Low back pain

1. بسم الله الرحمن الرحیم Low back pain By dr HABIBOLLAHI

2. LBP is one of the most common subjective health complaints in Western populations. In Britain, the 1 year prevalence was 49% and in the Nordic countries the 1 month prevalence of LBP was 35%. • Low back pain is one of the most frequent medical causes of absence from work, and disability arising from chronic back pain is now a major welfare and economic problem

3. Low back pain is the fifth most common reason for all physician visits in the United State • Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months, and 7.6% reported at least 1 episode of severe acute low back pain within a 1-year period • One third of all disability costs in the United States are related to low back pain.

4. Differential - three broad categories: • Mechanical (97%) • Nonmechanical (~1%) • Visceral (~2%)

5. 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 (2%) • Traumatic Fractures (<1%) • Congenital disease (<1%) • Severe Kyphosis or Scoliosis • Transitional Vertebrae • Spondylolysis • Internal Disc Disruption/Discogenic Back Pain • Presumed Instability

6. 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 Abscesss • Inflammatory Arthritis (0.3%) – note HLA-B27 association. • AnkylosingSpondylitis • Reiter Syndrome • Inflammatory Bowel Disease • Scheuermann Disease (osteochondrosis) • Paget Disease

7. 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

8. Interdisciplinary Team Approach to Chronic Spinal Disorders • Spine Surgeons • Neurosurgeons • Pain specialists • Psychiatrists/ Psychologists • Physiatrists • Radiologists Complex Problem Interdisciplinary Management Physiological factors Social factors Psychological factors

9. TERMINOLOGY

10. Acute low back • Low back pain present for fewer than 4 weeks, sometimes grouped with subacute low back pain as symptoms present for fewer than 3 months

11. Chronic low back pain • Low back pain present for more than 3 months.

12. Nonspecific low back • Pain occurring primarily in the back with no signs of a serious underlying condition (such as cancer, infection, or caudaequina syndrome), spinal stenosis or radiculopathy, or another specific spinal cause (such as vertebral compression fracture or ankylosingspondylitis). Degenerative changes on lumbar imaging are usually considered nonspecific, as they correlate poorly with symptoms.

13. Radiculopathy • Dysfunction of a nerve root associated with pain, sensory impairment, weakness, or diminished deep tendon reflexes in a nerve root distribution.

14. Sciatica • Pain radiating down the leg below the knee in the distribution of the sciatic nerve, suggesting nerve root compromise due to mechanical pressure or inflammation. Sciatica is the most common symptom of lumbar radiculopathy

15. Spinal stenosis • Narrowing of the spinal canal that may result in bony constriction of the caudaequina and the emerging nerve roots

16. Straight-leg-raise test • A procedure in which the hip is flexed with the knee extended in order to passively stretch the sciatic nerve and elicit symptoms suggesting nerve root tension. A positive test is usually considered reproduction of the patient’s sciatica when the leg is raised between 30 and 70 degrees. Reproduction of the patient’s sciatica when the unaffected leg is lifted is referred to as a positive “crossed” straight-leg-raise test

17. Spondylosis • A degenerative spinal disease that can involve any part of the VERTEBRA, the INTERVERTEBRAL .DISK, and the surrounding soft tissue.

18. Spondylolysis • Deficient development or degeneration of a portion of the VERTEBRA, usually in the pars interarticularis (the bone bridge between the superior and inferior facet joints of the LUMBAR VERTEBRAE) leading to SPONDYLOLISTHESIS.

19. Spondylolisthesis • Forward displacement of a superior vertebral body over the vertebral body below

20. Spondylarthritis • Inflammation of the joints of the SPINE, the intervertebral articulations

21. Osteoarthritis, Spine • A degenerative joint disease involving the SPINE. It is characterized by progressive deterioration of the spinal articular cartilage (CARTILAGE, ARTICULAR), usually with hardening of the subchondral bone and outgrowth of bone spurs (OSTEOPHYTE).

