Managing Low Back Pain A Challenge for the Next Millennium

1. Managing Low Back Pain A Challenge for the Next Millennium

2. OUTLINE • Incidence of Low Back Pain • What is Low Back Pain • Anatomy of Low Back Pain • Causes of Low Back Pain • Signs and Symptoms of Low Back Pain • Diagnosis • Treatment of Low Back Pain (Surgical/Nonsurgical) • Back Pain Prevention • Office Chair Selection

3. Incidence of Low Back Pain • Low back pain is one of the main reasons Americans visit their doctor • 80% of people will have low back pain at some point in their lives Each year, back pain costs Americans about $100 billion in medical bills, disability, and lost productivity. • It is the most expensive industrial injury, affecting 2% to 5% of the workforce and leading to 1,000,000 workers' compensation claims annually.

4. Incidence of Low Back Pain • Low back pain remains a serious health disorder, and, next to the common cold, it remains the most common reason why people seek medical care • During his or her life, about one in five persons will have a serious episode of back pain that will require medical attention. • Low back pain is the most expensive health care problem for people age 20 to 50 years.

5. What is Low Back Pain • Back pain is actually very common—about three in four adults will experience back pain during their lifetime, especially low back pain • Back pain may be acute or chronic. • Back pain comes in many forms, it may be sudden and sharp—or it may be dull. • Pain may occur with movement, and it may even occur with coughing and sneezing. You may also have numbness in your arms or legs. • It’s important to treat your back pain properly. Seek medical attention if your back pain persists—and seek immediate attention if you have any of the emergency signs listed below. • Warning Signs You Need Help • Pain is getting significantly worse • Pain affects every day activities • Severe symptoms • Groin or leg weakness or numbness • Arm or hand weakness, tingling, or numbness • Loss of bowel or bladder control

6. Anatomy of Low Back Pain • Your back, or spine, is made up of many parts • Your backbone, also called your vertebral column, provides support and protection and consists of 33 vertebrae (bones) • There are discs between each of the vertebra that act like pads or shock absorbers. • Together, the vertebrae and the discs provide a protective tunnel (the spinal canal) to house the spinal cord and spinal nerves • These nerves run down the center of the vertebrae and exit to various parts of the body.

7. Anatomy of Low Back Pain

8. Anatomy of Low Back Pain • Your back also has muscles, ligaments, tendons, and blood vessels. • Muscles are strands of tissues that act as the source of power for movement. • Ligaments are the strong, flexible bands of fibrous tissue that link the bones together, and tendons connect muscles to bones and discs. • Blood vessels provide nourishment. • These parts all work together to help you move about.

9. Anatomy of Low Back Pain • Back pain may be a result of injury to any or all of the previously mentioned body parts • Injury to the soft tissues (muscles, ligaments, tendons) results in sprains or strains, which are generally not considered serious • However, injury to bones, nerves, or blood vessels may be more serious • The outer layers of discs can also get tears or cracks, allowing the annulus fibrosus or nucleus pulposus to bulge out. • Any of these injuries can cause inflammation and pain.

10. Anatomy of Low Back Pain • The lumbar spine is made up of the lower five vertebrae often referred to as L1 to L5. • These five vertebrae line up to give the low back a slight inward curve. • The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, a triangular bone at the base of the spine that fits between the two pelvic bones

11. Anatomy of Low Back Pain • Intervertebral discs separate the vertebrae. • The discs are made of connective tissue. • Most connective tissue is made of fibers of a material called collagen. • These fibers help the disc withstand tension and pressure. • Healthy discs work like shock absorbers to cushion the spine. • They protect the spine against the daily pull of gravity. • They also protect it during strenuous activities that put strong force on the spine, such as jumping, running, and lifting. • Two spinal nerves exit the sides of each spinal segment, one on the left and one on the right. • As the nerves leave the spinal cord, they pass through a small bony tunnel on each side of the vertebra, called a neural foramin

12. Causes of Low Back Pain • Back pain has a variety of causes, including poor posture and poor body mechanics (ex. standing for long periods of time or sitting incorrectly can cause back pain) • Engaging in certain sports often carries a risk of back injury. • Low back pain is often associated with heavy physical work, lifting or forceful movement, bending or twisting, or awkward positions. • You may even have a back injury and not know it until a stressful movement aggravates the condition. • Don’t ignore back pain. Talk to your doctor if your pain persists.

