Occupational Occupational low low back back pain pain Dr mehdi habibollahi

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Rachel Chambers
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1 Occupational low back pain Occupational low back pain Dr mehdi habibollahi

2 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) i (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)

3 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.

4 Low Back Pain epidemiology ogy 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

5 Low Back Pain epidemiology ogy Most common cause of disability in people younger than 45. 1% of population is chronically disabled due to back problems.

6 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.

7 Categories of low back pain 1 non specific LBP 2 specific LBP

8 Categories of low back pain 1 mechanical LBP 2 non mechanical LBP

9 Differential Diagnosis of Low Back Pain

10 Differential: Mechanical LBP Lumbar Strain or Sprain (70%) Degenerative processes of disc and facets (10%) Herniated disc (4%) Osteoporotic Compression Fracture (4%) Spinal Stenosis (3%) Spondylolisthesis li i (2%) Traumatic Fractures (<1%) Congenital disease (<1%) Severe Kyphosis or Scoliosis i Transitional Vertebrae Spondylolysis Internal Disc Disruption/Discogenic Back Pain Presumed Instability

11 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

12 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

13 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

14 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.

15 LOW BACK PAIN RISK FACTORS Low back pain is a multifactorial problem It is a biopsychosocial problem

16 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, occupational factors such as work satisfaction, autonomy, supervisor empathy, monotonous or repetitive tasks, and prolonged exposure to heavy physical activities including 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, 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, 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 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.

17 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)

18 BACK PAIN RISK FACTORS Occupational risk factors Heavy Lifting Twisting Carrying & Lifting Vibration Reaching & Lifting Awkward Postures Sitting or Standing Slips, Trips & Falls

21 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

22 Physical Examination Inspection Palpation Range of motion Strength testing Neurologic examination Special tests

23 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

24 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

25 Movements Flexion schobers test <5cm = abnormal Extension pain and restricted extension in prolapsed disc and spondylolisthesis Lateral Flexion Rotation seated, movement is thoracic

26 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.

27 Abdominal and Cardiovascular examination Consider non musculoskeletal causes of back pain

28 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.

29 Look for further evidence of neurological involvement Patella (L3 4) Achilles (L5 S1) reflexes Lower Limb power Test sensation to pin prick

30 Straight Leg Raising

31 L4 L5 S1

32 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 Ui 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

33 Role of X rays (Radiology) Usually unnecessary and not helpful Plain X ray: Age>50 years No improvement after 6 weeks Other worrisome findings MRI: After 6 weeks if have sciatica

35 Radiographic Diagnosis: Discussion will focus on Mechanical and Non-mechanical etiologies. The following are some General indications for what imaging option you choose.

36 Plain Radiography: Most common spinal imaging gtest. Low cost and ready availability. 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. 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 angled sacral views if you suspect ankylosing spondylitis. Caution using lumbar radiography repeatedly, may damage the gonads, particularly in reproductive age females.

37 Plain Films Weaknesses: Neoplasm ~50% trabecular bone loss prior to becoming visible Infection similar, relatively late appearance of change Inability to distinguish acute from chronic compression fractures Disc herniation Spinal Stenosis

38 CT + MRI: CT Strengths: MRI Strengths: Axial bony anatomy Better soft tissue contrast than CT Cortical bony destruction Visualization of disc Facet degenerative changes Ligamentous pathology Vertebral marrow and spinal canal Disk herniation Neoplasm Soft tissue evaluation in patients who Infection (may be the best modality with cannot undergo MRI secondary to gadolinium enhancement) claustrophopia or implanted metal. Disc Herniation CT Myelography good for bony causes of Spinal stenosis spinal stenosis Nerve root impingement CT Weaknesses: MRI Weaknesses: Discogenic disease (nucleus pulposis Cannot detect cortical bone rupture, annulus fibrosis tears) Common degenerative disk disease and Spinal canal contents disease of facet joints too nonspecific Discitis Fractures seen best in the axial plane Subtle bl annular tears

39 Bone Scans: While plain films, CT, and MRI detect bony morphology, bone 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. 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 MRI had better specificity and sensitivity). Useful for subtle fractures and infarction. Useful for metabolic bone disease such as Paget Disease.

40 Discography: 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 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 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.

