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Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
Mechanical low back pain team 4 (aguilar barradas-guevara-luque)
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Mechanical low back pain team 4 (aguilar barradas-guevara-luque)

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  • 1. Mechanical Low Back Pain NUR 3066 Health Assessment and Promotion in Nursing Practice Instructor: Prof. Dawn Hawthorne PhD.  Dora Aguilar Isabel Barradas Linda Guevara Luz Luque Florida International University 1
  • 2. Mechanical Low Back Pain (LBP) Overview, Anatomy and Pathophysiology Isabel Barradas Causes, Risk Factors, Signs and Symptoms Luz Luque Impact on Society and Family Linda Guevara Prevention and Patient Education Dora Aguilar 2
  • 3. Overview  Worldwide, musculoskeletal conditions are the mostcommon causes of severe long-term pain and physicaldisability (USBJI, 2013) (GBD 2010, 2012). Mechanical low back pain (LBP) remains the second mostcommon symptom-related reason for seeing a physician inthe United States (Hill, 2012). In our country, the musculoskeletal conditions are aleading cause of disability, accounting for more than 130million patient visits to healthcare providers annually. Theyare the No. 1 reason people visit their physician, and affectnearly one in two Americans over the age of 18(USBJI, 2013). 3
  • 4. Disability in US and Worldwide  Current estimates of people affected Worldwide (BJD, 2012) •Back pain 632.045 millions •Neck pain 32.049 millions •OA knee 250.785 millions •Other musculoskeletal conditions 560.978 millions (Brault, 2008) Data were collected in June-September 2005 by U.S. Census Bureau using the Survey of Income and Program Participation (SIPP); CDC and the U.S. Census Bureau analyzed the most recent data and released their findings in May 2009. 4
  • 5. *For individuals younger than 45 years, mechanical LBP represents the most commoncause of disability and is generally associated with a work-related injury (Hill, 2012). *For individuals older than 45 years, mechanical LBP is the third most common causeof disability, and a careful history and physical examination are vital to evaluation,treatment, and management (Hill, 2012). *At the beginning of the 21st century, 750 national and international organizationspartnered to create the Bone and Joint Decade (2002-2011). More than sixty countries,including the United States, have established multidisciplinary National ActionNetworks to plan activities in these respective countries. *The United States Bone and Joint Initiative (USBJI) is the U.S. National ActionNetwork of the worldwide Bone and Joint Decade, a multi-disciplinary initiativetargeting the care of people with musculoskeletal conditions: bone and joint disorders. *Its focus is on improving the quality of life as well as advancing the understandingand treatment of those conditions through research, prevention and education. (USBJI,2013). 5
  • 6. Anatomy  *The spinal column is the body’s main support structurewhich contains the spinal cord. *The brain and spinal cord are known as the central nervoussystem, while the nerves that connect the spinal cord to the bodyare known as the peripheral nervous system. *The nerves that carry information from the brain to themuscles are called motor neurons. The nerves that carryinformation from the body back to the brain are called sensoryneurons. Sensory neurons carry information to the brain aboutskin temperature, touch, pain and joint position.(Gokzen, 2003). 6
  • 7. *The Spinal Column is formed by 33 bones: the vertebrae ; and divided into 5 regions:Cervical (7), Thoracic (12), Lumbar (5), Sacral (5), Coccygeal (4). It has also other componentssuch as: intervertebral dics (shock absorbers), paravertebral muscles (flexors, extensors andobliques) and ligaments (stabilizers). *From the brain , the spinal cord passes down the center of the back and is surroundedand protected by the bony spinal column. The spinal cord is surrounded by a clear fluidcalled cerebrospinal fluid (CSF), which acts as a cushion to protect the delicate nerve tissuedamage by impacts against the inside of the vertebrae. *The Spinal Cord consists of millions of nerve fibers that transmit electrical informationto the limbs, trunk and organs of the body, back to and from the brain. The nerves exitingthe spine at the top of the neck, control breathing and arms. The nerves that leave the spinalcord in the middle and lower back, control the trunk and legs, bladder, bowel and sexualfunction. (Hills, 2012). 7
