8. Roel Wilbers

The guest in this episode is Roel Wilbers.   

You have probably heard me as the host of this podcast and in this episode I will dive deeper into the things I learned through the years. I am a physiotherapist and specialised in tailbone pain for the last ten years. I am inolved in doing scientific research and will be a speaker at the upcoming World Congres of Coccyx Pain. On my website tailbonetherapist.com and Instagram under destuittherapeut,  I share a lot of info about tailbone pain, and mainly I treat a lot of people with these problems and they come and see me for that from all over the country. 

We will take a dive into the science and how tailbone pain is approached in the medical world and literature, and what effect this has on the treatment options patients are presented with. Also I will introduce you to another expert on the treatment of tailbone pain: Michael Durtnall, and share his research and treatment findings with you.

The webpage linked to this episode is https://destuittherapeut.nl/the-tailbone-podcast-roel/. Here you can find more info about me and this episode. 

For more info about tailbone problems and the other episodes, you can find me at tailbonetherapist.com. 

If you have any questions about anything in and outside of this episode, comments or requests, please let me know by sending me an email though the website or at roel@roelwilbers.nl. 

Transcript

SPEAKER_01 0:04

Welcome to the Tailbone Podcast. My name is Roel, and as your host, I bring you only experts. This for most doctors and therapists on known problem. Let's dive in with today's episode. Hi there and welcome to a new episode of my Tailbone Podcast, where I interview experts from all over the world. And after all the therapists that I already interviewed and you can listen to here on my platform, today I want to kind of close that section for now with myself. As for now, the last expert in the therapeutic field that can answer the questions you might have from my own experience. What I'm going to do is I'm going to go through all the questions that I asked the other experts, my colleagues, in the previous episodes, and also give you my take, my answer to them. And next to that, in this episode, I'm going to introduce to you a new expert who's unfortunately not longer with us, but did some really, really interesting work as a therapist, but also as a researcher on the topic of Tilbone pain. So I definitely want to share that with you and want to honor his work, although he's no longer with us. So actually get two experts in this episode. And after this episode, I will go more into the field of the medical specialist and the patients that have experience with that. And this doesn't mean that in future episodes there will be no therapists anymore. But for now I try to have kind of a logical buildup in this podcast. So today, one or actually two therapeutic experts, and again, a lot of sharing of information on what I personally learned about tailbone pain through all these years and the hundreds of patients that I saw and I treated with it. And this will be an episode where patients as well as colleagues can learn more about the background of tailbone pain, how it can be explained in a broader sense than is currently used in the literature, and also explains better why physios and other manual therapies work so well. And my challenge is often to not wanting to share everything with the world and just go through the highlights. But let's see how well I'm gonna do on the time management part here. But I promise you it will be an episode with a lot of information, a lot of personal experience in working with patients with tailbone pain for many years right now. So let's start with the question that I start with with all my guests. Could you introduce yourself here, who you are as a person and as a healthcare professional? And if you listen to previous episodes, you got to know me a bit already as the host of this podcast. But here's a bit more info about how I got where I am right now. So and with that, I want to elaborate a little bit on what I already shared in the first episode. So my name is Roel. I live and work in Amsterdam in the Netherlands. I'm just under 50 years old, so not even halfway. And you might know me from, of course, this podcast or the social media canal I have on my website, tailbone therapist.com, where I share a lot of free info. And the tailbone therapist or the stout therapeut, how it is in a Dutch language, is the name or like kind of the brand I work under. And this is also how my eight-year-old daughter actually calls me and introduces me at times when she refers to what dad does. And she actually last year Googled me for the first time. And then when I asked her how she did that, she said, rule tailbone therapist, and then of course in Dutch. So that was pretty funny. So inside of this household, I'm already world famous. So for my professional background, I'm a physiotherapist since 1999, and afterwards I specialized in the mechanical aspect of therapy. And I graduated as a musculoskeletal manual therapist Maitland, and that's a post-physio education that focuses mostly on the treatment of the joints and the spine. And after educations like Mackenzie and Mulligan, which are pretty famous names in the physio world, I dove deeper into the mechanical therapy. But that resulted not as expected in being able to treat all the patients, but there was something missing. And I was already in my personal life interested in studying about philosophy, psychology, and spirituality and made a deep dive into Buddhism and energy work and also on the broader vision on health. After I spent a lot of time on the meditation pillow and did a lot of courses there, I also dove into breath work. And all of these things I learned, I incorporated more and more into my therapy. And this is where my holistic approach started, because with just the biomechanical part, I ran into that I couldn't understand and solve a lot of problems. This was still in the period of my life that I didn't know anything about tailbone pain. And since 2016, I really dove into that and specialized in this little part of the body that can be so impactful. And through the years, I became a tailbone expert. In my educations, I learned totally nothing about a tailbone and didn't even touch one in 15 years of being a therapist. So how it started that I got into the tailbone therapy, I already addressed a bit in the first episode, with a story about my friends that visited Meine Veldmann, and that triggered my curiosity. And after getting introduced to my teachers on whose shoulders I stand, I went into it broad and deep and developed an approach built on the mechanical treatment of tailbone pain, as well as a holistic view on the problem. And in this, I developed new techniques and approaches that I hope to share in the near future with colleagues in my course for manual therapists in the wider sense of the world, and also for doctors. My road as a tailbone therapist really started after doing my first course. And in my somewhere between disbelief that this wasn't known yet and enthusiasm about this option, I wrote a web page on my already existing website about the treatment of tailbone pain. And I turned out actually to be one of the only ones that had that idea, funny enough, and people started finding me through this webpage. And not only people, even a national newspaper found me and interviewed me as their expert for their article about tailbone pain in 2017. And you can find a link to that on my website if you're interested in that. So the subject fascinated me from the start on. And I also started to keep track of the patients that I saw with Tilbone pain. And I started a database in mid-2021. And this database grew to now over 350 patients, and now growing with a pace of over 100 new patients a year. And I started it to see if I saw any patterns in these patients with tillbone pain and how well the therapy that I applied works, and this turns out to be very effective. And because I saw more and more patients, I started to develop more treatment techniques as well myself and created my vision based on the experiences I got. And after, of course, my teachers, which I'm still very grateful for, the hundreds of patients that I saw so far became my biggest teachers. This webpage on my other website that turned into an extensive website nowadays that you can find at tailbone therapist.com. And this name I adopted for my website in Dutch, the stuuttherapeut.nl, and later also claimed the English URL. I also started to do research projects with the Vrije University here in Amsterdam after I got in touch with a professor over there. I wrote an extensive article about where I evaluate the current model that is used to explain tailbone pain and where the medical literature is based on, and also its shortcomings. And this got me invited to speak at the World Congress on tailbone pain, among all the other experts this summer, which I'm looking very much forward to. And next to that, I'm writing two articles at the moment about the treatment results of the external mobilization of the tailbone. And I do that together with the researchers at the Vrije University here in Amsterdam. And one of the articles I want to see if we can get published in international magazine, because this affects actually the whole world. And one I'm writing for a Dutch magazine for medicine. I'm getting into the end phase of getting that published. So next to my website where I share a lot of free information, exercises, tips, and so on. I also have an Instagram account in Dutch where I share a lot of info and video about tailbone pain. And I found there was a need for that because online there's so much not really high-quality information about tailbone pain that I wanted to help patients to get more clarity. And therefore, also a few months ago I got the idea of this podcast to spread high-quality info through my colleague experts. And this is of course what you're listening to right now, and probably you also listen to previous episodes. Starting a podcast was not really new for me because I already had a podcast about meditation for many years now. So it was not hard to start a new one. But it's quite a project though, with around 10 hours of work per episode. And the few episodes that I posted over the last few months already reached listeners in 19 countries and in all continents outside of Australia so far. So hopefully this reaches down under as well anytime soon. And the coolest thing for me is that I get these replies from people that listen to this podcast and were helped with it. The first reaction I got into my mailbots was from someone living 2,500 kilometers from where I live and work, and with her consent, I can share her message. And she wrote to me, Daryl Wilbers, thank you for your podcast. I came across your podcast while searching for information about the tailbone pain I have experiencing since giving birth to my child. I'm still searching for reliable information regarding my tailbone condition, and I wanted to sincerely thank you for the useful information and expertise you share. Your work has been very helpful and encouraging. Thank you again for your valuable work and for making this information accessible. And this is, of course, exactly the goal why I started this podcast. And afterwards she wrote, It is important to recognize that your work has a real impact on others, and I hope this gives you the motivation to keep going. Again, I'm very, very grateful for this email, and yes, it does give me the motivation to keep going. Recently, I also had an online consultation with someone in Colombia that was helped a lot by this podcast, and he posted a review on my Google account that also really touched me. He says Rules Podcast, the Tailbone Podcast, has been an incredibly useful resource of information about tailbone pain. It gave me a lot of clarity about the fact that this is a niche injury and that information on the non-invasive treatments is limited, even among doctors. The podcast guest shared real experiences, the treatments they tried, what worked, what didn't, and their levels of progress. This led me to book a consultation with Ruhl where I was able to get personalized advice. He patiently heard me out as I explained everything from my side and gave me clear explanations and action steps on how to fix my situation, despite me not being physically in the Netherlands. I can't thank Ruhl enough for pointing me in the right direction and helping me get clarity on this topic. He changes lives. Well, again, I'm really, really touched by that. And I'm very, very grateful that I'm able to help people. So I'm very pleased to be able to receive these messages. So thanks a lot. And also, furthermore, I got replies from Canada and UK and had a few online consultations where I could actually help people with answering their specific questions where they didn't find an answer to. And this is actually my biggest salary and drive for this podcast and why I spend so much time and energy in it. Because there's not really a financial game. And of course, for me, I learned from my colleague experts, which enables me to help people even better. So if you're listening to this podcast and you want to get in touch or leave me a comment or whatever, it's very, very welcome. I'm very happy to receive any form of feedback and comments or to hear what it did for you. And again, I'm here to help and I hope it helps you as well. And I share this information in answering this question of who am I and why am I doing what I'm doing? And I see it as my mission to spread the tail message around the world and to empower patients with knowledge and explanations. And a patient I recently saw said, it's a very annoying problem, but the most annoying part of it is that it's so unexplainable. And after the first consultation, she left already more relieved because she finally got the information she was looking for and she could understand what actually was going on. So nowadays as a therapist, more than half of my working days I see people with tailbone problems. And although I get more and more referrals through patients, colleagues, or doctors, most people still find me through their own online research and find my website, or I'm suggested to them by artificial intelligence like ChatGPT. And I think this is a clear indication that this is still an unknown topic among doctors and therapists, that they just don't know where to refer to and that their treatment options when they encounter someone with tailbone problems. And unfortunately, this also leads to that a lot of patients that when they visit their doctor or therapist and present their problems, that they get the message that there unfortunately is nothing to do about this problem. And if they are presented solutions, it is mainly about injections to influence the pain and inflammation or surgery. And we already talked about these medical approaches, of course, in the previous episodes, and we definitely will when we get to hear from the doctors in the next episodes. And what you probably heard in the previous episodes is that most experts recognize that the people they see are not well informed about what's going on with the tailbone pain and what is possible in treatment. And as mentioned before, this is not ill will of the treating physicians or therapists, of course. It's just a lack of knowledge. And as also mentioned, there's hardly any or no information about the tailbone and its problems in almost all medical and therapeutic educations and training. And also there's hardly any research being done on the subject. Partly because it's a niche market and relatively few patients have tailbone pain compared to other parts of the spine like lower back or neck pain. But also there's no real pharmaceutical interest and gain. So a big sponsor of scientific research has no benefits by this. And when the science is lacking, there's also no access to the educations either. And this makes that patients that are often really suffering of a lot of pain of their tailbone don't get valid information or help in a regular medical and therapeutic healthcare, even though their pain and restriction, of course, can be very severe. So the problems that people present themselves with are basically local pain at the tailbone itself, and sometimes also the area around it, like the sacrum and the buttocks, and that the pain is provoked by compression. So that means sitting on it or manually push on it. And I think if one of these factors is not there, then it's already fair to question if it's really a tailbone problem. So if there's no pain at the tailbone itself, it's doubtful that the tailbone is actually in trouble. And the tailbone is just to be sure, because I still regularly see people that think their tailbone is where the belt is, the tailbone is just behind the anus, a little bit back and up from the anus. And also if there's no provocation or increase of pain during pressure, again like with sitting or pushing on it, it's also doubtful that there's a real tailbone issue going on. So I think this is something important to realize. It doesn't mean that the functioning of the tailbone is optimal, but if there's a tailbone dysfunction, what I see in practice, these characteristics are almost always there. And it's very exceptional that there's no pain during sitting, pain with pressure, and local pain at the tailbone itself. So as you understand, I'm now going through the questions which I asked the other experts as well. And what I'm always really curious about with the other experts I interviewed here is how they see tailbone problems. Therapists often approach it more from a biomechanical and mobility dysfunction, and look at the joints, look at the muscles, look at the connective tissue, the fascia. And doctors approach it from their education, often more from structural integrity. So if there's any deformities or fractures or tumors or cysts, and also they look at symptoms like inflammation or pain. And this makes sense because we therapists mostly treat with mobilizations and exercises, and physicians mostly treat with medication and surgery. And I like to take a part of this podcast to take you along in how tailbone problems are seen mostly and how they are described in the literature. And that's the text that healthcare professionals read if they seek for info about tailbone pain. And remember, this is not in almost any of the basic trainings. Also, as a healthcare professional, you really have to look for the information. And this is important because it gives you insight in how the doctors and therapists that you will encounter with your problems will approach the problem. And as mentioned in most episodes already, most doctors and therapists cannot give you any info at all and approach it from the knowledge they have, which is more based on the surroundings or excluding certain pathologies. So the ones that actually look into tailbumping and the specialized healthcare professionals are exposed to in the literature, are mostly inside of a model that easily leads up to treatment choices like medication through injection, nerve blocks, and surgery. And I want to explain this to you and give you a wider perspective so you understand it in a different context and you can make a more informed decision on what you want as therapy and as a solution for your problems, and you know what to look and ask for. And in this section, which I'm trying to make as painless and less boring as possible, I think it will interest you. I will also introduce you to the main characters, main persons, main investigators, main therapists, and doctors that formed our way of looking at tailbone problems. And also introduce the other expert here, Michael Dirdnell, which I already just mentioned in the intro. So the general model about how tailbone problems are perceived is the last decades mainly formed around mechanical issues. And this is largely based on the findings of Dr. Meigne. And this French doctor that recently retired invented the dynamic radiography