Many patients with Back pain also suffer from sciatica. Sciatica is usually described as a pain that arises in the back or the gluteal area and radiates down the side of the leg into the little toes or down to the back of the calf. There are variations of severity, the most being neuropathic pain; and associated symptoms such as muscle spasm, weakness, numbness and tingling. The classic cause of sciatica is compression or chemical irritation of the spinal nerves (dorsal nerve roots)  that make up the sciatic nerve. This is due to degenerative changes in the Lumbo-sacral spine such as disc prolapse, osteophytes from facet joints, spondylolisthesis and spinal stenosis. Often the sciatic nerve is compressed where it comes out at the pelvis at the greater sciatic notch together with the piriformis muscle. Commonly therapies are focused at stretching the piriformis muscle for this reason. Another cause of sciatica are myofascial trigger points in the Gluteus minimus muscle. this muscle is deep to the gluteus medius and gluteus maximus muscles and may develope trigger points from compressive forces in the maximus and medius muscle which in turn develop trigger points from Hip Rib impingement, tight iliotibial band or according to Janet and Travell commonly comes from sitting on a wallet in the back pocket. I have also noticed that people who wear a stiff tight belt may also activate the gluteal trigger points. The nerves from the gluteal muscle also go through the greater sciatic notch together with the piriformis muscle and the sciatic nerve so trigger points in the piriformis muscle will cause trigger points in the gluteal muscles also. In my opinion, Hip Rib Impingement causes swelling or inflammation of the sacroiliac joint (sacroilitis) which in turn compresses the piriformis muscle causing myofascial trigger points in the muscle which then tightens and compresses the sciatic and gluteal nerve as they go through the tight space of the greater sciatic notch similar to carpel tunnel syndrome.

What do you think?

This is the last blog for this year and wishing every one a merry Christmas from www.drchrischinbackpain.com.au

The incidence of back pain has increased steadily in the last 50 years. Why is it happening. There are numerous reasons why this could be happening. Lets focus on sitting. In the last 50 years we have the evolution of the television and along with that we are spending more and more time sitting in front of it. Studies done in the 1950s show that if you sit for more than 20 min at a time, your muscles start to fatigue. ( and so does the brain ) By getting military personnel to take a 30 sec break every 20 min, they were able to work effectively for their usual 8 hour shift. They have found that by sitting in front of the television, the average person burns less energy than when they are asleep. So if you want to lose weight, don’t sit in front of the television. Recent studies have shown that for every 30 min of sitting, you lose a day off your lifespan.

The television is not entirely at fault. The type of seat is also important. In the past, dining chairs used to be high and firm, but more recently, lounges and sofas seem to be lower and softer so when you sit on them your are crushing your lateral abdominal and hip muscles between your ribs and your hips. The older your lounge or sofa gets, the more they sag and the more difficult for you to get out. Its like a trap. The easiest remedy would be to get a wedge cushion and sit on top of it with the thick part of the wedge at the back to avoid sinking into the chair. This will benefit most chairs to make them firmer and more upright. Another alternative is to remove the cushions and place a piece of wood such as 5 ply on top of the frame of the chair, then replace the cushions back on top. You can also put more stuffing into the cushions. The third option is to purchase a taller and firmer chair especially if there are tall people in the household. When back pain is present, try to avoid sitting on lounges or sofas. Instead use the dining chair or office chair. they will also be easier to get up from. When the pain improves, try sitting on a fit ball as this will work your core muscles hard, strengthening them in the process. You can get up frequently if it becomes uncomfortable. remember to do the posture breathing when sitting.

from www.drchrischinbackpain.com.au

Its that time of the year again for the annual Acupuncture College conference. This Saturday, I have been invited to give 2 talks. The first is about all the Musculoskeletal Impingements that contribute to back pain, hip pain and sciatica. This will include Hip Rib Impingement which I have talked about on this blog and also include some of the other impingements such as 12 rib/L1 impingement, L5/iliac impingement and the groin impingements.

The second presentation will be on how Musculoskeletal Impingements cause neck pain, headaches and migraines. This includes Atlas impingement, Occipital impingement and interspinous muscle impingement. I hope to get some feedback to see if my theories on Musculoskeletal Impingements are publishable in an acupuncture, medical or science journal.

