Occupational low back pain Occupational low back pain Dr mehdi habibollahi
LBP definition LBP definition
Low back pain was defined as pain and discomfort Low back pain was defined as pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain ( i i ) (O kh di l ) (sciatica) (Omokhodion et al, 2002),
and as “pain limited to the region between the lower margins of the 12th rib and the glutei folds” with or margins of the 12th rib and the glutei folds with or without leg pain (sciatica) (Manek and Macgregor, 2005)
Low Back Pain epidemiology Low Back Pain epidemiology
Back pain is second to the common cold as
p gyp gy
Back pain is second to the common cold asa cause of lost days at work .
About 80% of people have at least one About 80% of people have at least oneepisode of low back pain during theirlifetime.
The most common age groups are the 30s ‐50s.
It usually feels like an ache, tension orstiffness in back.
Low Back Low Back Pain epidemiology Pain epidemiology o aco ac a ep de o ogya ep de o ogy
Annual prevalence is 15-20% 2nd most common symptomatic reason for
visits to primary care physiciansvisits to primary care physicians. 90% of all episodes will resolve within 6 weeks
regardless of treatment 90% of all persons disabled for more than 1
year will never work again without intense intervention
Low Back Pain epidemiology Low Back Pain epidemiology o ac a ep de o ogyo ac a ep de o ogy
Most common cause of disability in people Most common cause of disability in people younger than 45.
1% of population is chronically disabled due to back problemsto back problems.
DefinitionsDefinitions
Acute LBP: Back pain <6 weeks duration Sub acute LBP: back pain >6 weeks but <3
months durationmonths duration Chronic LBP: Back pain disabling the patient
from some life activity >3 months Recurrent LBP: Acute LBP in a patient who has
had previous episodes of LBP from a similar location.
Categories of low back painCategories of low back pain
1‐non specific LBP 1‐non specific LBP 2‐ specific LBP
Categories of low back painCategories of low back pain
1‐mechanical LBP 1‐mechanical LBP 2‐ non mechanical LBP
Differential Diagnosis of Low Back Pain
Differential: Mechanical LBPDifferential: Mechanical LBP
Lumbar Strain or Sprain (70%) Degenerative processes of disc and facets (10%) Herniated disc (4%) Herniated disc (4%) Osteoporotic Compression Fracture (4%) Spinal Stenosis (3%)
S d l li th i ( %) Spondylolisthesis (2%) Traumatic Fractures (<1%) Congenital disease (<1%)
h i li i Severe Kyphosis or Scoliosis Transitional Vertebrae
Spondylolysis Internal Disc Disruption/Discogenic Back Pain Presumed Instability
Differential Nonmechanical LBP:Differential ‐ Nonmechanical LBP:
Neoplasia (0.7%) Multiple Myeloma Metastatic Carcinoma Lymphoma and Leukemia Spinal Cord Tumors Retroperitoneal Tumors Primary Vertebral Tumors
I f i ( %) Infection (0.01%) Osteomyelitis Septic Discitis Paraspinous Abscess Epidural Abscess Shingles
Inflammatory Arthritis (0.3%) – note HLA‐B27 association. Ankylosing Spondylitis Reiter Syndrome Inflammatory Bowel Disease
Scheuermann Disease (osteochondrosis)P Di Paget Disease
Differential Visceral Disease:Differential – Visceral Disease:
Pelvic organ involvement: Prostatitis Endometriosis Chronic Pelvic Inflammatory Disease
Renal involvement Nephrolithiasisp Pyelonephritis Perinephric Abscess
Aortic Aneurysmy Gastrointestinal involvement
Pancreatitis Cholecystitisy Penetrating Ulcer
Symptoms of Benign LBPSymptoms of Benign LBP
Dull and achy quality No radiation Dull and achy quality Diffuse aching with
associated muscle
No radiation, paresthesias
No dermatomal patterntenderness
Exacerbated with movement
Pt. is able to find a position of comfortDTR ithi lmovement
Relieved with rest in recumbent position
DTR are within normal limits
Symptoms of Inflammatory back pain
Gradually in onset.y
Throbbing in nature.
