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

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

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

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

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.

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

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