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Apart from seating, bending and lifting at work are common problems encountered by patients with low back pain. Examples are floor tiling, carpet laying or welding where the person is at floor level and bending over most of the day. In these situations, it is better for the person to kneel than to squat. The difference is that in kneeling, the knees are lower than the hips and this increases the gap between the ribs and hips thereby reducing the risk of Hip Rib Impingement ( HRI ). in squatting, one or both knees are higher than the hips thereby compressing the hips into the lower rib cage causing HRI and trauma to the lateral abdominal muscles as well as the hip muscles and the intercostal muscles and the diaphragm.

 

Another situation where the knees are higher than the hips are teachers or carers of young children when the adult sits on the floor cross legged or sits on a child size chair to get down to the child’s level. This definitely causes HRI if not in the sitting position then in the course of getting up from that position. In the last few years some of my patients who work on computers have been provided with foot stools which have actually exacerbated their back pain. These foot stools raise the level of the knees till they are above the height of the hips causing HRI.

Lifting from floor level has the potential to cause or exacerbate lower back pain by causing HRI. The safest way to lift from floor level is again to start by kneeling, then hold the object as close to the body as possible and if the object does not have a handle then to tilt the object so that one hand is under the object and the other is under the tilted side. the next step is to perform the Airbag Technique before lifting and holding the breath in, keeping the torso as vertical as possible and keeping both knees below the level of the hips throughout the lift. Bending straight over at the hips to pick up an object from the floor is high risk as patients have described developing back pain picking up a tissue off the floor or the morning newspaper. Previous recommendations for lifting from the ground level allows one knee to be higher than the level of the hips while lifting and this has been a common cause of back pain for many.

Lifting objects or shopping from the boot of the car is also a high risk situation as people tend to bend over to avoid hitting their head on the boot lid reducing the Hip Rib Gap ( HRG ) and then lifting and twisting at the same time increasing the risk of unilateral HRI. Once again, by using the  Airbag Technique, keeping the torso as vertical as possible and twist at the hips and knees instead of the waist will avoid HRI and back pain.

That’s it from www.drchrischinbackpain.com

A large number of my patients have difficulty with car seats. They drive long distances to get to and from work or drive their children around to school and their sporting or social activities. They may also do a lot  of driving as part of their occupation such as pharmaceutical reps. There are many variables that determine if an individual will have problems with the car seat. In general, car seats are designed to be comfortable but also safe just in case of a crash. Most car seats are classified as bucket seats while some trucks have bench seats. the back of the seat is generally lower than the front of the seat. this is to prevent the occupant sliding under the seat belt in the event of the crash. The back of the seat usually come with an adjustable lumbar support. Unfortunately most headrests and upper part of the seat curves forward. I think this is because it is the safest position to prevent whiplash in the majority of people who have a slouch. This forces the occupant into the head forward position which then contributes to Hip Rib Impingement ( HRI ). To alleviate this problem I ask my patients to purchase a semicircular shaped lumbar cushion and place it vertically along the thoracic spine and adjust the lumbar support in the seat to maximum. They should adjust the back of the seat such that the angle between the back and bottom cushion is equal or greater than 90 degrees.

I then ask the patient to sit with their head touching the headrest at all times as this will increase the Hip Rib Gap (HRG ) and also reduce the risk of whiplash injuries in case of a crash. Putting the seat belt on and leaning across the passenger seat to get things will cause impingement on that side and is worse if they twist to get something from the back seat. If they have pain on one side with prolonged sitting in the car then they require a hemipelvic raise usually on the painful side ( I use a hand towel folded in half to raise the pelvis by about 2-3 mm. They are also asked to perform the Air bag Technique when getting in and out of the car and keep their torso as upright as possible. They should also do the Air Bag Technique every 15 to 20 min throughout the journey to reduce lateral abdominal muscle fatigue due to HRI. HRI can also occur if they go over speed bumps or potholes on the road. They should perform the Air Bag Technique if they are able to anticipate the bump. Tight belts and wallets in the back pocket may also aggravate back pain with prolonged sitting in a car. This advice also applies to air plane seats. Some of the exercises recomended to prevent DVT during flights unfortunately may cause or exacerbate HRI and back pain.