13. Causes of Low Back Pain • Common Causes of Low Back Pain Include: • Sprain/Strain • Obesity • Aging/Degeneration • Herniation

14. Causes of Low Back Pain • Sprain or Strain: • A sudden fall, car crash, or sports injury can cause a sprain or strain—or even just lifting something too heavy. • When a back injury occurs, muscles, ligaments, and tendons can become over-stretched, overused, or torn. • Tissues can swell, causing pain, tenderness, and stiffness.

15. Causes of Low Back Pain • Obesity: • Your spine caries a large portion of your weight. • Being overweight puts pressure and stress on the back, especially the low back. • In addition, carrying excess weight aggravates other health conditions such as osteoporosis (weak bones), osteoarthritis (joint pain), rheumatoid arthritis (an autoimmune disease), degenerative disc disease (described below in the aging section), spinal stenosis, and spondylolisthesis.

16. Causes of Low Back Pain • Degeneration • The intervertebral disc changes over time. • The first change that occurs is that the annulus around the nucleus weakens and begins to develop small cracks and tears • The body tries to heal the cracks with scar tissue. • The torn annulus can be a source of pain for two reasons. First, there are pain sensors in the outer rim of the annulus. They signal a painful response when the tear reaches the outer edge of the annulus. Second, like injuries to other tissues in the body, a tear in the annulus can cause pain due to inflammation. • With time, the disc begins to lose water, causing it to lose some of its fullness and height. As a result, the vertebrae begin to move closer together.

17. Causes of Low Back Pain • Degeneration • The intervertebral disc changes over time. • The first change that occurs is that the annulus around the nucleus weakens and begins to develop small cracks and tears • The body tries to heal the cracks with scar tissue. • The torn annulus can be a source of pain for two reasons. First, there are pain sensors in the outer rim of the annulus. They signal a painful response when the tear reaches the outer edge of the annulus. Second, like injuries to other tissues in the body, a tear in the annulus can cause pain due to inflammation. • With time, the disc begins to lose water, causing it to lose some of its fullness and height. As a result, the vertebrae begin to move closer together.

18. Causes of Low Back Pain • Degeneration • The intervertebral disc changes over time. • The first change that occurs is that the annulus around the nucleus weakens and begins to develop small cracks and tears • The body tries to heal the cracks with scar tissue. • The torn annulus can be a source of pain for two reasons. First, there are pain sensors in the outer rim of the annulus. They signal a painful response when the tear reaches the outer edge of the annulus. Second, like injuries to other tissues in the body, a tear in the annulus can cause pain due to inflammation. • With time, the disc begins to lose water, causing it to lose some of its fullness and height. As a result, the vertebrae begin to move closer together.

19. Causes of Low Back Pain • Herniations: • Herniation occurs when the nucleus in the center of the disc pushes out of its normal space. • The nucleus presses against the annulus, causing the disc to bulge outward. • Sometimes the nucleus herniates completely through the annulus and squeezes out of the disc. • Vigorous, repetitive bending, twisting, and lifting can place abnormal pressure on the shock-absorbing nucleus of the disc. • If great enough, this increased pressure can injure the annulus, leading to herniation. • A lumbar disc can also become herniated during an acute (sudden) injury

20. Causes of Low Back Pain • Herniation causes pain from a variety of sources. • Mechanical Pain. • This is pain that comes from the parts of the spine that move during activity, such as the discs and ligaments. • Pain from inflammation occurs when the nucleus squeezes through the annulus. • The nucleus normally does not come in contact with the body's blood supply. However, a tear in the annulus puts the nucleus at risk for contacting this blood supply. • When the nucleus herniates into the torn annulus, the nucleus and blood supply meet, causing a reaction of the chemicals inside the nucleus. • This produces inflammation and pain. • Neurogenic Pain • A disc herniation may also put pressure against a spinal nerve. • Pressure on an irritated or damaged nerve can produce pain that radiates along the nerve.