in the early 90s. And here there are two x-rays taken. Both are from the sides, and one is in standing, and the other one is in sitting position. And then which Dr. Meigne did and is revolutionary, but makes a lot of sense, he compared the two images and he looked how there's a difference in the position of the tailbone. And this way you can get an idea of the mechanics of the tailbone, how the tailbone actually moves in between these two positions. And this is something which should be the case because with normal mechanics the tailbone moves inwards with sitting down and in a backwards direction when you stand up again. And if this movement is not within the norms, problems can occur. And Dr. Menye concluded that this was the case in more than half of the cases of people with tailbone pain. And where there's pretty much consensus that tailbone pain is a mechanical problem, and Dr. Menye estimated it was around 70% of all problems, the therapy is mainly still in the medical area and aimed at medication and symptom reduction and not in influencing the biomechanics. And this does make sense if you look into what the conclusions were of Dr. Menye. Because in his findings, the mechanical problems are mostly an increased mobility of the tailbone. And that is either that the angle the tailbone makes is too big, so too much extending and mainly bending forward, or too much mobility that is more translatory, so where the bones lose alignment and shift forward and backwards one to another. And the medical approach here makes a lot of sense because this is not treatable. The tailbone cannot be stabilized through exercises or surgery, and so the problem can only be treated with symptom relief or surgery where the source of the pain is removed. And the surgery is a pretty big intervention, and there is consensus among non-surgeons and surgeons that this really is the last resource, and mostly it's advised that it's not done before a rehab period of at least six months. The medication is mostly applied locally through injection, but as the focus is more symptom-like on inflammation and pain, you can understand that the underlying mechanical cause is not addressed by it. And this also explains why mostly the effects of this approach are temporary. And more about that we will learn in the episodes with the doctors. From this perspective, it also makes sense that manual mobilizations are not considered to be favorable for tailbone problems and even considered to have adverse effects. In the book of Dr. Foy, and he wrote, I think, the only book out there on tailbone problems, and he's a real expert. He even mentioned that there are seven reasons against manipulation, so mobilization of the tailbone, and why it's not a good idea, and I will definitely come back to that in a little bit. This model of explanation, though, is in sheer contrast in what I see and what we see as therapists in practice. As mentioned in previous episodes by colleague therapist, what we see is that around 80 to 90% of patients we can resolve their problems by mobilization of the tailbone and relaxation of the muscle. And also, the earliest writings about coccix pain already mentioned the benefits of mobilization of the tailbone pain. And even this is the oldest therapy mentioned in scriptures, and it dates back many centuries. It is also always seen as having a positive effect and not having a negative effect. And in the theory, when the tailbone is too flexible, this treatment of mobilizing it, it should make the condition worse. But it doesn't. And that's kind of puzzling. So, me as a therapist started working with tailbone problems from a very practical approach. I learned the technique, I applied it to patients, they got better, everybody was happy, so was I. And I started thinking about this when I talked to this specialized doctor about this. And what this doctor said to me was, I really can't understand how your therapy works. I really can't. Most tailbones are overmobiled and not stiffened up. And this triggered me to dive into the literature, and I discovered, indeed, that this was a general understanding of tailbone pain and that instability was seen as the biggest cause. But on the other hand, I saw that mobilizing this allegedly hypermobile joint was clearly helping. And the percentage of people that were helped with it was bigger than the percentage of people that were reported by Dr. Menye in his research. Because he saw that more than half of the patients he assessed, and this was through x-rays, showed an increased mobility. But we as therapists see that more than 75% of people are helped with mobilization. So something didn't add up there. And this was a start for me doing research myself. And it's not that I doubt any of the research findings that Dr. Menye and his colleagues found as proof for this instability theory. But where I mainly looked at is how they interpreted their findings, and then also mainly from a mechanical viewpoint and how they can be seen differently. And this also kind of makes sense because the researchers mainly are doctors and they are less trained in the biomechanics than we physios are. So the conclusion I came to in my perception about the problem is that a reduced mobility of the tailbone is the underlying factor for most cases of tailbone pain. So that's the opposite of what is mentioned in the literature. And how this explains the results we as therapists have, of course, makes sense, but it actually can also explain the findings and scientific research where the conclusion was a hypermobility. And I'm going to go into that a little bit. But I first want to explain a little bit more about this reduced mobility idea. So, as mentioned, when I started out, I first did this one education on tailbone treatment. And later I did the other one. So I did both of the educations which are out there here in the Netherlands, at least, on treating tailbone pain through the external methods. And what I understood. Is that the idea is that there's a sideward deviation of the tailbone and that it's kind of out of place and it has to be repositioned so it's able to move freely again. And along the way, along the years that I treated these tailbone problems and I saw what was happening with the therapy I applied and also the new techniques I applied, my view on it changed a little bit more to a less specific form of decreased mobility. And where I still always test if there's a side reposition of the tailbone with patients, and I think to find it in almost all cases, I still find it hard to really feel it because it's a little little bit even after the thousands of times I already did this. And I also wondered why there's this lateral deviation. Is the joint really out of place, how it's often mentioned, or is it more the result of an asymmetrical tension in the two sides of the pelvic floor, which I also mostly find when I test it? So it doesn't mean that the tailbone is out of place and stuck there. And this is kind of the same as what we mentioned early in this podcast that the tailbone on imagery, like X-rays, tends to show a more forward-bended position. It doesn't have to be a wrong position. It can also be pulled there by an increased tension of the pelvic floor, which is mostly the case when there's persistent tailbone pain, because there's a muscular protective spasm when there's pain. The body wants to protect the injury. So that got me thinking. And in the process of all these years of trying to understand tailbone pain, my perception of what is happening with the therapy and why it's effective kind of changed. And in this, I don't really think that the tailbone needs to be repositioned or manipulated back into place. And this is often what is referred to when manual mobilizing techniques are mentioned. Dr. Foy writes in his book, and I quote here, the idea is to attempt to push or pull the tailbone back into a more normal alignment. And also Meine Feldman, who developed this external technique and who formed the basis of my work, mentioned it as repositioning. So in my perception, this is not what happens. And I can understand Dr. Foy's comment that just repositioning doesn't lead to a lasting position change. And that because the tailbone is kind of like this loosely moving structure, it will go back out of alignment automatically because it's not really stabilized. And of course, this makes sense. In my perception though, this is not what we are doing. And actually the question is, are we able to do that? Because to reposition it, you must be able to put it into the exact right position, up to the millimeter, which is understandably very hard. And this goes even without considering that nobody is exactly symmetrical, and a slight deviation could be normal for this person. And especially in a table where there's consensus that there is so much inter-individual differences in anatomy and position. And what I believe about therapy and healing is that the therapist or doctor doesn't perform the healing. The body does. And the same goes for the repositioning. In my perception, also the body does the work here. We just create circumstances. The body always has the urge and the intention to heal and align. But sometimes it's not able to do that because there's some stiffness that gets in the way. And this is also what is possible, of course, at the tailbone. And it can be in a joint, the muscles, the fascia, or other structures, somewhere the tailbone is not able to align anymore and function freely. And I see it as our job to create the circumstances for that instead of doing the repositioning. So when we create the circumstances and loosen up the area, nature will do its work and the realignment is something that the body will do for us as soon as it has the opportunity to do so. And this for me also changes the view on the mobilizations. It's not a repositioning, but to help the body find its natural alignment again. And so the body's natural wisdom of healing can take place. And the body, in my opinion, knows exactly and perfectly how to do that. So after giving you this context, it still doesn't explain why a reduced mobility is the problem, while there's a clearly visible hypermobility, over mobility in the joint, either in bending or sliding of the tailbones in a sitting position, which Dr. Menya and his colleagues found in their studies with the dynamic radiography. So what I found is where the tailbone was fine when people were standing, it was hyper mostly flexed or not aligned anymore in a sitting position. And it makes sense to conclude that this is the reason for the tailbone pain. And as I also mentioned, the normal biomechanics of the tailbone is that it tucks in when we sit down and kind of dives away from the incoming pressure of the seat below, and it moves back into the more straight position when we stand up again. And this, by the way, is confirmed with scientific research. So when the tailbone doesn't make this forward and inward movement anymore when sitting down, the tailbone gets compressed between the body weight and the pressure from the surface below. The bones have to go somewhere, and this is either an increased bending or extending in the mobile joints, or a kind of crumbling under the compression and a kind of sliding over each other off these bones, and then the alignment is lost. And this can be caused, of course, because the joints are too mobile and can't keep their alignment, or by a stiffness in a joint close by, wherefore the rest has to compensate. And this is a very well-known mechanism you see in physiotherapy. And also Sari as an osteopath in the last episode referred to. When there's stiffness in one joint, the neighboring area often starts to compensate. So let's use an example. If your knee or your ankle is stiffened up, you're gonna limp and you're gonna walk differently, and you start to compensate in your pelvis and hip area to still keep walking. So it's pretty easy if there's a stiffness in your knee or ankle that other areas have to compensate and you get into trouble in your pelvis or your lower back. We therapists also often see this with neck problems. When you turn your head, you move in your neck vertebrate, but also in the upper part of your back, the area where the shoulder blades are. If there's a movement restriction there, which we often see by people that are sitting for a long time, for instance, behind the computer, that means that the joints in the neck have to compensate for that and can be overdone, overused, and give pain. Although the cause of the problem is not in the neck, but in the rigid part, the less mobile part below. So that this form of hypermobility is seen on imagery, which of course I don't doubt is the case, could also be a compensation instead of the actual problem. And this is not taken into account in the literature as far as I'm aware of. And in this model of a reduced mobility in a neighboring area, the positive effects of mobilization can be explained, as well as the instability seen on the imagery. And when there's a non-compensational instability of hyperflexion or misalignment, the effects of the mobilization can't be explained. So this is kind of the new or improved or adjusted model which I'm trying to kind of bring into the world. And I wrote this extensive article about it, and I sent it actually to Dr. Menye for reviewing it. And based on this, I'm invited to the World Congress in Turkey to present this idea. So this is a different way of looking at tailbone problems and the mechanics that cause it than the one that is mainly used in the literature. And I think it's more complete because it's in line with the conclusions that most tailbone pain has a mechanical underlying factor and in line with the things we see on imagery, but again, also explains the effects we see in therapy after mobilizing the joints and the surroundings. Hypermobility or reduced mobility so far isn't considered as problematic by a lot of specialists in the field and a lot of literature. Also, and maybe because of that, the effect of the treatments of mobilization of the tailbone hasn't been really studied. And it goes for neither the treatment results nor the underlying problem why it can lead to pain. And here it's a perfect timing to bring in another expert, the one I already announced, and that is Michael Dirtnall. He worked as a chiropractor in London and also was very specialized in tailbone pain. And as mentioned, he unfortunately passed away, and otherwise he would have been a top-desired guest for this podcast. But I want to bring up his work here and honor him for the insights that he brought into his world. Michael Dirtnal unfortunately didn't come to any publications in the medical literature, but he presented his findings at the International Congress of Back Pain and Pelvic Pain in 2013 in Dubai, and also at the World Coccix Symposium in 2016 in Paris. And I really have to thank John Miles here, because he's the one who pointed me to the work of Dirtnall. And John was a guest here at the fourth episode of this podcast and has a major website about COCIX pain called coxics.org. And on here he posted information about Michael Dirtnall's presentations on these congresses and managed to give me the report Michael Dirtnell wrote about the findings he did and the research he did. So big thanks to John here, who for me is always a source of information whenever I'm looking for something specific. So Michael Dirtnall. As mentioned, he worked as a chiropractor in London in a SEA clinics, and he treated during multiple decennia hundreds of patients that also came to him from outside of the country with tailbone pain. He has, to my knowledge, written the most extensive clinically based description of the effects of mobilizations of the COCIX up till now. And in this he came to the same conclusion than me, namely that there's an underlying hypo or reduced mobility that is causing most tailbone problems. And of course, this seems to be the only logical condition when mobilizations reduce the symptoms. And where I base myself on the clinical findings, so what I see in daily practice, and the results of my treatment, Michael Dirtnall also made imagery in this practice, so x-rays to build his case on. He treated his patients manually with internal as well as external techniques of the coctics, and additionally applied physiotherapy, acupuncture, and exercises, and the results were good. As said, he presented the results on the just mentioned symposiums, and he addressed the effectiveness of manual mobilization or manipulation, how he called it, of the coccix for people with tailbone pain. And in his study he presented, he had a population of 87 patients, and the results were that 69% had an improvement of 70 to 100%, and 41% of his patients even had a 90 to 100% improvement of their problems. Only 7% had less than 30% improvement. And these are findings that match my data and the other experts I talked to on this podcast, treating with manual techniques and exercises. And what is also in line with what we experts see and that you hear on this podcast is that the amount of treatments that are needed to reach the results are low. He mentioned that 42% needed three to five treatments, and the average of all patients was six and a half treatments. So that's six to seven treatments to get to so much improvement, and almost 70% had over 70% reduce of problems. And he even stated that the success rates were around 100% at the first stage of his career with his therapy, and it later went down a little bit because he saw worse cases, and also people from outside of the country came to visit him at his clinic. And again, unfortunately, this didn't get published. What Michael Durdle also did is he looked at the explanatory model for tailbone pain. And that's why he also used the imagery, so could more closely see what was happening in the joints and especially also evaluate the conclusions of the dynamic radiography where the instability model is based on. And interesting enough, he came to the same conclusions that I have, but now shown on images. He noticed the same hypermobility, so increased bending or misalignment with the dynamic radiography method that Dr. Menya invented. But what he saw was a little detail that was not described in other literature. He saw that the joint above the one where the instability took place, so where there's excessive movement, this one was often less mobile and often slightly dispositioned and aiming more strained and not moving along. So where the joint mobility was indeed bigger at the location of the pain, the joint angles you would expect above that joint show to be less. And this confirms the theory that I have of the neighboring joint stiffness, which play a big part in developing tailbone pain. But he also saw that when the stiffness was resolved through therapy, the alignment of the tailbones on the X-ray after the treatments was normal again. So he indicated something on the imagery but seemed to be overlooked, and the focus was solely put on the pain spot where the increased mobility was. Which makes sense of course. But this completed the picture for me. And for him, of course. The ejected decreased mobility is the underlying cause of the pain. Just as the stiffness in the knee or ankle can be the cause of pain in the hip, back or pelvis because you're limping and the mobility and the functioning is off. And also there, the problem is not where it hurts, but the problem is somewhere along the line and causing for an overstraining in that area. And I can imagine that maybe it's hard to visualize what is actually meant with this one joint being not flexible and the other joints are on an X-ray. So to make this more visible, I will share a picture on the webpage that is linked to this episode. And this might be also very interesting if you have tailbone issues and there's an x-ray or scan being made from the site where you're sitting, which is again unfortunately not normal, but it is done every now and then. Just see if you can recognize this at your images. And this is one of the things that I'm looking for when people bring their images