Occupational low back pain Drmehdihabibollahiedc.mui.ac.ir/sites/edc.mui.ac.ir/files/Dr.Habibolahi3.pdf · CT Myelography good for bony causes of ... Slide Instead of Lift. Reduce

Occupational low back pain Occupational low back pain Dr mehdi habibollahi

LBP definition LBP definition 

Low back pain was defined as pain and discomfort   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 ( i i ) (O kh di   l   )  (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 margins of the 12th rib and the glutei folds  with or without leg pain (sciatica) (Manek and Macgregor, 2005)

Low Back Pain epidemiology Low Back Pain epidemiology

Back pain is second to the common cold as

p gyp gy

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

About 80% of people have at least one About 80% of people have at least oneepisode of low back pain during theirlifetime.

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

It usually feels like an ache, tension orstiffness in back.

Low Back Low Back Pain epidemiology Pain epidemiology o aco ac a ep de o ogya ep de o ogy

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

visits to primary care physiciansvisits 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 Low Back Pain epidemiology o ac a ep de o ogyo ac a ep de o ogy

Most common cause of disability in people Most common cause of disability in people younger than 45.

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

DefinitionsDefinitions

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

months durationmonths 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 painCategories of low back pain

1‐non specific LBP 1‐non specific LBP 2‐ specific LBP

Categories of low back painCategories of low back pain

1‐mechanical LBP 1‐mechanical LBP 2‐ non mechanical LBP

Differential Diagnosis of Low Back Pain

Differential: Mechanical LBPDifferential: Mechanical LBP

Lumbar Strain or Sprain (70%) Degenerative processes of disc and facets (10%) Herniated disc (4%) Herniated disc (4%) Osteoporotic Compression Fracture (4%) Spinal Stenosis (3%)

S d l li th i ( %) Spondylolisthesis (2%) Traumatic Fractures (<1%) Congenital disease (<1%)

h i li i Severe Kyphosis or Scoliosis Transitional Vertebrae

Spondylolysis Internal Disc Disruption/Discogenic Back Pain Presumed Instability

Differential  Nonmechanical LBP:Differential ‐ Nonmechanical LBP:

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

I f i  ( %) 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)P  Di Paget Disease

Differential  Visceral Disease:Differential – Visceral Disease:

Pelvic organ involvement: Prostatitis Endometriosis Chronic Pelvic Inflammatory Disease

Renal involvement Nephrolithiasisp Pyelonephritis Perinephric Abscess

Aortic Aneurysmy Gastrointestinal involvement

Pancreatitis Cholecystitisy Penetrating Ulcer

Symptoms of Benign LBPSymptoms of Benign LBP

Dull and achy quality No radiation Dull and achy quality Diffuse aching with

associated muscle

No radiation, paresthesias

No dermatomal patterntenderness

Exacerbated with movement

Pt. is able to find a position of comfortDTR ithi lmovement

Relieved with rest in recumbent position

DTR are within normal limits

Symptoms of Inflammatory back pain

Gradually in onset.y

Throbbing in nature.

M i   tiff Morning stiffness.

Exacerbates by rest and relived by activity.

Intensity increase in night and early morning.

It is chronic backache.

LOW BACK PAIN RISK FACTORSLOW BACK PAIN RISK FACTORS

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

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,y,

occupational factors such as work satisfaction, autonomy, supervisor empathy, monotonous or repetitive tasks, and prolonged exposure to heavy physical activities includingp g p y p y g 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, physicalhealth 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, 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 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 disc disease, which may lead to LBP.

BACK PAIN RISK FACTORSBACK PAIN RISK FACTORS

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

P   k   l     i  h bi 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 FACTORSOccupational risk factors

Heavy Lifting

TwistingTwisting

Vibration

Carrying &

Reaching & Lifting

Awkward PosturesCarrying & Lifting

Sitting or Standing Slips, Trips & Falls

DIAGNOSISDIAGNOSIS

Specific diagnosis is impossible in 80%p g p Differentiation of muscle, joint, ligamentous structures Mechanical versus systemic disorders is possible Categorize by clinical symptoms Subtyping will improve therapy

Physical Examination

Inspection Inspection Palpation Range of motiong Strength testing Neurologic examination Special tests

Inspection Inspection 

Ideally with back and legs exposed Ideally with back and legs exposed. Posture ?Scoliosis ? Kyphosis Skin café‐au‐lait spots, hairy patches, signs of p , y p , gpsoriasis.

