Almost all of the patients I have treated with back pain or fibromyalgia have evidence of Hip Rib Impingement. As previously mentioned most people under estimate how low their ribs are and how high their hip bones ( iliac crest ) are. The smaller the gap between the ribs and the hips, the more likely they are suffering from Hip Rib Impingement. The amount of muscle they have in the area is also significant as the more muscles they have between the bones, the less likely that they will suffer from impingement. This muscle can be loss very easily as prolonged illness such as the flu, prolonged bed rest or prolonged inactive holidays ( laying on the beach for more than 7 days ) can cause a significant muscle loss. This may be why work related injuries are more likely to occur after holidays.

Common daily activities that often cause Hip Rib Impingement are prolonged sitting, sitting on a low/soft chair, sitting twisted, getting out of a chair, bending, lifting, weeding and house work. Apart from modifying the postures and movements during these activities as described in my book, performing the Air Bag Technique may help the patient avoid impingement and so reduce the chances of exacerbating their back pain.

It is a simple technique, the person has to simply take a big a breath as possible and hold it for the duration of the activity. by practicing the Posture Breathing before hand ( previous blog and also described in the book ), the person is able to hold their breath more effectively and for longer to prevent impingement.

A classic example is when a patient gets a severe pain or leg weakness when they get up form a chair and has difficulty taking the first few steps. This occurs because with poor technique getting out of the chair, Hip Rib Impingement has occurred causing lateral abdominal and gluteal pain and trigger points which in turn causes weakness and stiffness of the muscle. By performing the Air Bag Technique while getting up from the chair, the patient is able to prevent impingement and an exacerbation of their pain while performing this common task.

In this scenario, the Air bag Technique also prevents falls as patients commonly describe getting out of a chair or bending over as a common incident just before they fall or break their hip. Commonly, patient have described that performing the Air bag technique gives them strength to get up from a chair or the bed and thereby improving their mobility as well as reducing their pain.

Performing the Air Bag Technique is the simplest way a patient can improve their back pain or fibromyalgia pain through out the day. It is quite easy to teach the patients at the end of a consultation even if they have poor English.

A vital part of treating patients with fibromyalgia is patient education, functional rehabilitation  and cognitive behavioral therapy. The passive treatment provided by laser acupuncture will only provide temporary relief unless the patient is able to change the way they think about the mechanical  factors that have been contributing to their pain and be encouraged to change them. Some patients may not be ready to participate in the rehabilitative process ( precontemplative ) and others are not prepared to put any effort into the healing process hoping for some instant magical cure. Unfortunately, as deconditioning of the neuromuscular system is part of the illness, we need to be able to convince the patient to strengthen their muscles without exacerbating  their pain. This process can be divided into 9 parts:

1     breathing technique

2    avoiding hip rib impingement

3     avoiding groin impingements

4    avoiding chest wall compression

5    avoiding shoulder impingements

6     avoiding neck impingements

7     safe stretches

8     pacing

9     safe strengthening exercises

The breathing technique I recommend is similar to the  reverse abdominal breathing technique often taught at Yoga or Qi Gong. In reverse abdominal breathing, the abdominal and pelvic floor muscles should contract with inspiration. Studies have shown that the diaphragm, intercostal muscles , the lateral abdominal muscles and pelvic floor muscles all co-contract . This means that when one of these groups of muscles contract, all the others also partially contract automatically. When this occurs the spine is braced or stabilised. This was what the system was designed to do. The co-contraction also increases intra-abdominal pressure thereby increasing venous return to the heart. This reduces the risk of fainting compared to the commonly taught abdominal breathing.

The main modifications to reverse abdominal breathing are that the patients should breath in and out only through the nose and to hold their breath as long as comfortable in inspiration. They should breathe out as little air as possible on expiration and breath in as deep as possible during inspiration. In this way more CO2 is retained and this increases O2 availability to the tissues (similar to Buteyko Breathing Technique ). I call this technique Posture Breathing as it corrects spinal posture, prevents hip rib impingement, chest wall compression and has the benefits of both reverse abdominal breathing and Buteyko breathing.  I will describe the Air Bag Technique in the next Blog at www.drchrischinbackpain.com

Apart from dietary and nutritional counselling and the management of psychosocial issues as described in the previous blog, I spend most of my time treating the tender and trigger points and teaching the patient about the required changes in the breathing technique, postures, movements and exercises that will allow the best possible recovery.

