Transcript Categories of low back pain

Occupational low back pain
Dr mehdi habibollahi
LBP definition
 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)
Low Back Pain epidemiology
 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.
Definitions
 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.
Categories of low back pain
 1-non specific LBP
 2- specific LBP
Categories of low back pain
 1- mechanical LBP
 2- non mechanical LBP
Differential: Mechanical LBP
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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 - Nonmechanical 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 – Visceral Disease:
 Pelvic organ involvement:
 Prostatitis
 Endometriosis
 Chronic Pelvic Inflammatory Disease
 Renal involvement
 Nephrolithiasis
 Pyelonephritis
 Perinephric Abscess
 Aortic Aneurysm
 Gastrointestinal involvement
 Pancreatitis
 Cholecystitis
 Penetrating Ulcer
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
Symptoms of Inflammatory back
pain
 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.
LOW BACK PAIN RISK FACTORS
 Low back pain is a multifactor problem
 It is a biopsychosocial problem
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
Occupational risk factors
Heavy Lifting
Twisting
Vibration
Reaching & Lifting
Carrying &
Lifting
Awkward Postures
Sitting or Standing
Slips, Trips & Falls
DIAGNOSIS
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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
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Inspection
Palpation
Range of motion
Strength testing
Neurologic examination
Special tests
Inspection
 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
Palpation
 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
Movements
 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 examination
 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
Straight leg raising
 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.
Look for further evidence of
neurological involvement
 Patella (L3-4) Achilles (L5- S1) reflexes
 Lower Limb power
 Test sensation to pin prick
Straight Leg Raising
•L4
•L5
•S1
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“Red Flags” in back pain
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
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management
Back Pain Management Tools
Medicine
Physical
Therapy
Care Manager
Pain
Management
Chiropractic Clinic
Neurosurgery
Neurology
EMG
Pain Management:
A More Flexible Approach*
 Different time frames
 Multiple therapies at one time
 Different starting points
Complementary
medicine, behavioral
programs,
adjuvant
meds
Corrective
surgery
Long-term
oral
opioids
Intrathecal
therapy or
neurostimulation
Physical
therapy,
TENS
NSAIDs,
over-the-counter
drugs
Chronic
Pain
Patient
Neuroablation
Management
 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.
Other treatment options
 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
Referral guidance
 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.
Prevention
Goal of the occupational medicine
Engineer Controls
 Eliminate (Engineer Hazard Out)
 Workplace design
 Tool design
 Preplan process
Eliminate the Lift
Use mechanical lifts
when possible
Administrative Controls
 Training of employees
and management
 Job rotation
Job Rotation
Rotate to non-lifting tasks
Pay Special Attention
1. Heavy lifting
2. Frequent lifting
3. Awkward lifting
Reduce Heavy Lifting
 60-70 pound wood pallet
 “Substitute”
 20 pound plastic pallet
Reduce Size of Box
Common sense controls
Reduce Heavy Lifting
Use mechanical assistance
Slide Instead of Lift
Reduce Heavy Lifting
Team Lifting*
Reduce Frequency
Mechanical Assistance
Reduce Frequency
Use Mobile Storage*
Reduce Awkward Lifting
Raise load mechanically
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 *
Size Up The Load
Make sure you can
lift the weight.
Test load by picking
up one end!
Proper Lifting
 Think defensively about your back
 Use common sense
 Follow good lifting techniques
 Keep load close to body
Lifting Power Zone
Baseball Strike 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
RETURN TO WORK
 I CANNOT RETURN TO WORK!!!!!!!
Disc herniation
PEARLS
Correlating Clinical and MRI
Scan Findings in Low Back Pain
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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.
Protrusion
Protrusion w/
migration
Protrusion w/
migration +
sequestration
Schmorl’s Nodes
Confusing “Spondy-” Terminology
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Spondylosis = “spondylosis deformans” = degenerative spine
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Spondylitis = inflamed spine (e.g. ankylosing, pyogenic, etc.)
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Spondylolysis = chronic fracture of pars interarticularis with
nonunion (“pars defect”)
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Spondylolisthesis = anterior slippage of vertebra typically
resulting from bilateral pars defects
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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