Prolapsed disc may cause a lumbar scoliosis, fl tt i g    l  f  l l b  l d iflattening or reversal of normal lumbar lordosis

PalpationPalpation

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

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

SI joints Palpable steps may indicate spondylolisthesis

MovementsMovements

Flexion – schobers test <5cm = abnormal 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 examinationHip and SI joint examination

Check hip joints for pain and limitation – internal  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 Consider non musculoskeletal causes of back pain

Straight leg raisingStraight leg raising

Looking for nerve root irritation L5‐ S1‐ 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 dorsiflexfoot, pain or paraesthesia aggravated.

Look for further evidence of neurological involvement

Patella (L3‐4) Achilles (L5‐ S1) reflexes Patella (L3‐4) Achilles (L5‐ S1) reflexes Lower Limb power  Test sensation to pin prickp p

Straight Leg RaisingStraight Leg Raising

•L4L4•L5•L5•S1•S1

Age < 15 or > 50“Red Flags” in back pain

Age < 15 or > 50 Fever, chills, UTI Significant traumag Unrelenting night pain; pain at rest Progressive sensory deficit Neurologic deficits Saddle‐area anesthesiaU i   d/  f l i ti Urinary and/or fecal incontinence

Major motor weakness Unexplained weight loss Unexplained weight loss Hx or suspicion of Cancer Hx of Osteoporosisp Hx of IV drug use, steroid use, immunosuppression Failure to improve after 6 weeks conservative tx

Role of X rays (Radiology)Role of X‐rays (Radiology)

Usually unnecessary and not helpful Usually unnecessary and not helpful Plain X‐ray: Age>50 yearsg No improvement after 6 weeks Other worrisome findings

MRI: After 6 weeks if have sciatica

Radiographic Diagnosis:Discussion will focus on Mechanical and

Non-mechanical etiologies.

The following are some General indications for what imaging option you choose.what imaging option you choose.

Plain Radiography:Plain Radiography:

Most common spinal imaging test.  Low cost and ready availability.p g g y y 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.y y p

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 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.

Plain Films  Weaknesses:Plain Films ‐Weaknesses:

Neoplasm ‐ ~50% trabecular bone loss prior to becoming visibleNeoplasm  50% trabecular bone loss prior to becoming visible Infection – similar, relatively late appearance of change Inability to distinguish acute from chronic compression fractures

Di  h i ti Disc herniation Spinal Stenosis

CT + MRI:CT + MRI:

CT Strengths: MRI Strengths: Axial bony anatomy Cortical bony destruction Facet degenerative changes Disk herniation Soft tissue evaluation in patients who 

Better soft tissue contrast than CT Visualization of disc Ligamentous pathology Vertebral marrow and spinal canal Neoplasm

Soft tissue evaluation in patients who cannot undergo MRI secondary to claustrophopia or implanted metal.

CT Myelography good for bony causes of spinal stenosis

CT Weaknesses:

Infection (may be the best modality with gadolinium enhancement)

Disc Herniation Spinal stenosis  Nerve root impingement

CT Weaknesses: Discogenic disease (nucleus pulposis 

rupture, annulus fibrosis tears) Spinal canal contents  Discitis

MRI Weaknesses: Cannot detect cortical bone Common degenerative disk disease and 

disease of facet joints – too nonspecific Fractures seen best in the axial plane

b l l Subtle annular tears

Bone Scans:Bone Scans:

While plain films, CT, and MRI detect bony morphology, bone p , , y p gy,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”.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 (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.

Discography:Discography:

Controversial method for diagnosing discogenic pain.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  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 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.visualize the tears with contrast enhancement.

Management Management 

Back Pain Management ToolsBack Pain Management ToolsCare ManagerMedicine g

Physical  Therapy NeurosurgeryPain 

Management

Chiropractic Clinic

g

lChiropractic Clinic NeurologyEMG

Pain Management:A More Flexible Approach*

Different time frames Multiple therapies at one time 

A More Flexible Approach*

Different starting points  Corrective surgery

Long-termoral

Complementary medicine, behavioral

Physical

oralopioids

Intrathecaltherapy or

programs,adjuvant

meds

therapy,TENS

neurostimulation

NSAIDs,over-the-counterdrugs

NeuroablationChronic PainPatient

ManagementManagement

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

Give information, reassurance and advice.  DO NOT prescribe bed rest.  Advise to stay as active as possible   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.usc e e a a ts

Other treatment optionsOther treatment options

acupuncture – fine needles are inserted into your skin  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 manipulated 

Chiropractor and osteopaths.