For some people some cars and their seats are just too low for them to get in and out of and they need to get a car or a 4wd with higher seating. I regulary have to convince some of my taller patients that their dream mid life crisis sports car is not good for their backs. Thats it from www.drchrischinbackpain.com

Many patients with low back pain, hip pain and sciatica will develop a sharp exacerbation of pain as they get up off a chair. This can be even more severe when they get out of bed or out of the car. It is also worse the lower the seat is. Some people may have difficulty walking or walk with a limp after getting up from a chair. What is occuring is that as most people would bend forward as they get up from a seat and cause instant and severe Hip Rib Impingement ( HRI ) which then causes a flare up of their pain. HRI may well be the cause of  #NoF as it may trigger a sudden loss of power in the hip muscles causing the neck of femur to fracture.

Ideally, at home, patients should choose to sit on seats that are firm, not too low and easy to get up from. Dining chairs and office chairs are preferable although a fit ball would be best as it stimulates muscle contractions when sitting. The worse seat is a sofa or couch which is too soft or too low. If the patient insists on sitting on a low or soft sofa then they should make modifications such as to put plywood under the cushions if they come off. They could also add a wedge cushion on top of the sofa to further elevate their hips and reduce HRI while seated and when they get up.

In the workplace, they should adjust the seat tilt and height so that their knees are lower than their hips as this would reduce the chances of HRI while working. They should also get up every 20 minutes to reduce muscle and mental fatigue. They should avoid crossing their legs and sit with their legs a bit apart for stability. I find that foot stools usually make their problems worse as it reduces the hip Rib Gap ( HRG )I reviewed an excellent office and therapy chair called Saiza produced by Smirthwaithe in UK a few years ago.

Finally, patients should be reminded to perform the Air Bag Technique when they get on and off the seat and to continue with posture breathing while they are seated.

Sway back, scoliosis, excessive lordosis and kyphosis are common postures associated with back pain. On the other hand, there are many people with these postures who don’t have back pain. So what is the mechanism of pain? All these postures would reduce the size of the gap between the lower ribs and the iliac crest thereby increasing the risk of Hip Rib Impingement. On the other hand, Hip Rib Impingement damages the para-spinal and lateral abdominal muscles thereby creating these postures.

When I see patients with these postures, I would measure the size of their Hip Rib Gap (HRG), then I would measure the HRG again when the patient has taken a deep breath to see if this would increase their HRG significantly. By using some of the exercises in the book, we can improve the patient’s posture and reduce the long term risk of Hip Rib Impingement. Posture breathing and the Abdominal Rotation Exercise would benefit all these postures; the Siesta stretch would be good for scoliosis and especially kyphosis. The single leg raisers would be good for the sway back especially but would probably be contra-indicated in the excessive lordosis.

Convincing patients to remember to do these exercises is another matter. If they see their own posture in a mirror especially when they walk around in shopping centres, that may trigger a reminder to straighten up; or if they walk pass someone with a bad slouch, that may cue them to straighten up. Ciao from www.drchrischinbackpain.com

Studies have shown that up to 70 % of recreational golfers suffer from injuries and back pain is one of the most common complaint. Golfers can develop back pain from playing golf, they can develop back pain which is then aggravated when they play golf or they develop back pain and find that they can no longer play golf. I therefore come across a lot of comments that golf may be bad for your back. In my opinion, playing golf can be good for the back as long as the patient follows a few simple guidelines.

1 the Air Bag Technique

2 walk along a slope, not across it.

3 shoulders and hips should rotate together

The Air Bag Technique should be used on every stroke from driving to the putting. Apart from preventing Hip Rib Impingement during the swing, it will provide stability, consistency and reduces unwanted body movements. Hip Rib Impingement is the most likely cause of loss of power/acceleration/club head speed during the golf swing. A few golf pros have noted that they can get 20-25 meters further from their drives just by performing the Air Bag Technique throughout the swing. It is very easy to breath out too early and so risk impingement at the end of the swing which is when it is most likely to happen. So I suggest golfers to keep holding their breath until the golf ball stops rolling; which is about 7-8 seconds according to Andy Mowatt.

It is also useful to perform the Air Bag Technique when teeing up the ball or picking it up or getting in and out of the buggy. Performing the Air Bag Technique while walking will help strengthen the core muscles as well as preventing impingement especially when carrying or pushing the golf bag.

The more slope there is on a  golf course, the more challenging it is, but if the golfer walks with one hip higher than the other across a slope then there is a greater risk if impingement. It is better to walk along the slope and follow the terrain  in such a way that the hips are level most of the time.

