Low Back Pain and Low Back Pain and Shoulder PainShoulder Pain

PRACTICAL SESSION FOR GP PRACTICAL SESSION FOR GP REGISTRASREGISTRAS

Georgina TaftGeorgina Taft

Chartered PhysiotherapistChartered Physiotherapist

AimsAims

Be able to perform a basic assessment of Be able to perform a basic assessment of the lumbar spine and shoulderthe lumbar spine and shoulder

Have an awareness of the most common Have an awareness of the most common conditionsconditions

Know who to refer to and when Know who to refer to and when Confident of when ‘alarm bells’ should be Confident of when ‘alarm bells’ should be

ringing in terms of serious pathology.ringing in terms of serious pathology.

LOW BACK PAINLOW BACK PAIN 90% of population will suffer LBP90% of population will suffer LBP 5-10% will become chronic and will account for 5-10% will become chronic and will account for

90% of the cost of treatment90% of the cost of treatment Recurrence is very common.Recurrence is very common.

Functional AnatomyFunctional Anatomy Spinal curvesSpinal curves DiscsDiscs Facet jointsFacet joints Neural systemNeural system

ASSESSMENTASSESSMENT

Subjective Subjective You should have a pretty good idea by the end You should have a pretty good idea by the end

of this.of this. Onset Onset CauseCause Ags and Eases Ags and Eases Try to establish irritability Try to establish irritability Clear red flags Clear red flags Differential diagnosis questionsDifferential diagnosis questions

ObjectiveObjective

Ensure the patient is undressed enough Ensure the patient is undressed enough for you to see!for you to see!

Posture and ? shiftPosture and ? shift ROM in stand –ROM in stand – SLRSLR Neural ? only if significant Neural ? only if significant Clear HipClear Hip Consider SIJ and PelvisConsider SIJ and Pelvis

What You Can DoWhat You Can Do Try to establish a diagnosisTry to establish a diagnosis Posture educationPosture education Ergonomic adviceErgonomic advice Mckenzie exercises if suspect discMckenzie exercises if suspect disc Advise them on correct lifting techniquesAdvise them on correct lifting techniques Car seat Car seat Lumbar rollLumbar roll Use ags and easesUse ags and eases If very acute may need few days [max] bed rest but if at all possible If very acute may need few days [max] bed rest but if at all possible

keep moving. BACKS LIKE MOVINGkeep moving. BACKS LIKE MOVING Recommend core stabililty – Pilates, yogaRecommend core stabililty – Pilates, yoga DrugsDrugs Refer on….Refer on….

To Spinal OrthopodTo Spinal Orthopod

-If have severe neuro symptoms-If have severe neuro symptoms - If you suspect Ca- If you suspect Ca May want to X-ray first, May want to X-ray first, partic if suspect partic if suspect

tumourtumour osteoporosisosteoporosis

To PhysioTo Physio NHSNHS- If not resolved with a few weeks of modified activity and - If not resolved with a few weeks of modified activity and

analgesia/NSAIDsanalgesia/NSAIDs Recurrent problemRecurrent problem Pain into legPain into leg Neuro symptomsNeuro symptoms Social factors eg.Social factors eg.single mothersingle mother

PrivatePrivate – Early treatment gets dramatically quicker results. Refer – Early treatment gets dramatically quicker results. Refer ASAPASAP

Even a one off appointment is beneficial to advise, reassure and Even a one off appointment is beneficial to advise, reassure and teach self help.teach self help.

If you suspect SIJ, pelvis SPD.If you suspect SIJ, pelvis SPD. Ask if patient has medical insuranceAsk if patient has medical insurance Use occy healthUse occy health

CORE STABILITYCORE STABILITY

What is it?What is it?

MisconceptionsMisconceptions Not core strength but this has its place.Not core strength but this has its place. If chronic pain needs to be very specificIf chronic pain needs to be very specific

.

SHOULDERSSHOULDERS

Functional AnatomyFunctional Anatomy The shoulder girdle is primarily designed The shoulder girdle is primarily designed

for mobility. What characteristics allowfor mobility. What characteristics allow for for this?this?

When considering the shoulder people When considering the shoulder people generally think of just the GHJ. What other generally think of just the GHJ. What other joints make up the shoulder girdle?joints make up the shoulder girdle?

SubjectiveSubjective

Very similar to LBP. Plus: Very similar to LBP. Plus: Area of pain – Area of pain – referall pattern. referall pattern. What might it What might it

suggest?suggest? Any pins and needlesAny pins and needles Night painNight pain –indicates serious path or rot –indicates serious path or rot

cuff tearcuff tear

ObjectiveObjective

Posture – look from behind, scapula postion, Posture – look from behind, scapula postion, spinal posturespinal posture

Any muscle wasting – Any muscle wasting – suggests thoracic nerve suggests thoracic nerve palsypalsy

Check cervical and thoracic spineCheck cervical and thoracic spine DBrDBr Shoulder ROM – active, passive and resisted. Shoulder ROM – active, passive and resisted.

