Details about low back pain

1. Low Back Pain
Chinmayee Sahu
MOT(ORTHOPAEDICS)

2. Content
• Introduction
• Epidemiology
• Incidence
• Clinical feature
• Causes and risk factor of LBP
• Evaluation
• Intervention

3. Introduction
• Also known as lumbago(at times reffered to as waist pain) is pain ( as name
implies) in the lower back (lumbar) region
• LBP is a complex multifaceted medical problem that represents an exciting
challenge to the occupational therapist
• LBP is defined as pain , muscle tension, or stiffness localized below the
costal margin and above the inferior gluteal folds, with or without leg pain
• It can impact almost every area of functioning from self-care activities to
child care and relationships to emotional functioning

4. Epidemiology of back pain
• 60-90% lifetime prevalence
• 80-90% have recurrent episode.
• Second most common complaint to prompt a medical evaluation
• Leading cause of long term work disability

5. Incidence of low back pain
• Mechanical LBP is very common, affecting between 70-85% of American adults at some
point during their lives.
• Back pain are second only to upper respiratory condition as a cause of work absenteeism
• Back pain is also the most common cause of disability in patients younger than 40 yrs
• In 90% cases LBP resolves within 6 weeks(self limited)
• In another 5% cases the pain resolves by 12 weeks after intiation
• <1% back pain is due to serious spinal disease, <1% back pain stem from Inflammatory
disease.<5%is true nerve root.

6. Natural history of low back pain
• Muscle imbalance
• Dysfunction
• Condition
• pain

7. Classification
• Acute: < 6 weeks duration
• Sub-acute:6-12 weeks duration
• Chronic: > 6 weeks duration
 Subclassification for Chronic LBP Taking Account of Disability
• Grade 1 =low pain intensity, low disability
• Grade 2 = high pain intensity, but low disability
• Grade 3 =moderately limiting, high disability
• Grade 4 = severely limiting, high disability (Von Korff et al., Pain 1992)
•

8. CLINICAL feature
• Back pain
• Leg pain
• Neurologic symptoms
• Spinal deformity

9. Cause of low back pain

10. Risk factor of LBP
• Heavy manual Labor
• Repetitive lifting and twisting
• Postural stress
• Whole body vibration
• Monotonous work
• Lack of personal control at work
• Low job satisfaction
• Poor physical fitness
• Poor or in adequte trunk strength
• Smoking

11. Significance of back pain
• Non- specific LBP is now clearly recognized as a major public health
problem
• The symptom of LBP is the second most complaint after common cold
• In 70% of cases , LBP has no obviously etiology or a well known
pathogenesis

12. When should a radiograph be used
• Acute uncomplicated LBP without red flags is a benign self-limited condition
that does not require imaging evaluation.
• In patients with red flags, MR has displaced CT and myelography as the initial
imaging modality of choice in complicated LBP, with contrast useful for
neoplasia, infection, and postoperative evaluation.
• However, CT is useful in patients with surgical fusion/instrumentation or bone
structural abnormalities, and in patients with MRI contraindications.
• Myelography/CT, discography/CT, and radioisotope bone scans are useful in
selected patients for problem solving.

13. Evaluation of patients with low back pain
• The history typically starts with a full analysis of pain by assessing the type of onset, site of
pain and radiation, character and continuity of pain, progression and intensity of pain at rest
and movement, factors altering pain, severity of pain, and associated symptoms.
• Type of pain may help the physician recognize the structure possibly injured, deep, nagging,
and dull pain usually indicates the bones.
• A dull ache indicates muscles.
• A sharp and shooting pain indicates nerve root. A sharp, bright, lightning-like pain might be
nerve.
• A burning, pressure-like, stinging, aching pain indicates sympathetic nerve. A throbbing
diffused pain is mainly vascular.
• It is recommended in history taking to inquire about suggestive features of specific serious
diagnosis associated with LBP like: cancer, infection, cauda equina syndrome, compression
fractures, spinal stenosis, ankylosing spondylitis (AS), herniated disc or radiculopathy.

14. Common LBP diagnosis
• :
1. Sciatic (nerve root) pain: the nerve is entrapped by a herniated disk.
2. Spinal stenosis: narrowing of the intervertebral foramen decreases the space
where the spinal nerve exits or enters the spine.
3. Facet joint pain: inflammation or changes in the spinal joints cause facet joint
pain.
4. Spondylosis: this is a stress fracture of the dorsal to the transverse process.
5. Spondylolisthesis: one vertebra slips on another.
6. Herniated nucleus pulposus: stress may tear fibers of the disk and result in an
outward bulge of the enclosed nucleus pulposus. This bulge may press on spinal
nerves and cause various symptoms, including nerve entrapment.
7. Compression/stress fractures: result of osteoporosis and occur in the vertebrae.