  • 8. Anatomy (Michaud & Hoa, 2009) 8
  • 9. Pathophysiology  *There are many structures in the lumbar spine that can cause pain ; anyirritation to the nerve roots that exit the spine, joint problems, the discs themselves,the bones and the muscles. *Many lumbar spine conditions are interrelated. For example, joint instabilitycan lead to disc degeneration, which in turn can put pressure on the nerve roots. *The most common cause of lower back pain is muscle strain or other muscleproblems. Strain due to heavy lifting, bending, or other repetitive use can be quitepainful, but muscle strains usually heal within a few days or weeks (Davis,2012). *Causes of mechanical low back pain (LBP) generally are attributed to an acutetraumatic event, but they may also include cumulative trauma.The severity of an acute traumatic event varies widely, from just twisting the backto being involved in a motor vehicle collision. *Mechanical LBP due to cumulative trauma tends to occur more commonly inthe workplace. 9
  • 10. *The lumbar spine position most at risk for producing LBP is forward flexion (bentforward), rotation (trunk twisted), and attempting to lift a heavy object with out-stretched hands (Hills,2012) *Repetitive, compressive loading of the discs in flexion (e.g., lifting) puts the discs atrisk for an annular tear and internal disc disruption. Likewise, torsion forces on the discscan produce shear forces that may induce annular tears (Shankar, Scarlett & Abrams,2009). *In lumbar flexion, the highest strains are recorded within the interspinous andsupraspinous ligaments, followed by the intracapsular ligaments and the ligamentumflavum. *In lumbar extension, the anterior longitudinal ligament experiences the higheststrain. *Lateral bending produces the highest strains in the ligaments contralateral to thedirection of bending. 10 *Rotation generates the highest strains in the capsular ligaments (Hills,2012)
  • 11. *Repeated episodes of injury results in the degeneration of the disc which becomesstiff and dry causing it to lose its shock absorbing properties, and making it more proneto new injuries. This process may continue until the disc is collapsed which increasesthe mechanical pressure on the bones and joints and may eventually lead to arthritis. *Degenerative changes are seen as decreased signal intensity and bulging of thediscs in the lumbar spine. (Shankar, Scarlett & Abram, 2009) (Hill, 2012) 11
  • 12. Mechanical Low Back Pain (LBP) Overview, Anatomy and Pathophysiology Isabel Barradas Caudle Causes, Risk Factors, Signs and Symptoms Luz Luque Impact on Society and Family Linda Guevara Prevention and Patient Education Dora Aguilar 12
  • 13. Mechanical Low Back Pain  Lower back pain is  50-80% of population of referred as pain, muscle United States will have tension or stiffness occur lower back pain at some between the costal point of their life. margin and gluteal folds, including or not leg pain. (Walker, 2012) 13
  • 14. Causes and Risk Factors Acute low back pain Chronic low back painDuration: less to 6 weeks; sub- Duration: more than 12 weeks.acute lasts between 6 to 12 weeks.Causes Causes• Sudden injury (strain or tears) to the • Arthritismuscles and ligaments. • Extra wear and tear on the spine• Compression fractures (osteoporosis) from work or sport.• Cancer • Past injuries• Herniated disk • Fractures• Sciatica • Past surgery• Spinal stenosis• Scoliosis or kyphosis • Herniated disk.• Osteoarthritis • Spinal stenosis. • Scoliosis or kyphosis(National Institute of Health, 2012) (National Institute of Health,2011). 14
  • 15. Causes and Risks Factors  Non-Specific causes Specific causes Inflammatory. Rheumatoid  Poor posture when sitting arthritis, ankylosing and standing, lifting spondylitis, and reactive ergonomics and unknown arthritis. causes. Mechanical. Osteoarthritis, facet joint pain, lumbar spondylosis, spondylolisthesis, radiculopathy, kyphosis, scoliosis, herniated disc, sciatic, degenerative disc or joint disease and fracture. Metabolic. Osteoporosis, Paget’s disease and osteomalacia. Others. Tumors and infections. 15 (Concannon, & Bridgen, 2011).