to therapy. And although this kind of makes sense, also radiologists and doctors often miss this because they look for other things on the images, like fractures or sharp bands or tumors and focus mainly on that. Because the biomechanical understanding with doctors is less because their training is not mainly focused on that. And that makes sense. So if you have imagery while being seated and it's from sideward, look if the curve of the tailbone is divided over all segments. And if there's a sharp angle, how the segment above looks. Is that joining the curve or is that kind of off and the angle below might be a composition? So Michael Dertnall for me is a big inspiration and a big help in understanding the theory why the tailbone hurts. And he indicated in his presentations on his finding that the stiffness in the joint above the one where the increased mobility is seen is often missed and overlooked, or reported as normal. In what he wrote about it, he stated that the over-reliance on findings of coccidal instability of the distal coxyol joints, this is where the overmobility is, as the primary cause factor in coccodinia, so tillbone pain, is questioned in the study. And when the stiff joint is treated to regain normal range of movement, the other joints regain curvature and shared mobility. And he also mentioned that the protective deep muscle spasm will go away and also the negative effect of that one on tilbone pain will disappear. And again, this is in line with what I see. So even when there's clear signs that there's an instability, so a lack of alignment or an increased mobility into flexion or extension, and that can be seen on imagery, the problem can be solved by mobilizations. And although I mostly don't have this imagery because the dynamic radiography is not a standard way of imaging with tailbone problems, unfortunately, also other factors that indicate instability, and Dr. Mania mentioned, for instance, a high body mass index and pain when rising during sitting or an onset by trauma. My data set shows me that still the mobilizing techniques are able to solve the problems in many cases. And I even had two cases where patients came in and they felt that the tailbone inside moved when they make a certain movement or tense their muscle in a certain way, which would be very logical to indicate instability. In both cases, I saw that the people that mentioned that were problem-free and didn't have that feeling anymore after mobilizing in the area. So I hope this is clear and it gives you a little bit of insight how tailbone pain often is addressed can also be seen in a different way. And it can also explain the value of this mobilizing therapy, which we therapists often successfully apply and help so many people with. When this is not taken into account, it makes full sense that the treating healthcare professional advises you to go for medication or surgery. And also Michael Durtnal commented on this because he stated regarding this pharmaceutical treatment for coccadinia, tillbone pain, which is a biomechanical problem, is not effective. Just as just resection of the part of the coccyx that shows the increased movement. And as you can imagine, I was very happy to find out about the work of Michael Dudnall because it backs up the theory I have, and now with imagery. And again, unfortunately, he didn't get to publish this. And I have only three sources of him, and you can find two of them on the website coccyx.org of John Miles. And I will provide a link to that if you're interested in looking into this as well. And in this podcast, I not only want to thank Michael Dudnall for his work during his lifetime, but also want to give him a stage, because in my eyes, this definitely should have gotten more attention. And it's also not that he didn't try to publish this by the way, and that he tried to get it published is indicated by his quote at the end of the International Back Pain and Pelvic Pain Congress in Dubai in 2013, where he said, and I quote here, I need to publish a well-designed study in spine, and here is he referring to Dr. Meny's work, I guess, to get the ball rolling internationally, to educate and change the worldwide medical approach to mechanical coccix conditions. To stop seeing it as normal to treat a simple mechanical problem as a depression or pain problem by describing drugs to suppress the pain and neurological activity which depresses and leads patients to become more obese, miserable, and destined to become victims who suffer long term. And this kind of also confirms where therapists run into doing research. It's often hard to get these things published. And in a way, Michael Durdn seemed to be ahead of his time. And although he said this after the work of Dr. Menya about instability was pretty well established, he was at his lecture at the International Congress of Back Pain and Pelvic Pain in 2013, as far as known, the first in the world to deliver a workshop lecturing on the coccix and musculoskeletally referred pelvic pain to an international audience of doctors, specialists, and professors on the diagnosis and effective treatment of coccidinia and referred pelvic pain. So hardly no material then. And he, just as Dr. Menye, was a true pioneer, and I want to mention and honor that here. And he also back then identified with what is my mission now to get better care for patients with tailbone pain and easier access to a low threshold and empirically experienced very effective treatment that is aimed at a biomechanical underlying factor. And I'm going to quote him here because he explains it perfectly in my eyes. He wrote, I have observed over many years that in France, Italy, Spain, and most of Europe, the majority of COCIX dysfunction and pain sufferers receive treatment with increasingly powerful painkillers, then injections of cortisone, which are repeated regularly over several years as a temporary effect wears off, and when it has failed, coccix removal surgery as the final step. Meanwhile, in the USA, it seems that everybody is given pain clinic drugs, then repeated injections of cortisone, then radio frequency ablation to burn the coccyx nerve center under the tailbone, which sends pain messages to the brain, while the coccyx remains dysfunctional and pain generating. And when a burned nerve center regrows over about a year, the patient is usually back to square one when the same or worse pain returns. And then finally, the coccyx removal surgery with or without good results. In the UK, the NHS route is years of painkilling drugs, which tend to make sufferers feel demoralized and miserable, and eventually they see an orthopedic surgeon who typically knows little about coccidinia but offers cortisone injections, which simply do not work except for a short-term pain cover-up. He continues, the vast majority of my patients have excellent outcomes without drugs, injections, or surgery. The tiny percentage who cannot be helped, we refer specifically to a few good surgeons internationally for cocidectomy. So that's a removal surgery for the coccix. And that was written by him more than 13 years ago now. And he also looked forward. He said for the future, efficient diagnosis with skilled and effective manipulation and physical therapy with intelligent advice must become the first treatment for patients with coccidia and pelvic pain. Cocidynia is misunderstood, poorly diagnosed, and badly treated everywhere in the world. And if we look back now over the last 13 years that he said this, did things really change? And unfortunately, in a lot of cases, it's still the same. And it's still a hard message to get out there without scientific publications. And as you notice, I try to pick up where people like Michael Dirtnall ended. So, next to honoring Michael Dirtnall and bringing his work and his expertise on this podcast, I hope you understand what I meant by wanting to give you a deeper view into the current explanatory model on tailbone pain and why it's important for the treatment choices given to you. And I hope this helps patients to make better choices that resonate with them and if you're a healthcare professional to have an optimal scope on the explanationary models on the treatment options. So I hope this was useful and also probably helps you to understand my quest to get the information out there better. And in this quest, before and after running into Michael Dirtnal's work, I ordered during my research period all the info I found into a document. And this grew from the basics of a mechanical perspective on tailbone pain into a quite elaborate paper where the current knowledge and literature was added and later also the work of Michael Dirtnal to further support my case. And in this paper I give an overview of what is the explanatory model in the literature among experts, where it doesn't explain the positive empirical effects found for mobilizations of the tailbone, why that's the case, and the proposal for a new model which incorporates as well the current scientific findings as the empirical findings about mobilizations. And I built this around three questions. First one is how can reduced mobility of the tailbone joints be explained as a potential cause of tailbone pain? A reduced mobility be an underlying factor in the current causal explanations, namely anatomical misalignment, instability, exostosis, and that's kind of like a bone spur at the end of the tailbone, and persistent inflammation. Third question: What would an optimal treatment pathway for patients with tailbone pain look like? And in this paper, I explained theoretically how a reduced mobility can be the underlying factor for instability that is seen on dynamic radiography. So the findings of Dr. Menya and his colleagues stay intact, but are just explained in a different way, and in line with what also Francis Dudnall came to in his clinical experiences. And this model also explains how mobilizations can be a solution for other causes mentioned in the literature, like chronic inflammation and the presence of this bone spur, this exostosis, as Pikelowitz is also called, at the tip of the tailbone. And in this article, I tried to back all this up by scientific findings of all the available literature I found on the topic. And this led to a reference list of around 100 publications. And although several colleagues and authors mentioned similar ideas and the same empirical findings, to my knowledge, this is the first time this is turned into an overview in a paper and backed up by the available science. And several hundreds of hours later, I completed my sort of manifesto where I propose for a wider view on tailwind pain than the current accepted model. And this became around 65 pages, which is totally unpublishable in its size and way too specific for these niche problems for any magazine to publish, of course. And I actually had no idea what to do with it, but I sent it to several specialists in the field to review and see if there was any mistakes I made in my thinking process and conclusions. And to my pleasant surprise, it was received very positively and even led to an invitation to the upcoming World Congress on tailbone pain in Turkey to present my ideas, which I'm, of course, honored to do. The full specialized paper I will freely share on my website as my contribution to the field of tailbone pain, and especially the therapeutic approach. And from here on I went on turning the ideas into accessible specific articles for publication elsewhere. And I hope it will be picked up. Because also, what Michael Dirtnall already kind of hinted to, it is not easy to get things about this niche problem, which has not a lot of pharmaceutical interest, which again is a big or the biggest sponsor of scientific research, published somewhere. And maybe if you're a listener here and has access to magazines that might be interested, let me know. Because this is a market where I'm truly unfamiliar in. So who knows there's a listener out there who wants to help me to get the message out there. So I hope my talk here was clear and useful and helpful, and that the articles further widen the scope and help to put mobilizations a little bit more on the map so it becomes better known and accepted as a useful form of therapy and also more available for patients all over the world. Because it might seem that I'm preaching for my own product, that of course I didn't event myself, but I do offer professionally, I want to get the message out there for the patients mainly. Because now they're withdrawn from a very effective therapy because it's not known yet. And where I don't think it's the solution for all the cases, I do think it has something very, very valuable to offer as a treatment. A very important reason for that is that if I compare the results of what I see and my colleagues see and report on this podcast to the alternatives, it's maybe the most effective treatment out there. It's also next to that is very accessible, where people more easily visit a therapist than, for instance, a hospital, where the medical treatments are mostly done. Also, it's non-evasive, so there's no injections or surgery needed. There's no use of any chemicals with side effects. And it often works quickly and has durable results. Also, and it's very important, I think, it aims to treat the underlying cause of the tillbone problem. And that makes it different from the more symptom-aimed treatments used in the current medical care. And as mentioned, among experts, there's some doubt about this therapy because it's not well known. And I already referred to the book of Dr. Foy. And Dr. Foy is an American doctor who is one of the most specialized and knowledgeable experts on tilbone pain in the world. And I'm in touch with him to be a guest here on this podcast episode, so I hope I can make an appointment with him in his very busy schedule soon. And he, in his book, didn't show to be a big fan of the subject of mobilization. And as mentioned, he even has seven reasons against manipulations. So he's reluctant to the mobilizing of the coccyx. And this book is back from 2015, but still very accurate, I think, in the information is given, and I highly recommend the book, except that I have a different view, of course, on the mobilizing therapy. And in here, he mainly referred to the internal manipulations. And with that, he means it is book. And I quote sudden, forceful techniques as well as the more gradual controlled mobilizations. So this also affects the therapy that me and most of my colleagues in this podcast episodes do. And I just want to walk you through these seven objections he has, and which I think are fair, but could and maybe should put into perspective. First one of the seven is that instability is the most common cause of coccadinia, and we already talked about that with the work of Michael Dirtnall and me, where yes, this instability is seen on imagery, but it can also be a compensation for reduced mobility somewhere else. The second objection of not performing mobilizations is the presence of an exercise. So this is this bone spur. And also just mentioned the bone spur can be present, but doesn't have to be symptomatic, and often becomes symptomatic when the tailbone doesn't tuck in and the mobility is not there. So then it stays more straight and you kind of land on your tailbone if you sit down. And I can imagine that this exostosis, this bone spur, this pointy little bone, can give pain. But if the tailbone tucks in again when it's mobilized, even with the presence of a bone spur, it doesn't have to lead to pain. And often also the question is how long is this bone spur already present? Maybe it is there for a long time before the tailbone pain actually started. His third argument is the presence of a fracture where you shouldn't mobilize. And of course, I fully agree with that. When there's an extra joint because a bone is broken, you're not going to mobilize there. But taken into consideration here is that a lot of times there's a fracture mentioned and this is not even actually present. So with a fracture, the bone is not intact. And often you see that there's a misalignment of the coccyx, so that there's a strong angle in the shape of it. But if you look at the MRI, you see that it's at the joint level and not at the bone level. So this means a dislocation and not a bone fracture. And maybe this misunderstanding often comes from that also doctors think that the coccyx is one bone, which is not, although it's called tailbone, it's actually tailbones. But it's not always diagnosed correctly. And if you have any imagery of your tailbone problems and they diagnose a fracture, see if there's the bone is damaged or that there's a dislocation more at the joint, and that is not a fracture. On the other hand, there can be fractures, of course, but if there's an old fracture and often they consolidate after time, also here the mobilizations can be safely performed. And the majority of the patients, and that's in my database, 90% of the people I see have a chronic form of filbon pain. So if it's a year after the fracture, you can question if the fracture is still the problem. Also, the techniques that I at least used and most of my colleagues use are mild. And if there's an excessive pain, I'm not going to increase the pressure anymore. I'm going to stop. So because it's quite pain regulated, the chances that you can actually damage something or work on a present fracture and increase the problems are rare. So, yes, the presence of a fracture is definitely not a good plan to mobilize. But if the surrounding area became stiffened up, that can also be a reason for the problem. And if we mobilize them, maybe the solution is found. So the fourth one, repositioning does not lead to lasting position change. So we already talked about that one, right? Yes, this is understandable as the COCIX is relatively free in relation to the surrounding structures, and if you want to reposition it, but as I mentioned, in my view, we just give it the freedom to realign itself. So and that's a natural process and not something done by us, which can be undone when you start moving and functioning again. So the fifth objection is that some patients experience substantial exacerbation of cocidinia after undergoing a forceful manipulation. So this is literally quoted on how we stated it. So this is something I totally not recognize after the hundreds of patients I see. And I understand that in cases of high irritable pain, increase of symptoms may occur following a forceful manipulation, which most therapists don't use. It's more mild and gradual techniques. I personally, outside of sometimes a little bit more painful one or two days, never saw someone that actually got worse after such a therapy session. So it's definitely not structural and also it's rare. So I don't recognize what he describes here. The sixth objection is that manipulation clinicians often recommend that the procedure is repeated frequently, sometimes recommending a series of dozens of manipulation sessions. This is also something I don't recognize because mostly, as mentioned, there's only a few sessions needed and the results are quick. And I think if there's anything that needs repetition, it's the injections with the corticosteroids and not the thing that we do. So I don't know if this is a valid point. And the last point is that discomfort of internal mobilizations. And this objection, of course, applies to internal mobilizations and not to the external mobilizations which I do. And what I understood of my colleagues and also mentioned here in this podcast, these internal mobilizations are when the patient is relaxed, not that uncomfortable. And I think that what I saw firsthand that an injection into the tailbone is much more painful and much more uncomfortable than a mobilization. But again, I know an expert on the internal mobilization, so I just also have to go on what I see in here. So this is kind of the objections that are heard in a field which I think are not too valid, and that the techniques we use with the mobilizations are pretty safe. And this is based on what I see in practice every day again.