41 Management

42 Back Pain Management Tools Medicine Care Manager Physical Therapy Pain Management Neurosurgery Chiropractic Clinic Neurology EMG

43 Pain Management: A More Flexible Approach* Different time frames Multiple therapies at one time Different starting points Physical therapy, TENS Complementary medicine, behavioral programs, adjuvant meds Corrective surgery Long-term oral opioids Intrathecal therapy or neurostimulation NSAIDs, over-the-counter drugs Chronic Pain Patient Neuroablation

44 Management Initially rest perhaps p 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. ea a

45 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 Chiropractor and osteopaths.

46 Referral guidance If red flags suggest a serious condition, refer with appropriate p 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.

47 Prevention

48 Engineer Controls Eliminate (Engineer Hazard Out) Workplace design Tool design Preplan process

49 Eliminate the Lift Use mechanical lifts when possible

50 Administrative Controls Training of employees and management Job rotation

51 Job Rotation Rotate to non lifting tasks

52 Pay Special Attention 1. Heavy lifting 2. Frequent lifting 3. Awkward lifting

53 Reduce Heavy Lifting pound wood pallet Substitute 20 pound plastic pallet

54 Reduce Size of Box Common sense controls

55 Reduce Heavy Lifting Use mechanical assistance

56 Slide Instead of Lift

57 Reduce Heavy Lifting Team Lifting*

58 Mechanical Assistance Reduce Frequency

59 Reduce Frequency Use Mobile Storage*

60 Reduce Awkward Lifting Raise load mechanically

61 Awkward Lifting Add Handles

62 Awkward Lifting Rearrange Storage

63 Awkward Lifting Mechanical assistance Stacker stacks up to 12 feet high

64 Awkward Lifting To reduce twisting use conveyors *

65 Size Up The Load Make sure you can lift the weight. Test load by picking up one end!

66 Proper Lifting Think defensively about your back Use common sense Follow good lifting techniques Keep load close to body

67 Lifting Power Zone Baseball Strike Zone

68 Lifting Techniques Lift with your legs, not your back Place your feet close to the object Center yourself over the Center yourself over the load

69 Lifting Techniques Bend your knees Get a good hand hold Lift straight t up smoothly

70 Don t Twist or Turn Feet facing the lift Keep it steady No twisting/turning

71 Know Your Path! Is your path clear? Are there any holes? Are there any spilled liquids? Check your footing.

72 Set it Down Safely Just as critical to back safety as liftingi 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

73 Push vs. Pull If the object is on rollers, push Pushing puts less strain on your back Uses largest muscle group

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

77 Disc herniation

79 PEARLS

80 Lumbar Spine AP View

81 Lumbar Spine Lateral View

82 Source: CW Kerber and JR Hesselink, Spine Anatomy, UCSD Neuroradiology

83 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.

84 Protrusion Protrusion w/ migration Protrusion w/ migration + sequestration

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

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

89 Central Disc Protrusion

90 Schmorl s Nodes

91 Confusing Spondy- Terminology Spondylosis = spondylosis deformans = degenerative spine Spondylitis = inflamed spine (e.g. ankylosing, pyogenic, etc.) Spondylolysis y = chronic fracture of pars interarticularis with nonunion ( pars defect ) Spondylolisthesis = anterior slippage of vertebra typically resulting from bilateral pars defects Pseudospondylolisthesis d li i = degenerative spondylolisthesis li i (spondylolisthesis resulting from degenerative disease rather than pars defects)

92 Spondylolysis / Spondylolisthesis

93 Spondylolysis Spondylolisthesis

$fracture of pars$ interarticularis Repetitive

94 Spondylolysis Stress fracture of pars interarticularis Repetitive flexion/extension LBP with occasional radicular symptoms past buttocks and thighs, no neurologic deficits

95 Spondylolisthesis Slipping of vertebrae 75% have LBP Restrictive ROM

97 Degenerative Disc (and Facet Joint) Disease

98 Degenerative Disc (and Facet Joint) Disease Foraminal stenosis Thickening/Buckling of Ligamentum Flavum

Epidemiology of Low back pain

Epidemiology of Low back pain Low Back Pain Definition Pain felt in your lower back may come from the spine, muscles, nerves, or other structures in that region. It may also radiate from other areas like the mid or upper back, a inguinal