Topic.9 Low Back and Neck Pain.pdf

Unit 11 Low Bak and Neck Pain 1 Prevalence • Low Back pain is reported by 60% people at some time in their life • 2022 - 13,2 million GP consultations • 202- Cost to SNHS : 398 millions 2 1 Low Back Pain • Age 20 - 55 years • Lumbosacral, buttocks, thighs • “Mechanical” pain without irradiat...

Unit 11 Low Bak and Neck Pain 1 Prevalence • Low Back pain is reported by 60% people at some time in their life • 2022 - 13,2 million GP consultations • 202- Cost to SNHS : 398 millions 2 1 Low Back Pain • Age 20 - 55 years • Lumbosacral, buttocks, thighs • “Mechanical” pain without irradiation 3 LOW BACK PAIN . CALSSIFICATION 1. Acute or sub-acute low back pain with mobility deficits. 2. Acute/subacute/chronic low back pain with impaired coordination of movement 3. Acute/subacute/chronic low back pain with radiating pain LL 4. Acute/subacute/chronic low back pain with related cognitive or affective tendencies. 5. Chronic low back pain GPC Low back pain APTA 2012 4 2 GPC Low back pain APTA 2021 5 GPC Low back pain APTA 2021 6 5 6 3 GPC Low back pain APTA 2021 7 GPC Low back pain APTA 2021 8 7 8 4 Low Back Pain. Resume Measures not recommended: Complete rest. Immobilising orthoses if there are no fractures. Acute cases. EDUCATION. Unloading and mobilisation manoeuvres. Stretching. Peripheral and segmental pain treatment: TENS, IF, massage therapy. Depending on the aetiology: thermo/criotherapy. . Chronic cases: EXERCISE and EDUCATION. Global techniques and lumbopelvic stabilisation. Transversus abdominis training ++++. 9 9 Rest or Activity • RCTs show bed rest for 2-7 days is worse than ordinary activity • RCTs show advice to continue ordinary activity gives better results than the traditional “let pain be your guide” advice” ..if pain don´t move ...wrong • Aim is to use symptomatic measures to control pain and so allow activity 10 5 Exercises • Evidence available at present, : specific back exercises produce clinically significant improvement in acute LBP • Core Control exercises may produce short term symptomatic improvement in acute LBP • Strong theoretical arguments for exercise programs by 6 weeks 11 Core Control Lumbar concept of stability " Optimal and correct control of the column and the pelvic region to ensure efficient transfer and summation of forces through a segment , so that is made with maximum precision and safety of the dynamic activity alignment" . • Panjabi (1994, 1995), • Jull et al (1994), • Richardson et al (1991, 1995, 2001) • Hides et al (1997, 2001), • Hodges (2000). 12 12 6 Risk factors for chronicity • Previous history low back pain : 3 x year • Nerve root involvement • Poor physical fitness • Self rated health poor • Heavy smoking • Psychological distress • Disproportionate illness behaviour • Low job satisfaction 13 NECK PAIN 1/3 of the population, at least 1 episode throughout his life. 10% in both sexes. + In women(2/1) . Often associated with work activity : Madrid 2013: Temporary Incapacity , 6.7 % of all causes. Average INACTIVITY : 50 days !!!!!!!. Blanco M et al. Características de la incapacidad temporal de origen músculoesquelético en la CAM durante un año. Rev Esp Reumatol 2020; 27: 48-53. 14 14 7 NECK PAIN AETIOLOGY • Mechanical origin :postural disorders • Compressive radiculopathy . • Osteophytosis. • inflammatory , infectious and neoplastic conditions Roig Escofet D. , 1970 ; Mathews JA. Neck pain, 1994; Swezey RL. Chronic neck pain.1996 15 15 CERVICAL PAIN : CLASSIFICATION Neck pain with mobility deficit. Neck pain with movement coordination disorders Neck pain with headache (cervicogenic). Neck pain with radiating pain. Fritz & Brennan 2007, Childs 2008, GPC Neck Pain APTA 2017. 16 16 8 Neck pain with mobility deficit. Common symptoms: • Central and/or unilateral neck pain. • Limitation of neck movement reproducing symptoms. • May have pain in the shoulder girdle or upper extremities. Limitation of cervical ROM. Reproduction of pain at the end of active and passive ranges. Decreased cervical and thoracic segmental mobility. Neck and referred pain reproduced with provocation of the segmental movement or musculature involved. In patients with subacute or chronic pain, motor control and strength deficits in cervical-scapulothoracic musculature. 17 GPC Neck Pain APTA 2017. 