CLINICAL UPDATE
Active selfmanagement of back pain
PIVET MEDICAL CENTRE By Dr Chris Chin, GP, Cockburn Medical Centre
H
ip Rib or Costo-iliac Impingement has been documented in the medical literature as the cause of pain at the iliac crest, rib tip pain in cricketers and patients with osteoporosis and loss of spinal height. This model can also explain musculoskeletal changes in patients with non-specific back pain (accounting for 95% of chronic back pain) enabling us to give more specific advice for selfmanagement, improving compliance.
Compressive forces occurring at the inferior margins of the 11th and 12th rib against the iliac crest can traumatise the origins and insertions of the quadratus lumborum, gluteal, iliopsoas and lateral abdominal muscles causing pain and muscle dysfunction. Peripheral nerves, which penetrate these muscles, may also become traumatised leading to peripheral sensitisation. Tractional forces at the lumbar sacral area may contribute to sacroiliitis, strain of the multifidus muscles and contribute to spinal degeneration. The easiest way to find evidence of Hip Rib Impingement is to examine the patient standing up. Palpate the inferior edge of the lower ribs and the iliac crest looking for corresponding tender areas and observe how much gap there is between the ribs and the iliac crest. A gap of 5cm. (two fingers) or less increases the likelihood of impingement. A history of pain exacerbated by getting out of a chair or bending forward is supportive.
Targeted advice Avoid exercises which cause Hip Rib Impingement such as lateral flexion, forward flexion, flexion and rotation and excessive hyperextension at the waist. More specific biomechanical advice may be required depending on the patient’s exercise pursuits. To avoid impingement, take a deep breath and hold it while changing postures such getting out of a bed, chair or car and with lifting, bending and going up or down stairs. Encourage sitting upright on higher dining or office chairs or fit balls and avoid low soft seating. Slow deep breathing, while walking on flat grass is the safest initial exercise program. Aim for 30-40 minutes, three days a week, starting with 10 minutes and increase by five minutes every fortnight. Schedule reviews to monitor progress and reinforce the message SUMMARY By applying the Hip Rib t &YBNJOF GPS UFOEFS NVTDMFT Impingement model in CFUXFFO UIF MPXFS SJCT patients with ongoing back BOE JMJBD DSFTU pain of unknown aetiology, we can safely promote t "WPJE QPTUVSFT PS NPWFNFOUT DBVTJOH JNQJOHFNFOU active self-management, reduce fear of movement, t 5BLJOH BOE IPMEJOH B EFFQ CSFBUI minimise the perpetuation, SFEVDFT JNQJOHFNFOU XIFO exacerbation and recurrence DIBOHJOH QPTUVSFT PS FYFSDJTJOH of persistent back pain and t "WPJE MPX VOTVQQPSUJWF TFBUJOH disability. O t 4MPX EFFQ CSFBUIJOH XIJMTU XBMLJOH PO GMBU HSBTT TUSFOHUIFOT DPSF BOE MVNCBS NVTDMFT
References on request.
Specialists in Reproductive Medicine & Gynaecological Services
ANDROLOGY NEWS
by Medical Director Prof John Yovich
Varicocele Ligation ‌ renewed interest In 1955 W. Selby Tulloch, urological surgeon from Edinburgh and father of our very own Alistair Tulloch, published his excellent results in the BMJ on Varicocele ligation. Using the Palomo Ligation technique (high – above the inguinal ring) he reported LPSURYHG VHPHQ SURÀOHV DQG SUHJQDQFLHV LQFOXGLQJ WZR FDVHV who previously had azo-ospermia! However, the Palomo operation along with other surgical methods performed within the inguinal canal, fell into disrepute by the 1980s as life-table statistical evaluation showed no improvement in Q Dr Darren Katz, above and below, using the VTI fertility compared ultrasound Doppler to identify the testicular artery. to no-surgical treatments. Cochrane studies twice panned varicocele ligation surgery. What I noted in Perth when setting up Fertility Services in 1980, was that most men who had surgeries had persistence or recurrence of varicoceles. However, the new data of Peter Shlegel and Marc Goldstein from Cornell University in New York has changed the picture and even Cochrane is revising its conclusions as the new data reveals EHQHÀWV 7KH QHZ WHFKQLTXH LV VXE LQJXLQDO RYHU WKH H[WHUQDO inguinal ring) and requires a microsurgical technique to identify the veins and preserve the testicular artery within the spermatic FRUG )XUWKHUPRUH FRPPXQLFDWLQJ YHLQV KDYH WR EH LGHQWLÀHG for ligation. 9DULFRFHOH LV LGHQWLÀHG LQ DOPRVW RI PHQ LQ VXE IHUWLOH VHWWLQJV EXW RQO\ DSSHDU UHOHYDQW ² GLVSOD\LQJ VHYHUH VHPHQ anomalies, increased DNA fragmentation, reduced testicular YROXPH • POV DQG UHGXFHG VHUXP WHVWRVWHURQH OHYHOV $OWKRXJK IVF with ICSI can overcome the fertility problem for many cases, WKH EHQHÀW RI YDULFRFHOH FRUUHFWLRQ FDQ EH ZLGH UDQJLQJ including long-term testosterone elevation and improved embryo quality in IVF.
NOW AT 2 LOCATIONS PERTH & BUNBURY
Author competing interests: Dr Chris Chin has received honoraria for involvement in educational activities provided by Pfizer. Reader questions, contact the author on Tel 9418 3722.
medicalforum
For ALL appts/queries: T:9422 5400 F: 9382 4576 E: info@pivet.com.au W: www.pivet.com.au
39