21. Causes of Low Back Pain

22. Signs and Symptoms of Low Back Pain • Disc herniations produce inflammation when the nucleus comes in contact with the body's blood supply • The inflammation can be a source of throbbing pain in the low back and may spread into one or both hips and buttocks. • A herniated disc can press against a spinal nerve, producing symptoms of nerve compression. • Nerve pain follows known patterns in the lower limbs (It can be felt on the side of the upper thigh, in the calf, or even in the foot and toes) • Pressure on the nerve can also cause sensations of pins, needles, and numbness where the nerve travels down the lower limbs

23. Signs and Symptoms of Low Back Pain • Back pain is its own symptom. • Your back pain may be acute or chronic. • Acute pain lasts four to six weeks, but chronic pain is persistent, long-term pain—sometimes lasting throughout life. • Back pain may be sudden and sharp—or it may be dull. • Pain may occur with movement, and it may even occur with coughing and sneezing. • You may also have numbness in your arms or legs. (Leg symptoms are often referred to as sciatica caused by a pinched nerve.) • It's important to treat your back pain properly. • Seek medical attention if your back pain persists—and seek immediate attention if you have back pain with any of the following emergency signs: • Pain is getting significantly worse • Pain affects every day activities • Severe symptoms • Groin or leg weakness or numbness • Arm or hand weakness, tingling, or numbness • Loss of bowel or bladder control

24. Signs and Symptoms of Low Back Pain • Rarely, symptoms involve changes in bowel and bladder function. • A large disc herniation that pushes straight back into the spinal canal can put pressure on the nerves that go to the bowels and bladder. • The pressure may cause low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. • The pressure on the nerves can cause a loss of control in the bowels or bladder. • This is an emergency. If the pressure isn't relieved, it can lead to permanent paralysis of the bowels and bladder. • This condition is called cauda equina syndrome • Doctors recommend immediate surgery to remove pressure from the nerves.

25. Signs and Symptoms of Low Back Pain

26. Signs and Symptoms of Low Back Pain • In summary, symptoms from low back problems vary. • They depend on a person's condition and which structures are affected. Some of the more common symptoms of low back problems are: • low back pain • pain spreading into the buttocks and thighs • pain radiating from the buttock to the foot • back stiffness and reduced range of motion • muscle weakness in the hip, thigh, leg, or foot • sensory changes (numbness, prickling, or tingling) in the leg, foot, or toes

27. Diagnosis • The diagnosis of low back problems begins with a thorough history of your condition. • Your doctor or therapist will ask you questions to find out when you first started having problems, what makes your symptoms worse or better, and how the symptoms affect your daily activity. • Your doctor or therapist will then physically examine the muscles and joints of your low back. • It is important that your doctor or therapist see how your back is aligned, how it moves, and exactly where it hurts. • Some simple tests to check the function of the nerves are performed. • These tests are used to measure the strength in your lower limbs, check your reflexes, and determine whether you have numbness in your legs or feet. • The information from your medical history and physical examination will help your doctor or therapist decide which further tests to run. • The tests give different types of information.

28. Treatment of Low Back Pain • Ninety percent of people who experience low back pain for the first time get better in two to six weeks without any treatment at all. • Patients often do best when encouraged to stay active and to get back to normal activities as soon as possible, even if there is still some pain. • The pain may not go away completely. • One goal of treatment is to help you find ways to control the pain and allow you to continue to do your normal activities.