There are 2 basic ways that the shoulders and hips move in relation to each other during the golf swing. The first way is when there is little hip movement but the shoulder is rotated to the maximum in a winding up fashion on the back swing and then rotated rapidly in the other direction during the swing. Unfortunately this is the method that has caused the most back pain in my golfing patients. This rotation of the rib cage can also cause impingement of the intercostal muscles which can result in thoracic, chest and shoulder pains. The alternative swing is when there is hip rotation in relation to the ground but the shoulder moves in the same direction so that the shoulders and hips move together during the back swing and the follow through. In this swing the hips are less likely to hit the ribs during the swing and so reduces the risk of developing pain and improving club head speed. The Air Bag Technique also prevents the shoulders from dropping at the end of the swing which contributes to compression of the intercostal muscles.

By advising my golfing patients on the Air Bag Technique, how to walking on slopes and hip/shoulder rotation I hope they can continue playing golf and benefit from the exercise, social and mental aspects of the game for the sake of their health. Thats all from www.drchrischinbackpain.com

Chronic dyspnea is commonly seen in patients with Chronic Obstructive Pulmonary Disease (COPD) and Chronic Heart Failure (CHF). It is also associated with back pain.  Since back pain is such a common co-morbidity in patients with chronic lung and heart disease we don’t usually see the importance of the relationship. Lately I have been seeing a few relatively younger patients with back pain and shortness of breath who have no cardiac or respiratory pathology to explain their dyspnea. Eventually they have discovered that the source of their breathing difficulties was from an exercise machine that they have just started using. These machines were designed to tone their abdominal muscles, but vigorous use of the machines have caused Hip Rib Impingement from repetitive side flexing movements. The repeated impingement would cause injury not only to the lateral abdominal and gluteal muscles, but would also cause injury to the lower intercostal muscles and the insertion of the diaphragm along the lower rib margins. This would explain the development of back pain as well as dyspnea.

As there are variations of the size of the Hip Rib Gap (HRG) between individuals, and the amount of muscles in the gap, these exercise machines would cause more problems with people with the smaller gaps and the least amount of lateral abdominal muscles. Getting back to the patients with chronic cardiac or respiratory problems; these patients would be more sedentary, but if they had poor sitting posture especially if they had to sleep propped up in bed, then Hip Rib Impingement would occur and contribute to their dyspnea. I have treated patients with dyspnea and medically managed COPD and CHF in the past, relieving them of dyspnea despite their ongoing cardiac or respiratory pathology. I wonder what percentage of patients with COPD or CHF with some degree of dyspnea who will benefit from treatment. The treatment would also be useful for patients with dyspnea where no medical cause ould be found.

Hip Rib Impingement postoperatively may also play a significant part in the aetiology of post operative pneumonia due to injury to the diaphragm when patients are propped up in hospital beds.

Low back pain can occur at any sport or recreational activity and at any level. One of the aims of participating in sport is to obtain and maintain a certain level of fitness and health, so low back pain is something to be avoided. Once it occurs, people tend to exercise less and become less physically active in all other aspects of their life. It may also contribute to stress and depression as any severe or chronic pain can do especially if there is a loss of income involved or loss of an opportunity to compete in an important career forming event. If your career or reputation is based around sports coaching, exercise trainer or educator then it is even harder to take time off  because of back pain. I have seen sports people who have had to give up the sport they love or their sporting career because of their backs and related injuries.

Apart from managing their back pain, I help them to return to a certain level of activity in their chosen sport. Sometimes this is not possible if they participate in contact sport or their sport or exercise program expects them to use a posture or movement which causes Hip Rib Impingement and risks further damage to their back. They may choose to go back in a coaching role hopefully imparting what they have learnt about the mechanics of back pain to their charges.

I have presented my theory of the mechanics of Hip Rib Impingement in a poster presentation at a Sports Medicine Australia conference in Alice Springs in 2004 and received a lot of positive feedback from sports physiotherapists who have often  found tender and trigger points on the hips and ribs of their patients. As there are so many exercises and their variations around that can cause Hip Rib Impingement, I was encouraged to put as many as possible in my book in a way that is easy to understand. To make things clear, I have placed ticks and crosses on most of the illustrations so that there is no confusion as to what exercises, postures or movements can cause low back pain. My patients with back pain were the greatest source of information of what exercises cause or exacerbate their back pains. Thats it from www.drchrischinbackpain.com

Apart from low back pain, Hip Rib Impingement may also explain why some cyclists and rowers develope stress fractures of their ribs and why some runners and football plays develop groin pains, tight iliotibial bands, hamstrings and subsequent knee injuries.