17 Neck pain with movement coordination disorders Common symptoms: ▪ Traumatic mechanism. ▪ May present with shoulder girdle pain or MMSS. Assessment: ▪ Positive pressure algometry. Presence of PGM’s. ▪ Cervical Joint Position error ▪ Deficits in cervical muscle strength and endurance. ▪ Dizziness / nausea. ▪ Neck pain during movement which worsens at the limits. ▪ Distress. ▪ Neck pain and referred pain, reproduced by provocation of the affected cervical segments. GPC Neck Pain APTA 2017. 18 18 9 Neck pain with headache (cervicogenic). Cervical Joint Position Error (JPE) • Laser overhead. • Target 90 cm above the laser. • Adjust to the centre of the target. • Close eyes and make a maximum movement in one parameter. • Return to starting position with eyes closed. • Repeat three times. • Obtain arithmetic mean. • Positive: displacement ≥ 7cm (4,5º) Revel 1994, Roren 2009 19 19 Neck pain with headache (cervicogenic). Common symptoms: Assesment: ▪ Neck pain, preferably unilateral, non-continuous and associated (referred) with headache. ▪ Reproduced headache with provocation of cervical segments . ▪ The headache is precipitated or aggravated by neck movements, or sustained positions/postures. ▪ Limited cervical ROM. Decreased strength, endurance and coordination deficit of the cervical musculature. GPC Neck Pain APTA 2017. 20 20 10 Neck pain with radiating pain. Common symptoms: Assesment: ▪ Neck pain with radiating pain (thready and lacerating) to the involved upper extremity. • Neck pain and radiating pain reproducible or relieved ➢ Nerve mobility test (ULNT), ➢ Spurling test, ➢ Cervical distraction, ▪ Dermatoma of the upper • Cervical ROM decreased extremity with paraesthesia • Neurological deficits in the involved or numbness, and weakness roots: sensibility, strength and reflexes. of the muscles of the corresponding myotome. 21 GPC Neck Pain APTA 2017. 21 PROGRESSION OF CERVICAL PAIN Acute Subacute Chronic The condition is usually very irritable. Moderate irritability. Mid-range movements worsening with endrange spinal movements (with tissue resistance). Low degree of irritability. Worsens with sustained end-range spinal movements or positions (overpressure on tissue resistance). Pain at rest. Pain on mid-range spinal movements (before tissue resistance). GPC Neck Pain APTA 2017. 22 22 11 RED FLAGS AND YELLOW FLAGS CRITERIA Immediate referral pathology (red flags) Cervical myelopathy. Tumors Upper cervical ligament instability. Inflammatory or systemic pathology. Vertebral artery insufficiency. Secondary conditions (yellow flags) Attitudes and beliefs. Behaviours. GI pathology under treatment. Cardiovascular pathology under treatment. Childs 2004. 23 23 ALGIAS VERTEBRALES CERVICALGIA. VALORACIÓN. • • • • • • Inspección: +++ fonación, respiración, deglución... Palpación: Buscamos PGM o zonas álgicas. BA: global y por segmentos: – C0-C1, C1-C2, C2-C7. – ATM. – E-C-Clv. Test de provocación. Estudio neurológico: pares craneales y plexo braquial. Catastrofismo y prognosis: Neck Disability Index, Fear-Avoidance Beliefs Questionnaire 24 24 12 TREATMENT Acute. • Chronic. Thoracic manipulation/mobilisation. Cervical mobilisation. ADD : Cervical ROM work, stretching and isometrics. • Coordination exercises, proprioceptive, strengthening and graded exposure. Cervical and scapular strength and endurance training. • Others: dry needling, electrotherapy, Education: Active lifestyle. 25 GPC Neck Pain APTA 2017. 25 TREATMENT II Subacute and Chronic. Acute. • • • Education: importance of staying active. Education: importance of promoting active behaviour. • Painless cervical ROM work at home. Postural work. Active, isometric, low-load cervical exercise. • Supervised exercise: motor control. • Monitoring evolution. • Reduce the use of immobilisation GPC Neck Pain APTA 2017. 26 26 13 TREATMENT III Chronic. Acute. • Mobilisation: C1-C2 Sustained• Cervical and thoracic mobilisation and manipulation. Natural Apophyseal Glides • Active cervical, scapular and thoracic (SNAG's) exercise, with neuromuscular emphasis (motor control, biofeedback). • Exercise: C1-C2 auto-SNAG. • Multimodal treatment including both of the above. 27 GPC Neck Pain APTA 2017. 27 TREATMENT IV Acute. Subacute. Exercise based on SN mobilisation, tensioning. Low intensity ELECTRO. Possible need for short-term use of cervical distractor collar . GPC Neck Pain APTA 2017. Chronic. • Education: reinforcing active participation and exercise. • Combined exercise, based on stretching and strengthening. • Cervical and thoracic mobilisation. • Intermittent traction. 28 28 14