29. Treatment of Low Back Pain(Nonsurgical) • Whenever possible, doctors prefer to use treatments other than surgery. The first goal of these nonsurgical treatments is to ease your pain and other symptoms. • Bed Rest • In cases of severe pain, doctors may suggest a short period of bed rest, usually no more than two days. Lying on your back can take pressure off sore discs and nerves. • Most doctors advise against strict bed rest and prefer that patients do ordinary activities using pain to gauge how much is too much. • Back Brace • A back support belt is sometimes recommended when back pain first strikes. • It can help provide support and lower the pressure inside a problem disc. • Patients are encouraged to gradually discontinue wearing the support belt over a period of two to four days. Otherwise, back muscles begin to rely on the belt and start to shrink (atrophy). • Medications • Many different types of medications are typically prescribed to help gain control of the symptoms of low back pain. • There is no medication that will cure low back pain. • Medications are prescribed to help with sleep disturbances and to help control pain, inflammation, and muscle spasm.

30. Treatment of Low Back Pain(Nonsurgical) • Physical Therapy and Exercise • In addition to other nonsurgical treatments, doctors often ask their patients to work with a physical therapist. • Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. • A therapist can design a rehabilitation program to address a particular condition and to help the patient prevent future problems. • There is a great deal of scientific proof that exercise and increased overall fitness reduce the risk of developing back pain and can improve the symptoms of back pain once it begins. • Injections • Spinal injections are used for both treatment and diagnostic purposes. T • here are several different types of spinal injections that your doctor may suggest. • These injections usually use a mixture of an anesthetic and some type of cortisone preparation. • The anesthetic is a medication that numbs the area where it is injected. • If the injection takes away your pain immediately, this gives your doctor important information suggesting that the injected area is indeed the source of your pain. • The cortisone decreases inflammation and can reduce the pain from an inflamed nerve or joint for a prolonged period of time.

31. Treatment of Low Back Pain(Surgical) • Only rarely is lumbar spine surgery scheduled right away. • Your doctor may suggest immediate surgery if you are losing control of your bowels and bladder or if your muscles are becoming weaker very rapidly. • For other conditions, doctors prefer to try nonsurgical treatments for a minimum of three months before considering surgery. • Most people with back pain tend to get better, not worse. • Even people who have degenerative spine changes tend to gradually improve with time. • Only one to three percent of patients with degenerative lumbar conditions typically require surgery. • Surgery may be suggested when severe pain is not improving.

32. Treatment of Low Back Pain(Surgical) • There are many different operations for back pain. The goal of nearly all spine operations is to remove pressure from the nerves of the spine, stop excessive motion between two or more vertebrae, or both. The type of surgery that is best depends on that patient's conditions and symptoms. • Laminectomy • removes part or all of the lamina to release pressure on the spinal nerves. • Discectomy • operation to remove the portion of the disc that is pressing on the nerve roots is called a discectomy • This operation is performed through an incision in the low back immediately over the disc that has ruptured. • Lumbar Fusion • When there is excessive motion between two or more vertebrae, the excess motion can cause both mechanical pain and irritation of the nerves of the lumbar spine. • In this case some type of spinal fusion is usually recommended. • The goal of a spinal fusion is to force two or more vertebrae to grow together, or fuse, into one bone. • The pain is reduced because the fusion reduces the constant irritation and inflammation of the nerve roots

33. Back Pain Prevention: 4 Harmful Habits • #1 - Twisting when Lifting So many people make this mistake! We forget to check our body mechanics while lifting, yet too much of this type of movement can be very damaging to your back. When lifting, follow these steps: • Get close to the object • Bend your knees and grasp the object firmly • Lift straight up (don't twist!) in one fluid motion • Hold the object close to your body • Move close to where you want to place the object • Bend you knees when lowering the object Wrong!!