Referral guidanceReferral guidance

If red flags suggest a serious condition, refer with appropriate g gg , pp purgency. 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 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.multidisciplinary back pain service or a chronic pain clinic.

Prevention Prevention 

Engineer Controls Eliminate (Engineer Hazard Out)

Engineer Controls

Workplace design

Tool design

Preplan process

Eliminate the Lift

Use mechanical lifts 

Eliminate the Lift

Use mechanical lifts when possible

Administrative ControlsAdministrative Controls

Training of employeesand management

Job rotation

Job RotationRotate to non‐lifting tasks

Job Rotation

Pay Special Attention

1  Heavy lifting

Pay Special Attention

1. Heavy lifting

2. Frequent lifting

3. Awkward lifting

Reduce Heavy Lifting 60‐70 pound wood pallet

Reduce Heavy Lifting7 p p

“Substitute”

20 pound plastic pallet

Reduce Size of BoxCommon sense controls

Reduce Size of Box

Reduce Heavy LiftingUse mechanical assistance

Reduce Heavy Lifting

Slide Instead of LiftSlide Instead of Lift

Reduce Heavy Lifting Team Lifting*

Reduce Heavy Lifting 

Reduce FrequencyMechanical Assistance

Reduce Frequency

Reduce FrequencyUse Mobile Storage*

Reduce Frequency

Reduce Awkward LiftingRaise load mechanically

Reduce Awkward Lifting

Awkward LiftingAdd Handles

Awkward Lifting

Awkward LiftingRearrange Storage

Awkward Lifting

Awkward Lifting Mechanical assistance

Awkward Lifting

Stacker – stacks up to12 feet high

Awkward LiftingTo reduce twisting – use conveyors *

Awkward Lifting

Size Up The LoadMake sure you can

Size Up The Loady

lift the weight.

Test load by pickingup one end!

Proper Lifting

Think defensively about your backy y

Use common sense

Follow good lifting techniques

Keep load close to bodyp y

Lifting Power Zone

Baseball Strike Zone

Lifting Power Zone

Baseball Strike Zone

Lifting Techniques

Lift with your legs  not your  Lift with your legs, not your back

Place your feet close to the  Place your feet close to the object

Center yourself over the  Center yourself over the load

Lifting Techniques

d k Bend your knees

Get a good hand hold Get a good hand hold

Lift straight up smoothlyt st a g t up s oot y

Don’t Twist or Turn

Feet facing the lift Feet facing the lift

Keep it steady p y

No twisting/turning

Know Your Path!

Is your path clear?

Are there any holes?

Are there any spilled liquids? Are there any spilled liquids?

Check your footing.

Set it Down Safely

Just as critical to back safety  lif ias lifting

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

Push vs. Pull

If the object is on rollers, j ,push

Pushing puts less strain on your back

Uses largest muscle group

RETURN TO WORKRETURN TO WORK

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

Disc herniation Disc herniation 

PEARLS PEARLS 

Lumbar Spine – AP View

Lumbar Spine – Lateral View

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

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/

migrationProtrusion w/migration +migration g

sequestration

Spinal Stenosis

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

Lumbar Spinal Stenosis

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

Central Disc Protrusion

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 p y y pnonunion (“pars defect”)

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

P d d l li th i “d ti d l li th i ”• Pseudospondylolisthesis = “degenerative spondylolisthesis” (spondylolisthesis resulting from degenerative disease rather than pars defects)than pars defects)

Spondylolysis / Spondylolisthesis

Spondylolysis

SpondylolisthesisSpondylolisthesis

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

SpondylolisthesisSpondylolisthesis “Slipping of vertebrae”pp g 75% have LBP Restrictive ROM

Degenerative Disc (and Facet Joint) Disease

Degenerative Disc (and Facet Joint) Disease

Foraminal stenosis

Thickening/Buckling of Ligamentum Flavum