Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Sprains and Strains, Back


Medical Codes

ICD-9-CM:
846.0 - Sprains and Strains of Sacroiliac Region, Lumbosacral Joint
846.1 - Sprains and Strains of Sacroiliac Region, Sacroiliac Ligament
846.2 - Sprains and Strains of Sacroiliac Region, Sacrospinatus (Ligament)
846.3 - Sprains and Strains of Sacroiliac Region, Sacrotuberous (Ligament)
846.8 - Sprains and Strains of Sacroiliac Region, Other Specified Sites
846.9 - Sprains and Strains of Sacroiliac Region, Unspecified Site
847.1 - Sprains and Strains of Other and Unspecified Parts of Back, Thoracic Spine
847.2 - Sprains and Strains of Other and Unspecified Parts of Back, Lumbar Spine
847.3 - Sprains and Strains of Other and Unspecified Parts of Back, Sacrum; Sacrococcygeal (Ligament)
847.4 - Sprains and Strains of Other and Unspecified Parts of Back, Coccyx
847.9 - Sprains and Strains of Other and Unspecified Parts of Back, Unspecified Site; Back NOS

Related Terms

  • Back Sprain
  • Back Strain
  • Lumbago
  • Lumbar Sprain
  • Sacral Sprain
  • Thoracic Sprain

Overview

A back sprain involves injury of one or more nonmuscular structures (such as ligament, disc, facet, or capsule) of the back, whereas a strain involves musculotendinous injury of the back. The terms are often used interchangeably because of the difficulty in isolating the actual structure that is affected in a soft tissue injury.

Back sprains usually result from overstretching a ligament, most often due to twisting, heavy lifting, or sustained postural loading. Like sprains elsewhere in the body, back sprains are graded from mild to severe, depending on the degree of damage to the ligaments or other muscular structures. In a mild sprain (first-degree), only a few fibers are torn. Moderate sprains (second-degree) result in more fibers being torn and, consequently, some instability around the joint. Acute sprains of this type are usually associated with pain and muscle spasm. In a severe sprain (third-degree), the ligaments are completely disrupted, and joint instability may be severe. Most back sprains are first- or second-degree.

Back strains are most often caused by overstretching or overusing a muscle, and they are usually not as severe as a back sprain. In fact, strains involving the back may not even cause symptoms until the following day. Back strains are most often seen in persons whose occupation or leisure activities involve excessive lifting or torso rotation. Many strains are the result of inadequate warm-up, excessive training, or inadequate healing of a previous muscular injury. Muscle and tendon strains are similarly graded according to the severity of muscle or tendon fiber damage. In a grade I strain, muscles or tendons become stretched, with few torn fibers and no loss of muscle strength. Grade II strains involve a greater number of injured muscle or tendon fibers with noticeable loss of strength. With a grade III strain, the muscle or tendon is completely torn (ruptured), resulting in complete functional loss of the affected muscle or tendon.

Back strains and sprains are best avoided by receiving instruction on how to properly lift and move heavy items, realizing one's limitations, and taking the time to stop and ask another person for help when appropriate. Whether an individual has a ligamentous back sprain or a muscular back strain can be differentiated with passive and resisted test movements, respectively.

Incidence and Prevalence: Lower back pain is the second most common complaint seen by physicians. Among people living in the US, 85% will experience lower back pain during their lifetime. Pain that persists for more than 2 weeks is experienced by 14% of people. Lower back pain is the most common cause of work-related disability among people 45 years of age or younger (Hills).

Source: Medical Disability Advisor



Diagnosis

History: The individual may report sharp pain and tenderness. If bleeding in the muscle has occurred, swelling (edema) beneath the skin may be present. As a result of the injury and accompanying pain, the individual's movement may be limited, even to the point of requiring temporary immobilization. The pain may be persistent or associated with a specific movement or activity. Turning, sitting, and bending forward usually worsen pain.

Physical exam: The exam may reveal tenderness to the touch or upon pressure, localized swelling, and areas of discoloration along the back and gluteal area. Range of motion will be limited due to pain and muscle spasm, and the involved muscles may be tense. The physician may try to identify the particular movements or positions that aggravate the pain and determine whether the pain is relieved by lying down or rest.

Tests: Most cases of back strains and sprains do not require any diagnostic tests. Occasionally x-rays or MRI may be necessary to rule out other potential causes of back pain. For example, x-rays of the spine may be taken to rule out fracture. MRI allows good visualization of discs and nerves and can provide valuable diagnostic information in cases in which symptoms persist despite treatment (El Abd).

