EAST CUMBRIA VOCATIONAL TRAINING SCHEME

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EAST CUMBRIA VOCATIONAL TRAINING SCHEME

• MUSCULOSKELETAL 1
• BACK AND NECK PROBLEMS

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BACK PAIN

• Lower back pain affects over 24 million people in
  the UK every year!
• 90 per cent of adults will suffer neck and back
  pain in their life.
• Affects young as well as old.
• Over 1 million people registered disabled with
  back pain.
• Cost to the economy is billions of pounds.

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SPINAL ANATOMY

• Vertebrae
• Disc
• Ligaments
• Spinal cord and nerve roots
• Muscles

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Vertebral Disc

• Annulus fibrosus
• Nucleus pulposus
• Disc bulge/prolapse
• Nerve supply

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SIMPLE BACKACHE

• Onset 20-55 years
• Lumbosacral, buttock and thigh pain
• Mechanical pain
• Patient generally well

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NERVE ROOT PAIN

• Unilateral leg pain gt back pain
• Radiates to foot or toes
• Para/anaesthesia in same area
• SLR reproduces leg pain
• Localised neurological signs
• Piriformis Syndrome

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SERIOUS SPINAL PATHOLOGY

• Non mechanical pain
• Onset age lt20 and gt55
• Thoracic pain
• Past medical history
• Unexplained weight loss
• Structural deformity
• Widespread neurological signs

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Spinal Stenosis

• Neurogenic claudication
• Cramping pain in the legs
• Check distal pulses for vascular problem
• If spinal pain increases on walking and decreases
  on sitting.

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Red Flags for Cauda Equina

• Perianal/perineal anaesthesia
• Sphincter disturbance
• Gait disturbance
• Major motor weakness (knee extension/ankle
  plantar flexion/foot dorsiflexion)
• IMMEDIATE REFERRAL

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Red flags for Spine fracture

• Major trauma (RTA, Fall from height)
• Minor trauma osteoporosis

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Red flags for cancer or infection

• Age over 50 and new back pain
• Age under 20
• History of cancer
• Fever/chills/unexplained weight loss
• Recent bacterial infection
• IV drug abuse
• Immune suppression
• Severe night pain or pain that worsens when supine

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Yellow Flags

• These are psychosocial factors which have been
  shown to be indicative of long term chronicity or
  disability.
• Can often be influenced dramatically by how the
  patient is dealt with in the early stages of a
  problem.

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Yellow Flags

• Negative attitude that back pain is severely
  disabling or harmful.
• Fear avoidance behaviour.
• Expectation that passive rather than active
  treatment will help.
• Depression or low morale and social withdrawal.
• Social or financial problems.
• Reduced activity levels.

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Management of Back Pain

• Check for Red Flags and serious spinal pathology.
• If present refer immediately

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Management of Back Pain

• Advice on how to manage the problem.
• Relative rest
• Pain control ice/analgesia
• Movement
• Graduated return to function-work/hobbies
• Occupational issues
• PHYSIOTHERAPY if no change at 2 week review. No
  Change at 3 months refer to Spinal Unit.

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Management of Leg Pain/Sciatica

• If patient has acute sciatica try strong
  analgesia physiotherapy
• Review at 4-6 weeks and if no improvement refer
  to Spinal unit.

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Management of Chronic Back Pain

• Hands on physiotherapy may be useful if the
  patient has a flare up of a chronic problem but
  not routinely.
• Acupuncture
• Spinal fitness programme exercises, increase
  aerobic fitness, gym
• Educate.
• Benefits make take 3 months to materialise.

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Treatment/Surgery

• spinal epidural,
• micro-discectomy,
• interbody fusion,
• nucleoplasty,
• disc replacement,
• facet joint injections.

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PHYSIOTHERAPY

• What do we do?
• First appointment takes about 1 hour and the aim
  is a differential diagnosis.
• Assessment
• Subjective
• Objective
• Treatment

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Case Study.

