2. 1 Injuries: Knee/Shoulder/Low Back

3. 2 My Objectives To teach you something interesting Review common injuries and how they relate to physiotherapy Compare private clientele vs CSST/SAAQ Update on research

4. 3 Outline The Shoulder The Knee Low Back Pain – Chronic Pain

5. 4 The Shoulder

6. 5 111 special tests known (and growing!) Common conditions Subacromial impingement Rotator cuff tear Frozen shoulder

7. 6 Subacromial impingement Impingement of R/C Bursa Biceps tendon Acute vs chronic Physio: find the cause

8. 7 Rotator cuff tear Usually traumatic Non-traumatic if tendinosis Surgery required if full- thickness tear Weak abd or ER Refer to physio and ortho Try to maximize strength

9. 8 Capsulitis Unknown cause Diabetics, post-stroke, post-breast CA Women 40-60 y/o Non-dominant > dominant Spontaneously resolve 1-3 yrs

10. 9 Capsulitis Capsular pattern ↓↓ ER > abd > IR Distensive arthrogram Up to 3 every 4 weeks Physio 2-3hrs after, x 2-3d Intensive physio to ↑ ROM

11. 10 The Knee

12. 11 The Knee Common conditions Ligament sprains – MCL – ACL – Meniscus Osteoarthritis Overuse – Patellar tendonitis – PFPS

13. 12 MCL injuries Usually recover well – Pes Anserine – +/- brace Early weight-bearing and ROM – Strengthening of medial knee muscles Ice, NSAIDS

14. 13 ACL injuries Traumatic – Sudden deceleration, rotation – Feel a “pop” Rapid effusion Complete tear ≠ surgery – Case-by-case – Good scarring + strength Must be managed properly – 80% OA after 3 years Refer to physio asap – ROM asap; maximize strength – +/- brace

15. 14 Meniscus injuries Traumatic or not Swelling 24-48hrs after Knee clicks, locks, or cannot fully flex Most reliable test: joint-line pain Tear ≠ surgery Physio – ↑ strength to give more stability – ROM if needed

16. 15

17. 16 Osteoarthritis Large joint Loss of ROM Deformity (varus) Effusion

18. 17 Osteoarthritis Age Genetics Obesity Previous injury Physio maximize strength, ROM To do, not to do

19. 18 Overuse injuries

20. 19 Quadrant assessment

21. 20 Overuse injuries Physio – Mobility – Flexibility – Strength Make sure everyone is doing their job

22. 21 Low Back Pain

23. 22 Diagnoses Lombalgie / low back pain Sciatalgie / sciatica Entorse lombaire / sprain Hernie Discale / herniated disc Spasme musculaire / muscle spasm

24. 23 Problem : The anatomical site or pathological process can be determined in only 20% of low back pain patients.

25. 24 Arthritis

26. 25 Disc Degeneration

27. 26 Arthritis Maintain mobility (ROM) Strengthening +++ Find and address imbalances

28. 27 Sciatica

29. 28 Sciatica Lumbar spine Piriformis Sacro-iliac joint Hip Nerve mobility

30. 29 Nerve root compression

31. 30 Sciatica Maintain mobility (ROM) Strengthening +++ Find and address imbalances Monitor pain, weakness

32. 31 Disc Herniation

33. 32

34. 33 Disc herniation Avoid repetitive or constant flexion – Crunches – Bike Extension protocol – Strengthen in this position

35. 34 Entorse Lombaire

36. 35 Entorse Lombaire To do Rest / stay active Ice NSAIDS Physio Not to do Push through the pain

37. 36 Muscle Spasm

38. 37 Sacro-Iliac Joint

39. 38 Muscle spasm Massage Light stretching (often) Reassess when spasm ↓

40. 39 Treatment priorities ↓ Pain – Treat the cause, not the symptoms – Differential diagnoses ↑ ROM Strengthening / stabilization Modalities ?

41. 40 Modalities Limited evidence on most modalities Should be used only as a small part of a treatment plan Pietrosimone et al, 2011 – TENS + exercise in knee OA D’Andrea Greve et al, 2009 – Shockwave no better than conventional physio in plantar fasciitis at 3 months

42. 41 Chronic Pain

43. 42 Explain Pain – Butler & Moseley

44. 43 Typical scenario Patient with LBP – Muscle spasm, hypomobility, weakness Treatment – Massage, stretch, mobilize, strengthen Re-evaluate – ↓ spasm, ↓ stiffness, stronger Subjectively Ø ∆ !