unknown 54:08

Dr.

SPEAKER_01 54:09

Foy also added that the studies that are out there show a lack of effectiveness, and here we refer to the studies of Dr. Meigne and his colleagues. So what I always ask my guest is: is there any scientific research done on the therapy that you use? And if the mobilizations are mentioned in the literature, mostly they refer to these studies done by Dr. Meigne. And this is the French doctor that invented the dynamic radiography and a true pioneer here on this subject. And he published more clinical studies than anybody so far on the subject. And with this, he contributed maybe more than anybody to the current knowledge and ideas about tailbone pain. And he also studied the effect of mobilization and published two studies about it, one in 2001 and one in 2006. And although they were set up professionally, both studies have a few shortcomings that are essential to the conclusions that are drawn from, in my opinion. And therefore the conclusions there are, in my view, questionable. The mobilizations Dr. Menye used were performed through stretch and massage of the muscles and mobilization of the joint in one direction. In my opinion, but also the empirical findings, and see for that also the episodes with the pelvic physios, and there's also research on this, both muscle and joint input have positive influence on the functioning of the tailbone. And what we learn as a manual therapist is that in the spine, mostly the muscle follows the joint. And what is meant with that is that there's primarily a joint dysfunction, and the muscle then has this protective reaction to it. So if you look at muscle problems, that's mostly a tear or a sprain. And this is what we see in hamstrings and in calves, for instance, with sport injuries. Well, I have in all my years as a physiotherapist never seen a sprain or a muscle tear in the muscles around the spine. So that goes for neck and lower back problems as well. I also never have seen a problem in the spine where the muscles were not tensed up and have a protective spasm. So the question is, is this the problem or is this the result, the reaction of the body? And for tailbone problems, the pelvic floor tenses up as a reaction to protect the injury. So I think it's very important to look at also the joint mobilizations. And in this research of Dr. Menye, the therapy on the joint was just a stretch in one direction, where me and my colleagues move it often in multiple directions. Next to that, it just was applied shortly and not clear if it was performed by an experienced person. And as he mentioned in one of his articles, experience is very important in tailbone treatments like injections and surgery, and that there's a learning curve, that the effects get better with experience. And I think the same applies to manual treatment. And this I also know from a personal experience. I regularly see people in my practice that had a similar treatment with the external mobilizations and also internal mobilizations with other therapists already, but that when I do it, it provides a satisfactory effect that previously didn't happen. And maybe it is in the experience where the difference is between success or not. And although there are several hundreds of physiotherapists in the Netherlands trained in this technique, there's only a few that are really experienced in this and see a lot of patients. So actually build up an expertise and experience in doing this. And that this is a skill that needs to be trained. I also saw when I showed this technique for tailbone mobilizations to a very experienced manual therapist I know. And this colleague found it really hard to feel what was going on locally, although she had over 20 years of experience as a physiotherapist, and I know she's a good one. So you can imagine that in my case, my skills became much more precise and subtle over all the years of experience, and I think this is quite inevitable. So back to the studies of Dr. Menye. If we take a closer look to the studies, where mostly the opinion about the mobilizing techniques are based on, is that the treatment consisted of mobilizations of the joint and the muscles around it through an internal approach. And this was done in 2001 with 74 patients and in 2006 with 50 patients, which is for tailbone research quite an okay group size. And in both studies, the effect of the treatment was named low or moderate. And what they found was in 2001, as in 2006, that around 25% of the patients had a reduction of their problems for 60% or more. So it makes sense that it's not very supportive for the manual mobilizations. But if we have a closer look and my main beef, let's say it like that with these studies, is the treatment dose. This was very limited. In the 2001 study, the participants received three sessions of two times 30 seconds of treatment. So in total, three minutes of therapy. In the second study, the participants got three treatments of five minutes. So 15 minutes of therapy. So that means the results are based on just three to fifteen minutes of therapy, which is quite low. And I think in that perspective, 60% or more decrease of problems in 25% of people after such a minimal intervention is not that bad at all. Actually, I think it's quite impressive. Me and my colleagues mostly have sessions of half an hour. So this is equal to one session with us. And even more impressive, they did a long-term follow-up. And strikingly enough, the results of the 15 minutes of treatments in the 2006 study hardly diminished after six months. And after half a year, eight percent of the people had more than 90% decrease of their problems. As I mentioned, after 15 minutes of therapy. In the 2001 study, the effects did hardly decrease after two years, even. So three minutes of therapy gave effects like 60% or more reduction of the problems for 25.7% of the people, and after two years, still 24.3% reported to have that same improvement, which indicated that the therapy has a durable effect. And this is in line what I find in my database, but also the colleagues I interviewed in this podcast report, and also Michael Dertnall stated that most patients remain very well, and there's only a small number of patients returning with a new episode of tailbone pain. And of course, these reports are all based on empirical experience and not on publications in the literature, but I think it gives an indication. So it depends on how you look at these studies, on how you interpret the effect of these mobilizations. And if you just look at the outcome after a very limited form of therapy where it's not really sure how experienced the one that applied it is, then you could conclude that manual mobilizations are not that very effective. But if you take a different look and see that there's this long-term effect after a minimal dose of mobilization, then I think you can also very easily interpret it as a very effective method. And unfortunately, there's no follow-up research with a bigger dose of therapy. And if you do a bigger dose of therapy, like me and my colleagues do, you might scientifically find evidence that the therapy is very effective. And what I see in my database is that of around 125 patients I studied so far which completed the treatment and gave their informed consent to use the data for scientific research, around 80% is fully problem free. Around 10% is better, but not fully problem-free, but mostly have a more than 50% decrease of their problems. And around 10% of people I couldn't help but didn't get worse after the treatment. I think this therapy is pretty promising. And what I found is that the people that became fully problem-free got there on an average of four and a half sessions. So that means good and quick results. So I hope to get this data published soon. And currently I'm writing the first draft of this article. So as you might have noticed, I'm clearly very enthusiastic about the therapy with mobilizations. And in this episode, I don't just want to tell you that this is the case, I also want to give you a deeper understanding why that is the case. As well as for maybe colleagues or doctors that are listening, as well as people that are suffering from tailbone problems. I want to understand their problems better. And I also want to back it up a little bit by science, and this is why I dove a little bit deeper into this. And I'm so enthusiastic about it because I see how it helps so many people, and how happy and grateful they are is the main fuel for all the work I put into spreading this message. Again, it feels like my mission to spread this message out there that this therapy exists. And it's not because of any quest for fame, because I think I'm in the wrong industry for that. And as a visual, I got more work than I can handle already. I also think the real heroes here are the ones that invented these techniques and made it available, like Meine Veldmann, which I'm very grateful for. But also people like Michael Durdnall that did the efforts to research it and spread the message. I feel that I stand on their shoulders and want to take it from here where they left off and make the next step to make this therapy accessible for as many people as possible. In my view, it should be the first thing offered to patients with tailbone problems. Not because it's the only therapy that works, and the currently first consulted healthcare professionals, the doctors, are not helping people. It is because I think there's a lot to be looked at first and connected to an underlying cause before we're going to treat the symptoms or remove the painful structure through surgery. And I hear and read from doctors that often the people they see went through it all before they come to them, but I doubt that a specialized physiotherapy was part of this trajectory in most of the cases. In my practice, I often see people that had injections already, and even people that are up for surgery and that decide to consult me and tell me they haven't had any specialized therapy yet. And there's a clear difference between having visited a physio, osteopath, chiropractor, or other manual working therapist, and even in most cases a pelvic therapist or pelvic physiotherapist, and that the tailbone was treated, or visiting a specialist on tailbone pain. The medical approach is super valuable, but I think as a plan B where therapy cannot solve it. And I think when the specialized therapist is consulted first, a lot of workload can be taken away from the doctors and hospitals with an approach that is very low threshold, a lot cheaper, and is less invasive and has less side effects than the medical interventions. A lot of benefits that are now lost, but therapy is at least empirically showing at least as effective as surgery and much more effective and with more durable effects than injections. Although I fully understand that only after scientific validations can these effects can be verified. But the question is, do we have to wait for that though? The results are seen and reported by many different healthcare professionals and also reported for many centuries already. And I hope we can change the approach worldwide. What is important for that is that the therapists are also educated in this specific field of examining and treating tailbone problems. And there's a lack of that. And also here I like to contribute to the field by teaching these skills to other healthcare professionals as well. And I'm finishing now a course to train doctors, colleagues physios, and other manual working therapists like pelvic physios, osteopaths, and chiropractors on how to diagnose, understand, examine, and treat tailbone problems. And in a few days of training, it is very possible to learn this if you're already a trained healthcare professional or a doctor. And in this way, I hope to help to spread this therapy also internationally. And this is the external technique Meinel Feldman discovered and where he personally gave me his blessing of passing it on. And again, I'm standing on the shoulders of these teachers, but also the several extra manual techniques to work with the tailbone that I myself developed and which I work with on a daily basis, and to me have proven their effectiveness in clinical practice. And unfortunately, these manual external techniques are not very available outside of the Netherlands, where they're kind of invented. So I hope to bring them there as well. And in this course, I also incorporate the more holistic approach on how to address tailbone problems, and we'll talk a little bit more about that later in this episode. So, if you are or you know a therapist that would like to help me organize a course wherever in the world, let me know and let's see what we can do. So, for the listeners that are suffering from tailbone pain and are looking for a specialized therapist, I can imagine it's not available close to most homes in the world. What often is available is a pelvic therapist that does internal treatments of the pelvis. This can be a specialized physiotherapist but also an osteopath. And where they also don't have knowledge or training in tailbone pain mostly, they know how to work in the area. And what I often advise people abroad in online consultations is to find one of these therapists and ask if they're willing to mobilize the tailbone. And depending on their openness and how comfortable they are with trying a technique that they're not trained in, it isn't too hard to perform. It comes down to grabbing and moving the tailbone. And the easiest is with one finger, the index or the middle finger, into the rectum and taking the tailbone in between that finger and the thumb on the outside, and then moving it forward and backward and maybe also sidewards. And the aim is loosening up the tailbone. And this should be performed gently and without too much pain. As I learned from my colleagues, the internal palpations are mostly not painful if the therapist is skilled and the patient relaxed, and that the therapist can find a place to hold on to the bone that is not too painful on touch, and then gently move and mobilize for a few minutes, and again always respecting pain. If there's a fracture or anything that is not okay, it will hurt. And if the treatment is done gently and pain-free, harm is not easily to be done. For the rest, this can be supported mainly by relaxing the muscles around it. Directly if the therapist is skilled through massage or maybe trigger points or dry kneeling, or more indirect through exercises. And these you can actually also find on my website as well under exercises. And the link for this you can find in the show notes of this episode. You can even let your therapist listen to this session or share the whole episode. And maybe even he or she wants to see if we can plan a training for a group of therapists in their area. I'm more than happy to come over and spread the techniques that I have learned and developed. Also, this will not be a financial big m business model for me, I'm afraid, but it does help to get better care for patients as far as my message can reach. And that is the bigger goal here. So this practical advice I just gave already helped a patient in South America that consulted me. And this person went to an osteopath that did the internal mobilizations, and already after the first treatment there was a massive effect, and the pain was gone for five days. So I hope this advice can also help you if you're not close to a specialized therapist. So after this elaborate story about mobilizations and how it is that they work and why they work, I want to go back to the questions and the more practical info for people that are looking into treatment to manual memorizations of the tailbone. So, how does it work and what is it that the therapist actually does? So people make an appointment, and before the intake, I personally sent them a questionnaire to get an idea of the problems and circumstances for healing. So this intake form is pretty elaborate and also asks about the levels of stress and sensitization of the nervous system. And this is where the holistic part starts already. Sometimes people think I want to see if the problems are caused by mental issues or stress, but for me, it's mainly very important to see how the circumstances for healing are. The more out of balance the system is as a whole, the amount of healing capacity will be reduced. Also at the intake, I ask a lot of questions, and partly this is gathering info for the research