Transcript Occupations & back pain

LOW BACK PAIN
By Fardad Ahmadzadeh ; MD
Occupational & environmental medicine specialist
Introduction
LBP is common health complaints.
LBP is second most common symptomatic reason
for visit physicians.
LBP is major cause of disability, compensation,
limitation, and economic loss.
70-80%
adult will experience a significant
episode of LBP at least once in lives.
Rapid rises in reported disability due to low
back pain in the 1970s and 1980s led some
authors to describe an ‘epidemic’ of low back
pain.
More recent data have shown a 34% decrease
in the number of low back pain claims and
compensation payments for low back pain in
the US between 1987and 1995.
Anatomy
Causes of low back pain
 Common :
 Intervertebral joint sprain
 Stress Fx of pars interarticularis (spondylolysis)
 Sacroiliac joint injury
 Para spinal muscle trigger points
 Less Common :
 Spondylolisthesis
 Lumbar instability
 Spinal canal stenosis
 Fibromyalgia
 Nerve root compression (disc herniation)
Personal risk factors
 Age
 Gender
 Overall level of physical fitness
 Lumbar mobility & strength
 Tobacco use
 Non-work physical activity
 PMH of low back disorders
 Structural abnormalities
Workplace risk factors
 Lifting
 Forceful movements
 Whole body vibration ( 4-6 Hz )
 Awkward postures (bending &
twisting)
 Heavy physical work
 Prolonged sedentary work
Mechanical stresses of the spine
Psychosocial factors
 Job satisfaction
 Personality traits
 Job control
 Low decision latitude
 Social support at work
The most important immediate goal of the history is
to determine if a patient has pain related to a serious
local condition .
Fracture
Malignancy
Infection
Neurologic disorder requiring surgical evaluation(cauda
equina syndrome)
‘Red flags’ which indicate the possible presence of a disorder more
serious than non-specific LBP.
Red flags include :
History of trauma
Age >50 or <20,
History of malignancy or immune compromise,
Pain which worsens when supine,
Recent onset bowel or bladder dysfunction,
Saddle anesthesia, and
Severe or progressive neurologic deficit of the lower
extremities.
Other history which may suggest a medically serious
cause of low back pain includes :
Age over 70
History of corticosteroid use (suggesting compression fracture),
Unexplained weight loss (suggestive of malignancy),
IV drug use
Recent urinary tract infection (suspicion for spinal infection)
Pain of over 1 month duration
Failure to improve with conservative therapy
History of prolonged early morning back pain and stiffness,
especially in persons under age 40
1. Is the pain caused by a systemic disease?
2. Is there neurologic compromise that may require surgical
evaluation?
3. Is there social or psychological distress that may amplify or
prolong the pain?
4. What occupation does he follow?
Occupations & back pain
Construction laborers
Carpenters
Agricultural workers
Truck &Tractor operators
Nursing personnel
Maids
Biopsychosocial assessment
Bio
 Review diagnostic triage
- nerve root problem
- serious spinal pathology
 CBC, ESR & plain radiography
Psycho
 Attitude and beliefs about back pain
-fear avoidance beliefs about activity and work
-personal responsibility for pain & rehabilitation
 Psychological distress and depressive symptoms.
 Illness behavior
Social
Family
- attitudes and beliefs about the problem
- reinforcement of disability behavior
Work
- physical demands of job
- job satisfaction
- other health & non-health problems
causing time off or job loss
Definitions
 Low back pain (LBP):
 Specific LBP: specific cause can be found (disease,
injury)
 Non Specific LBP: specific cause can not be
found(80%of all)
Non Specific LBP
 Acute NSLBP : Back pain =<7 days.
 Sub acute NSLBP :Back pain >1 weeks but <4 weeks.
 At-risk NSLBP : Back pain >4 weeks but <12 weeks.
 Chronic NSLBP :Back pain >12 weeks but <6 months.
 Chronic pain syndrome :Back pain > 6 months.
Diagnosis
 NSLBP
- Age 20-55
- Lumbosacral, buttocks & thighs mechanical
pain (varies with time & physical activity)
- Patient medically well
- Prognosis good (90% recovery within 6 weeks)
Diagnosis
 Lumbar nerve root pain compression (sciatica)
- unilateral leg pain worse than low back pain
- Pain generally radiates to foot or toes
- Numbness and paresthesia in dermatom
- Never root irritation signs
Reduced SLR with leg pain
- Motor, sensory or reflex change
Limited to one nerve root
- Prognosis reasonable(50% recover within 6 weeks)
Red Flags for possible neurologic disorders
 Difficulty with micturition
 Saddle anesthesia
 Loss of anal sphincter tone or fecal incontinence
 Widespread(>1 nerve root) or progressive motor
weakness or gait disturbances
 Sensory level
Cauda equina syndrome is indicated by laxity of the anal sphincter, perineal or
perianal sensory loss, major motor weakness or paraparesis, and hyperactive or
hypoactive reflexes.
Inflammatory disorders
 Gradual onset
 Marked morning stiffness
 Persisting limitation of spinal movements in all
directions
 Peripheral joint involvement
 Iritis, skin rashes (psoriasis), colitis
 Family history
Lumbosacral Spine Exam
 Inspection
 Palpation
 Range of Motion
- Flexion
- Extension
- Lateral Bending
Neurologic Exams
60 degrees
25 degrees
25 degrees
Sciatic Stretch Tests
SLR (Lasègue test)
Crossed SLR
BRAGGARD
meta-analysis reported the accuracy as:
SLR:
sensitivity 91%
specificity 26%
Cross SLR:
If raising the opposite leg causes pain (cross straight
leg raising):
sensitivity 29%
specificity 88%
Trendelenburg's test
Laboratory tests &
Imaging
Laboratory & Imaging
X-rays:

