Occupational low back pain Dr mehdi habibollahi

1. Occupational low back pain Drmehdihabibollahi

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) (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 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 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: 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

10. 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

11. 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

12. 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

13. 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.

14. LOW BACK PAIN RISK FACTORS Low back pain is a multifactor problem It is a biopsychosocial problem

15. 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)

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

18. 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

19. Physical Examination • Inspection • Palpation • Range of motion • Strength testing • Neurologic examination • Special tests

20. 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

21. 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

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

23. 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.

24. Abdominal and Cardiovascular examination Consider non musculoskeletal causes of back pain

25. 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.

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

27. Straight Leg Raising

28. L4 • L5 • S1

29. “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 • 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

30. management

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

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

34. Management Initially rest - perhaps 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.

35. 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

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

37. Prevention Goal of the occupational medicine

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

39. Eliminate the Lift Use mechanical lifts when possible

40. Administrative Controls • Training of employees and management • Job rotation

41. Job Rotation Rotate to non-lifting tasks

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

43. Reduce Heavy Lifting 60-70 pound wood pallet “Substitute” 20 pound plastic pallet

44. Reduce Size of Box Common sense controls

45. Reduce Heavy Lifting Use mechanical assistance

46. Slide Instead of Lift

47. Reduce Heavy Lifting Team Lifting*

48. Reduce Frequency Mechanical Assistance

49. Reduce Frequency Use Mobile Storage*

50. Reduce Awkward Lifting Raise load mechanically