I'm doing, but mainly to get an as clear as possible idea about the problem. And the intake I sometimes also do online if people live far away. And then of course I don't have the info from the examination and can't treat, but it gives an indication and saves time with the first visit. And I can already explain and advise people, which of course also can be interesting for people living abroad. If there are scans or x-rays available, as mentioned, I ask people to bring the images to see them myself for clues. And although I'm not trained in reading imagery, as mentioned, often things are not seen because the people that interpret them are not thoroughly trained in tailbone problems and just focus on fractures, tumors, and luxations. And again, these luxations in the joint are even often framed as fractures, although the bones are intact. And this is something you can actually see yourself when you look at imagery. And here the patient often is shocked to see that the tailbone is not even on the image, like we talked about in previous episodes, where they went in with tailbone pain, images are made, the report says there's nothing special to be seen for the tailbone, and the tailbone is not even on it. So it's kind of correct, but in a different way than we expected. And although doctors and also patients often think it's important, also out of desperation that it might show what is actually wrong, I myself never ask people to do any imagery. Except when I think there's maybe something really wrong, like a recent fracture or a tumor or a bone infection. This is because the amount of info on this imagery is often minimal and it doesn't change the treatment approach. Recently a patient wrote me that since she found my website, she finally had the chance to see orthopedic specialists, one in the Netherlands and one from her home country. And now we finally she had the two-row test reports and treatment plans. And although she mentioned none of them recommended physiotherapy, by the way, she would like to come in for treatment. And this patient unfortunately lost a lot of time and probably money. Of course, it's important to rule out serious things like the fractures and tumors and cysts and bone infections. But also here, often we don't need the imagery for that because they're accompanied with different issues as well that can be filtered out in the intake. Think of things like fever, sweating at night, which is not related to the temperature, unexplainable weight loss, pain that is not changing with posture or movement, and pain during the night. All these things indicate that there might be more than just a mechanical problem. And for fractures, they can be seen, but in chronic pain, they're often not a problem because it's so long after the fracture that the bone kind of healed already, but the pain persisted. And it definitely can be that there's a mechanical underlying factor. What I read in the literature is that in 95% of cases the body heals the broken bone itself. And if the problems continue, it is questionable if it comes from the bones or the change biomechanics. And also for a fracture, there should be indications too, like a trauma as an onset. If the pain came not after a strong mechanical impact or started days or weeks after that, a fracture is very, very unlikely. Same goes for pain that starts after an impact, but disappears again after two weeks and then comes back. That doesn't really make sense if you really think about it. It's very important to use common sense. I recently saw a patient that fell and was sent in for an x-ray. There they saw something that looked like a fracture, according to the hospital report. And she understood from her general practitioner that the bone didn't heal and attached in a good way. When I asked her about what happened, she said she fell down on her side and then her belly. So there wasn't any impact on her tailbone. And that she had these tailbone problems before. If there's no impact on your tailbone, you cannot break this bone. She was pretty upset because she got the idea nothing could be done about her problem because there's not much to be done to a broken bone that didn't heal in the right way. So she was pretty desperate when she said before me. When I explained her that the report said there was a suspect of a fracture, but I didn't really see one. And I gave her the explanations which I just gave you, she was already reassured. And she's still in therapy, but after a few treatments, the problems are already a lot better. And this brings us to another possible issue with imagery: the restlessness after false positives and anatomical findings that don't match with the expected norm. A false positive is something that you see on imagery, but is not related to the problem. I think a nice example of that is that when a lady of 80 years old comes to the doctor and says she has back pain for the last six weeks and didn't have it before, x-rays are taken and the doctor says, Yes, I see degeneration or arthrosis in your lower back joints. Yes, that makes sense. She's 80 years old, and that's probably there for longer than the six weeks that she had the problems. So we must question if that's the cause of the problem. Also, with herniated disks in the lower back, we know from scientific research that they don't always give problems, and a lot of people without pain in the backs have seriously herniated disks in the lower back. So there's not a one-on-one, and it can be a false positive, what they call it, what we see on imagery. I also mentioned anatomical findings that don't match with an expected norm. Anatomy-wise, there's a wide variation to the tailbone. And there's complete consensus about that among researchers. So things in the anatomy of the bone and the positions of the tailbone can be widely different between people. Also, changes there can be secondary, like a more forward bent or flexed tailbone because of the pull of a tensed pelvic floor that is present with almost every chronic tailbone pain. And as mentioned, even dislocations during sitting can be not a problem when a segment above or in the area is less mobile, and it often corrects itself when this is solved. I very often see patients that have some abnormalities found and seen on imagery when the problems dissolve, and probably if the imagery was done again, the same things would be visible. I think it's good to take into account what imagery does and doesn't say, and that patients are explained this. I was talking to a doctor recently and he shared that he sometimes sends people in for x-rays, in this case for lower back issues, so he could point out to something and use that as a stimulation for the person to go and do exercises. And I understand the idea, but next to the cost and radiation exposure, I think it might have some side effects as restlessness in patients and do they really recover if they're convinced that there's something wrong there? And in these cases, imagery brings more restlessness to the table than clarity and benefit. So I am pretty reluctant in going for imagery, except of course when there's indications for serious underlying problems in the intake. And then also especially for static images. As mentioned, there seems to be consensus that most problems are biomechanical when it comes to tailbone pain. And then it makes sense that the biomechanics should be made visible with imagery. So if done, I would go for the dynamic radiography like developed by Dr. Menya. But I hear it's often difficult because radiologists have a hard time to do that. And finally, also experts often don't rely on imagery. At least two of the future guests you will hear declare that it often doesn't bring them any valid information. So let's go back to the intake. So after the questions, I explain what my thoughts are after the information I received from the patient and how tailbone pain is often related to biomechanical dysfunction. Then I move on to the physical examination of the tailbone. I always test how tolerable the tailbone is for loading and then how the tailbone is positioned and moves. Also, I want to locate the exact pain spot at the tailbone. Although the tailbone is often tender when touched, the examination is mostly pain-free because the palpations that have techniques are mild. And patients often mention that they actually like that the tailbone is touched, and the right spot, the spot of pain is given attention because a lot of times previous doctors and therapists didn't and didn't even touch the spot where it hurt so much. So where it definitely can be a little bit tender or sensitive. I always try to approach this in a non-painful way because I don't want to irritate the problem any more than necessary. And it's also mostly not needed to do that. So after the intake and the examinations, finally, at the end of first sessions, I mostly also have time to treat. And as with the examination, this happens with the clothes on and from externally in my practice. And this is mostly in sitting, and here I try to give more mobility and freedom to the tailbone area. And also, this is mostly experienced as fully pain-free. And this is not the same with all therapists, because some therapists opt for the effect of the mobilization over pain-dealing treatment. So they rather have this mechanical impact where they reposition the tailbone, if that's of course a theory, and that is a little bit painful, rather than have a more mild approach or a mild technique applied. So this is a personal choice, and I always choose rather mild techniques so that the healing and relaxation is not affected by it. And I think it's very important to understand that in relaxation, it is where the healing process of the body finds place. This is where we adjust and develop. That's for instance why babies sleep so much, because this is the time that they grow. Same as that your muscles grow not in a gym, but outside of your training session. In the gym, you trigger this process by dysregulating your system, but the increase in fitness and muscle volume happens when you rest. And also here, and in how I approach it, it is not about relocation, but in giving the body freedom so the tailbone can relocate itself. Mullen pavil techniques are sufficient and the patient can stay in this painless and relaxed mode. And this relaxation is something that I like to embed in the whole treatment. If the patient feels safe and relaxed, this directly triggers the healing mode. So I hope this gives you a little bit of an impression how such a first intake and first session is, at least with me. And also with me, I only treat people through the external technique. I'm not trained in the internal technique, and as mentioned in previous episodes, the teachers of both courses in the Netherlands for treating tailbone pain, and they both give external techniques, and that's Cecile in episode 2, and Siska Lohohoff, who developed the Nemoc method, they both mention that although they also learnt the internal mobilization by the rectal approach, they always choose the external technique because in their experience it is as effective. And I think there's nothing wrong with the internal approach, and it can have benefits like the ability to mobilize towards extension, so backwards, because you can touch the tailbone from the front side. It also has downsides because it's more invasive, and this can be an issue for a lot of people, especially if they have a history of abuse, and in my case, being a man where most patients are women. People I think are much more relaxed with the external approach, and relaxation in the area is essential for releasing the tailbone and healing. And this is also why I almost always treat with close on. And my pulpation skills are that developed three years that I can also feel the tailbone through those layers. So, following to this, I always ask my guest in these podcast episodes on what kind of scientific research is done on the therapy they perform. So I already addressed that earlier in this episode. And where the research is lacking for manual mobilizations or the research done, like the studies by Dr. Menye, are in my eyes maybe not interpreted optimally, there's also not a lot of research done for any form of therapy about the tailbone. And although the injections and surgical removal are a bit better researched, they still lack high-quality studies. And for injections, there's not even a real consensus for the spot technique or dose of the injection. And in general, the data we have on tailbone pain is low. And even prevalence data, so how often it occurs under the population, is unknown. And the attention of the scientific world for this niche market seems to be almost absent. And then again, especially for the therapeutic approaches, because we mostly don't work in institutions and hospitals, so often have less access to funding and support on the science part of it, and that is where a lot of us are not trained in. And although real high-quality research is lacking, the mobilization of the tailbone is the oldest mentioned therapy in the scriptures, and that dates already from the 7th century onwards. And through the centuries, doctors and later therapists reported good results of the internal mobilization method, but always in case studies of small groups. And these reports of doctors treating tailbone pain with mobilizations stopped appearing around 60 years ago, and this is when the injections with corticosteroids became the new fashion and tailbone pain became a medical procedure. It seems kind of like what happened with breathing problems like asthma or bronchitis. Before there were pretty effective therapies through exercises, but when pharma entered the stage, this took over, and even less effective treatments of medicine compared to the previous therapies became the norm. So around 60 years ago, it became silent in the literature for mobilizations until just after the turn of the century, and Dr. Menye there published the before-mentioned articles. And probably because next to most recent, they were the first that actually matched the standards of modern science and used bigger groups with the 50 and 74 patients, they're the two most cited ones. And although the reports were not too positive, in my eyes, they show actually excellent and durable results after a minimal dose of mobilizations. And these reports looked at the internal mobilizations. For the external mobilizations that I use, there's still no studies available, outside a few theses of master's students. And out of the six, four were on my database in 2025. And they all showed good results of the external therapy. So not too long before that, I came to the conclusion that the scientific research was necessary to actually get the attention for this method. And also that probably I was one of the few to be able to do that because I see the patients. And to my knowledge, there are not a lot of colleagues that see so many patients with tailbone pain in a year as I do. And where I did want to contribute with that, I had no idea how, because scientific research is not my cup of tea, nor actually had my interest. Where I am nerd enough to collect data and make a good database and have enough knowledge about the topic to do the clinical reasoning about the findings, I had no training whatsoever in doing scientific research. And just like most figures, I also didn't have the funding and expertise backup from an institute like a hospital. And here, life stepped in and helped me out, which seemed to be the case in my whole tailbone journey. As mentioned in episode one, I got in one week two messages of friends that separately from each other talked about this tailbone treatment that immensely helped them. And it led to a strong interest that I cannot really explain because it was a brand new subject for me, and I never had a strong attraction to a subject like this. It also made me start making a web page when I learned the technique to treat it from Meinu Veldmann, and I started to make a database for the people I treated, both which just came to me as something I wanted to do but never did before, and I still don't know why. Just like I woke up with the idea of wanting to make a podcast about Tilbone Pain and writing this huge article that I knew was unpublishable and didn't understand across for it. I just followed what I felt was good and needed. And afterwards, this web page led to a flow of patients and is the basis for my