15. Physical examination for LBP
GAIT:
• Gait: straight walking while watching for abnormal flexion
(stenosis or facet joint), extension (disc), or Trendelenburg gait.
• Screening: walking on toes then on heels.
• Position: watch as patient changing position.
INSPECTION:
• Alignment: Kyphosis, scoliosis, or loss or exaggerated lordosis.
• Skin: Erythema, hair patch, nodules, and or scars.
• Inequality: watch for iliac crest and pelvic inequality at the
level of L4-5: ask patient to flex his/her hip.
• N.B: Always inspect the patient posteriorly and laterally.

16. PALPATION:
• Examine the patient in the prone position.
• Spinous processes: tenderness or defects.
• Inter-spinous ligament.
• Supraspinous ligament.
• Paraspinal muscles.
• Iliac crest: tenderness (Spondyloarthritis) or nodules.
PSIS – sacroiliac joint –S2
• Ischial tuberosity – sciatic nerve – greater trochanter

17. Range of motion
Flexion: Finger-floor.
Extension: stabilize the pelvis and measure the distance.
Lateral flexion: Finger – fibula (against the wall)
Thoraco-lumbar rotation: 70 degree normally.

18. Special test
• Straight leg raising test (SLRT)
• Slump test
• Sacro-iliac joints exam: Patrick test and compression test
• Modified- Modified Schober’s test
• Neurological exam: muscle bulk by tape (Radiculopathy) and rectal tone
(S3,4,5).

19. Intervention
• Surgical management
Discetomy
Disc replacement surgery
Non- surgical management
• Pharmacotherapy
• McKenzie approach
• Alternative therapies
• Spinal manipulation
• Acupuncture
• Massage therapy
• Exercise therapy
• Other therapies

20. OT EVALUATION
• The occupational therapist's primary goals during the evaluation are to determine which occupations are impacted by LBP and how the person's
actions influence pain.
• This can be done by using self-report questionnaires, assessment tools, patient/caregiver interviews, or patient demonstration, depending on the
treatment setting.
• Common Low Back Pain Assessment Tools
1. Canadian Occupational Performance Measure (COPM)
2. Brief Pain Inventory
3. Pain Self-Efficacy Questionnaire
4. Beck Depression Inventory-II
5. Activity of daily living checklists
6. Numeric rating scale
7. Wong-Baker Faces
8. Oswestry Low Back Disability Questionnaire
• Educating the patient about the role of occupational therapy and how occupational therapists can help improve function is vital in the evaluation so
the patient can correctly identify areas of functional difficulty

21. OT intervention
1. Client Education
• Knowledge of basic anatomy and physiology to help client understand
what is occurring while engaging in occupations.
• Foundations for building the intervention plan.
• Education provided in both individual and group settings.

22. Back stabilization and neutral spine
• Before starting each activity, client should be helped to identify his or her
proper lower back position.
• In addition to developing a neutral spine, the client will need to learn and
integrate different techniques into activities to help in lifting and
movement.
• For example: squats, diagonal lift, and golfers lift

24. Body Mechanics
• It is important that clients thoroughly understand how to use body
mechanics to stabilize their backs.
• This includes maintaining a straight back, bending from the hip, avoiding
twisting, maintaining good posture, carrying objects close to the body,
lifting with the legs to promote safe performance, and using a wide base of
support.

25. Adaptive equipment
• Adaptive equipment is often useful for patients with LBP.
• The most frequently recommended pieces of equipment for persons with
LBP are used primarily to prevent the client from excessive spinal
movement and include long-handled sponges or brushes, reachers, long-
handled shoehorns, sock aids, elevated commodes or toilet seats, wiping
wands for toileting, handheld shower sprayers, and footstools.

