don't really remember exactly when it started. I have two children, and if I remember correctly, I've had pain going from the sitting to standing position since sometime between the birth of my first child and conception of my second child. I do not recall any accidents of significance that would have caused injury. However, my first delivery and recovery were a bit tough. I had an episiotomy that didn't quite heal right, so the pain I felt at the time was attributed to my delivery. I had no idea at the time that the pain wasn't normal until my 6 week checkup. What a surprise!

Anyway, with my second pregnancy, the pain I felt in my tailbone seemed to get worse all the time. Again, I just attributed this to normal aches and pains for an ever-changing pregnant body. My second delivery was wonderful and I realized how a good, normal recovery is supposed to be. I had no problems with the episiotomy and very little pain sitting down. However, the tailbone pain began to appear again, gradually getting worse. It really seemed to get bad once my maternity leave was over (after 8 weeks) and I had to go back to sitting in the office chairs for 8 hours a day. I would find myself making excuses to walk around the office or trying to sit in all these different positions so that it wouldn't hurt when I had to stand up.

After one extremely frustrating and painful day I realized that I needed to go see a doctor. It was ridiculous that I've been trying to deal with this for so long. I made an appointment with my primary care physician (PCP). I had only seen her twice before and that was for sinus infections and a pregnancy test prior to my first child. My ob/gyn was the doctor I'd been seeing so much of. Anyway, my PCP asked a bunch of questions about symptoms, then sent me off to get an x-ray. The x-ray came back as negative. There was no break or other abnormalities to my coccyx or lower spine.

She then referred me to a spine specialist. This doctor thoroughly checked my spine and lower back. She seemed to believe that the problem I was having was muscular related, not bone related. Her assessment was that the ligaments and muscles that attach to the tailbone were inflamed. She recommended a steroid injection at the site of tenderness, to which I agreed to try. The steroid injection included the use of a local anesthetic. The injection was mildly painful at first, much like a bee sting. Immediately afterwards, the effects of the anesthetic took all of my pain away. I thought, "This is wonderful! The answer to my prayers!" But within an hour or so, the local anesthetic had worn off and the steroid injection site was hurting more than ever. It seemed to hurt no matter what position I was in, sitting, standing, laying down. I thought I had made the biggest mistake ever. You know, what's worse is that the pain is in such a place that you can't really talk to people about what you're going through. Fortunately, I have a loving husband and a close friend that I can confide in. I have a lot of friends who joke around a lot. They don't mean to hurt anyone's feelings, but I know if word got out that I had this kind of pain I'd never hear the end of the "pain in the ass" jokes. I was pretty much in tears after that appointment. I felt humiliated and more in pain than ever.

I found your website a mix of consolation and worry. So many people have written in with experiences both positive and negative. I wasn't sure what to make of it all. Anyway, in addition to the steroid injection, the spine specialist prescribed an anti-inflammatory medication called etodolac. She also prescribed some vicodin for what she called "breakthrough pain". Her instructions were 1 tablet of etodolac every day until my follow-up visit and no more than 8 vicodin a day. I find myself taking 1 etodolac and 1 vicodin just before I go to bed and that seems to work pretty well. I would never ever take that much vicodin. It makes me too dizzy and nauseous to take any more than one. She also recommended that I set up an appointment with a physical therapist and her "prescription" was for 2-3 times a week for 4 to 6 weeks.

The physical therapist has been working with me to help identify the muscles causing the pain. She commented that I have poor posture and terrible stability. I know I have awful posture, but I never thought it would cause this pain. She determined that I had poor stability by having me stand facing her, my feet pointed towards her and slightly apart, no more than shoulder width, and she pushed squarely on my shoulders. She told me to try to push back, without changing my stance. I could hardly hold my own. She said that poor stability in my spine could be responsible for my tailbone hurting, because some of the muscles are pulling and twisting and are not as elastic as they used to be. She next had me lay on a table, on my stomach and she felt around the tailbone region to determine if it was pulled more to one side. It was, being pulled more to the left. Now that she was comfortable knowing my condition, she suggested several steps. First, I need to correct my posture. To find my appropriate posture position, she had me slouch, then had me exaggerate a straight back, then relax to a more comfortable straight position in between. I realized my posture was worse than I thought. Next, she recommended that I invest in either a donut pillow or a wedge pillow that I could sit on at work, home, etc. This would alleviate the pressure of sitting on my tailbone. I still haven't done this one. I guess I'm just being lazy. She then put me on an exercise regime that concentrates on stretching the gluteus and abdominal muscles.