22. Spondylarthropathies • Heterogeneous group of arthritic diseases sharing clinical and radiologic features. They are associated with the HLA-B27 ANTIGEN and some with a triggering infection. Most involve the axial joints in the SPINE, particularly the SACROILIAC JOINT, but can also involve asymmetric peripheral joints. Subsets include ANKYLOSING SPONDYLITIS; REACTIVE ARTHRITIS; PSORIATIC ARTHRITIS; and others

24. Occupational factors for low back pain Job related Related to Individual • Manual handling tasks • Lifting • Twisting • Bending • Falling • Reaching • Excessive Weights • Prolonged Sitting • Vibration • Prior Episode • Job Dissatisfaction • Smoking • Obesity • Genetic factors

25. Back Safety & Lifting • Common Causes of Back Injuries Heavy Lifting Twisting Reaching & Lifting Carrying & Lifting Awkward Postures Sitting or Standing Slips, Trips & Falls

26. Heavy Lifting Twisting Reaching & Lifting Back Safety & Lifting • Job requires heavy lifting: • Use equipment when possible or ask for help. • Try to avoid repetitive lifting over a long period of time. • Twisting at the waist while lifting or holding a heavy load. • Injury usually occurs when reaching over the head, across a table or out the back of a truck.

27. Carrying & Lifting Awkward Positions Back Safety & Lifting • Injury usually occurs when carrying or lifting objects with awkward or odd shapes. • Inappropriate postures that can contribute to back pain are caused by poor workstation layout and/or equipment design. • It is very easy to injure your back, neck or legs while slipping, tripping or falling. Slips, Trips & Falls

28. Back Safety & Lifting • Sitting or standing too long in one position. Sitting can be very hard on the lower back. • For every one to two hours sitting, stand up and take a stretch. • For every one to two hours standing, sit down or move around and stretch. Sitting or Standing

29. Back Safety & Lifting • Back Injury Prevention • Avoid lifting and bending whenever you can. • Place objects up off the floor. • That way you won’t have to reach down to pick them up again. • Raise / lower shelves. • The best zone for lifting is between your shoulders and your waist. • Put heavier objects on shelves at waist level, lighter objects on lower or higher shelves.

30. Back Safety & Lifting • Back Injury Prevention • Reducing exposure to known risk factors • Repetition • Awkward Position • Force • Object weight • Load Distribution • Object friction • Duration

31. Back Safety & Lifting • Back Injury Prevention Cont.: • Avoid Hyper extension movements of the back. • Avoid Hyper flexion movements of the back.

32. Back Safety & Lifting • Back Injury Prevention cont.: • Maintain good posture • Lift objects holding them close to your body • Never “twist” when carrying, handling, or transferring a heavy object • Avoid “locking out” the knees • Use proper lifting techniques

33. Back Safety & Lifting 4 3 2 1 Assess Plan Prepare Perform Principles of Safe Handling

34. Back Safety & Lifting • Assess the task: • Posture • Pacing, rate of work, breaks • Requirements for team handling • Assess Your Own Capabilities: • Strength, height, etc. • Health problems • Gender, age, fitness Assess

35. Back Safety & Lifting • Assess the Load: • Weight, shape, size • Handles, packaging • Stability • Contents: hot, cold, hazardous • Assess the environment: • Space constraints • Flooring condition, levels • Temperature, humidity, ventilation • Tidiness, general housekeeping Assess Cont.:

36. Back Safety & Lifting • Task • What is the most appropriate posture? • Is there mechanical aid available? • Is there anyone else to help? • Route • Consider start and end points • Can any obstructions be cleared Plan

37. Back Safety & Lifting • Prepare the load: • Can the load be split? • Can the load be made more stable? • Make sure contents are evenly distributed? • Move the load’s center of gravity close to yours • Cover sharp / abrasive edges • Prepare yourself and the area: • Check space constraints • Move obstacles • Check final destination • Check housekeeping • Get a good grip on the load • Use PPE where appropriate Prepare

38. Back Safety & Lifting Perform • Apply principles of biomechanics to reduce the load on the spine • Keep a wide base of support. • Maintain the lumbar curve (low back) as much as possible. • Get a good grip. • Position feet in direction of travel. • Use smooth controlled movements. • Use friction to minimize force. • Try to avoid twisting and stooping. • Use team lifting where appropriate.