no routine evaluation within the first 4 weeks
unless a red flag and high index of suspicion.

CBC & ESR: If symptoms >4 weeks
MRI: persistent or progressive neurological deficits and

an exam consistent with a nerve root impingement
asymptomatic adults, prevalence of disk herniation of 2240%.
Spinal Graphy
 Collapse
 Sclerosis
 Spondylolysis
Normal X-rays of spine
Collapse
 Metastasis
 Infection
 Osteoporosis & Osteomalasia
 Trauma
 Eosinophylic granoloma
Infection
Osteomyelitis&diskitis due to salmonella
Osteoporosis & Osteomalacia
Trauma
Sclerosis
 Metastasis
 Malignant Lymphoma
 Paget Disease
 Hemangioma
Metastasis
Spondylolysis
 Metastasis
 Multiple myeloma
 Malignant Lymphoma
 Infection
Trauma
Spondylolisthesis
Spondylolisthesis (oblique view)
Scottish dog
Ankylosing Spondylitis
Lumbar Disc Herniation
 Ages affected (Most common 30 -50 )
 Spinal levels affected (Most common L4-5 & L5-S1
 Progressive degeneration of disc nucleus pulposus
 Protrusion of disc (most commonly posterior-lateral)
 Other Changes: Spondylosis
 Spur Formation
 Disc space narrowing
 Facet joint degeneration
Lumbar Disc Herniation
 Usually insidious onset
 Acute trauma may have preceded symptoms
 Low back pain (deep aching)
 Aggravated by activity, coughing, and sneezing
 Relieved by rest
 Localized to affected disc
 Intense Radicular Pain
 Referred pain to iliac crest or buttock
 Radiation of pain down posterior thigh and calf
 Pain may radiate to foot
Lumbar Disc Herniation
Parestesia
• Numbness or tingling in distal extremity
Restricted low back range of motion
Pain exacerbated by bending to affected side
Local tenderness and muscle guarding
Posturing to avoid pressure on disc
• Bent away from affected side
• Hip and knee flexed on affected side
Nerve Root Tension Tests (SLR)
NSLBP Management
 Early return to work & work modification
 Efforts to alter lifestyle factors
 NSAIDs
 Muscle relaxants
 Opioid analgesics
 Antidepressants
 Manipulation : wait for 2-3 weeks
 Miscellaneous
Herniated disk Management
 In the absence of cauda equina syndrome or progressive
neurologic deficit, conservative management (at least a
month).
 Early treatment parallels the treatment of NSLBP with
the caveat that the safety and effectiveness of spinal
manipulation are not clear.
 Epidural corticosteroid injection
 In patients who still have significant pain or neurologic
deficits after 4 weeks discectomy should be considered.
Risks for Chronic Disability
 Total work loss in past 12 months
 Previous episodes of back pain Radiating leg pain
 Reduced SLR
 Signs of nerve root involvement
 Poor physical fitness
 Multiple previous musculoskeletal complaints.
 Psychological distress and depressive symptoms
 Low job satisfaction
 Alcohol, drugs, cigarettes..
Elements of Prevention
 organization of work flow
 job design/redesign (including environment)
 eliminate heavy MMH
 decrease MMH demands
 reduce stressful body movements
 improve environmental conditions
 pre-placement procedures, where necessary
 Training
Force on the spine
Good lifting technique
 Test the load; get help if needed.
 Plan the lift and the path you will take.
 Keep the load as close to the body as possible.
 Pivot and move your feet with a broad base of support to
avoid twisting.
 Try to keep your movements smooth and coordinated.
 Keep the back in a straight line from “head to tail”.
Good lifting process
THANKS
FOR
ATTENTION