Occupational low back pain

Dr mehdi habibollahi

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 (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 without leg pain (sciatica) (Manek and Macgregor, 2005)

LBP definition

Back pain is second to the common cold as a cause of lost days at work .

About 80% of people have at least one episode of low back pain during their lifetime.

The most common age groups are the 30s - 50s.

It usually feels like an ache, tension or stiffness in back.

Low Back Pain epidemiology

Annual prevalence is 15-20% 2nd most common symptomatic reason for visits

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

Most common cause of disability in people younger than 45.

1% of population is chronically disabled due to back problems.

Low Back Pain epidemiology

Acute LBP: Back pain <6 weeks duration Sub acute LBP: back pain >6 weeks but <3

months 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.

Definitions

1-non specific LBP 2- specific LBP

Categories of low back pain

1- mechanical LBP 2- non mechanical LBP

Categories of low back pain

Lumbar Strain or Sprain (70%) Degenerative processes of disc and facets

(10%) Herniated disc (4%) Osteoporotic Compression Fracture (4%) Spinal Stenosis (3%) Spondylolisthesis (2%) Traumatic Fractures (<1%) Congenital disease (<1%)

Severe Kyphosis or Scoliosis Transitional Vertebrae

Spondylolysis Internal Disc Disruption/Discogenic Back Pain Presumed Instability

Differential: Mechanical LBP

Neoplasia (0.7%) Multiple Myeloma Metastatic Carcinoma Lymphoma and Leukemia Spinal Cord Tumors Retroperitoneal Tumors Primary Vertebral Tumors

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) Paget Disease

Differential - Nonmechanical LBP:

Pelvic organ involvement: Prostatitis Endometriosis Chronic Pelvic Inflammatory Disease

Renal involvement Nephrolithiasis Pyelonephritis Perinephric Abscess

Aortic Aneurysm Gastrointestinal involvement

Pancreatitis Cholecystitis Penetrating Ulcer

Differential – Visceral Disease:

Symptoms of Benign LBP

Dull and achy quality Diffuse aching with

associated muscle tenderness

Exacerbated with movement

Relieved with rest in recumbent position

No radiation, paresthesias

No dermatomal pattern Pt. is able to find a

position of comfort DTR are within normal

limits

Gradually in onset.

Throbbing in nature.

Morning stiffness.

Exacerbates by rest and relived by activity.

Intensity increase in night and early morning.

It is chronic backache.

Symptoms of Inflammatory back pain

Low back pain is a multifactor problem It is a biopsychosocial problem

LOW BACK PAIN RISK FACTORS

NON OCCUPATIONAL genome Poor posture Poor conditioning Weakness Stiffness Faulty body mechanics 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 FACTORS

BACK PAIN RISK FACTORS

Heavy Lifting

Sitting or Standing

Awkward PosturesCarrying & Lifting

Twisting

Reaching & Lifting

Slips, Trips & Falls

Vibration

Occupational risk factors

DIAGNOSIS

Specific diagnosis is impossible in 80% Differentiation of muscle, joint, ligamentous

structures Mechanical versus systemic disorders is possible Categorize by clinical symptoms Subtyping will improve therapy

Physical Examination

Inspection Palpation Range of motion Strength testing Neurologic examination Special tests

Ideally with back and legs exposed. Posture ?Scoliosis ? Kyphosis Skin café-au-lait spots, hairy patches, signs

of psoriasis. Prolapsed disc may cause a lumbar scoliosis,

flattening or reversal of normal lumbar lordosis

Inspection

Check for bone tenderness – this may indicate serious pathology eg infection, fracture, malignancy

With patient leaning forwards check for tenderness between the vertebral spines and paraspinal muscles. Eg prolapsed disc, mechanical back pain

SI joints Palpable steps may indicate

spondylolisthesis

Palpation

Flexion – schobers test <5cm = abnormal Extension – pain and restricted extension in

prolapsed disc and spondylolisthesis Lateral Flexion Rotation – seated, movement is thoracic

Movements

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.

Hip and SI joint examination

Consider non musculoskeletal causes of back pain

Abdominal and Cardiovascular examination

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 dorsiflex foot, pain or paraesthesia aggravated.

Straight leg raising

Patella (L3-4) Achilles (L5- S1) reflexes Lower Limb power Test sensation to pin prick

Look for further evidence of neurological involvement

Straight Leg Raising

•L4•L5•S1

Age < 15 or > 50 Fever, chills, UTI Significant trauma Unrelenting night pain; pain at rest Progressive sensory deficit Neurologic deficits

Saddle-area anesthesia Urinary and/or fecal incontinence Major motor weakness

Unexplained weight loss Hx or suspicion of Cancer Hx of Osteoporosis Hx of IV drug use, steroid use,

immunosuppression Failure to improve after 6 weeks conservative

tx

“Red Flags” in back pain

management

Back Pain Management ToolsCare

Manager

Physical Therapy

Chiropractic Clinic

NeurosurgeryPain Management

NeurologyEMG

Medicine

Different time frames Multiple therapies at one time

Different starting points

Pain Management:A More Flexible Approach*

NSAIDs,over-the-counterdrugs

Physical therapy,TENS

Corrective surgery

Long-termoralopioids

Intrathecaltherapy orneurostimulation

NeuroablationChronic PainPatient

Complementary medicine, behavioral

programs,adjuvant

meds

Initially rest - perhaps with a board under the bed - was recommended for back pain. The new guidelines recommended active rehabilitation. The new principles of management involve keeping the patient active and giving analgesia to facilitate this.

Give information, reassurance and advice. DO NOT prescribe bed rest. 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.

Management

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

Other treatment options

If red flags suggest a serious condition, refer with appropriate urgency. 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 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.