• Female 38
• March 08 developed left low back and referred
  pain
• Oct 08 developed shift and problems extending
  back
• Off work
• MRI scan Dec 08
• Epidural suggested

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Case Study

• Jan 09 sat in bath felt pop
• Decreased sphincter control
• Numbness left lower limb
• Pain
• A/E scan disc rupture
• Admitted to Newcastle two level discectomy

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Cervical Spine

• Anatomy similar to the rest of the spine but
  vertebral artery runs through vertebral foramen.
• Affects women more than men
• Most of the population will experience neck pain
  at some point.
• Related to posture, computer work, repetitive
  neck movements, sustained neck flexion.
• Wear and tear

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Cervical Spondylosis

• Mainly affects C4-7
• Due to degenerative changes in the vertebral
  joints
• Develops in older people
• Can lead to radiculopathy
• Can lead to myelopathy

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Neck and Radicular pain

• Disc bulge/Degenerative changes
• Nerve root irritation or compression
• SYMPTOMS
• Pain in neck /or upper limb
• Loss of power
• Changes in sensation

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Neck and Radicular Pain

• Refer if
• Radicular pain not settling in 6 weeks
• Progressive neurological changes
• Any features suggestive of cervical myleopathy

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Cervical Myleopathy

• Often no neck pain
• Pins and needles both hands
• Weakness in arms or legs
• Loss of balance

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Whiplash Injury/Acute Neck Sprain

• Acceleration/deceleration of head on neck
• Direction of impact affects outcome
• Poorer prognosis if neck rotated at time of
  impact
• Affects 23 of people in RTA
• Can occur with trips/slips and head injury
• Usually affects soft tissue structures

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Quebec Whiplash Score

• Grade 0 no neck pain, stiffness, or any physical
  signs
• Grade 1 complaints of neck pain, stiffness or
  tenderness only but no physical signs
• Grade 2 neck pain decreased range of motion and
  point tenderness in the neck.
• Grade 3 decreased range of motion plus
  neurological signs such as decreased deep tendon
  reflexes, weakness, insomnia and sensory
  deficits.
• Grade 4 neck complaints and fracture or
  dislocation, or injury to the spinal cord.

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Symptoms

• Ache/stiffness worse day after accident
• Usually neck/shoulder region
• Can affect thoracic and lumbar spines
• Dizziness
• Headaches
• Pain on swallowing
• Sleep disturbance
• Problems concentrating

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Management

• Explain injury and reassure patient
• Advice re relative rest, ice, posture and pain
  control
• Keep mobile within limits of discomfort
• Try to regain full range of mobility as soon as
  possible
• BY
• Neck and shoulder mobilising exercises
• If not settling in 4 weeks refer to physiotherapy

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Assessment Treatment

• Same principle as the lumbar spine
• Check shoulder girdle and upper limb movements
• Manual therapy, acupuncture, exercises to
  mobilise and stabilise the neck
• Electrotherapy
• Advice, education and reassurance
• Rehabilitation programme for chronic pain

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Case Study

• RTA 29/7/08 rear end collision stationary at
  impact
• Developed neck pain immediately and right
  referred pain immediately
• GP advised rest - nil else
• A/E 3/7 later
• XRAY NAD given paracetamol
• Wrist pain - put in plaster
• Weepy, anxious, problems ADL, housebound

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Case Study

• Sept 08 assessment spinal injection suggested
• Oct 08 Medico-legal assessment and ref to physio
  minimal help
• Dec 08 reassessment offered settlement but as in
  pain asked for more physio

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Case Study

• Right neck/shoulder pain, elbow pain
• Numbness right hand
• Min arm/hand function
• Neck mobility ½ range

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Thoracic Pain

• Check if referred from the neck- common to the
  medial border of the scapula.
• Check other organs
• Check for red flags

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Thoracic Pain

• Assessment is as for the Lumbar spine.
• The thoracic spine can refer pain to the anterior
  chest and round the rib cage.
• If localised musculoskeletal problem will respond
  well to manual therapy and exercises.
• Osteoporotic collapse

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Thoracic Outlet Syndrome

• involves compression at the superior thoracic
  outlet that affects the brachial plexus and/or
  the subclavian artery and vein.
• Compression can be positional or static.
• Causes are often RTA, use of computers in non
  ergonomic postures, anatomical anomalies

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Thoracic Outlet Syndrome

• Adson's Test With the patient in a sitting
  position, hands resting on thighs, the examiner
  palpates both radial pulses as the patient
  rapidly fills the lungs by deep inspiration and,
  with breath held, hyperextends the neck and turns
  the head toward the 'affected' side. If the
  radial pulse on that side is decidedly or
  completely obliterated, the result is considered
  positive.

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Conclusion

• Educate patients
• Reassure patients
• Consider red and yellow flags
• Adequate pain control
• Discourage bed rest
• Recommend gradual return to normal activities
• Refer to physiotherapy.