M i tiff Morning stiffness.
Exacerbates by rest and relived by activity.
Intensity increase in night and early morning.
It is chronic backache.
LOW BACK PAIN RISK FACTORSLOW BACK PAIN RISK FACTORS
Low back pain is a multifactorial problem Low back pain is a multifactorial problem It is a biopsychosocial problem
Sociodemographic factors such as age, gender, education ,and marital status have all been identified as risk factors for developing or prolonging episodes of common LBP.9,13 Similarly,y,
occupational factors such as work satisfaction, autonomy, supervisor empathy, monotonous or repetitive tasks, and prolonged exposure to heavy physical activities includingp g p y p y g lifting, carrying, and manual handling, have also been identified as risk factors for common LBP.2,14‐16 General health factors including tobacco use, body weight, physicalhealth factors including tobacco use, body weight, physical activity levels, and the presence of systemic, physical, or psychological comorbidities have also been implicated in LBP.6,9,17 Socioeconomic factors including income level, LBP.6,9,17 Socioeconomic factors including income level, involvement in worker’s compensation, personal injury, or other litigation, and availability of supplemental disability insurance are also thought to impact the severity or duration insurance are also thought to impact the severity or duration of common LBP.9,16 Genetic factors have also been identified that may increase the risk for development of lumbar degenerative disc disease which may lead to LBP disc disease, which may lead to LBP.
BACK PAIN RISK FACTORSBACK PAIN RISK FACTORS
NON OCCUPATIONAL genome Poor posture Poor conditioning Weakness Weakness Stiffness Faulty body mechanics
P k l i h bi Poor work, sleep, or eating habits Smoking Psychosocial‐‐bad attitude, stress, emotional Other pathology (i.e. fibromyalgia, chronic fatigue or pain
syndrome, osteoporosis)
BACK PAIN RISK FACTORSOccupational risk factors
Heavy Lifting
TwistingTwisting
Vibration
Carrying &
Reaching & Lifting
Awkward PosturesCarrying & Lifting
Sitting or Standing Slips, Trips & Falls
DIAGNOSISDIAGNOSIS
Specific diagnosis is impossible in 80%p g p Differentiation of muscle, joint, ligamentous structures Mechanical versus systemic disorders is possible Categorize by clinical symptoms Subtyping will improve therapy
Physical Examination
Inspection Inspection Palpation Range of motiong Strength testing Neurologic examination Special tests
Inspection Inspection
Ideally with back and legs exposed Ideally with back and legs exposed. Posture ?Scoliosis ? Kyphosis Skin café‐au‐lait spots, hairy patches, signs of p , y p , gpsoriasis.
Prolapsed disc may cause a lumbar scoliosis, fl tt i g l f l l b l d iflattening or reversal of normal lumbar lordosis
PalpationPalpation
Check for bone tenderness – this may indicate Check for bone tenderness this may indicate serious pathology eg infection, fracture, malignancy
With patient leaning forwards check for With patient leaning forwards check for tenderness between the vertebral spines and paraspinal muscles. Eg prolapsed disc, mechanical back painback pain
SI joints Palpable steps may indicate spondylolisthesis
MovementsMovements
Flexion – schobers test <5cm = abnormal Flexion – schobers test <5cm = abnormal Extension – pain and restricted extension in prolapsed disc and spondylolisthesis
Lateral Flexion Rotation – seated, movement is thoracic
Hip and SI joint examinationHip and SI joint examination
Check hip joints for pain and limitation – internal Check hip joints for pain and limitation – internal rotation is often the earliest sign hip disease.
FABER test. Place foot across knee of opposite leg, apply gentle pressure to knee and opposite ASIS. Pain in SI area may indicate a problems with these joints.
Abdominal and Cardiovascular examination
Consider non musculoskeletal causes of back pain Consider non musculoskeletal causes of back pain
Straight leg raisingStraight leg raising
Looking for nerve root irritation L5‐ S1‐ Looking for nerve root irritation L5‐ S1‐ Patient supine, passively raise leg with knee extended, stop when back or leg pain. <45o positive
Lower leg until the pain disappears then dorsiflexfoot, pain or paraesthesia aggravated.