Most people with fibromyalgia have hundreds of tender and trigger points. The general consensus is that there is a systemic problem or a nervous system problem that has caused the development of numerous tender and trigger points throughout the body and so treating these points would not make a difference to the underlying pathological condition. In my experience, treating these points have provided patients with symptomatic relief not only of pain but the associated sympathetic and parasympathetic symptoms such as rhinitis, irritable bowel, urinary incontinence. It is also able to improve central nervous system symptoms such as chronic fatigue, dizziness and insomnia. By improving these symptoms then the patient is more able to comply with exercise programs which will then strengthen their muscles and thus improve functioning.

There may well be numerous risk factors and causative factors for fibromyalgia but once they develop a negative cycle of pain causing disability, immobility, loss of muscle then more pain which can go on indefinitely, then that becomes the pathological process. The treatment I use can be regarded as Laser Acupuncture or Very Low Level Laser Therapy ( VLLLT ). I use 2 lasers, both are 5 mw,  one is green with a wavelength of 532nm, and the other a red one at 670nm. I only apply them on the points for 2 seconds each. Some people benefit more from one colour than the other. I palpate the points to elicit some tenderness ( De Qi ) just before I apply the laser. Some people will feel tiredness or worse for a few days if you give too much treatment. In acupuncture terms we would say that they are strong responders. I don’t think that there is much importance between trigger points and tender points. The trigger points classically cause a referred pain pattern when compressed where as the tender points only cause local tenderness. In practise I am only interested in eliciting tenderness as more forceful palpation or compression may exacerbate the patients pain. I am sure that a large number of tender points are also trigger points and all trigger points are also tender. All these points are also acupuncture points; they may be on one of the 12 classical meridians, 8 extraordinary meridians, associated tendinomuscular meridians or Ashi points, some of which we learn from the grand masters when we attend conferences. I refer to Simon and travell’s books and wall charts on a regular basis and I find that the wall charts are useful for patient education as it explains why I am treating one part of their body when their presenting complaint is some where else.

I will discuss CBT for breathing, posture, movements and exercises in the next blog. As mentioned previously, this information is based on my clinical experience and the theories I form to try to explain my observations. For more evidence based studies, you will have to wait about 14 years when I semi-retire and have the time to do some double blind cross over trials. thats it from www.drchrischinbackpain.com

Recently I have been seeing an increasing number of patients with low back pain who also suffer from numerous other pains throughout their body. Fibromyalgia always comes to mind. Some of them have already had their diagnosis made by other medical practitioner, but most have not, and have not even heard of it before. The 2 main criteria for making the diagnosis is:

1     do they complain of pain in all 4 quadrants of the body ( 5 if you include the head )

2    do they have 11 or more of the required tender points.

Other things I ask about are

1   Life stressors such as shifting house, death of a significant relative/friend

2   Stress especially if it is still ongoing, such as conflicts at work, difficult teenagers.

3   Anxiety

4   Depression

5 Post traumatic Stress which may well have precipitated the condition.

Other precipitating factors may include:

1   Any accident especially including some whiplash of the neck and back

2  Severe illness especially infections such as Glandular fever or one requiring long stints in hospital or bed rest causing muscular deconditioning

3   Gastro-intestinal problems such as irritable bowel as I commonly find these patients have lactose/fructose intolerence/malabsorbtion.

Other associated conditions include:

1  Chronic fatigue,

2  Insomnia,

3   Migraines,

4   nasal allergies,

5  Tempromandibular dysfunction,

6    hypoglycaemia,

7    hot flushes.

8    neuropathic pain.

As there is no specific cause and no standard cure for Fibromyalgia, I have found that in most cases, I can  provide symptomatic relief. The 3 main areas I attend to are:

1   Low fructose/lactose/amine/trans fat /cholesterol diet, nutrition and some common supplments such as magnesium, zinc and krill oil.

