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Do you screen Spine in the presence of Shoulder Pain?

Shoulder Pain is considered to be one of the most commonly encountered problems in Musculoskeletal (MSK) area. Epidemiology suggests that nearly 10 to 16 per 100 patients suffer from shoulder pain (Winters et al; 99). Once present, it is proven to be persistent and recurrent, with 50% still unresolved after 18 months (Croft et al; 96). Thus suggesting that shoulder pain is one of the leading cause of referral to Physiotherapy (Winters et al; 99).

There are various ways by which clinicians diagnose Shoulder Pain. One of them is use of Ultrasound and Scans. Various changes like bursal thickening, AC Joint OA and Supraspinatus tendinosis in 96% of asymptomatic population (Girish et al; 14), and Rotator Cuff tears in nearly 65% of asymptomatic population (Mingawa et al; 13) has been noted. Another common method to diagnose shoulder pain is by using special tests. Poor accuracy and poor inter-rater reliability of various special tests has been shown (Hughes et al; 08, Gadogan et al; 11). Lack of uniformity in diagnostic labelling of shoulder pain, suggests use of an approach which relies on common characteristics that can easily be reproduced and are valid (Schellingerhout et al; 08). Majority of the times, cervical spine screening is not considered as a part of assessment for shoulder pain patients (Walker et al; 18) and this could affect the time of discharge (Abady et al’17), which could have a huge impact on shoulder pain epidemiology and its outcome.

Mechanical Diagnosis and Therapy (MDT)/ McKenzie Method is the system of assessment and management, which utilises postures, positions and movements to classify patients into subgroups (McKenzie and May’00). In MDT, classification guides treatment. Primary aim/goal in the MDT system is screening of the spine in the presence of shoulder pain.

Cervical spine can give referred pain to shoulder (Menon & May’13; Bogduk’00). Various structures around the cervical spine could give pain across the shoulder. Using the MDT system, it is shown that nearly 1/3 rd of the shoulder pain originates from the cervical spine (Abady et al’17), implying the importance of screening the spine first. The reliability of classifying the patients with shoulder pain of cervical origin is excellent (Abady et al’14). The essence of the system is to give a direction specific exercise which brings lasting change in shoulder pain and all shoulder movements (Abady et al’17; Long et al’04). Here, if cervical spine is found to be the symptom generator for shoulder, the exercise is focused on cervical spine. It was also noted that the patients who demonstrated positive shoulder special tests during assessment, later, post directional specific cervical spine exercise demonstrated negative special tests for shoulder pain where the symptom generator was the cervical spine.

The McKenzie assessment and treatment system is a low technology, effective and valid tool that helps to differentially diagnose the shoulder and cervical sources of symptoms. The system may have a significant impact on the quality of life as well as health care utilization for majority of the patients with shoulder pain.