Look for further evidence of neurological involvement
Patella (L3‐4) Achilles (L5‐ S1) reflexes Patella (L3‐4) Achilles (L5‐ S1) reflexes Lower Limb power Test sensation to pin prickp p
Straight Leg RaisingStraight Leg Raising
•L4L4•L5•L5•S1•S1
Age < 15 or > 50“Red Flags” in back pain
Age < 15 or > 50 Fever, chills, UTI Significant traumag Unrelenting night pain; pain at rest Progressive sensory deficit Neurologic deficits Saddle‐area anesthesiaU i d/ f l i ti Urinary and/or fecal incontinence
Major motor weakness Unexplained weight loss Unexplained weight loss Hx or suspicion of Cancer Hx of Osteoporosisp Hx of IV drug use, steroid use, immunosuppression Failure to improve after 6 weeks conservative tx
Role of X rays (Radiology)Role of X‐rays (Radiology)
Usually unnecessary and not helpful Usually unnecessary and not helpful Plain X‐ray: Age>50 yearsg No improvement after 6 weeks Other worrisome findings
MRI: After 6 weeks if have sciatica
Radiographic Diagnosis:Discussion will focus on Mechanical and
Non-mechanical etiologies.
The following are some General indications for what imaging option you choose.what imaging option you choose.
Plain Radiography:Plain Radiography:
Most common spinal imaging test. Low cost and ready availability.p g g y y AP and Lateral views demonstrate alignment, disc and vertebral
body height, and gross assessment of bone density and architecture. Sacroiliitis occurs early in Ankylosing spondylitis and is readily detected by plain films.y y p
Agency for Health Care Policy and Research Guidelines currently do not recommend routine oblique and spot lateral views. Get oblique if you suspect spondylolysis; good for pars interarticularis. Get flexion and extension films if you suspect lumbosacral instability. Get flexion and extension films if you suspect lumbosacral instability. Get angled sacral views if you suspect ankylosing spondylitis.
Caution using lumbar radiography repeatedly, may damage the gonads, particularly in reproductive age females.
Plain Films Weaknesses:Plain Films ‐Weaknesses:
Neoplasm ‐ ~50% trabecular bone loss prior to becoming visibleNeoplasm 50% trabecular bone loss prior to becoming visible Infection – similar, relatively late appearance of change Inability to distinguish acute from chronic compression fractures
Di h i ti Disc herniation Spinal Stenosis
CT + MRI:CT + MRI:
CT Strengths: MRI Strengths: Axial bony anatomy Cortical bony destruction Facet degenerative changes Disk herniation Soft tissue evaluation in patients who
Better soft tissue contrast than CT Visualization of disc Ligamentous pathology Vertebral marrow and spinal canal Neoplasm
Soft tissue evaluation in patients who cannot undergo MRI secondary to claustrophopia or implanted metal.
CT Myelography good for bony causes of spinal stenosis
CT Weaknesses:
Infection (may be the best modality with gadolinium enhancement)
Disc Herniation Spinal stenosis Nerve root impingement
CT Weaknesses: Discogenic disease (nucleus pulposis
rupture, annulus fibrosis tears) Spinal canal contents Discitis
MRI Weaknesses: Cannot detect cortical bone Common degenerative disk disease and
disease of facet joints – too nonspecific Fractures seen best in the axial plane
b l l Subtle annular tears
Bone Scans:Bone Scans:
While plain films, CT, and MRI detect bony morphology, bone p , , y p gy,scintigraphy detects biochemical changes in bone.
Most useful in detecting the age of compression fractures. Old fractures will appear “cold” while new fractures will appear
“hot”.hot . Very useful for determining primary bony tumors (usually benign,
i.e. osteoid osteoma, osteoblastoma, aneurysmal bone cyst, and osteochondroma) degree of metastasis and certain infections (infectious spondylitis in particular – gallium67 when compared with (infectious spondylitis in particular gallium67 when compared with MRI had better specificity and sensitivity).