26. Ergonomics
• Ergonomic task chairs that permit seat height, seat depth, back angle, and back
height or lumbar placement adjustments allow users to fit the chair to their bodies.
• A chair for desktop work must provide back support (ideally all the way up to the
shoulders) and maintain the hips and knees at 90 degrees with the feet flat on the
floor or a footrest.
• Tilt on a chair can also provide desk decompression periodically throughout the
day.
• Often clients place their chairs too high, resulting in pelvic anterior tilt and putting
strain on the low back.
• Frequent changes in position and rest breaks required

28. Occupations to increase strength and
endurance
• Once the principles of energy conservation have been taught and incorporated
into several of the client's occupations, it is important to build on that knowledge
and enable the client to increase strength and endurance for more occupational
engagement.
• For example, given the opportunity to prepare a meal nightly, the client can soon
develop the endurance to prepare a meal for guests.
• Sitting at a computer to write a letter while maintaining a neutral spine
strengthens the abdominal muscles and sitting tolerance, which can increase the
ability to sit in the car for a moderate to long car ride.

29. Strategies for stress reduction and coping
• Relaxation techniques
• Meditation
• Prayer
• Guided imagery
• Deep breathing
• Avoiding frustrating situations and anger management
• Participation in meaningful occupations

30. Intervention Strategies for Frequently
Impacted
Occupations
1. Bathing
• Shower is better than a bath because it is easier to maintain a neutral spine
when standing
• Keeping all bath items within easy reach
• Long-handled scrub, brushes or sponges
• Hand held shower
• Shower chair

31. Dressing
• Keeping the back in a neutral position is the main goal when dressing.
• The client can sit in a chair or lie flat on the bed while using mostly hip flexion to
get clothing onto the lower extremities, as opposed to spinal flexion.
• To don and doff socks and shoes, the client should sit and bring the foot to rest on
the knee using external rotation at the hip, or place the foot on a stool using
mostly hip flexion.
• Long handled shoe horn
• Looping belt through the loop before donning pant to avoid twisting
• Loose fitting clothes easier to pull up

32. Functional Mobility
• Use of the logroll technique to maneuver in bed requires moving the body as a
whole unit.
• To sit up, the client lies on one side, bends the knees over the side of the bed,
and pushes up with the arms while coming to a sitting position, using the weight
of the legs as leverage.
• To lie down, the client brings the legs up and uses the arms to lower the body to
the bedside.
• During both movements, the client must keep the back straight and tighten the
abdominal muscles to support the back.

34. • When getting on and off the toilet, the client must maintain a straight back
and neutral spine
• a toilet frame or grab bars at the side of the toilet can be used
• The client can use the chair arms to push up to a standing position, and the
firm pillows will better support the back while seated.
• To reduce stiffness, the client should stand and walk or stretch frequently
(about every 15-20 minutes).

35. Personal hygiene
• Activities at the bathroom sink can be difficult, as most sinks are hip or waist
height, requiring most adults to bend forward, increasing stress and strain on the
low back.
• While brushing the teeth, shaving, or washing the face, the client should place
one foot inside the base cabinet to reduce strain on the lower part of the back and
bend from the hips while keeping the back as straight as possible
• The client may bend forward and bear weight through one knee while extending
a straight leg back for balance and support and maintaining a neutral spine
position.
• Using hand held mirrors or adjustable mirror attachments to a wall to apply
cosmetics.

36. Sleep
• A firm, supportive mattress is important, as mattresses that are too soft or plush will not
maintain neutral alignment.
• The pillow should support the neck and head without causing the neck to flex forward or
laterally.
• While sleeping on the back, the client should place a pillow under the knees to reduce
strain on the lower part of the back and help maintain a balanced lower back position.
• While lying on the side, the client should place a pillow between the knees to prevent the
hips from collapsing in toward the bed and twisting the lower part of the back.
• While sleeping on the abdomen, place a small pillow under the feet to bend the ankles
and knees.

37. Toileting
• When cleaning after toileting, the client should reach between the legs to
avoid twisting the back, using a long-handled tissue holder if needed.
• When turning to flush the toilet, the client should stand first, then turn all
the way around and face the toilet rather than twisting and reaching.
• During an acute episode of back pain, the client can straddle the toilet seat
and face the back of the toilet.
• This affords a wider base of support and allows one to use the toilet tank
when coming to a standing position

38. Child care
• Sudden movements can increase the client's pain and interfere with the ability to
handle the child safely.
• Clients should use a changing table or elevated surface when dressing the child.
• Bathing can be performed in a kitchen sink or in a portable tub on an elevated
surface.
• Many contemporary cribs have drop-down rails so that the client does not need to
extend his or her arms to lift the child over the crib.
• To lift a child from the ground, the client should squat down and bring the child
close before using the legs and buttock muscles to stand up, all while engaging
the abdominals.

