[Company Name]

1
LOW BACK PAIN
By Fardad Ahmadzadeh MD Occupational
environmental medicine specialist
2
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.

3

• 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.

4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
Anatomy
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
Etiology
20
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)

21
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

22
Workplace risk factors

• Lifting
• Forceful movements
• Whole body vibration ( 4-6 Hz )
• Awkward postures (bending twisting)
• Heavy physical work
• Prolonged sedentary work

23
Mechanical stresses of the spine
24
Psychosocial factors

• Job satisfaction
• Personality traits
• Job control
• Low decision latitude
• Social support at work

25
History
26

• 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.
27

• Red flags include
• History of trauma
• Age gt50 or lt20,
• 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.

28

• 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

29

• Is the pain caused by a systemic disease?
• 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?
30
Occupations back pain

• Construction laborers
• Carpenters
• Agricultural workers
• Truck Tractor operators
• Nursing personnel
• Maids

31
Biopsychosocial assessment

• Bio
• Review diagnostic triage
• - nerve root problem
• - serious spinal pathology
• CBC, ESR plain radiography

32

• 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

33

• 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

34
Diagnosis
35
(No Transcript)
36
Definitions

• Low back pain (LBP)
• Specific LBP specific cause can be found
  (disease, injury)
• Non Specific LBP specific cause can not be
• found(80of all)

37
Non Specific LBP

• Acute NSLBP Back pain lt7 days.
• Sub acute NSLBP Back pain gt1 weeks but lt4
  weeks.
• At-risk NSLBP Back pain gt4 weeks but lt12 weeks.
• Chronic NSLBP Back pain gt12 weeks but lt6 months.
  
• Chronic pain syndrome Back pain gt 6 months.

38
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)

39
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)

40
Red Flags for possible neurologic disorders

• Difficulty with micturition
• Saddle anesthesia
• Loss of anal sphincter tone or fecal incontinence
• Widespread(gt1 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.

41
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

42
Physical examination
43
Lumbosacral Spine Exam

• Inspection
• Palpation
• Range of Motion
• - Flexion 60 degrees
• - Extension 25 degrees
• - Lateral Bending 25 degrees
• Neurologic Exams

44
Sciatic Stretch Tests

• SLR (Lasègue test)
• Crossed SLR
• BRAGGARD

45
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
46
(No Transcript)
47
(No Transcript)
48
(No Transcript)
49
(No Transcript)
50
Trendelenburg's test
51
Laboratory tests Imaging
52
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 gt4 weeks
• MRI persistent or progressive neurological
  deficits and an exam consistent with a nerve root
  impingement
• asymptomatic adults, prevalence of disk
  herniation of 22-40.

53
Spinal Graphy

• Collapse
• Sclerosis
• Spondylolysis

54
Normal X-rays of spine
55
Collapse

• Metastasis
• Infection
• Osteoporosis Osteomalasia
• Trauma
• Eosinophylic granoloma

56
Infection

• Osteomyelitisdiskitis due to salmonella

57
Osteoporosis Osteomalacia
58
Trauma
59
Sclerosis

• Metastasis
• Malignant Lymphoma
• Paget Disease
• Hemangioma

60
Metastasis
61

62
Spondylolysis

• Metastasis
• Multiple myeloma
• Malignant Lymphoma
• Infection
• Trauma

63
Spondylolisthesis
64
Spondylolisthesis (oblique view)
Scottish dog
65
Ankylosing Spondylitis
66
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

67
(No Transcript)
68
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

69
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)

70
(No Transcript)
71
(No Transcript)
72
(No Transcript)
73
(No Transcript)
74
(No Transcript)
75
(No Transcript)
76
Management
77
(No Transcript)
78
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

79
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.

80
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..

81
PREVENTION
82
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

83
Force on the spine
84
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.

85
Good lifting process
86
THANKS FOR
ATTENTION