45. 44 Statistics 80-85% Private – RV 6-8 10-15% CSST/SAAQ – RV 30-35 5% Other

46. 45 Explain Pain – Butler & Moseley Pain is a normal response of what the brain perceives as a threat. Pain intensity is not always proportional to the amount of tissue damage. Pain perception depends on many sensory inputs.

47. 46 Explain Pain – Butler & Moseley When pain persists, the nervous system becomes hypersensitive. Neurons become more excitable and creates more synapses. Thoughts and beliefs contribute to the problem. Danger receptors in the tissues contribute less and less to the signals sent to the brain.

48. 47 A day in the life…

49. 48 Risk Factors for Chronic Pain Psychosocial factors are the best indicators of chronic pain. (Waddell et al 2003) Rapid return to daily activities decreases the risk of chronic pain. (van Tulder et al 2000)

50. 49 Risk Factors Age > 55 y/o Pain > 4 weeks ↓ mobility > 2 sites of pain Physical → very physical work 3 or + inorganic signs Previous treatments “Lifestyle” questionnaires

51. 50 Risk Factors for Chronic Pain The patient – Passive, pain=damage, “catastrophizing” The health care professional(s) – Different Dx, inactivity, medical terminology, prolonged work stoppage The employer – Litigation, rules regarding RTW Insurance company – Negative interactions, delayed 1 st payment

52. 51 C L I P Simple back pain – Lx or lumbosacral pain, mechanical – General health is good Back pain with neurological involvement – Pain radiating below the knee, numbness – SLR, neuro tests +ve Back pain with suspected serious pathology (red flag) – Violent trauma – Constant pain – Incontinence, pelvic pain – Hx of cancer

53. 52 C L I P There is no evidence of a causal relationship between x-ray findings, particularly degenerative changes, and simple back pain. (van Tulder 1997) LBP > 12 weeks the probability of RTW becomes < 60%.

54. 53 C L I P O-4 weeks : NSAIDS, muscles relaxants, remain active. 4-12 weeks : Progressive activities; exercises; multidisciplinary program. > 12 weeks : multidisciplinary program; exercises.

55. 54 CLIP – Modalities Acute – No evidence: u/s, diathermy – Not recommended: TENS Sub-acute – No evidence: u/s, diathermy, TENS Chronic – Not recommended: u/s, TENS

56. 55 Lambeek et al. (2010) Time until sustainable return to work was 88 days for the integrated group compared with 208 days of the usual care group.

57. 56 Rapid referral to physiotherapy Zigenfus et al 2000 3800 workers ↓ consultations, ↓ time off work Ehrmann-Feldman et al 1996 ↑ chance of RTW in less than 60 days Wand et al 2004 ↑ function, humor, QOL, overall health

58. 57 Radiological Testing Verify presence of “red flags” – Cancers, infections, cauda equina Challenge: 3% serious pathology vs 97% mechanical (benign)

59. 58 X-Rays “…patients randomly receiving radiographs, while more satisfied with their care, had more doctor visits, more disability and more likely to report LBP three months later compared to those not receiving radiographs.” – Kendrick et al 2001

60. 59 MRI Patients asymptomatic 83% disc desiccation (mod to severe) 64% disc bulging 56% diminished disc height 32% >1 disc protrusion 6% >1 disc extrusion – Jarvic et al 2001

61. 60 Stuart McGill If pt has good & bad days, there is potential for improvement.

62. 61

63. 62 Physiotherapy Decrease symptoms Increase pain free ROM Train proper muscular movement patterns Reinforce proper alignment of body structure Increase muscular strength and endurance Home exercises to prevent further injury

64. 63 Occupational therapy Restore function- Holistic Approach (Person, Environment & Occupation) Regain functional capacities Education – Posture – Proper movement mechanics – Energy conservation techniques – Joint Protection techniques – Office Ergonomics – Minimize influence of psychosocial barrier

65. 64 Week 0 to 4 symptoms management Week 4 to 6 Increase mobility & activity level Week 6 to week 8 strengthen & condition Week 8 to week 10 role related capacities Week 10 to week 12 Home program to prevent further injury PT + OT PT + OT + strengthening CBI Health Group Inter-Disciplinary Care Program PT + OT

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