40. Computer use
• Keyboard and monitor should be directly in front of the client.
• Top of the monitor should be approximately at eye level.
• Use of proper work height and seat height with flat on the floor.
• Wrists in a neutral position with forearms parallel to the floor.
• Elbows at 90 degrees.
• Encourage client to lower their eyes to look at screen instead of flexing
their necks.
• Encourage stretch breaks and change position often.

41. Driving
• When transferring in and out of a car, the client should sit on the seat while
facing the door and turn the body as a unit to keep from twisting.
• The client should also increase the height of the seat to decrease the effort needed
to sit and stand, as well as sit with the knees no higher than the hips to reduce
strain on the low back.
• A small, rolled-up towel positioned in the lumbar area will suffice as well.
• Adjustments in seat height, seat angle, seat position, and steering wheel angle,
and some even come with adjustable lumbar support.
• Schedule breaks during long drives.
• Use of cruise control to allow frequent changes in position.

42. Home management
Organization:
• If the client is planning to bake cookies, flour, sugar, baking spices, bowls,
measuring cups, and maybe a mixer should all be within reach.
• Routinely used items should be stored on the countertop, in the lowest cabinets,
or in the highest drawers to limit back extension, reaching, and bending.
• Items in lower cabinets can be accessed with a partial or full squat.
• Cabinets can be modified with slide-out shelves/drawers that eliminate the need
to reach far back into the cabinet

43. Laundry:
• The client should use a golfer's lift to reach inside the machine.
• To place clothes in a front-load washer or dryer, the client is instructed to use a
squat or to use an underhand toss without any spinal twisting or bending.
• To retrieve clothes from a front-load machine, the client repeats the squat,
removes the clothes, and places them in a basket that is positioned nearby.
• For ironing, ironing board is to be raised to a proper height.
• While ironing, client should rest one foot on a low stool.
• Ironing can also be done while sitting.

44. Cleaning
• A long-handled brush, sponge, or Swiffer mop is recommended to clean
low surfaces such as the floor or bottom of a tub.
• Using a handheld spray cleaner is easier than scrubbing and rinsing the
surfaces.
• While vacuuming, clients should move their feet and legs rather than reach
or bend forward.

45. Shopping
• When retrieving items from a lower shelf, the client should squat or kneel while keeping
the back straight.
• Shelf can be used as support when returning to a standing position.
• When items located overhead, the client should get as close as possible and use hand for
support on the shelf.
• To use a shopping cart, the client should find his or her neutral spine position, keep the
abdominals activated, stand up straight, and push the cart with the elbows at the side,
using the legs and gluteals for pushing force instead of the back.
• Using a cart is preferred over carrying a basket.
• Golfer’s lift while unloading cart

46. Work
• Depending on the type of the job, the demands would vary considerably.
• Using the background information that we have so far, discuss some of the
modifications that can be used for clients we see in different types of jobs

47. Post operative ot evaluation and intervention
• History, occupational profile, description of home environment.
• Client education even before observation of performance.
• Education regarding proper body mechanics and practicing basic ADLs in
the hospital.
• Post-discharge do’s and don'ts pamphlets.
• Provision of adaptive equipment

48. MCKENZIE approach to low back pain

49. Effect of conventional occupational therapy and yoga in chronic
low back Pain
Ravi B. Wattamwar (M.O.Th.)*, Co-Authour : Mrs. Karuna Nadkarni (M.Sc. O.T.)**
• Objectives: To study the effect of conventional occupational therapy and yoga as compared to only
conventional occupational therapy in Chronic Low Back Pain.
• Methods: Total 24 subjects of chronic mechanical low back pain were selected in 2 groups Group A -
Conventional OT and Group B - Conventional OT and Yoga ; detailed medical history; assessed on
Range of motion of thoracolumbar spine(inches); Muscle strength of abdominal and back extensors using
Daniel method; Rolland and Morris patient questionnaire, Oswestry Low Back Pain Disability
Questionnaire. The assessments were done on day 1 and at the end of 5th and 10th week. Subjects of both
the group were treated thrice a week for a total period of 10 weeks.
• Result: The study shows conventional occupational therapy and yoga is more effective than conventional
occupational therapy, showing significant improvement in the back extensor strength, spine range of
motion, & social life of the patient.
• Conclusion: Yoga can be effectively used as an adjunctive method with conventional occupational
therapy in patients with chronic low back pain for a sound mental and physical health.