39. Back Safety & Lifting Get close to the load Slowly Lift Proper Lifting Techniques Hug the Load Squat Down Grip the Load

40. Back Safety & Lifting Get close to the load • Proper Lifting Techniques • Get as close to the load as possible with your feet wide apart about shoulder width, with one foot slightly in front of the other for balance. • Test the object’s weight before lifting it. • Ask for assistance from a co-worker when appropriate. • Have the object close to the body and put less force on the low back. • Avoid rapid, jerky movements.

41. Back Safety & Lifting Squat Down • Proper Lifting Techniques Cont.: • Keep yourself in an upright position while squatting to pick up. • Squat by bending the knees and hips. • Keep the three Curves of the Back properly aligned: • Ears, Shoulders, and Hips are in a straight line.

42. Back Safety & Lifting Grip the Load • Proper Lifting Techniques Cont.: • Tightening the stomach helps support the spine. • Do not hold your breath while tightening the muscles. • Get a firm grasp of the object before beginning the lift. • Use both hands. • Use whole hand, not just fingers. • Use gloves as needed to prevent “pinched” grips or to protect the hands during lift.

43. Back Safety & Lifting Hug the Load • Proper Lifting Techniques Cont.: • Legs are the strongest muscles in the body – so use them. • Avoid back flexion. • Hold objects close to body. • Slide the object from the knee on the ground to mid-thigh. • Keep the head forward. • Hug the object to your stomach & chest.

44. Back Safety & Lifting Slowly Lift • Proper Lifting Techniques Cont.: • Lift with the legs to allow the body’s powerful leg muscles to do the work. • Flex the knees and hips, not the back. • Avoid bending & twisting at the waist. • Try to keep the back “straight” during the lift. • Do not look down at the object during lift. • Look up to help “straighten” the position of the back for a safer lift. • Never Bend, Lift, and Twist at the same time.

45. L5/S1 Disk 12 in. 36 in. L5/S1 Disk 16 in. 0 in. 30 lbs. 30 lbs. 85 lbs. 85 lbs. Back Safety & Lifting Torque = Load x Distance Box = 30 lbs. Body wgt = 170 lbs. (30 lbs. x 36 in.) + (85 lbs. x 12 in.) = 2,100 in-lbs. (30 lbs. x 16 in.) + (85 lbs. x 0 in.) = 480 in-lbs. (Box) (Employee) (Box) (Employee)

46. Back Safety & Lifting • Exercises • Exercises that work your back, hips, thighs, and abdominal muscles can minimize back problems. • Stand behind chair, hands on chair. Lift one leg back and up, keeping the knee straight. • Warm up slowly and exercise regularly.

47. Back Safety & Lifting • Exercises Cont.: • Starting Position: Standing tall, feet shoulder width apart, chin tucked in • Place your palms on the small of your back, fingers pointing down. • Keep your head up as you lean back slowly as far as possible. • Hold for at least 10 seconds. • Return to starting position and relax.

48. Back Safety & Lifting • Exercises Cont.: • Wall Squats • Stand with back leaning against wall • Walk feet 12 inches in front of body. • Keep abdominal muscles tight while slowly bending both knees 45 degrees. • Hold 5 seconds. • Slowly return to upright position. • Repeat at least 5 to 10 times.

49. Back Safety & Lifting • Exercises Cont.: • Lie on the floor on back. • Keeping arms folded across chest, tilt pelvis to flatten back, chin tuck into chest. • Tighten abdominal muscles while raising head and shoulders from floor. • Hold at least 10 seconds and release. • Repeat at least 5 to 10 times.

50. Back Safety & Lifting • Summary • Common Causes Of Back Injuries • Heavy Lifting • Twisting • Reaching & Lifting • Carrying & Lifting • Awkward Positions • Sitting or Standing • Slips, trips, and falls • Back Injury Prevention • Reduce exposures to known risk factors