This document discusses mechanical low back pain (LBP) and is presented in four sections by four student authors. It provides an overview of LBP, including that it is the second most common reason for physician visits in the US. It also discusses the anatomy and pathophysiology of the back, causes and risk factors for LBP, the impact of LBP on both society and family, and strategies for preventing and educating patients about LBP.

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 most
common causes of severe long-term pain and physical
disability (USBJI, 2013) (GBD 2010, 2012).
Mechanical low back pain (LBP) remains the second most
common symptom-related reason for seeing a physician in
the United States (Hill, 2012).
In our country, the musculoskeletal conditions are a
leading cause of disability, accounting for more than 130
million patient visits to healthcare providers annually. They
are the No. 1 reason people visit their physician, and affect
nearly 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 common
cause 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 cause
of 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 organizations
partnered to create the Bone and Joint Decade (2002-2011). More than sixty countries,
including the United States, have established multidisciplinary National Action
Networks to plan activities in these respective countries.
*The United States Bone and Joint Initiative (USBJI) is the U.S. National Action
Network of the worldwide Bone and Joint Decade, a multi-disciplinary initiative
targeting 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 understanding
and treatment of those conditions through research, prevention and education. (USBJI,
2013).
5

6. Anatomy

*The spinal column is the body’s main support structure
which contains the spinal cord.
*The brain and spinal cord are known as the central nervous
system, while the nerves that connect the spinal cord to the body
are known as the peripheral nervous system.
*The nerves that carry information from the brain to the
muscles are called motor neurons. The nerves that carry
information from the body back to the brain are called sensory
neurons. Sensory neurons carry information to the brain about
skin 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 components
such as: intervertebral dics (shock absorbers), paravertebral muscles (flexors, extensors and
obliques) and ligaments (stabilizers).
*From the brain , the spinal cord passes down the center of the back and is surrounded
and protected by the bony spinal column. The spinal cord is surrounded by a clear fluid
called cerebrospinal fluid (CSF), which acts as a cushion to protect the delicate nerve tissue
damage by impacts against the inside of the vertebrae.
*The Spinal Cord consists of millions of nerve fibers that transmit electrical information
to the limbs, trunk and organs of the body, back to and from the brain. The nerves exiting
the spine at the top of the neck, control breathing and arms. The nerves that leave the spinal
cord in the middle and lower back, control the trunk and legs, bladder, bowel and sexual
function. (Hills, 2012).
7

8. Anatomy

(Michaud & Hoa, 2009)
8

9. Pathophysiology

*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 themselves,
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 lower back pain is muscle strain or other muscle
problems. Strain due to heavy lifting, bending, or other repetitive use can be quite
painful, 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 acute
traumatic event, but they may also include cumulative trauma.
The severity of an acute traumatic event varies widely, from just twisting the back
to being involved in a motor vehicle collision.
*Mechanical LBP due to cumulative trauma tends to occur more commonly in
the workplace. 9

10. *The lumbar spine position most at risk for producing LBP is forward flexion (bent
forward), 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 at
risk for an annular tear and internal disc disruption. Likewise, torsion forces on the discs
can produce shear forces that may induce annular tears (Shankar, Scarlett & Abrams,
2009).
*In lumbar flexion, the highest strains are recorded within the interspinous and
supraspinous ligaments, followed by the intracapsular ligaments and the ligamentum
flavum.
*In lumbar extension, the anterior longitudinal ligament experiences the highest
strain.
*Lateral bending produces the highest strains in the ligaments contralateral to the
direction 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 becomes
stiff and dry causing it to lose its shock absorbing properties, and making it more prone
to new injuries. This process may continue until the disc is collapsed which increases
the mechanical pressure on the bones and joints and may eventually lead to arthritis.
*Degenerative changes are seen as decreased signal intensity and bulging of the
discs 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 pain
Duration: 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 • Arthritis
muscles 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. This
Arthritis, infections, surgery, ca
provides a view of irritating
ncer 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 20
Requires 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 of
and used of advanced diagnostic prescription medications
technologies
(BMUS,2008)
25

26. • Increased number and cost of spine surgeries performed due to disabling
back pain and an ineffective non-surgical treatment.
(BMUS,2008) 26

27. •The resulting sickness leave and work disability outcome an economic impact to the
state 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 and
emotionally, 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 of
mood
•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 life
because in order to give support to the pain sufferer they experiment social and
family roles restructuration. Some of these changes are:
• Addition of responsibilities usually done for the sufferer for maintain the home
stability 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 and
finances
•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

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prevention
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53. THANK YOU

53