  • 16. Causes and Risks Factors  Non-specific factors increasing the risk of developing chronic back pain: Overweight Smoking Pregnancy Long-term use of medication Stress Depression Occupation 16 (Concannon, & Bridgen, 2011)
  • 17. Signs and Symptoms History of an event that caused Pain complaint.immediate low back pain:  Quality: sharp, dull, Lifting and/or twisting burning, intermittent, or while holding a heavy diffuse. object.  Onset :sudden or insidious Operating a machine that vibrates.  Localization and Radiation Prolonged sitting.  Exacerbating and relieving Involvement in a motor factors vehicle collision  Associated symptoms Falls  Intensity.Past medical history :  24-hour pattern. ThisArthritis, infections, surgery, ca provides a view of irritatingncer or degenerative diseases. and easing factors.Vocational history. (Concannon & Bridgen, 2011; (Hill, 2012) Walker, 2012) 17
  • 18. Red Flags No emergency red flags Indicators of probable spinal pathology.  Age of onset younger of 20Requires immediate referral: years or older of 55 years  History of violent trauma  Constant progressive non Loss of sphincter tone mechanical pain Urinary or fecal  Fever incontinence  History of malignancy Saddle anesthesia  Infection Gait disturbance.  Neurological disturbance  Night sweats and weight loss.(Concannon & Bridgen, 2011; Walker, 2012). 18
  • 19. Yellow flags Indicators of possible chronicity of back pain. Poor physical fitness History of low back pain Radiating leg pain Total work loss as a result of low back pain in the past 12 months Disproportionate illness behavior Low job satisfaction Psychological distress and personal problems. (Concannon & Bridgen, 2011; Walker, 2012) 19
  • 20. Physical Examination  Changes in spinal  Diagnostic Tests: alignment or sagittal balance. X ray, CT Scan and MRI. Restricted movements of the lumbar spine Evaluate disturbance of patellar and ankle reflexes. Assess the strength and sensation of myotomes and dermatomes to determine neural compression. Low back pain can cause leg symptoms such as pain, numbness or tingling, and difficulty standing straight. (Concannon & Bridgen, 2011; Walker, 2012) 20
  • 21. Types of Employment Some types of jobs make the  employees more vulnerable to acute and chronic back pain The American Chiropractic Association in 1994, determined the jobs most at risk for back pain.  Drivers of heavy trucks and tractor-trailers.  Construction workers and shingles roofers.  Landscapers.  Police officers.  Peace officers: fireman and emergency medical technicians.  Farmers and delivery drivers.  Nurses, especially home nurses. (The Healthy Back Institute, 2011) 21
  • 22. Mechanical Low Back Pain (LBP) Overview, Anatomy and Pathophysiology Isabel Barradas Caudle Causes, Risks Factors, Signs and Symptoms Luz Luque Impact on Society and Family Linda Guevara Prevention and Patient Education Dora Aguilar 22
  • 23. Impact on Society and Family  Back pain is an underestimated, common, and growing problem that is impacting not just the quality of life of the pain sufferer but his/her family, society and the nation (Schofield et al, 2012). In March 2002, was declared the National Bone and Joint Decade with the specific mission: To improve bone and joint health by promoting and facilitating research and collaboration among professional organizations within all 50 U.S states, by educating and creating awareness of the growing musculoskeletal disease that leads to a better prevention, diagnosis and treatment (The Burden of musculoskeletal diseases in the United States (BMUS,2008). 23
  • 24. Impact on Society During the last decade the cost of spine conditions has increased by 49% (Davis,Onega, Weeks & Laurie, 2012; BMUS, 2008). Some of the causes are: Growing prevalence of back pain due to the aging of the population (BMUS, 2008) 24
  • 25. •Elevated number of medical visits •The subsequent increasing number ofand used of advanced diagnostic prescription medicationstechnologies(BMUS,2008) 25
  • 26. • Increased number and cost of spine surgeries performed due to disablingback pain and an ineffective non-surgical treatment.(BMUS,2008) 26
  • 27. •The resulting sickness leave and work disability outcome an economic impact to thestate due to: *Lost income taxation *Increased benefits payments *Lost gross domestic product(Ludeke, van Mechelen, et al, 2010; Lipincott &Wilkins, 2012). The amount lost in productivity by disability is $10-20 billion each year (Davis, Onega, 27 Weeks & Lurie, 2012).
