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