Low back pain & ergonomics

Low back pain & ergonomics - for Physiotherapists

1. LOW BACK PAIN & E R G O N O M IC MEASURES Dr M.Rajani Cartor BPT MP T V Ortho, DHA, DSPS,. VAPMS COLLEGE OF PHYSIOTHERAPY, VISAKHAPAT

2. INTRODUCTION ANATOMY PATHOPHYSIOLOGY CAUSES & RISK FACTORS SIGNS & SYMPTOMS PHYSICAL EXAMINATION PHYSIOTHERPEUTIC MANAGEMENT

3. INTRODUCTION – LOW BACK PAIN Low back pain is a leading cause of disability. It occurs in similar proportions in all cultures, interferes with quality of life and work performance, and is the most common reason for medical consultations. Most common cause of disability in patients < 45 years old.  Acute back pain is the most common presentation and is usually self-limiting, lasting less than three months regardless of treatment. Chronic back pain is a more difficult problem, which often has strong psychological overlay: work dissatisfaction, boredom, and a generous compensation system contribute to it. Few cases of back pain are due to specific causes; most cases are non-specific.

4. A N A T O M Y Spinal column is formed by 33 vertebrae and divided into 5 regions : Cervical - 7 Thoracic – 12 Lumbar – 5 Sacral – 5 Coccygeal – 4 It has also other components such as : intervertebral discs ( shock absorbers), paravertebral muscles (flexors, extensors and obliques) & ligaments ( stabilizers).

5. LBA – Any pain in the low back region i.e., usually characterised by dull, continous pain and tenderness in the lower lumbar, lumbosacral or sacro-iliac regions, sometimes referred to leg, following the distribution of the sciatic nerve. International Association for the study of pain (IASP) Low Back Pain Lumbar spinal pain Sacral spinal pain Lumbosacral pain Gluteal and Loin pain (not considered LBP)

6. CLASSIFICATION OF LBA Mechanical ( OA, spinal stenosis, spondylolisthesis, compression fracture) Nonmechanical Tumor (metastasis, multiple myeloma, lymphoma) Infection (osteomyelitis, diskitis) Inflammatory arthritis (RA, AS) Visceral disease (nephrolithiasis, pancreatitis, prostatitis Complicated (“Red Flag” conditions) Specific Diagnosis Lumbar Radiculopathy Lumbar Spinal Stenosis Others such as Ankylosing Spondylitis Uncomplicated (Non-Specific) A diagnosis of exclusion

7. RED FLAGS 1 . 2 . 3 . 4 . 5 . 6 . 7 . Metastatic CA ( History of cancer *, Unexplained weight loss, Rest pain, Age >50 ) Infection ( Unexplained fever *, Recent bacterial infection, Immunosuppression) Fracture ( Steroids *, Osteoporosis, Recent trauma, Age >70) Cauda Equina Syndrome (Urinary retention or incontinence, Saddle anesthesia, Decreased rectal tone, Bilateral lower extremity weakness/numbness) Severe or progressive focal neurologic deficit Failure to improve with therapy Pain > 4 weeks (* Most important in the condition)

8. RED FLAGS

9. YELLOW FLAGS

10. PATHO PHYSIOLOGY There are many structures in the lumbar spine that can cause pain ; any irritation to the nerve roots that exit the spine, joint problems, the discs, the bones and the muscles. Many lumbar spine conditions are interrelated. For example, joint instability can lead to disc degeneration, which in turn can put pressure on the nerve roots. The most common cause of LBA is muscle strain or other muscle problems. Strain due to heavy lifting, bending, or other repetative use can be quite painful, but muscle strain usually heal within few days or weeks.

11. CAUSES AND RISK FACTORS CAUSES OF ACUTE LBA CAUSES OF CHRONIC LBA DURATION: <6weeks; subacute lasts between 6-12 weeks. More than 12 weeks Sudden injury ( strain or tears) to the muscles and ligaments) Arthritis Compression fractures (osteoporosis) Extra wear and tear on the spine from the work or sport Cancer Past injuries Herniated disc Fractures Sciatica Past surgery Spinal stenosis Scoliosis or Kyphosis Osteoarthritis Herniated disc Spinal stenosis Scoliosis or kyphosis

12. SPECIFIC AND NON SPECIFIC CAUSES SPECIFIC CAUSES NON – SPECIFIC CAUSES INFLAMMATORY Rheumatoid arthritis, ankylosing spondylitis, and reactive arthritis Poor posture when sitting and standing, lifting ergonomics and unknown causes. M E C H A N I C A L Osteoarthritis, facet joint pain, lumbar spondylosis, spondylolisthesis, radiculopathy, kyphosis, scoliosis, herniated disc or joint disease and fracture M E T A B O L I C Osteoporosis, paget’s disease and osteomalacia OTHERS Infections and tumors

13. OTHER NON – SPECIFIC CAUSES: Work that requires heavy lifting; bending and twisting; or whole-body vibration, such as truck driving Physical inactivity Obesity Arthritis or osteoporosis Pregnancy Age >30 years Bad posture Stress or depression Smoking