current website and platform. And the big article was the reason why I was invented as a speaker for the World Congress on Tilbone Pain this year in Turkey. So I believe strongly in that life opens doors for your personal path and that there's an inner voice that tells you to take it. Even or maybe especially if it doesn't make sense. So I try to take it if the urge feels so strong. And this made a lot of things moving in this area for me. This podcast is still fresh and I don't know what it brings, although I already see that it's helping people all over the world, and I'm super happy with that. And it doesn't have to be a clear visible result, of course. Also, now it fully makes sense why I made this database, of course. The moment that I thought about I maybe needed to do research and contained already over 200 patients. And also for starting scientific research, life stepped in again, and literally the first working day after I thought I needed to start with it, but not knowing how, I got a new patient with tilbone pain that was a university professor for health sciences at the Vue University in Amsterdam. And he helped students doing research. And even before I mentioned anything about my thoughts doing research, he already offered his help and said that if I ever needed help with research, he was more than happy to help me with that. So I told him I kind of did, and he enthusiastically arranged internships. And four months later, there were four students, health scientists, that had a three-month internship that analyzed my database and they wrote their end theses about it. And their students didn't only do that, they also taught me a lot about doing research in a scientific way and helped me to set a good basis for scientific information gathering. They professionalized the database significantly, and I started a new database next to the one I already had, and that now contains over 100 patients and is still growing in a rate of 100 plus new patients a year. This now, together with the results of the first data phase of around 250 people, forms the basis of the articles I'm currently writing. And also here, the right people came at the right time on my path to help me with the scientific parts that I'm not trained in. And with this data from these databases, we can get an idea of the achieved results of the therapy, which is mainly built around mobilizations of the tailbone area. And as mentioned, the results seem pretty good. And I can help over 90% of the people that can stop me. And again, often the worst case scenarios. Through this research project with the interns, I also started to collect data on the durability of the effects of the treatment. So I started to do follow-up, and I want to do that up to three years. The data collection here is slowly growing, but I have around 60 people that reply to my request to update after a year after the last session, and almost all had no fallback. Also, the recurrence of tailbone pain, meaning the people that visit me for a new episode of tailbone pain, is low. It's under 5% and mostly after a new incident, like giving birth or falling down. And again, I'm not the only one experienced these things. And it's fully in line with what my colleague therapist said here on the podcast already, and people like Michael Dertnall expressed. And where the treatments are mostly painless, I also already answered if the treatments are uncomfortable or painful or not. And during the treatment, but also after the treatment, people hardly ever report pain. And in the rare cases where they do have some extra pain afterwards, it recovers quickly. Also, so far, none of the patients I treated pain became worse because of the treatments. In the worst case scenario, we ended up at the Same amount of pain that they had originally when they came in with. Only one person, Lisa, that will be a guest on this podcast in a future episode, actually became worse during the trajectory that I saw her. But that was the development of the problem itself, though, and not due to the treatments, which almost always brought a relief, although just temporary. And the mild approach also has a benefit that there are no real contraindications for this treatment. If there's a problem that shows pain at the tailbone and is mechanically changing by pressure and mainly provoked by sitting or pushing on it, for me that's an indication to treat with mobilizations. And of course, if someone has actually a tailbone, of course. Because once I had a patient that came in after a surgical removal years before that, I wanted to have a check. And I kind of told her there's nothing to check for me anymore, of course, because it's kind of like going to a knee specialist. Well, you have an amputation at your upper leg. And of course, if there's red flags we don't treat, and tumors and bone infections and those kind of things, of course, should be treated elsewhere. But even then, treatment doesn't do any harm. But of course, it's not effective. Also during pregnancy, it's no problem to treat. Actually, it can help very well there to resolve the problems and have a good functioning tailbone, it's beneficial to the birthing process. If it can sufficiently move backwards, it doesn't widen the bird canal optimally. And that can be very painful for the tailbone with the amount of pressure that is put upon it during the passing of the baby. And of course, you want the baby also to have the optimal amount of space during the process. And where pregnancy is for the medical procedures and even imagery a reason not to examine or treat, for mobilizations, this is not the case. Also, other factors that make physicians reluctant to treat, like an oversensitized nervous system, which has a negative influence on the outcome of, for instance, surgery, is no problem for manual mobilizations. Of course, also we expect the recovery to take a little bit longer, but the results show that also these cases mostly have a good recovery. Then are there advices I give during the treatment directory? The first one is general, and I give to all my patients. Respect pain. It's the body's alarm system, and it tells you clearly where the boundaries are and what the injured area is capable of handling. And this is something to respect in order to have the ideal circumstances for healing. So don't push yourself beyond these limits. This is one of the reasons why I'm not a big fan of pain medication either, because it blurts your perception of where these limits are. And when there's a disbalance somewhere, it is so important to be closely in touch with what your body communicates to you and not to numb it like we do with painkillers when we're in pain, coffee when we are tired, alcohol and cigarettes to calm us down, and things like sugar, bad food, and entertainment to screens when we don't feel happy. And then there's also the side effects of medication, which are often told are harmless. But in the end, it's always chemistry that your body has to deal with. And if this changes one factor, it has inevitably implications for other processes in the body too. So if not necessary, there are multiple good reasons not to use medication, especially before any strenuous activities, like events where you have to sit for a long time. If you use them to have a better night of sleep or rest, that is of course understandable because too much pain and chronic pain can also have negative side effects, as well as more muscle tension and pelvic floor, where there's a direct increased pull on the sensitive tailbone. But if you use medication before doing something strenuous, where you need to be in touch with your body even more to clearly know where the boundaries are, this is not a good idea to take medication first, because you're much easier to overdo yourself and overstrain yourself. A better option to help you through periods of longer sitting is a tailbone pillow. And these I do advise in some cases, but often it's not necessary because the treatment is effective quickly and they're not needed. Tailbone pillows, as well as special saddles on bikes and sometimes even chairs, they have a hole at the back where the tailbone is. So the pressure is taken off there. In a lot of online recommendations, and especially also medical literature and guidelines, I see that ring-shaped, so-called donut pillows are advised. And I think that advice is questionable because they often increase pressure on the tailbone because the tailbone area kind of sinks into the hole in the middle. I would recommend you to look for a special tailbone pillow, and there are several different options in firmness and in shape. Like you have more wet-shaped ones that are high in the back part, so it helps you to sit up more straight. To get an idea about tailbone pillows, I recorded a video about the ones that I have in the practice, so people can try them out if they're interested. And in this video, I show the pillows and talk about their specific features and qualities. You can find the video on my Instagram canal and website, and you have to look there for the Dutch part of the website under info and videos. And the video is in Dutch. If you don't master our language over here, you can still clearly see what the options are. Another option is the use of a flat folded towel for underneath the sitting boards, which raises the pelvis from the surface below, and the compression on the tailbone is less likely to happen. And I always advise to do this with a lumber support as well, so the tailbone is also moved towards a less pressure area because your back is more hollow. And if you want to learn about that, I describe this process with pictures clearly on my website under tips. Also on my website, I have some exercises that can help you reduce the tension of the pelvic floor and the body in general. And you can find it in the menu under exercises, which kind of makes sense. And there's even an audio that guides you to a complete relaxation exercise. And these tips and exercise pages are also available in English. When it comes to exercises, one of my favorite exercises nowadays came from my guest in the last episode, and that is the deep squat sitting. I am practicing it myself now a lot too, and my patients love it so far. And check that episode or the connected web page where it's further explained. I also describe it more elaborately on my website and mainly add the importance of really being relaxed in this pose. So no hoovering above your heels where there's tension in your buttocks and/or your pelvic floor, and make sure that you get into a relaxed pose by putting something underneath your heels or holding on to something where you can lean back a little bit and really relax into this deep squat sitting. Without tailbone pain, it might be okay to do it in a less relaxed way, but with tailbone pain, it's very important that the pelvic floor is relaxed and the pose is not straining because of the muscle activity. Also, a good way to make sure it has optimal mobility and relaxation benefits is to breathe downwards towards the pelvic floor and in that way expanding the bottom of the pelvis in all directions. And if you want to read more about it, visit my website and you will find it under exercises. And when it comes to exercises, I normally often don't give them because, especially the first treatments, I want to see what the treatments do and not blur the effects of that with possible effects of the exercises. And also most of the exercises are not even needed because there's a quick improvement. And I think there are not a lot of exercises that actually affect the tailbone itself and more just the surrounding structures. Although they, of course, can benefit in creating the circumstances for healing and optimal functioning. If you look online for exercises for tailbone pain, you can find a great deal of offer. Because most exercises in my eyes are not effective at all. And I couldn't even explain how they're effective. They often are aimed at stretching the glutes, and it's good to pay attention there because they attach directly to the tailbone itself. So too much stretch can be painful. And also there's a lot of exercises around that stretch the other more superficial and not tailbone affecting muscles and approach more the pelvis and the lower back. And this mostly feels nice while doing them, but in the end it has no effects on the area of the tailbone itself, although that is what is often mentioned by also, I think, well-intended trainers and therapists. The second sort of exercises mentioned are strengthening exercises of the core. Also, in my eyes, completely ineffective for tailbone pain. Because the pain here is rarely related to reduced core stability or the lack of strength. Just think about it. If that would be the case, the problems would present themselves during activities where you need strength. And not in the rest situations like sitting, where almost all patients with tailbone pains have the most trouble. The exercises where you're asked to engage the glutes and pelvic floor, and that I also often see are more likely to increase tailbone pain than reduce it because of the direct pull on the injured joints of the tailbone. If you do strengthening exercises at all, try to keep the pelvic floor as relaxed as possible if you have tailbone pain. The videos that are recorded for exercises, especially for tailbone pain, are probably done with the best intentions, but often without a lot of experience and not getting to the core of the problem, which is hard to do through exercises. Although there are good exercises, of course, like the squat sitting that Sahari mentioned in the last episode, and the ones for the pelvic floor that the pelvic physiotherapist mentioned. And the peacock exercise that Cecile mentioned in episode two. They create circumstances for healing. But again, the question is: do they directly affect the tailbone itself? And are they separately capable of helping you with your tailbone problems? Then there are exercises that are simply, yeah, just to say terrible. The one topping this is of a therapist that advises to sit on a semi-hard ball at the tailbone and roll over it. If you ever saw a tailbone patient, I think you know that this is the worst idea ever. And I think I understand he wanted to massage the area around it, but pressure on the tailbone is the last thing you want if you're a tailbone patient. And it will most likely just irritate the area much more. The same as the stretching exercises I see in the videos for patients with tailbone pain where they actually are sitting straight on the tailbone. Sorry, but it is the last thing you would want to do in advice. So, what you heard me do if you listen to previous episodes of this podcast with my colleague therapist, I always ask them if they have a specific exercise they want to share with the listeners that can help them with tailbone pain. And all these exercises so far were great. And again, will support healing and are mainly aimed on relaxation of the area around the tailbone. And of course, I also want to provide you with one today. There's a lot of exercises you can find on my website. And what I want to add to the exercises we're already given is an exercise which aims less for the mechanical aspect of tailbone pain and approaches tailbone pain and healing from a wider perspective. And if you'd like to experience this, just follow me here and I will talk you through this. So, first let's start with the position to start in. If you're pretty comfortable sitting or you're sitting on a tailbone pillow, that's fine, but it shouldn't hurt. And if the sitting is too uncomfortable or uncomfortable in any way, it's better to do this exercise in sideline. So I would advise you to lie down on your side, doesn't matter which side it is. And in this sideline, try to bend your hips a little bit so you're lying in a stable position. And if you're comfortable where you are at the moment, then I want you to bring your hand towards your tailbone and touch the painful area. And when you do that, I want to ask you to become aware of how you're touching your tailbone area. This often gives some insight in how you approach your problem and also how this influences recovery. Often we have resistance to or are even fighting with the part of our body that gives us so much pain and restrictions. And your touch of that area can be an indication of that. So just examine how you are touching your tailbone.