2   Psychosocial issues using  modified Emotional Freedom Technique (EFT )

3  Tender points and Myofascial Trigger Points which I will expand on in the next blog

4  Cognitive Behavioral Therapy in relation to posture, movement and exercise to avoid exacerbating symptoms ( also in the next blog at www.drchrischinbackpain.com )

 

Scoliosis is a common problem I see in people who present with back pain. Chronic scoliosis, by the time they come to see me  have already been assessed,  diagnosed and  managed at some time in the past and they have come for treatment due to chronic or recent back pain, neck pain or shoulder pain. In these cases the scoliosis has reduced the space between the lower ribs and iliac crest and  may well has contributed to Hip Rib Impingement. This in turn then causes their back pain. On the other hand, I have seen patients with an acute scoliosis as a result of their back pain. In these cases, it is the Hip Rib Impingement which has caused muscle spasm on one side more than the other and so caused a lumbar scoliosis. The way I pick that this is an acute scoliosis in contrast with a chronic one is the lack of a compensatory thoracic scoliosis, so the patients seem to be leaning to one side. Apart from the usual treatment and cognitive behavioral therapy ( CBT ) based on the Hip Rib Impingement, I emphasize the Siesta Stretch which is a form of traction they can do at home on a bed, without the need for traction equipment.

According to Wikipedia, approximately 65 % of scoliosis cases are idiopathic. It may well be that in the cases of idiopathic and neuromuscular scoliosis, Hip Rib Impingement in pre and early adolescence may be a significant causative mechanism.  The next time you see children sitting, whether it is in front of the TV, playing computer games or prolonged sitting on the floor at school during assemblies, observe their postures and imagine how much Hip Rib Impingement is going on.

I was speaking at an educational meeting with the physiotherapists from Spearwood Physiotherapy and Melville Physiotherapy a couple of weeks ago.

We were discussing how Hip Rib Impingement could cause back pain, hip pain and bursitis. By understanding how impingement occurs we can predict where we are more likely to find tender points and myofascial trigger points in the area of the lower ribs, iliac crest and gluteal areas for treatment. We can also modify the rehabilitation process to avoid providing exercises that can cause impingement and exacerbation of pain.
What I learnt from the physios was that apart from the greater trochanteric bursa, there are 12 other possible areas of bursitis around the hip, gluteal and groin  area which could contribute to local and referred pain. Gluteus Medius muscle tears are also common findings on ultrasound in people with trochanteric bursitis or lateral thigh pain. As Hip Rib Impingement can cause a tight iliotibial band it may play a part  in these two pathologies.

When I tell a patient that Hip Rib Impingement is the cause of their ongoing back pain, the most common reaction is disbelief. One of the reasons for this disbelief is that they have not heard of it before. The other common reason is that they have no idea where their lower ribs are in relation to the top of the iliac crest. Common illustrations of the human skeleton show a relatively large gap between the 2 structures but in my clinic, I rarely see anyone with a gap greater than 5 cm. By examining the patient in the standing position and demonstrating to them how much of a gap they have between the lower edge of the 11th rib and the top if their hip by placing your fingers in the gap you can easily convince themof how easily they can collide and damage the lateral abdominal muscles. They will be even more convinced if while moving your fingers up and down between their ribs and their hips you can find some tender spots. The evidence that Hip Rib Impingement occurs is there on everybody’s hips. The search for  a cause of mechanical back pain has been going on for many years and I believe that Hip Rib Impingement is the simple explanation for this massive problem. This solution to the problem is classic lateral thinking and thinking outside the square. The theory does not contradict any evidence that we have on back pain at present.

One of the features that I look for in a patient who complains of   mechanical low back pain or spinal pain is the Hip Rib Gap.

This is the amount of space they have between their 11th rib and the iliac crest. The smaller the space makes it more likely that they suffer from hip rib impingement as a major cause or perpetuating factor in their back pain. When you ask a person to put their hands on their hips, they usually place them on their greater trochanter which is part of the leg bone. they don’t realise that the iliac crest which is the top part of the hip bone is much higher up. With the patient standing straight, I try to squeeze my fingers in between their 11th rib and the top of the iliac crest and try to estimate the amount of gap that they have. Apart form documenting this gap, by demonstrating how small the gap is to the patient, they are more easily convinced that they suffer from hip rib impingement. I no longer get my patients to bend from side to side as this movement can cause impingement and exacerbate the patients pain at the consultation which is not a good thing as they usually come to be fixed and not to go home feeling worse. I also do away with the slump test and the touching of the toes test as they can also cause a severe exacerbation of their symptoms. I still do a straight leg raising test to check for  nerve  root entrapment. Another test performed  for lumbosacral integraty is to get the patient to squat and walk like a duck. I have seen many instances where patients without back problems ended up with chronic back problems performing this exercise.