Useful for subtle fractures and infarction. Useful for metabolic bone disease such as Paget Disease.
Discography:Discography:
Controversial method for diagnosing discogenic pain.Controversial method for diagnosing discogenic pain. Used to delineate whether suspicious discs found on MRI were
the true cause of the patients’ pain. However the use of discography as an indicator of general disk However, the use of discography as an indicator of general disk
disease has been found to be suspect. One study by Holt, et al., found 38% positive rate when they tested healthy subjects. Can we utilize a test with that degree of inaccuracy? Recent studies we utilize a test with that degree of inaccuracy? Recent studies have shown a lower degree of specificity but the jury is still out.
Good for posterolateral annulus fibrosis tears when CT is used to visualize the tears with contrast enhancement.visualize the tears with contrast enhancement.
Management Management
Back Pain Management ToolsBack Pain Management ToolsCare ManagerMedicine g
Physical Therapy NeurosurgeryPain
Management
Chiropractic Clinic
g
lChiropractic Clinic NeurologyEMG
Pain Management:A More Flexible Approach*
Different time frames Multiple therapies at one time
A More Flexible Approach*
Different starting points Corrective surgery
Long-termoral
Complementary medicine, behavioral
Physical
oralopioids
Intrathecaltherapy or
programs,adjuvant
meds
therapy,TENS
neurostimulation
NSAIDs,over-the-counterdrugs
NeuroablationChronic PainPatient
ManagementManagement
Initially rest ‐ perhaps with a board under the bed ‐was y p precommended for back pain. The new guidelines recommended active rehabilitation. The new principles of management involve keeping the patient active and giving analgesia to facilitate thisanalgesia to facilitate this.
Give information, reassurance and advice. DO NOT prescribe bed rest. Advise to stay as active as possible Advise to stay as active as possible. Prescribe regular pain relief (paracetamol, non‐steroidal
anti‐inflammatory drugs) and consider a short course of muscle relaxants.usc e e a a ts
Other treatment optionsOther treatment options
acupuncture – fine needles are inserted into your skin acupuncture – fine needles are inserted into your skin at certain points on the body
exercise classes – aerobic exercise, muscle strengthening and stretching
manual therapy – your back is massaged or manipulated manipulated
Chiropractor and osteopaths.
Referral guidanceReferral guidance
If red flags suggest a serious condition, refer with appropriate g gg , pp purgency. This means immediately for CES.
If there is progressive, persistent or severe neurological deficit, refer for neurosurgical or orthopaedic assessment, preferably to be seen within 1 week.
If pain or disability remain problematic for more than a week or two, consider early referral for physiotherapy or other physical therapy.
If, after 6 weeks, sciatica is still disabling and distressing, refer for neurosurgical or orthopaedic assessment, preferably to be seen neurosurgical or orthopaedic assessment, preferably to be seen within 3 weeks.
If pain or disability continue to be a problem despite appropriate pharmacotherapy and physical therapy, consider referral to a multidisciplinary back pain service or a chronic pain clinic.multidisciplinary back pain service or a chronic pain clinic.
Prevention Prevention
Engineer Controls Eliminate (Engineer Hazard Out)
Engineer Controls
Workplace design
Tool design
Preplan process
Eliminate the Lift
Use mechanical lifts
Eliminate the Lift
Use mechanical lifts when possible
Administrative ControlsAdministrative Controls
Training of employeesand management
Job rotation
Job RotationRotate to non‐lifting tasks
Job Rotation
Pay Special Attention
1 Heavy lifting
Pay Special Attention
1. Heavy lifting
2. Frequent lifting
3. Awkward lifting
Reduce Heavy Lifting 60‐70 pound wood pallet
Reduce Heavy Lifting7 p p
“Substitute”
20 pound plastic pallet
Reduce Size of BoxCommon sense controls
Reduce Size of Box
Reduce Heavy LiftingUse mechanical assistance
Reduce Heavy Lifting
Slide Instead of LiftSlide Instead of Lift
Reduce Heavy Lifting Team Lifting*
Reduce Heavy Lifting
Reduce FrequencyMechanical Assistance
Reduce Frequency
Reduce FrequencyUse Mobile Storage*
Reduce Frequency
Reduce Awkward LiftingRaise load mechanically
Reduce Awkward Lifting
Awkward LiftingAdd Handles
Awkward Lifting
Awkward LiftingRearrange Storage
Awkward Lifting
Awkward Lifting Mechanical assistance
Awkward Lifting
Stacker – stacks up to12 feet high
Awkward LiftingTo reduce twisting – use conveyors *
Awkward Lifting
Size Up The LoadMake sure you can
Size Up The Loady
lift the weight.