34. Back Pain Prevention: 4 Harmful Habits • #2 - Bad PostureHow often to you think about your posture? • Bad posture - slouched shoulders, head down, knees locked - places an enormous amount of stress on the spine. • Good posture keeps your body in balance and helps avoid that stress. Here's what good posture looks like when standing: • Feet slightly apart • Knees straight • Chin slightly tucked in • Shoulders back • Be sure to check and correct your posture during your everyday activities. • Soon you will find that you are actually more comfortable when your spine is in balance! Stand tall!

35. Back Pain Prevention: 4 Harmful Habits • #3 - Too Little Exercise, Too Much Weight • A sedentary lifestyle has become all too common in our society today. • Eventually our spines will pay the price. • Research shows that people who do not exercise regularly and are overweight are more likely to suffer from back injures and pain. • To keep that from happening to you, get up and get moving! Find a way to put exercise into your daily activities. Not only will it help keep your spine healthy, it will help you to shed those unwanted pounds and feel great too! Exercise can be fun!!

36. Back Pain Prevention: 4 Harmful Habits • #4 - Ignoring the Pain • None of us like going to the doctor, but persistent back pain should not be ignored. • If you suffer from persistent, chronic, or recurring back pain, see your doctor. • In most cases there is an easy, non-surgical treatment that can return you to a pain free life. • However, if left untreated or allowed to progress, back pain can lead to serious and severe disability. Don't ignore unresolved pain

37. Back Pain Prevention • Tips to Minimize Stress at the Desk • Don't lean over the desk for prolonged periods of time • Don't sit too far from the work and/or with the back unsupported. • Raise or lower the chair to the proper height so the knees are bent at a 90-degree angle. • Keep the elbows bent at a 90-degree angle. The elbows may rest on the work surface. • Don't bend or twist the neck to cradle the phone against the shoulder.

38. Back Pain Prevention • How To Maintain a Neutral Spine While Standing • The feet should be placed slightly apart with the knees straight and chin tucked in to maintain a neutral spine. • Do not stand in one position for a prolonged period of time; shift the weight from one foot to the other frequently. • Use a footstool to elevate each foot from time to time may be helpful.

39. Back Pain Prevention • Spine Safety – Carrying • First take a look at the object to be moved. If it appears to be too heavy or cumbersome, find help! Next, consider where the object is going. Are there obstacles along the way? If so, move them out of the pathway. • Depending on the shape of the object, try to hold it at the side and bottom while keeping it close to the body. Remember to keep the back straight. Carry the object with the elbows slightly bent. • An extra tip ... Carry a balanced amount of weight in each hand. For example, when carrying shopping bags or luggage, split the load in two. • The shoulders should be held slightly back and level. • Each ear should line up with the shoulders. • The chin is slightly tucked and the pelvis is shifted forward so the hips are aligned with the ankles.

40. Back Pain Prevention • Spine Safety – Lifting • First take a look at the object to be moved. If it appears to be too heavy or cumbersome, find help! • If there are obstacles in the way, move them before lifting the object. • Maintain good posture and keep the head properly aligned. Try to get as close to the object as possible and bend at the knees.

41. Back Pain Prevention • Spine Safety - Reaching • Consider the size, weight, and location of the object. Use a sturdy stool or ladder if necessary. Don't even think about standing on tiptoe! • Next, directly face the object and get as close to it as possible. One hand could be used for additional support. Try not to look overhead for prolonged periods of time. This could cause unnecessary stress to the neck. • An extra tip ... Store items that are used often within easy reach. This may mean rearranging shelves and/or closets. • Don't lift yet! Make sure the feet are slightly apart and flat on the floor. To turn, instead of twisting the body, pivot with the feet. This will help to provide a stable base of support. • Keep breathing and tighten the stomach muscles. Smoothly lift the object using the arms and legs ... not the back! Remember ...Poor posture and incorrect body mechanics are two of the leading causes of neck and back pain

42. Back Pain Prevention • What is the correct way to sit? • Keep your feet flat on the floor. • Try to avoid sitting in the same position for more than 30 minutes. • At work, adjust your chair height and work station so you can sit up close to your work and tilt it up at you. Rest your elbows and arms on your chair or desk, keeping your shoulders relaxed. • When sitting in a chair that rolls and pivots, don't twist at the waist while sitting. Instead, turn your whole body. • When standing up from the sitting position, move to the front of the seat of your chair. Stand up by straightening your legs. Avoid bending forward at your waist. Immediately stretch your back by doing 10 standing backbends. It is ok to assume other sitting positions for short periods of time, but most of your sitting time should be spent as described above so there is minimal stress on your spine.