Referral guidance

Goal of the occupational medicine

Prevention

Eliminate (Engineer Hazard Out)

Workplace design

Tool design

Preplan process

Engineer Controls

Use mechanical lifts when possible

Eliminate the Lift

Training of employees and management

Job rotation

Administrative Controls

Rotate to non-lifting tasksJob Rotation

1. Heavy lifting

2. Frequent lifting

3. Awkward lifting

Pay Special Attention

60-70 pound wood pallet

“Substitute”

20 pound plastic pallet

Reduce Heavy Lifting

Common sense controls

Reduce Size of Box

Use mechanical assistance

Reduce Heavy Lifting

Slide Instead of LiftSlide Instead of Lift

Team Lifting* Reduce Heavy Lifting

Mechanical Assistance

Reduce Frequency

Use Mobile Storage*

Reduce Frequency

Raise load mechanically

Reduce Awkward Lifting

Add Handles

Awkward Lifting

Rearrange Storage

Awkward Lifting

Mechanical assistance

Stacker – stacks up to 12 feet high

Awkward Lifting

To reduce twisting – use conveyors *

Awkward Lifting

Make sure you can lift the weight.

Test load by picking up one end!

Size Up The Load

Proper Lifting

Think defensively about your back

Use common sense

Follow good lifting techniques

Keep load close to body

Baseball Strike Zone

Lifting Power Zone

Lifting Techniques

Lift with your legs, not your back

Place your feet close to the object

Center yourself over the load

Lifting Techniques

Bend your knees

Get a good hand hold

Lift straight up smoothly

Don’t Twist or Turn

Feet facing the lift

Keep it steady

No twisting/turning

Know Your Path!

Is your path clear?

Are there any holes?

Are there any spilled liquids?

Check your footing.

Set it Down Safely

Just as critical to back safety as lifting

Bend knees slowly

Let legs do the work

Don’t let go of the load until it is secure on the floor

Push vs. Pull

If the object is on rollers, push

Pushing puts less strain on your back

Uses largest muscle group

I CANNOT RETURN TO WORK!!!!!!!

RETURN TO WORK

Disc herniation

PEARLS

Correlating Clinical and MRI Scan Findings in Low Back Pain

.

Indications for MRI lumbar spine

• Progressive neurological deficit- weakness most important

• Cauda equina syndrome- bowel/bladder retention/incontinence, saddle anesthesia

• No significant improvement with 4-8 weeks of conservative therapy/PT

• Severe, intractable pain• Red flags- fever, weight loss, previous

cancer, IV drug use

Lumbar Disc Anatomy

Disk herniation grading

Disc protrusion patterns

• Central disc protrusion• Lateral disc protrusion• Far lateral/Foraminal disc protrusion

Central Disc Protrusion

Central Disc Protrusion General Characteristics

• Frequent cause of recurrent mechanical/axial low back pain in the <50 year-old

• Frequently injured/aggravated by flexion• Pain is frequently worse with coughing,

sneezing, laughing or valsalva• Pain is frequently worse with prolonged

sitting/long car ride• Normal lower extremity neuro exam

MRI scan slide #1

MRI scan slide #2

MRI scan slide #3

MRI scan slide #4

Lateral disc protrusion

Lateral disc protrusion general characteristics

• Lower extremity radicular pain worse than low back pain

• Lower extremity pain follows radicular and dermatomal pattern

• Pain is generally worse with coughing and sneezing, valsalva maneuvers

• Pain is generally worse with flexion and sitting• L3-4 disc-L4 radicular pain, L4-5 disc- L5

radicular pain, L5-S1 disc- S1 radicular pain

Lateral disc protrusion continued

• Careful lower extremity neuro exam may be able to identify specific nerve root lesion

• Straight leg raising usually reproduces radicular pain

• May respond to oral steroids or transforaminal epidural steroid injections

• Persisting pain may need discectomy to relieve lower extremity pain

MRI scan slide #5

MRI scan slide #6

Far lateral/foraminal disk protrusion

Far lateral/foraminal disk protrusion general characteristics

• Lower extremity radicular pain much worse with standing and walking, usually improved with sitting

• Lower extremity pain follows radicular and dermatomal pattern

• Usually not worsened by coughing or sneezing• Careful lower extremity neuro exam may be able

to identify specific nerve root involvement• Diskectomy can be difficult because of facet joint

blocking exposure

MRI scan slide #8

Spinal stenosis

Lumbar Spinal Stenosis

Disc bulge, facet hypertrophy and flaval ligament thickening frequently combine to cause central spinal stenosis

MRI scan slide # 12

Spinal stenosis

• Low back pain with radiation to bilateral buttocks and lower extremities which is worse with prolonged standing and walking

• Neurogenic claudication may need to rule out vascular claudication first

• PT for stabilization and flexibility• Caudal epidural steroid injections• Surgical decompression for resistant cases

MRI scan slide #13

Lumbar Spine – AP View

Lumbar Spine – Lateral View

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/

migration

Protrusion w/migration +

sequestration

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 nonunion (“pars defect”)

• Spondylolisthesis = anterior slippage of vertebra typically resulting from bilateral pars defects

• Pseudospondylolisthesis = “degenerative spondylolisthesis” (spondylolisthesis resulting from degenerative disease rather than pars defects)

Spondylolysis / Spondylolisthesis

Spondylolysis

Spondylolisthesis

Spondylolysis Stress fracture of pars interarticularis Repetitive flexion/extension LBP with occasional radicular

symptoms past buttocks and thighs, no neurologic deficits

Spondylolisthesis “Slipping of vertebrae” 75% have LBP Restrictive ROM

Degenerative Disc (and Facet Joint) Disease

Degenerative Disc (and Facet Joint) Disease

Foraminal stenosis

Thickening/Buckling of Ligamentum Flavum