Low Back Pain and Shoulder Pain

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Low Back Pain and Shoulder Pain

• PRACTICAL SESSION FOR GP REGISTRAS
• Georgina Taft
• Chartered Physiotherapist

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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.

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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

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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

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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

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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.

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To Spinal Orthopod

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

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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

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CORE STABILITY

• What is it?
• Misconceptions
• Not core strength but this has its place.
• If chronic pain needs to be very specific

.
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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?

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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

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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?

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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

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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

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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.

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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.

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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

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Impingement

• Primary how your made ie bony structure
  occupying sub acromial space
• Secondary due to underlying instabililty eg
  young swimmer.
• Management
• Physiotherapy

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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

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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

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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

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What You Can Do

• Try to make a diagnosis
• Establish severity/disability
• Posture Education
• Range of Movement exercises
• Thoracic mobility exercises
• Rotator cuff strengthening