SPEAKER_00 1:39:48

Is this firm and more mechanically? Or is this soft and warm? Do you touch a thing or do you touch a part of yourself?

SPEAKER_01 1:40:11

And while touching, realize that you and your body, and specifically here the tailbone area, have the same goal.

SPEAKER_00 1:40:22

That is functioning without any problems and doing anything you want in life.

SPEAKER_01 1:40:29

But with an injury, your body is not capable of doing that. And it asks your help for some rest and circumstances to heal and to recover. Through touching this area and bringing awareness to it, can you recognize this question of your body?

SPEAKER_00 1:40:57

This question related to this injury. And sometimes, even if you touch it, you can notice a deeper message that is underneath the problems. Sometimes there's a certain emotion or feeling that surfaces on inside why you're not capable to relax and sit on one place anymore. Why you're not able to bring your attention from your busy heads into your body to sink into your body away from the activity and the control of what your head is often trying to achieve?

SPEAKER_01 1:41:52

Anyway, your touch approach the area as something that is asking for your help instead of something that is restricting you.

SPEAKER_00 1:42:05

Can you approach it with compassion? With your attention, with understanding.

SPEAKER_01 1:42:24

Maybe even in a comforting or soothing way.

SPEAKER_00 1:42:33

Bringing your attention somewhere is a healing thing in itself. Because where attention goes, energy flows.

SPEAKER_01 1:42:54

See now if you can breathe towards your hands. And not only touch the area physically from the outside with your hands, but also on the inside with your breathing. So breathe towards your tailbone and that way connect with it. And then you breathe out again. Just repeat this for a few times. Maybe you notice that it's not easy to do and not even easy to connect with it when touching it. And if you're not in touch with this area, chances are big that the healing is limited in a way.

SPEAKER_00 1:44:05

And through your breathing, you can also bring something extra to the area of the tammone or the injury.

SPEAKER_01 1:44:14

And this is what makes sense to you.

SPEAKER_00 1:44:16

You can imagine that when you breathe in, you bring good nutrition there, healing, attention, light, good vibes, love, and other energy. Whatever rocks you about and works for you. As long as it resonates with you with every inhale, you bring down any form of positivity that will support the body, that will support healing. And with every exhale, you just relax and you let it sink in.

SPEAKER_01 1:45:00

With every inhale, you kind of feed it. Try to help support your tailbone area. The area of pain of injury.

SPEAKER_00 1:45:08

In a loving way, understanding way. With every exhale, you relax your tailbone area, you kind of uncurl your tailbone. You might even release all the extra tension that is there with your exhale. So that everything you don't need anymore there can leave the area on your exhale. Just experiment with it.

SPEAKER_01 1:45:42

It can be kind of abstract for people to feel and to work with it like that, but or maybe it directly resonates with you. Just play with it, and the harder it is at the start, the more you can gain. It's so important to connect and stay in touch with the area where the problems are. This area that is trying to reach out to you through signals of pain and discomfort. Asking for attention, asking for help, asking for the right circumstances to recover. And often it is hard to see it like that. And not wanting to fight the area which is limiting you so much and giving you so much discomfort.

SPEAKER_00 1:46:38

So you can continue this exercise as long as you want.