Test load by pickingup one end!
Proper Lifting
Think defensively about your backy y
Use common sense
Follow good lifting techniques
Keep load close to bodyp y
Lifting Power Zone
Baseball Strike Zone
Lifting Power Zone
Baseball Strike Zone
Lifting Techniques
Lift with your legs not your Lift with your legs, not your back
Place your feet close to the Place your feet close to the object
Center yourself over the Center yourself over the load
Lifting Techniques
d k Bend your knees
Get a good hand hold Get a good hand hold
Lift straight up smoothlyt st a g t up s oot y
Don’t Twist or Turn
Feet facing the lift Feet facing the lift
Keep it steady p y
No twisting/turning
Know Your Path!
Is your path clear?
Are there any holes?
Are there any spilled liquids? Are there any spilled liquids?
Check your footing.
Set it Down Safely
Just as critical to back safety lif ias lifting
Bend knees slowly
Let legs do the work
Don’t let go of the load until it Don t let go of the load until it is secure on the floor
Push vs. Pull
If the object is on rollers, j ,push
Pushing puts less strain on your back
Uses largest muscle group
RETURN TO WORKRETURN TO WORK
I CANNOT RETURN TO WORK!!!!!!! I CANNOT RETURN TO WORK!!!!!!!
Disc herniation Disc herniation
PEARLS PEARLS
Lumbar Spine – AP View
Lumbar Spine – Lateral View
Source: CW Kerber and JR Hesselink, Spine Anatomy, UCSD Neuroradiology
Adapted from: “Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology,” 2001.
ProtrusionProtrusion w/
migrationProtrusion w/migration +migration g
sequestration
Spinal Stenosis
Disc bulge facet hypertrophy Disc bulge, facet hypertrophy and flaval ligament thickening f tl bi t frequently combine to cause central spinal stenosis
Lumbar Spinal Stenosis
Disc bulge, facet hypertrophy and flaval ligament thickening frequently combine to cause central spinal stenosisstenosis
Central Disc Protrusion
Schmorl’s Nodes
Confusing “Spondy-” Terminology
• Spondylosis = “spondylosis deformans” = degenerative spine
• Spondylitis = inflamed spine (e.g. ankylosing, pyogenic, etc.)
• Spondylolysis = chronic fracture of pars interarticularis with p y y pnonunion (“pars defect”)
• Spondylolisthesis = anterior slippage of vertebra typically• Spondylolisthesis = anterior slippage of vertebra typically resulting from bilateral pars defects
P d d l li th i “d ti d l li th i ”• Pseudospondylolisthesis = “degenerative spondylolisthesis” (spondylolisthesis resulting from degenerative disease rather than pars defects)than pars defects)
Spondylolysis / Spondylolisthesis
Spondylolysis
SpondylolisthesisSpondylolisthesis
SpondylolysisSpondylolysis Stress fracture of pars interarticularisp Repetitive flexion/extension LBP with occasional radicular symptoms past buttocks and thighs, no neurologic deficits
SpondylolisthesisSpondylolisthesis “Slipping of vertebrae”pp g 75% have LBP Restrictive ROM
Degenerative Disc (and Facet Joint) Disease
Degenerative Disc (and Facet Joint) Disease
Foraminal stenosis
Thickening/Buckling of Ligamentum Flavum