14. SIGNS AND SYMPTOMS

15. H/O an event that caused immediate low back pain : Lifting and/or twisting while holding a heavy object Operating a machine that vibrates eg;truck Prolonged sitting Involvement in a motor vehicle collision Falls Past H/O : Arthritis, Infections, Surgery, Cancer or Degenerative diseases, Vocational history. Pain complaint: Quality : sharp,dull,burning,intermittent or diffuse Onset : sudden or insidious Localisation or radiation Exacerbating and relieving factors Associated symptoms Intensity

16. PHYSICAL EXAMINATION Changes in spinal alignment or sagital balance Restricted movements of the lumbar spine Evaluate disturbances of patellar and ankle reflexes Asses strength and sensation of myotomes and dermatomes to determine neural compression LBA can cause leg symptoms such as pain, numbness or tingling and difficulty in standing straight. Diagnostic tests : x-ray, CT scan, MRI

17. DIAGNOSTIC PHYSICAL TESTS :    SLR Or Laseque’s sciatic nerve test :- It’s an important diagnostic protective reflex test which causes traction on sciatic nerve, lumbosacral nerve roots and duramater. It’s a passive test done in supine. Appearance of pain in the distribution of sciatic nerve upto 45degrees of hip flexion with knee extended indicates - +ve SLR If pain thus felt, is aggrevated by passive flexion of neck and passive dorsiflexion of the foot, then only it os a ‘positive neural sign’ Real stretching of the inflammed dura is possible only with all these three manoeuvrs. Note : while conducting SLR don’t confuse it with hamstrings stretch,due to straight leg raises, especially in patients with hamstrings tightness ( which is confirmed by dull pain over the posterior aspect of the knee joint )

18. ALTERNATE SLR: Whenever there is doubt about the genuineness of the test, ask the patient to sit up with legs straight. If the sitting posture can be assumed without flexing the knee, test is negative.

19. Bowstring sign: In this test SLR is carried out untill the pain is reproduced. At this point the knee is gradually flexed till the pain disappears. The examiner rests the limb on his/her shoulder and places the thumb in the popliteal fossa over the sciatic nerve. Sudden firm pressure on the nerve produces pain in the back/pain radiating down the legs indicating ‘+ve BOWSTRING SIGN’ Or significant root tension

20. SLUMP TEST – For mobility at the intervertebral foramen and the spinal cord     Passive neck flexion and straight leg raising (SLR) help in detecting any reduce in mobility of pain sensitive structures within intervertebral foramen or the vertebral canal. If these prove negative, then the ultimate test for mobility of these structures is done by slump test. Test : the patient is made to sit in a slouch sitting with knees in relaxed flexion at the edge of the table. The physiotherapist passively bends the head and the trunk forward, as much as possbile, with total suport, bringing the head down between the knees. The patient is then asked to extend the knees alternately to the maximum, maintaining foot in dorsiflexion. If pain is reproduced on attempting knee extension, the limiting range is noted. +ve test : indicates interfernce of the mobility at the intervertebral foramen or at the vertebral canal.

21. Lumbar 3 rd nerve root test (Reverse Lasegue test ) The patient is made to lie in prone, maintaining the hip in neutral extension. The knee is passively flexed. Pain in the distribution of femoral nerve indicates irritation of 3 rd lumbar nerve root. The test is positive if the symptoms aggrevated on passively extending the hip.

22. Test for sacro-iliac irritation : Presence of tenderness on palpation at sacro-iliac joint is tested further to confirm the lesion at this joint by two tests. 1. Gaenslen’s test : The patient is made to lie on the side of the unaffected hip joint, and asked to flex the unaffected hip to the knee chest position. The holds the thigh firm against chest. The examiner passively extends the other hip joint, keeping the knee straight. This produces rotary strain on pelvis and tends to rotate half of the ilium against sacrum, eliciting pain a SI joint in the presence of SI joint pathology. 2. Pelvic compression test : Pain is elicited in SI joint by pelvic compression or by attempting to ‘open out’ the pelvis. This is done by thumbs hooks around the ASIS.

23. PHYSIOTHERAPY MANAGEMENT

24. A I M S : To decrease pain To strengthen the weak muscles To improve endurance to the muscles To decrease mechanical stress to spinal structures To stabilise hypomobile structures To improve posture To improve mobility and flexibility To improve fitness level to prevent the recurrence.

25. A. Role of spinal exercises.  Flexion exercises Extension exercises Rotational exercises Mobility exercises Stretchings Self correction & it’s maintainence aerobics

26. 1. Flexion exercises - WILLIAMS

27. 2. Extension exercises – Mckenzie’s

28. 3&4Rotational & Mobility exercises :

29. 5. Stretchings

30. b. Physical agents o o o o Aims : o To reduce pain To control spasm To reduce inflammation To facilitate the use of specialised techniques like mobilisation, traction and exercise To reduce depression, tension or any other psychological factor

31. Ultrasound Cryotherapy TENS MOIST HEAT Diathermy Electrical stimulation Massage Spinal traction

32. THANK YOU