NB MrotNB Mrot If Passive significantly more than Active If Passive significantly more than Active

suggests what?suggests what?

Special TestsSpecial Tests

Can look at instability, impingement, labral lesions Can look at instability, impingement, labral lesions and rotator cuff tears.and rotator cuff tears.

InstabilityInstability Aprehension/Relocation TestAprehension/Relocation Test Sulcus SignSulcus Sign ImpingementImpingement Empty canEmpty can Scarf test. Scarf test. Also ACJAlso ACJ Neers TestNeers Test

Common ConditionsCommon Conditions

Shoulder CapsulitisShoulder Capsulitis Only 2% of shoulder problems. Gets ‘overdiagnosed’ Only 2% of shoulder problems. Gets ‘overdiagnosed’ Predisposing factorsPredisposing factors TraumaTrauma DiabetesDiabetes FemaleFemale Older Older CV diseaseCV disease Cerebro vascular diseaseCerebro vascular disease

Diagnosis Diagnosis – capsular pattern– capsular pattern

ManagementManagement

Depends on what stage they are in:Depends on what stage they are in: Stage 1Stage 1 – Pain is the main problem. – Pain is the main problem. Advice and drugsAdvice and drugs Stage 2-Stage 2- Stiffness is the main problem Stiffness is the main problem Physiotherapy to push ROMPhysiotherapy to push ROM Stage 3-Stage 3- Resolving. Resolving.

Condition normally self limits in approx 18/12.Condition normally self limits in approx 18/12.

DislocationDislocation

Very different management of young, older Very different management of young, older patient and 1st time dislocation.patient and 1st time dislocation.

Check neurology and vascularity Check neurology and vascularity Ideally always refer to Physiotherapy, but Ideally always refer to Physiotherapy, but

prioritise by range of movement, function prioritise by range of movement, function and recurrence.and recurrence.

InstabilityInstability

Can be inherent – hypermobile patientCan be inherent – hypermobile patient Traumatic – post dislocationTraumatic – post dislocation Repetitive – eg thrower, swimmerRepetitive – eg thrower, swimmer

ManagementManagement 1st line – Physiotherapy to retrain scapula 1st line – Physiotherapy to retrain scapula

mechanics and rotator cuff strength.mechanics and rotator cuff strength. 2nd line – If not successful refer to orthopod as 2nd line – If not successful refer to orthopod as

may well need surgery to stabilise may well need surgery to stabilise

ImpingementImpingement

PrimaryPrimary – how your made ie bony – how your made ie bony structure occupying sub acromial spacestructure occupying sub acromial space

SecondarySecondary – due to underlying instabililty – due to underlying instabililty eg young swimmer.eg young swimmer.

ManagementManagement PhysiotherapyPhysiotherapy

Rotator Cuff TenonopathyRotator Cuff Tenonopathy

- Can develop due to impingement, trauma - Can develop due to impingement, trauma or degeneration.or degeneration.

- Specific clinical tests and MRI/US - Specific clinical tests and MRI/US confirmconfirm

- Can develop into calcific tenonopathy- Can develop into calcific tenonopathy

ManagementManagement Partial tearPartial tear – Physio and/or injection – Physio and/or injection Full tearFull tear – Surgery – Surgery

Sub Acromial BursitisSub Acromial Bursitis

Can be acute eg due to fall onto shoulderCan be acute eg due to fall onto shoulder Overuse ie altered mechanics.Overuse ie altered mechanics.

ManagementManagement Responds well to injection.Responds well to injection. Physiotherapy to address altered Physiotherapy to address altered

mechanics if applicable mechanics if applicable

PhysiotherapyPhysiotherapy Exercises and manual techniques to increase ROMExercises and manual techniques to increase ROM Exercises to increase muscle strength, particularly the Exercises to increase muscle strength, particularly the

rotator cuffrotator cuff Exercises to correct scapula mechanics and improve Exercises to correct scapula mechanics and improve

stabilitystability Soft tissue techniques to surrounding musculature that Soft tissue techniques to surrounding musculature that

will tend to compensatewill tend to compensate Mobilisations to surrounding structures that may be Mobilisations to surrounding structures that may be

tight due to compensation, or as a contributing factor tight due to compensation, or as a contributing factor eg thoracic spineeg thoracic spine

TapingTaping Advice/EducationAdvice/Education Refer on appropriatelyRefer on appropriately

What You Can DoWhat You Can Do

Try to make a diagnosisTry to make a diagnosis Establish severity/disabilityEstablish severity/disability Posture EducationPosture Education Range of Movement exercisesRange of Movement exercises Thoracic mobility exercisesThoracic mobility exercises Rotator cuff strengthening Rotator cuff strengthening