Low Back Pain and Shoulder Pain

1. Low Back Pain and Shoulder Pain PRACTICAL SESSION FOR GP REGISTRAS Georgina Taft Chartered Physiotherapist

2. Aims Be able to perform a basic assessment of the lumbar spine and shoulder Have an awareness of the most common conditions Know who to refer to and when Confident of when ‘alarm bells’ should be ringing in terms of serious pathology.

3. LOW BACK PAIN 90% of population will suffer LBP 5-10% will become chronic and will account for 90% of the cost of treatment Recurrence is very common. Functional Anatomy Spinal curves Discs Facet joints Neural system

4. ASSESSMENT Subjective You should have a pretty good idea by the end of this. Onset Cause Ags and Eases Try to establish irritability Clear red flags Differential diagnosis questions Onset –suden/gradual. Cause- careful quest. Ags/eases eg flex, walk, computer. Irritab- const Red flags-bladder emptying key Diff diag - =ve cough, pain on ext, pain on ex, stops with rest, pain on walk stops with flex Onset –suden/gradual. Cause- careful quest. Ags/eases eg flex, walk, computer. Irritab- const Red flags-bladder emptying key Diff diag - =ve cough, pain on ext, pain on ex, stops with rest, pain on walk stops with flex

5. Objective Ensure the patient is undressed enough for you to see! Posture and ? shift ROM in stand – SLR Neural ? only if significant Clear Hip Consider SIJ and Pelvis Amount and how they move. ? Reproduces their pain. Most pts say Dr didn’t even examin meAmount and how they move. ? Reproduces their pain. Most pts say Dr didn’t even examin me

6. What You Can Do Try to establish a diagnosis Posture education Ergonomic advice Mckenzie exercises if suspect disc Advise them on correct lifting techniques Car seat Lumbar roll Use ags and eases If very acute may need few days [max] bed rest but if at all possible keep moving. BACKS LIKE MOVING Recommend core stabililty – Pilates, yoga Drugs Refer on….

7. To Spinal Orthopod -If have severe neuro symptoms - If you suspect Ca May want to X-ray first, partic if suspect tumour osteoporosis

8. To Physio NHS- If not resolved with a few weeks of modified activity and analgesia/NSAIDs Recurrent problem Pain into leg Neuro symptoms Social factors eg.single mother Private – Early treatment gets dramatically quicker results. Refer ASAP Even a one off appointment is beneficial to advise, reassure and teach self help. If you suspect SIJ, pelvis SPD. Ask if patient has medical insurance Use occy health

9. CORE STABILITY What is it? Misconceptions Not core strength but this has its place. If chronic pain needs to be very specific Core cylinder. Mobiisers, stabilisers. Pain inhibs stab system, clinically provenCore cylinder. Mobiisers, stabilisers. Pain inhibs stab system, clinically proven

10. SHOULDERS Functional Anatomy The shoulder girdle is primarily designed for mobility. What characteristics allow for this? When considering the shoulder people generally think of just the GHJ. What other joints make up the shoulder girdle?

11. Subjective Very similar to LBP. Plus: Area of pain – referall pattern. What might it suggest? Any pins and needles Night pain –indicates serious path or rot cuff tear UFT, Tx, Cx, 1st and 2nd rib. Shoulder is C5 dermatome. Chest pain more likely 2nd rib. Gall bladder UFT, Tx, Cx, 1st and 2nd rib. Shoulder is C5 dermatome. Chest pain more likely 2nd rib. Gall bladder

12. Objective Posture – look from behind, scapula postion, spinal posture Any muscle wasting – suggests thoracic nerve palsy Check cervical and thoracic spine DBr Shoulder ROM – active, passive and resisted. NB Mrot If Passive significantly more than Active suggests what?

13. Special Tests Can look at instability, impingement, labral lesions and rotator cuff tears. Instability Aprehension/Relocation Test Sulcus Sign Impingement Empty can Scarf test. Also ACJ Neers Test

14. Common Conditions Shoulder Capsulitis Only 2% of shoulder problems. Gets ‘overdiagnosed’ Predisposing factors Trauma Diabetes Female Older CV disease Cerebro vascular disease Diagnosis – capsular pattern

15. Management Depends on what stage they are in: Stage 1 – Pain is the main problem. Advice and drugs Stage 2- Stiffness is the main problem Physiotherapy to push ROM Stage 3- Resolving. Condition normally self limits in approx 18/12.

16. Dislocation Very different management of young, older patient and 1st time dislocation. Check neurology and vascularity Ideally always refer to Physiotherapy, but prioritise by range of movement, function and recurrence. Young- increase stab old-increase mob 1st time refer to orthopodYoung- increase stab old-increase mob 1st time refer to orthopod

17. Instability Can be inherent – hypermobile patient Traumatic – post dislocation Repetitive – eg thrower, swimmer Management 1st line – Physiotherapy to retrain scapula mechanics and rotator cuff strength. 2nd line – If not successful refer to orthopod as may well need surgery to stabilise

18. Impingement Primary – how your made ie bony structure occupying sub acromial space Secondary – due to underlying instabililty eg young swimmer. Management Physiotherapy . Medial rotators become very strong, lateral rotators weak. No longer oppose deltoid effectively so humeral head moves superiorly into sub acromial space. Medial rotators become very strong, lateral rotators weak. No longer oppose deltoid effectively so humeral head moves superiorly into sub acromial space

19. Rotator Cuff Tenonopathy - Can develop due to impingement, trauma or degeneration. - Specific clinical tests and MRI/US confirm - Can develop into calcific tenonopathy Management Partial tear – Physio and/or injection Full tear – Surgery

20. Sub Acromial Bursitis Can be acute eg due to fall onto shoulder Overuse ie altered mechanics. Management Responds well to injection. Physiotherapy to address altered mechanics if applicable

21. Physiotherapy Exercises and manual techniques to increase ROM Exercises to increase muscle strength, particularly the rotator cuff Exercises to correct scapula mechanics and improve stability Soft tissue techniques to surrounding musculature that will tend to compensate Mobilisations to surrounding structures that may be tight due to compensation, or as a contributing factor eg thoracic spine Taping Advice/Education Refer on appropriately

22. What You Can Do Try to make a diagnosis Establish severity/disability Posture Education Range of Movement exercises Thoracic mobility exercises Rotator cuff strengthening