I do tons of stretches. I've had 5 sessions so far and at every session they introduce a different stretch. They are concentrating on strengthening my muscles and increasing my stability. I have found that with the steroid, the medication, and the exercises, I'm doing pretty good. Sometimes I don't feel the pain at all and so I forget to take the medication or I skip the exercise because I'm tired and it's late. Then the pain comes back and I realize that I need to keep up with this or it will never get better. In fact, at my last PT session, the therapist reamed me for not doing the exercises regularly at home. (I have a hard time motivating myself - what can I say?) She said that I was soon going to be discharged from the program because they felt that I could maintain the exercises at home and my pain was under control. She said if I didn't do the exercises EVERY DAY, then it wasn't going to help. She said it could take months or years for me to build up the strength and stability to prevent further damage. It really hit home and I have tried to keep up with the program ever since. I am looking into joining a gym so that I can have access to the equipment, a personal trainer, and the motivation to keep up with the exercises. I have my follow up with the spine specialist next week. I don't know what she will say, but for now it seems like things are working. Perhaps the steroid shot will wear off and I will need another injection. I guess I could live with that.

Update, 2004-02-01:

I've noticed a pattern. I feel absolutely no pain at all over the weekends and pain starts up as I go back to work and gets worse throughout the week. I think it definitely has something to do with the chairs I sit in at work. 

My follow up visit with the spine specialist was this morning. She was happy to hear that the injection had helped. She said if I get to the point of unbearable pain I can get another injection but she said that it's best not to get more than 2-3 shots a year, so we should try other options before getting another injection. She renewed my prescription for physical therapy for another 2 weeks. I think the therapy helps. If it isn't helping the muscles in the tailbone region, it's definitely helping my morale! She also switched the anti-inflammatory medication to Celebrex and ordered me a donut to sit on. She wants to see me again in 4 weeks. In the meantime, it's exercises and anti-inflammatories every day!! I think the pillow will help a lot. I am looking forward to recovery!! 

I'll try to let you know how it's going. There is hope!!

Update, 2004-02-29:

Well several weeks have passed and a lot has happened. Where should I begin?

The pattern I noticed is still on-going. I do well on weekends and get worse by the end of the week as I spend more time sitting at work. The donut pillow is of very little relief. It doesn't seem to take the pressure off the way I thought it would. I am positive now that my condition is muscular-related.

I continued with physical therapy, which I found very interesting. My therapist shifted her focus from stretching and muscle toning techniques to counterpressure and massage techniques. She spent a lot of time evaluating my posture, my lower back muscles and even checked to see if my legs were the same length. What she found (or what she thinks, anyway) is that the muscles are tighter in my lower back/buttocks on the left side and in my abdomen on the right side. She said that my legs appear the same length when I am lying down, but one is ever-so-slightly longer than the other when sitting up with my legs stretched out straight. She said that more than likely my hip is twisted - somehow contorted, possibly from my pregnancy. She said the key was to release the tension in the muscles and re-train the muscles to their appropriate position.

