Rehabilitasi Komprehensif:

Nyeri Punggung Bawah pada

Pekerja

KSM Kedokteran Fisik dan Rehabilitasi, Akupunktur Medis

dr. Ibrahim Agung, SpKFR dan Kedokteran Okupasi
RSCM
 Overviews

• Definition of low back pain

• Causes of Back pain
• Red Flag in low back pain
• Yellow Flag in low back pain
• Finding ‘Source of Pain’ & Possible Cause of Back Pain
• Comprehensive management
• Conclusion
 Low Back Pain
• Most commonly reported musculoskeletal problem
• Prevalence as high as 84%
• Low back pain is a symptoms
• Back pain is defined as chronic or acute pain, pain in the lumbar or
buttock area, between costal margin and gluteal folds, or in the
upper leg region  major work-related disorder
• Major problem  disability, poor services, sickness absences

Wami et al., Work-related risk factors and the prevalence of low back pain among low wage workers: results from a cross-sectional study. BMC Public Health. 2019. 19:1072; Braddom. Physical Medicine& Rehabilitation. 5th edition. 33: 711-712
 Low Back Pain
• Related to
• Ergonomic stressors at work
• Environmental
• Psychosocial
• Personal risk factors

• Most patients have short attacks of pain that are mild or moderate
and do not limit activities, but these tend to recur over many years 
10-15% becomes chronic pain

Wami et al., Work-related risk factors and the prevalence of low back pain among low wage workers: results from a cross-sectional study. BMC Public Health. 2019. 19:1072; Braddom. Physical Medicine& Rehabilitation. 5th edition. 33: 711-712
Causes of Back Pain
Referred
Mechanical Neurogenic Non-Mechanical Visceral Pain

• Vertebral • Herniated • Neoplastic • GIT disease

fracture Disc • Inflammatory • Renal
• Spondylosis • Cauda LBP disease
equina
syndrome

Steven P Cohen, Charles E Argoff, Eugene J Carragee.Management of Low Back Pain. BMJ Jan 2009 Vol. 338.
Red Flag

Braddom. Physical Medicine& Rehabilitation. 5th edition. 33: 719

Yellow Flag

Braddom. Physical Medicine& Rehabilitation. 5th edition. 33: 719

 Source of Back Pain
• Structural problems

• Biomechanical changes

• Abnormalities/ postural
misuse/injury to tissue  tensional
balance changes  stress on
muscle contraction & surrounding
tissue

Scarr, Graham. Biotensegrity: the structural basis of life. 2014. 11; https://www.physio-pedia.com/Thoracolumbar_Fascia; Braddom. Physical Medicine& Rehabilitation. 5th edition. 33: 715-716
Assessment
• History taking:
• Location • Onset • Frequency • Cancer
• Severity • Duration • Signs of infection
• Timing • Alleviating and • Fracture
aggravating factors

• Physical examination: • ROM • Postures • Stability test

• Supportive findings: Imaging, EMG-NCV

Braddom. Physical Medicine& Rehabilitation. 5th edition. 33: 718-743

• Movement analysis  ask either pain
is increasing/ decreasing with specific
movement  pain stimulation

• The lower back is an anatomically

diverse set of structures  many
potential sources of pain

• The degree of flexion of the lumbar

spine affects the size of the
intervertebral foramina and vertebral
canal  potential for deforming the
nucleus pulposus

rd
Neumann, Donald A. Kinesiology of the Musculoskeletal System 2 nd edition. Cahp 32 : 688-697
Braddom. Physical Medicine& Rehabilitation. 5th edition. 33: 720-728
Braddom. Physical Medicine& Rehabilitation. 5th edition. 33: 720-728
Possible Causes of Back Pain
Possible Causes of Back Pain

Neumann, Donald A. Kinesiology of the Musculoskeletal System 3rd edition. 3 : 365-366.

Possible Causes of Back Pain
 Possible Causes of Back Pain

• Impaired muscle support / weak back

muscle  causing pain

• Weak back muscles  compensated

by quadratus lumborum muscle 
impaired muscle  Low Back Pain (QL
Pain)

Sions et al. 2017. Trunk muscle characteristics of the multifidi, erector spinae, psoas, and quadratus lumborum in older adults with and without chronic low back pain. Journal of orthopaedic & sports physical therapy. 47(3):173-179
Asha Satish Barge, Satish Mahadeo Barge. Qudaratus lumborum: one of the many significant causes of low back pain. Indianjpain 2018 32(3): 184-186
Management of LBP
• Most patients have • Medications
spontaneous recovery within 3 • Exercise to prevent deconditioning
weeks
 stretching and strengthening
• Physical Modalities/Manipulation/
• Being active as normally as Manual Mobilization
possible  quicker recovery
and lead to less disability Multiple therapies
• Orthosis

Braddom. Physical Medicine& Rehabilitation. 5th edition. 33: 718-743

Treatment
• Medicine
• NSAIDs
• Muscle relaxants
• Antidepressants
• Opioids
• Anticonvulsants
• Topical treatments
• Exercises, Manipulations
• Orthosis
• Invasive therapy:
• Steroid injections
• Acupuncture

Braddom. Physical Medicine& Rehabilitation. 5th edition. 33: 718-743

 Exercises
• 30 min of moderate aerobic, 5x/
week
• Regularly exercise
• Lumbar stabilization programs 
strengthening abdominal, low back,
hip muscles, increasing flexibility
• Yoga
• Pilates
Exercises
Physical Modalities/Manual Mobilization /
Manipulation
• Traction
• TENS
• Massage
• Laser
• Diathermy
• ESWT (Extra Corporeal Shockwave
Therapy)

Braddom. Physical Medicine& Rehabilitation. 5th edition. Chap 13: 276, 283; Chap 33: 718-743
Manual Mobilization / Manipulation
• Alexander tech: educational approach to
posture and normalizing movement
patterns

• Feldenkrais method: combination of

classes and hands-on work with
therapeutic exercise to promote natural
and comfortable movement patterns
and improve body awareness.

Braddom. Physical Medicine& Rehabilitation. 5th edition. 33: 718-743

Orthotic consideration

LSO Corset LSO Brace

Cuccurullo. Physical medicine and rehabilitation board review. 3rd edition. 6 : 541-547; Braddom. Physical Medicine& Rehabilitation. 5th edition. 13: 281-2
Orthotic Consideration

Cuccurullo. Physical medicine and rehabilitation board review. 3rd edition. 6 : 541-547; Braddom. Physical Medicine& Rehabilitation. 5th edition. 13: 281-2
Interventional Pain Management
• Selective nerve root block
• Medial Branch block
• Facet joint injection
• Sciatic nerve block
• Piriformis injection
• Transforaminal block
• RFA (Radio Frequency Ablation)
• PLDD (Percutaneous Laser Disc Disectomy)
When to undergo surgery?
• Persistent and severe sciatic pain
• Disc Herniation
• Cauda equina syndrome
• Progressive and severe neurologic deficits
 Initial
Management
Pre and
Source of
Post
Pain
Surgery

Working and
Biomechanical
IPM Comprehensive Change/Modific
Rehabilitation ation
Management

Exercise Medication

Therapeutic
Orthotic
Modality
Conclusion
• Low back pain is a symptoms
• Work-related disorder esp. ergonomic stressors
• Can cause limitation  10-15% becomes chronic pain
• Know the signs (red or yellow flag)
• Being active as normally as possible despite the pain
• Seek for help !
• Do some stretching/ exercises
THANK YOU