Screening for specialist referrals in the cervical and lumbar spine: Presentation by Katy Street and Spine surgeon Mr Dean Mistry
Physiotherapist Katy and Mr Mistry presented at the National GP Conference in Rotorua 2014 and 2016 on screening for specialist referral in the cervical and lumbar spine.
Click on the PDF below for a great overview of this topic including;
• Review serious pathologies in the cervical and lumbar spine
• When to refer patients?
• Case presentations
Knee Osteoarthritis (OA)
If you are suffering from arthritis that is slowing you down and stopping you from doing the things you love.. help could be just a phone call away. There is now a lot of good quality research to support the use of manual therapy ('hands on' physio), exercise, and strength training to improve function, reduce pain and to reduce disability in people with arthritis.
At Auckland Physiotherapy we can help you get back on track by prescribing personalised home exercise programmes. We generally recommend a combination of manual therapy and exercise based rehabilitation to reduce your pain and get you more active again. All our treatments are based on your own personal goals and ability.
For more information check out the research article below to read a summary of how Physiotherapy can help your arthritis.
If you have any questions feel free to give us a call on 09 366 4480, we would love to hear from you.
Massive Rotator cuff tears
Due to the design of the human shoulder joint, shoulder injuries are extremely common. The shoulder is a ball and socket joint, but unlike the hip joint (which is a stable ball and socket joint) there is a very large ball sitting on a small relatively flat socket. This design allows movement in all directions and substantial flexibility.
The rotator cuff is the name for the group of muscles that stabilise and move the shoulder joint. The rotator cuff comprises of 4 muscles; supraspinatus, infraspinatus, subscapularis and teres minor. It is common for one or two of these muscle to become torn during injury or as part of aging. These muscles work together and you can usually still use your shoulder if you have a rotator cuff tear. However, if you have a massive tear this may be a different story.
In a massive tear the rotator cuff muscles may become completely torn and retracted. In this case you may be unable to lift your arm. This is not only painful but significantly limits someones ability to use their arm during activities of daily living. Until recently it was thought that surgery such as a reverse total shoulder joint replacement was the treatment of choice. However, this surgery often relieved pain but did not restore shoulder function.
Fortunately, our collegues in England have come up with a strengthening programme which trains another shoulder muscle (the deltoid) to function to lift the arm. This programme will not restore normal shoulder function but can significantly improve pain and function. The programme takes a minimum of 12 weeks and patients generally start to see improvements after 6-12 weeks. Results thus far have been very promising with all patients in the studies seeing improvements after 12 weeks.
We do advise that you discuss the programme with a physiotherapist as they can confirm your diagnosis, track your changes and ensure you are doing the exercises correctly. They may also be able to advise you on other techniques to manage your pain.
LOW BACK PAIN SUBGROUPING
It is well known that low back pain has poor correlations to abnormal imaging findings, therefore clinical prediction rules are helpful. Treatment subgroups are obtained through a thorough subjective and objective assessment and are based on Clinical Prediction for Success of Interventions for Managing Low Back Pain (Herbert et al, 2008). Subgrouping has been shown to significantly improve success rates for treatment. We have described subgrouping for low back pain patients briefly below for your interest.
1.EXTENSION EXERCISE GROUP:
Studies have found that subgrouping patients dependent on directional preference considerably improves outcomes (Long et al, 2004; Long & May, 2008). Patients that fit into this group have an extension directional preference (worse with sitting/bending/rising, better with walking/standing), and often symptoms below bottom. The most common cause of symptoms in this subgroup is posterior disc prolapse or “derangement”. McKenzie repeated movement assessment is used to confirm whether or not patients will respond to conservative management. If the disc derangement is reducible (ie. the annular wall is intact) the patient’s symptoms will centralize with repeated movements during assessment. Ainaa et al, 2004 found that 91% of patients who displayed the centralization phenomenon had a competent annulus. If the annular wall has been breached and disc material has been extruded the symptoms will not centralize during repeated movement assessment, but may peripheralize. In this event patients can be treated conservatively if they do not want to be assessed for surgical management. In these cases management focuses on maintenance of range of motion/function and avoidance of any nerve root adherence (McKenzie & May, 2003).
2.FLEXION EXERCISE GROUP:
To be included in this group patient’s either spinal imaging shows spinal stenosis, they have a clinical diagnosis of spinal stenosis, or have a flexion directional preference (worse with walking/standing, better with sitting/bending). Cook et al, 2011 use five clinical findings to diagnosis spinal stenosis – 1) bilateral symptoms; 2) leg pain more than back pain; 3) pain during walking/standing; 4) pain relief upon sitting; 5) Age >48 years. They found that if a patient has ≥4/5 positive findings you can diagnosis spinal stenosis with a specificity of ≥98%. Patients with facet joint pathology also benefit from flexion based exercises and diagnosis is made by exclusion of disc or SIJ pathology (Laslett et al, 2005). No test other than anesthetic facet joint blocks has specificity high enough to rule in facet joint pathology at present. Facet joint pathology can however be ruled out using the extension rotation test (Cook & Hegedus, 2011; Laslett et al, 2006).
3. STABILISATION EXERCISES:
These exercises have been found to be most beneficial for patients <40yrs, with an active straight leg raise of >91 degrees, positive prone instability test, and aberrant movement patterns. When these findings are present the success of intervention increases from 33 to 67% (Hicks et al 2005). Clinical findings of a lack of hypomobility with intervertebral testing plus flexion>53 can also be used to predict radiological instability (Fritz et al, 2005).
Manipulation is generally utilized for patients who have no symptoms below knee, have had symptoms for less than16 days duration, have a clinical finding of hypomobility in a spinal segment, score <19 on the fear avoidance beliefs questionnaire, and have hip internal rotation of >35 degrees. When these findings are present success rates of manipulation have been shown to increase from 45 to 95% (Flynn et al, 2004; Childs, 2004).
This is rarely required but may be beneficial for patients with symptoms distal to buttock who have nerve root signs present, and who peripheralise with extension based exercises. These patients may have a large disc prolapse with a crossed SLR sign. There is no strong research to support this, but studies have reported clinical usefulness (Fritz et al., 2007).
OTHER DIAGNOSES WE SCREEN FOR ALSO INCLUDE:
Sacroiliac joint pain:
SIJ symptoms can be diagnosed with 2/4 (thigh thrust, distraction, compression, and sacral thrust) or 3/6 positive tests (includes Gaenslen test on each side). Note that thigh thrust is the most sensitive test and distraction is the most specific, therefore these tests are generally performed first (Laslett, 2005). Patients with SIJ symptoms often complain of unilateral symptoms past the buttock and back pain below L5. They often have a history of trauma or may be post partum.
Chronic pain / non-specific low back pain:
Chronic pain syndrome is commonly associated with psychosocial factors. These factors can have a large impact on ongoing low back pain, and can also influence the diagnostic accuracy of clinical tests (Laslett, 2006). We look for signs of fear avoidance, poor coping skills, and catastrophizing during our assessment. We also use outcome measures to help us screen for yellow flags, such as the ACC acute low back pain questionnaire, the fear avoidance beliefs questionnaire and other relevant screening tools. Addressing these factors at an early stage helps to prevent any unnecessary time of work and will reduce the risk of symptoms becoming chronic.
If you would like any of the articles to read then please let us know and we can email or send them out to you.