She started with counterpressure to the muscles in the tailbone area. She could tell very easily which muscles needed the counterpressure, because they were sensitive (painful) to the pressure. The massage technique involved sustained pressure, with occasional gentle rubbing or "strumming" of the muscle fibers. Sometimes, she would have me move my leg in a "windshield wiper"-like motion. If I were lying on my stomach, I would bend my leg at my knee and sway my foot to the left and to the right as she was applying the pressure. I could feel the muscle moving. After a few sessions, she felt the back muscles were sufficiently relaxed and shifted her focus to the abdominal muscles. There are muscles that stretch lengthwise down your abdomen that control the position of your hips. She applied counterpressure to these muscles, much the same as she had done on my backside. This was quite painful - like a knife to my stomach. She said she wasn't pressing hard - but it hurt so much. She said it has to do with how tense those muscles had gotten. It was odd that my right side was so much more painful than my left side - I guess that just reaffirms my therapist's evaluation. All the exercises seemed helpful - they allowed me to keep my pain at a manageable level.
What seems to have made the biggest impact, though, is the Celebrex. It took me longer to start the medication than anticipated, because my insurance company was unwilling to cover it. The pharmacy, the doctor's office, and the insurance company spent two and a half weeks with their paperwork back and forth, trying to allow/disallow coverage for the prescription. I finally ran out of the other medication I was taking and gave up on the insurance. I purchased the medicine myself (a whopping $83 US). I've been taking the medication for 1 week now. I am in heaven!!! I went all last week with only a slight twinge of pain. On a scale of 1 to 10, 10 being the worst pain, by Friday I was maybe at a 1. With the other medication (Etodolac - the generic for Lodine) the pain never seemed to dull. Once the pain flared up there was nothing I could do to lessen it except go home and stay off of it. With Celebrex, the pain is so mild I hardly notice it. If it feels as if it's coming back, I can stand up, stretch, walk around, and go back to sitting for several hours.

After hearing that my hip may be twisted, I evaluated my lifestyle over the past two or three years. What have I done differently with my posture? I wondered if my mattress had something to do with my poor posture. You know, I began sleeping on my side almost exclusively with my first pregnancy, since I'd read that blood flows better to the baby if you sleep on your left side. My mattress is not exactly the top-of-the-line and my husband is a bit larger than me, so I tend to get sucked into the cavern in the middle. I convinced my husband to let me buy a new mattress, just so I could eliminate it from the equation. He was a little resistant to the idea, because he thought our mattress was fine, but I won and we went shopping. We ended up buying a Tempurpedic mattress - the space foam or memory foam that was created by NASA and is sold on TV infomercials. I don't know if the mattress is making much difference, since it was delivered the same weekend I began taking the Celebrex, but I really like it. I definitely feel like I'm getting better support on my back. After the first night, I woke up feeling a little stiff, but now I feel pretty well rested. I don't know if this plays a role in me feeling better, or not, but it was worth trying!

I had another follow-up today with the spine specialist. She was surprised that I was paying for the Celebrex outright. She said that it would be too expensive to maintain a prescription for long term treatment, if I were to continue paying for it out of my pocket. (Also Celebrex could be related to GI problems if used long term). She wants me to wean back off the Celebrex for only flare-ups and use a strong ibuprofen instead. Why should I stop using the only thing that has brought me relief?? She also said that if the pain comes back I could get another steroid & lidocaine shot - not something I am looking forward to. She recommended an ice pack after a long day of sitting, and continuing my home exercise program. I am a little frustrated with her diagnosis and approach to treatment. My physical therapist seemed to take so much more time with me, evaluating the problem and trying different forms of treatment. While the Celebrex has taken away the pain (I am so grateful!), I don't believe it has addressed the true cause of the pain. I guess I've been hoping for a miracle cure that would heal my pain, never to return. I asked the spine specialist about getting an MRI done, but she insisted that the treatment for my condition wouldn't change - even if something did show up on the MRI. I am tempted to search out a second opinion, but not sure where to go.

My physical therapist has discharged me (but I have her number if I need her). The spine specialist will see me on an as-needed basis. I have a prescription for ibuprofen and 1 refill for the Celebrex. I have a list of exercises and a donut cushion. My freezer has an ice-maker. I suppose I am armed with all I need to get better for good. I just need to keep up the positive attitude.

I wish everyone out there dealing with this pain the best of luck! I hope I can keep mine under control for good!

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