SPEAKER_01 1:46:43

And you can pause the audio. Got the idea. It was sufficient for you, or maybe it is not completely not your exercise, that's also possible. And it doesn't resonate, that's also fine, of course. And I hope at least it was useful and it also shows you a different aspect of working with Tilburn problems and health problems in general. Just be in touch with your body, listen to what it wants, listen to what it needs. And just really pay attention to that and not go into the automatic avoidance that we have to any unpleasant sensation. And if you like this exercise and it was useful for you, I will make a separate audio file of this part of the episode. And I'll post it on the webpage connected to this episode. And the link to that you can find in the show notes. So I hope this was also a nice break in this quite lengthy episode. Because, like I started, I really want to inform you, but also leave you inspired and helped in this episode. And there's a few last questions that I asked my guests, and I don't want to withhold the answers I have for you on them. So the last little bit of this podcast episode, I want to go into those. And one question here is what do you do when after your therapy the patient is not better or not fully problem-free? Is there anybody you refer to if you can't manage to solve the problem sufficiently? Well, as mentioned in the last episode, Sari is the one I like to refer to. And this is because she does different things than I do, and that what she does is very complementary. If I would send her to a therapist that does kind of the same things that I do, the chances of them finding the solution are less. So I like to look for someone that does actually the most different things than what I do. And what Sari does is very complementary. And actually, some people ask me because of this episode if this means that Sari is able to do more for tailbone problems than I can. And I don't know if that's true because our treatment results in the end are the same, and we both are often the last resort for people after a lot of other therapists and doctors. And where there's definitely things she can do that I can't, it is probably also the other way around as well. And I think if you listen to the other episodes, all of my guests have special skills that I don't have and do things that I don't do. But on the other hand, my techniques and approaches offer something that my colleagues often can't do. So we're more compatible than that one approach is the best for every patient. And again, all of the guests have similar results. And around 80 to 90% of all the people that visit us, we can help. And all of us have specific knowledge, skills, and experience. So and that also determines where I send people if I cannot help them. So all the guests explain what their specific skills are. And if there's a dysfunction with the pelvic floor musculature that prevents the body from healing, and that I cannot solve with the skills and techniques I have for that, I refer the patient to one of the pelvic fissures that have a specialty in tilbone pain. And as you heard, two of them I already interviewed in this podcast series. And I also do that if I think the internal approach would be useful in this case. And I can also send them to my pelvic therapy colleagues and also to Sadi. Also, I often take into account where the people live, so how close they are to my colleagues. And finally, of course, where I expect that a biomechanical approach isn't going to be the solution for their problems and they need medical care, I give them a different advice. And then I like to refer them to the Proctor's Clinic here in the Netherlands. And my go-to there is Grietje van der Meijnsbrugge. And she's a very skillful doctor that will be a guest in a future episode of this podcast series. But the good news, mostly this referral is not needed because the problems get solved through the treatment I can offer them. But of course, it's good to have a plan B and C for the people. So this is where I refer to. And although tailbone experts are rare, my network is growing and also partly because of this podcast. And of course, I also hope your network is growing by this and you know where to go. Because where doctors are very skillful and very helpful, most patients with tailbone problems are seen from the start till the end only by doctors. And just know that there are therapists out there or therapists have skills to treat tailbone pain as well, which is in a lot of cases very effective. So I also often ask my guests here how they see tailbone problems in a more holistic way. And holistic is a popular term nowadays, and it's used to market therapy often as well. And often people refer to holistic as not only looking at the physical part but also the psycho-emotional aspects. But that is, in my vision, a bit limited view. Holistic means whole, so body and mind, and that goes beyond physical and psychoemotional, but also contains the domains energetic and spiritual. And this is what is incorporated in the Eastern approach, but we Western healthcare professionals are not or hardly trained in, and especially not in contrast to our colleagues in the traditional Eastern medicine. In our Western approach, it's often either the physical or the psychoemotional that is looked at, and hardly ever both. And there's even a tendency if we cannot find it physically, then it must be psychoemotional. And people with not understood problems are sent to a psychologist or psychiatrist. And just realize, if you go to the GP and you present your problem, they're going to send you either on the physical part, so the therapist, like the physiotherapist, chiropractor, and so on, or the hospital, or they sent you to the psychologist or psychiatrist. And the two parts of healthcare, they never meet anymore. They're often even in different locations, and in a lot of cases, they're not a lot of contact between these two sites of healthcare. And of course, you have multidisciplinary teams that work on it, but in most cases, it's either or. But just realize that the influence of the non-physical, the non-mechanical aspect in Tilbone pain can be huge. And in some cases, I help people off their pain without even touching the tilbone. Because their story already gave me so many indications that it was not a mechanical problem. But they did have pain. So what I often tell people that as a physiotherapist, I'm a translator, I translated what their body was trying to tell them. And it's not always that there's mechanical loading or strain where it goes wrong. Your body can also tell you when there's non-physical things going on. So for instance, that your belly can hurt in certain circumstances, or you can actually perceive a broken heart or something in your throat that blocks you. Well, there's physically nothing there, and this is all triggered by a feeling or an emotion. And through my extra interest and training, I can often understand things from a wider perspective than just the mechanical. Also for tailbone pain. And it is in my eyes not a coincidence that the first chakra is exactly where the tailbone is. And the chakras are something that is pretty well known, of course, in the Eastern medicine. And this is such a big topic that I will record a full episode on this in the near future. And I also explain a lot about it on my website already. So you can take a peek there already if you're interested. And it's on the page of Tilbone Pin. And you can find that in the menu. And of course, also the exercise which I just shared with you. It's also looking at a little bit of a wider perspective than just the mechanical. And of course, I did it on purpose to add something extra. And maybe from that, or at least looking at what I write on my website about it, you'll probably find that my approach here is not ariferi, but pretty concrete. Spiritual means nothing more than connecting to your own essence. And this is very concrete in itself, although it can be brought very abstract, of course. And if we look at energy, it's something we all experience and work with. This is for a large part how we interact with the world and others. And we can all experience feeling a certain atmosphere, like being at a concert or festival, or being very comfortable or totally not feeling comfortable with someone you just met before you even talk to each other. We can all experience energy and it influences us all. And if people tell me that they don't believe in energy, this by the eye invisible force that influences us, I ask them if they don't believe in gravity. And energy is not only what Eastern philosophy indicates as an essential part of who we are and healing, also hardcore quantum physics with people like Einstein point out that energy might be the essence and is very, very important. And in the end, if you really look at it, Western science can't even prove that matter exists. So if you look at the matter parts of the atom, like the core and the electrons around it, are less than 1% of the whole atom. And if matter would not exist, also the mechanical theory about Tilbone pain becomes questionable. And the question is even if the treatment effects through mobilizations have anything to do with moving matter. And maybe more to be found in influencing the non-mechanical, but without wanting to sound too airy-fairy here again, I will record an extra episode on this. And also there I will keep it concrete and down to earth. So back to the therapy. I think it became clear that I like the holistic approach. And just as I use my skills and knowledge as a meditation trainer, what I do over 10 years now, and I wrote a book about, and as mentioned, I have a podcast which has currently around 100 episodes. And also my skills as a breathing coach, where I have a certification and two different educations. I also use what I know of energy, where I teach a 30-hour course in for several years already. And I also use my studies in the spiritual field. And this is, I think, one of the things that I have to offer more than most therapists and doctors. I can help people beyond what most specialists are trained in. And this is also an aspect that I will deeper explain in my course for colleagues. Again, all down to earth and where possible, backed up by science and what we can see in nature, but also by patient cases and personal experiences. And if you know what to look for, things often become clear. And this is also what I mean with being a translator. If you know what certain things mean, then you can understand the context to the presented problems better. And this is, of course, a way to help people. Just this week I saw this new patient, and the problems arose after being in a hospital where a young child was struggling and they didn't know what actually was going on. And they had to be seated inside of this room for a long time. And this is where the pain got triggered. And then you can approach it from a mechanical perspective of long sitting. But it was not something that she was not used to. I mean, there was not an abnormal amount of sitting, but the circumstances were different. She was in a place where she didn't want to be. And of course she wanted to be with her kid, but she didn't want to be in a situation where her kid was in a hospital and she had to sit still where she actually wanted to do stuff, but was not able to. And also, if you looked at her, it's a very energetic, very externally oriented, helping person, and someone who takes action if something is wrong. And all of these things were taken away from her in that situation, and she just had to sit still in a situation which was uncomfortable in many, many ways. And she couldn't go into her comfort zone and do the things where she's normally good at. And that was an emotionally triggering situation. And there you can mechanically explain it as a heightened tension in a pelvic floor, more pull on the tailbone, but also you can maybe approach it from a much broader perspective, like the Eastern philosophies do. And maybe explain it from that something in her grounding, in her core, in her essence, in her safety, where the first chakra is connected to. Something there was off. And then sometimes problems make a lot more sense. So this was just an example. So with the cliffhanger for a full episode on a wider spectrum of tailwind pain in the future, we kind of come to the end of this episode. And I applaud you for staying all the way with me here and listening to all of it. And if my throat and my voice is even telling me to maybe stop talking, you notice that I'm very enthusiastic and passionate about the topic, and I wanted to share as much as possible with you here. This is the whole goal of this podcast. And in this episode, you got me, and I hope I made this as inspiring as possible for you. So the tailbone that really grabbed my interest is a very specific part of the spine that moves and has biomechanical qualities that can become dysfunctional and can be treated. But like we ended, also can have a wide variety of connections to other disruptions in our system. And I saw multiple patients where the treatment of the tailbone led to more mental space and clarity, more connection to the whole body. Things started flowing again. And even solvation of pain and stiffnesses elsewhere in the body where there's no real logical mechanical connection to. And now I even see a patient where after the first treatment, he told me that his complete posture changed, and even the people around him commented on it. He felt that his knees were not locked anymore and that his shoulders were a lot lower than they normally were, just by treating a tailbone. So it's a fascinating, fascinating area of the body with a lot of connections. And I hope I transferred my enthusiasm and my passion about it well to you in this episode. That leaves me with the final question I always ask my guests. What tip or advice do you have for people with tailbone pain? And I guess I can only answer it the same way as almost all guests on this podcast already did. Keep on searching. There's a solution for most tailbone problems. You just have to find the right therapist that has the right approach. And sometimes it is through the pelvic floor, sometimes it's mechanical through the bones, sometimes it's fascia, sometimes it's something else that you can influence through therapy on the body. And what the last little segment of this podcast episode explained. Maybe it's something completely different. And also in that area, there's therapists that can help you. So keep on searching. And as you can learn from my guest here on the podcast, there's a wide variety of approaches to tailbone pain. And also the therapeutic results of treatment of the tailbone are mostly very good. Even for people that visit us, specialists that you hear in this podcast, as their last resort and had a lot of therapy and treatment already. None of us can cure everybody, but together we can accomplish a lot and help a very big group end up without any problems left. So keep your hopes up and keep searching and don't take there's nothing to do for an answer. The probably best reply to that is that you appreciate the person's expertise, but you won't accept their verdict. So thanks again for listening. There will be a webpage linked to this episode where I shall share the links of the things that I mentioned during this episode, like of the exercises and audio on my website and the info about Michael Durtnall's findings. And as mentioned, I love to spread the skills. And if you're a doctor or therapist that wants to learn how to understand, examine and treat the tailbone and are interested in hosting a course in your country, then let me know. With this course, you will learn a lot of what I know and what I do in a few days, and you can really, really help people with tailbone problems and through that spread the mission that I'm on. So for everybody listening, thanks for tuning in. And if you have any questions or comments regarding this episode or outside of it, or if you just wanted to share with me that you enjoyed this episode or this podcast at all, let me know. I love to receive your messages and hopefully you tune in for the next episode again. And after this, there will be more doctors also explaining their approach and their vision. Although my experience so far is that it's pretty hard to get into their schedule. So most of them are very enthusiastic, but to really get to an appointment takes a little bit more extra time. But as you probably know by now, I'm willing to put a little bit of work in it. So I wish you a very nice day wherever you are and whatever time of day it is. And again, hopefully until next time. All the best here from Amsterdam. Thanks for tuning in. If you're looking for more high quality info, tips, or exercises, you can find me at tailbone therapist.com.