  • 28. Impact on Family  The impact of back pain in a family should be seen by considering its effect in the sufferer and in the rest of the family members.Person with pain Usually a person with back pain is affected psychosocially, physically andemotionally, changing his/her quality of life. Some of the changes are:• Limitations in his/her abilities to perform activities of daily living (ADLs) 28
  • 29. •Unpredictable changes ofmood•Depression •Physical and emotional dependence•Isolation 29 (Smith et al, 2001; Schofield et al, 2012)
  • 30. Family Members The impact on the family members is upon almost every aspect of the family lifebecause in order to give support to the pain sufferer they experiment social andfamily roles restructuration. Some of these changes are:• Addition of responsibilities usually done for the sufferer for maintain the homestability and income• Restructuring relationships and self-identities• Sometimes anger 30
  • 31. •Communication is centered on the illness•Diminished social activities due to lack of time andfinances•Isolation from friends and community •Increased medical care expenditure 31 (Lewadonski et al, 2007; Smith et al, 2001; Schofield et al, 2012)
  • 32. Mechanical Low Back Pain (LBP) Overview, Anatomy and Pathophysiology Isabel Barradas Caudle Causes, Risks Factors, Signs and Symptoms Luz Luque Impact on Society and Family Linda Guevara Prevention and Patient Education Dora Aguilar 32
  • 33. Prevention and Patient Education   Prevention of mechanical low back pain (LBP) can be achieved using appropriately the biomechanical principles when performing heavy manual labor.  Prevention information depends on education and raising the awareness levels of individuals at risk for developing mechanical LBP. (Hill, 2012) 33
  • 34. Exercise  Exercise  Aerobic exercise: Maintaining healthy and strong muscles.  Strengthening exercises: Abdominal area, back and extremities.  Stretching exercises: Flexible joints and ligaments. (Batt & Todd, 2000; Walker, 2012; WebMD, 2012). 34
  • 35. Weight and Diet   Healthy Weight: Maintaining an appropriate body mass index (BMI) between 18.5 and 25.  Healthy Diet:  Feel better  Have more energy  Lower risk for disease  Eat calcium, Vitamin D, fish, green vegetables, soy, to prevent osteoporosis. 35 (Jarvis, 2011; WebMD, 2011)
  • 36. Lifting Objects Safely   Lifting objects safely  Stop: Be careful when picking up the weight.  Plan: How to lift the weight.  Lift and move: Cautiously and slowly. Never twist the trunk or lift over the shoulder level when lifting a heavy object. (Potter et. al., 2013; Walker, 2012) 36
  • 37. Workplace Factors  Five physical workplace factors resulting in low-back injury:  Leaning and twisting adopting bad positions  Excessive physical labor.  Sudden and violent motions.  Vibration of the entire body  Motionless postures. Work related mechanical LBP in nursing:  Ask for help  Use mechanical lift devices (Byrns, et. Al, 2010; Potter, 2013) 37
  • 38. Posture   Good posture while standing:  Head erect  Shoulders and hips aligned.  Abdomen tucked.  Knees and ankles lightly flexed.  Feet slightly apart.  Toes pointing forward. (Potter, et. al., 2013) 38
  • 39. Sitting Posture  Good posture while sitting:  Head erect.  Ears, shoulders and hips aligned.  Slightly curve in the lower back.  Thighs run alongside.  Both feet on the floor.  Knees below the hips.  Keep space between the popliteal fossa and the border of the chair. (Walker, 2012) 39
  • 40. Sleeping Positions  Sleep on one of the sides. Use pillow between the knees. Sleeping on his or her back, use a pillow under the knees. (Potter, et. al., 2013) 40
  • 41. Shoes  Low-heeled shoes:  Heels less than 1 inch create a more stable posture on the lower back.  In contrast: effect of high heels on the foot. (WebMD, 2011) 41
  • 42. Avoid Smoking  Risk of osteoporosis Less nutrition in the intervertebral disc. (Jarvis, 2012; WebMD, 2011) 42
  • 43. Stress Management  Time  Deal with it  Delegate it  Dump it Lifestyle  Sleep well  Eat healthy foods  Be active Interacting with others (Batt & Todd, 2000; WebMD, 2011) 43
  • 44. References  44
  • 45. References  American Psychological Association (APA) (2012). Annual Convention. Presentation guidelines for speakers. Retrieved from http:// www.apa.org/convention/presentation-guidelines.pdf Batt, M. E.,Todd, C. (2000). Five facts and five concepts for rehabilitation of mechanical low back pain. Br J Sports Med 2000;34:261. doi:10.1136/ bjsm.34.4.261 Byrns, G., Reeder, G., Jin, G., & Pachis, K. (2010). Risk factors for work- related low back pain in registered nurses, and potential obstacles in using mechanical lifting devices. Journal of Occupational and Environmental Hygiene, 1, 11-21. DOI:10.1080/15459620490249992 Bone and Joint Initiative USA (USBJI) (2013). The burden of musculoskeletal diseases in United States. Retrieved from: http:// www.usbji.org/index.cfm?CFID=7638696&CFTOKEN=9 0091126&jsessionid=f03071b8dbd7ac5c7e5933287e196b4d4764 45