43. Back Pain Prevention • What is the correct way to sit? (Cont’d) • Sit up with your back straight and your shoulders back. Your buttocks should touch the back of your chair. • All three normal back curves should be present while sitting. A small, rolled-up towel or a lumbar roll can be used to help you maintain the normal curves in your back. • Here's how to find a good sitting position when you're not using a back support or lumbar roll: a. Sit at the end of your chair and slouch completely b. Draw yourself up and accentuate the curve of your back as far as possible. c. Hold for a few seconds d. Release the position slightly (about 10 degrees). This is a good sitting posture. • Distribute your body weight evenly on both hips. • Bend your knees at a right angle. Do not sit with your knees crossed. Keep your knees even with or slightly higher than your hips.

44. Back Pain Prevention • What is the correct way to sit while driving? • Use a back support (lumbar roll) at the curve of your back. Your knees should be at the same level or higher than your hips. " • Move the seat close to the steering wheel to support the curve of your back. The seat should be close enough to allow your knees to bend and your feet to reach the pedals.

45. Back Pain Prevention • What is the best position for sleeping and lying down? • The best lying or sleeping position may vary, depending on your symptoms. No matter what position you lie in, the pillow should be under your head, but not your shoulders, and should be a thickness that allows your head to be in a normal position. " • Try to sleep in a position which helps you maintain the curve in your back (such as on your back with a pillow under your knees or a lumbar roll under your lower back; or on your side with your knees slightly bent). Do not sleep on your side with your knees drawn up to your chest. You may want to avoid sleeping on your stomach, especially on a saggy mattress, since this can cause back strain and can be uncomfortable for your neck.

46. Back Pain Prevention • What is the best position for sleeping and lying down? (Cont’d) • Select a firm mattress and box spring set that does not sag. If necessary, place a board under your mattress. You can also place the mattress on the floor temporarily if necessary. If you've always slept on a soft surface, it may be more painful to change to a hard surface. Try to do what's most comfortable for you. • Try using a back support (lumbar support) at night to make you more comfortable. A rolled sheet or towel tied around your waist may be helpful. • When standing up from the lying position, turn on your side, draw up both knees and swing your legs on the side of the bed. Sit up by pushing yourself up with your hands. Avoid bending forward at your waist.

47. Office Chair Selection: 9 Ergonomic Tips • 1. Height Adjustment • Easily raises or lowers the seat to bring your hips and torso to the correct 90 degree sitting position appropriate for the level of your work area. • With both feet flat on the floor and knees bent at a comfortable angle, your lower legs are supported without putting pressure on your thighs.

48. Office Chair Selection: 9 Ergonomic Tips • 2. Angle Adjustment • Can be at the back, seat or both, and allows you to change the angle between your torso and thighs. • Puts you in the correct neutral position to support and maintain the natural curve of your spine.

49. Office Chair Selection: 9 Ergonomic Tips • 3. Seat Pan • The seat pan should be at least once inch wider than your hips and thighs on either side, and should not be too long for your legs. • Chairs with seat slider adjustments can accommodate users of almost any side. • A contour seat is highly recommended for proper distribution of weight over the seat's surface to reduce fatigue and leg pain and allow you to sit for extended periods.

50. Office Chair Selection: 9 Ergonomic Tips • 4. Adjustable Tilt and Tension Control • Allows you to regulate the angle support, from locked in place to free floating. • Especially useful for multi-tasking, and to help maintain support as you lean into/away from your desk throughout the day.