In 2004 I measured 50 people with back pain and they averaged a gap of 5 cm in the supine position. I have given many public talks on back pain and I always teach my audience to measure their own gaps and I have not come across many people with a gap much greater than 5 cm while standing. It looks like the gaps portrayed in anatomy books and illustrations are  a bit misleading as they usually show a wide gap.

 

I read a good article on Regional Pain Syndrome and Complex Regional Pain Syndrome this week form the June edition of Medicine Today (Australia). It was written by Professor Geoffery Littlejohn. Some of the points I gleaned from the article was that:

1   there was central or peripheral sensitisation involved in the ongoing perpetuation of pain in the presence or absence of the original injury.

Comment: This also describes the mechanism for neuropathic pain. Is Regional Pain Syndrome similar to neuropathic pain?

2  Emotional distress and medicolegal complications enhances central sensitisation and makes this problem difficult to treat.

Comment: most people with chronic pain have a range of psychosocial risk factors (yellow flags), Chronic pain also causes emotional distress often leading to depression. The initial injury may also cause symptoms of Post Traumatic Stress.

3  Strong evidence base for the treatment of this condition is lacking due to the lack of good studies partially due to the fact that most patients have emotional distress and medico-legal complications of varying degrees and the making high quality clinical studies difficult to perform.

Comment: Painful conditions are always hard to study as the perception of pain is so subjective and dependent on all the other aspects of the patent’s life. Despite the various pain scores available, the ultimate result of any treatment should be Zero pain.

4  The presence of Myofascial trigger points as a feature of this condition.

Comment: It is very refreshing to read an article by a specialist and professor that has included Musculoskeletal dysfunction and trigger    points as a feature of a painful condition. In time, I hope to prove that Myofascial trigger points are the major factor in the perpetuation and exacerbation of chronic pain especially in Regional pain syndrome, neuropathic pain or fibromyalgia.

 

It is quite common for golfers to develop back pain or injuries. They can injure their backs from the game of golf itself or by other means. Once the back becomes painful, it may affect the golf swing and also the enjoyment of the game. It may also become aggrevated by the game causing some to have a break from the game or worse to give it up all together.  Common injuries may be caused by the golf swing, putting, pitching as well as teeing and picking up the ball. Nine out of ten of the right handed golfers I see get worse pain on the right side.

The main reason for this is that during or just after the clubhead comes into contact with the ball, the golfer tends to flex his body  to the right causing hip rib impingement. This then injures the lateral abdominal muscles, iliopsoas muscles, gluteal muscles and the paraspinal muscles on that side. As these are the stabilizer muscles of the lumbosacral region, repeated injury would cause the development of trigger points in these muscles with associated referred pain to the back, down the legs or into the groin. Loss of lumbosacral stability in this region would increase the risk of injury to the lumbar spine creating disc protrusions and osteoarthritis of the facet joints. Myofascial trigger points in this area could also contribute to the development of groin, hip joint or knee injuries.

Apart from treating these myofascial trigger points, we aim to get the golfer back into the game and play his/her best as soon as possible. I instruct them on how to perform the Airbag Technique as described on page 23 of my book and to reduce flexion and rotation at the waist during the golf swing (page 56). As most people are unaware of their posture and movement, it helps to get the assistance of a Golf Professional.

Andrew Mowatt, the head professional at the Royal Fremantle Golf Club Pro Shop uses video to great effect in guiding golfers to change their posture and the way they move during the golf swing. He has observed that by avoiding these musculoskeletal impingements during the golf swing, not only does the golfer avoid further back problems but also drives further. The Airbag technique improves the stability of the whole trunk during the golf swing and so improves consistancy and accuracy.

Walking on grass is one of the best ways to train up the stabilizer muscles of the spine as long as the golfer avoids walking on a side slope such that one hip is higher than the other. Kneeling instead of squatting when teeing up or picking up the ball will also reduce the risk of hip rib impingement during the game. The handle of the putter can also be fitted with a grip with a suction cup to retrieve the ball without bending.

In my opinion, hip rib impingement is the most important previously unknown cause of back pain and injuries in golf. By preventing impingement in the golf swing we can avoid the development of this common injury and produce better golfers in the future.