  • 46.  Brault, M.(2008) Americans with disabilities: 2005, current population reports, P70-117, Washington, DC: US Census Bureau. Retrieved from http://www.census.gov/prod/2008pubs/p70-117.pdf Centers for Disease Control and Prevention (CDC) (2005). Prevalence and Most Common Causes of Disability Among Adults United States. MMWR 58(16); 421-426. Retrieved from http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5816a2.htm Concannon, M., & Bridgen, A. (2011). Lower back pain: a need for thorough assessment. Practice Nursing, 22, 458-463. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db =rzh&AN=2011330773&site=ehost-live Das, P., Samarasekera,U. (2012). The story of GBD 2010: a “super- human” effort. The Lancet (380) 9859: 2067-2070. DOI: 10.1016/S0140-6736(12)62174-6 46
  • 47.  Davis, E. (2012). Causes of pain in the lumbar spine. Spine-Health.com. Retrieved from http://www.spine-health.com/conditions/spine- anatomy/causes-pain-lumbar-spine Davis, M., Onega, T., Weeks, W., Lurie, J. (2012). Where the United States spends its spine. doi: 10.1097/BRS.0b013e3182541f45 Global Burden Disease 2010 Study (GBD) (2012). Musculoskeletal conditions: the second greatest cause of disability. The Lancet (380). Summary. Retrieved from http://www.thelancet.com/themed/global-burden- of-disease Gokzen, S. (2003). Spine and back. The well-tempered cellist. Retrieved from http://www.cello.org/newsletter/articles/ tempered/tempered4/tempered4.htm 47
  • 48.  Hill, E. (2012). Mechanical low back pain. Retrieved from http://emedicine.medscape.com/article/310353-overview Horton, R. (2012). GBD 2010: understanding disease, injury, and risk. The Lancet (380)9859: 2053-2054. DOI: 10.1016/S0140-6736(12)62133-3 Jarvis, C. (2012). Physical examination & health assessment. 6th ed.). St. Louis, MO: Elsevier Saunders. Lewadonski, W., Morris, R., Draucher, C., Risko. J. (2007). Chronic pain and family. doi: 10.1080/0161284070522200 48
  • 49.  Lippincott, W. & Wilkins (2012). Patient spending for spinal care in U.S. has nearly doubled over past decade. ScienceDaily. Retrieved fromhttp://www.sciendaily.com/releases/2012/09/ 120905110857.htm Ludeke, L., van Mechelen, W., Knoi, D.,Loisel, P., Anema, J., (2010). Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. British medical journal. Retrieved from http:// www.ncbi.nlm.gov/pmc/articles/PMC2840223/- Michaud,A., and Hoa,D. (2009). IMAIOS. E-anatomy. Anatomy of the spine. Retrieved from http://www.imaios.com/en/e-Anatomy/ Spine/Spinal-cord-diagrams 49
  • 50.  National Institute of Health. (2011). Low back pain - chronic. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/007422.htm National Institute of Health. (2012). Low back pain - acute. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/007425.htm. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing (8th ed.). St. Louis, MO: Elsevier Mosby Shankar, H., Scarlett, J., Abram, S. (2009). Anatomy and physiology of intervertebral disc disease. Techniques in Regional Anesthesia and Pain Management (13):67-75. doi:10.1053/j.trap.2009.05.001 50
  • 51.  Schofield, D., Shrestha, R., Percival, R., Passey, M., Callender, E. & Kelly, S. (2012). The personal and national costs of early retirement because of spinal disorders: impacts on income, taxes, and government support payments. Spine journal. (12) doi: http://dx.doi.org.ezproy.fiu.edu/10/1016/j.spinee.2012.09.036 Smith, B., Elliott, A., Chambersa, W., Smith, W., Hannaford, P., Pennyb, K. (2001). The impact of chronic pain in the community. Retrieved from http://fampra.oxfordjournals.org/content/18/3/292.full The Bone and Joint Decade (BJD)(2012) Musculoskeletal conditions: the second greatest cause of disability. The Lancet. Retrieved from: http://bjdonline.org/?p=1516 The Burden of musculoskeletal diseases in United States (BMUS, 2008). Health care utilization and economic cost of musculoskeletal diseases. Retrieved from http://www.boneandjointburden.org/ 51
  • 52.  The Healthy Back Institute. (2011). The 12 worst jobs for low back pain. Retrieved from http://www.losethebackpain.com/12worstjobs- forbackpain.html? utm_nooverride=1&ref=07-09-09-HBI-Enews- 12Jobs-BackPain-Cust U.S. Census Bureau (2005). Survey of income and program participation. Retrieved from http://www.cdc.gov/Features/ DisabilityCauses/chart.html Walker, J. (2012). Back pain: pathogenesis, diagnosis and management. Nursing Standard, 27, 49-56. Retrieved from http://ehis.ebscohost.com.ezproxy.fiu.edu/ehost/pdfviewer/pd fviewer?vid=3&sid=5ec61691-6878-46a3-b3a. WebMD (2011, May). Back pain health center. Retrieved from http://www.webmd.com/back-pain/tc/low-back-pain- prevention 52
  • 53. THANK YOU  53

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