Source: Medical Disability Advisor



Treatment

Sprains and strains are treated in the same manner. Activity level should be adjusted according to what the individual can tolerate. Overall, the individual should avoid activities such as lifting, bending, or twisting, if they cause the pain to recur or become aggravated. The individual's activity level should be increased gradually. Bed rest of more than 2 days is not recommended because it has been shown to delay recovery. Pain and swelling may be relieved through the application of ice during the first 48 to 72 hours following injury, and heat, massage, or therapeutic ultrasound thereafter. Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for relief of pain and inflammation. If pain is severe, a mild narcotic may be prescribed for an appropriate short period. In addition, "muscle relaxants" may be prescribed for a short period. Lidocaine patches applied to the skin of the lower back (topical application) can reduce pain intensity and have provided relief in clinical trials. Severe sprains and strains are treated with physical therapy, modalities such as moist heat and electrical stimulation, trigger point injections, and short-term immobilization with a brace (corset). Exercise tolerance should be explored immediately and instituted within 2 weeks for the majority of individuals. Passive therapies should be eliminated or restricted severely after 1 month.

Source: Medical Disability Advisor



Prognosis

Most first- and second-degree sprains and strains heal on their own without significant functional impairment. There may be an increased potential for recurrence of symptoms, particularly in individuals with more severe injuries or in those who do not allow previous injuries to heal completely. Nonetheless, the prognosis is good. After 1 month, approximately 35% of individuals with diagnoses of back strain or sprain have recovered; at 3 months, 85%; and at 6 months, 95% (Hills). Some individuals may need regular follow-up and monitoring to ensure the best possible outcome. An interdisciplinary approach that combines medical management of pain with physical and occupational therapy to restore motion and function may be appropriate. Recurrence of back pain during the next year or two following recovery is not uncommon.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Chiropractor
  • Family Physician
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist

Source: Medical Disability Advisor



Rehabilitation

The goal of rehabilitation for low back pain is to decrease pain and promote an active lifestyle. Regular participation in an exercise program will help the individual regain mobility and strength to the involved area of the spine and the supporting muscles (Malmivaara).

Therapy, such as manipulation, to reduce symptoms followed by spinal exercises may be all that is required for mild cases. However, more involved rehabilitation is required for severe symptoms. Passive intervention should be time limited, with emphasis on active exercise. Rehabilitation will be based upon the duration of time from the onset of symptoms.

Acute Phase (up to 1 week): Recovery may be improved by a few sessions of manipulation, followed by instruction on safe postures and positions. The individual should be encouraged to resume activities that can be tolerated (Bigos).

Subacute Phase (2 to 12 weeks): Instruction should be given on an exercise program that will help maintain the individual's well-being. Physical therapy may include modalities such as moist heat and electrical stimulation in order to promote physical activity. To prevent further injury, the physical therapist should instruct the individual on proper body mechanics. The individual may also benefit from spinal injections for pain control. During this phase, the workplace should undergo an ergonomic evaluation so that changes may be implemented to assist the employee's return to work. Toward the later stages of this phase, if the individual shows a lack of or slow progress, a health psychologist should evaluate the individual to determine whether or not there are signs of psychological distress secondary to the injury (Kendall). There is evidence that a multidisciplinary treatment approach can be effective in treating these individuals and returning them to a full level of activity (Loisel).

Chronic Phase (more than 12 weeks): Exercise instruction must continue, and the program should combine coordination, aerobic conditioning, and flexibility. The individual should continue to be educated on functional exercises and proper body mechanics. A short course on cognitive pain management may reduce pain. Again, an ergonomic evaluation with modifications may enable the individual's return to work and reduce the risk of reinjury. Vocational services should be available for individuals who cannot return to their previous job title or do not have a job to which to return (van Tulder).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistSprains and Strains, Back
ChiropractorUp to 3 visits within first week of onset
Occupational TherapistDaily up to 6 weeks
ErgonomistUp to 2 visits within 8 weeks
Vocational CounselorUp to 3 visits within 6 weeks
Physical TherapistUp to 12 visits within 6 weeks
Physical TherapistDaily up to 6 weeks
Clinical PsychologistUp to 12 visits within 6 weeks
Clinical PsychologistUp to 2 visits within 6 weeks of onset
As part of multidisciplinary intervention (work condition).
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Comorbid Conditions

  • Alcoholism
  • Degenerative joint disease
  • Depression
  • Drug-seeking behavior
  • Hypochondriasis
  • Obesity
  • Recurrent episodes of back pain
  • Sciatica (pain extending below the knees)
  • Skeletal anomalies
  • Smoking
  • Traumatic injuries

Source: Medical Disability Advisor



Complications

Complications of severe lower back injuries include fractures, dislocations, and avulsion injuries (tearing away of a part or structure). An avulsion fracture involves the tearing away of a piece of bone with a ligament at the point of attachment and can result in spinal instability or nerve root or spinal cord injury. Bleeding into a muscle can result in severe pain.

Source: Medical Disability Advisor



Factors Influencing Duration

Factors include the severity and extent of the injury, the severity of the pain associated with the injury, the method of treatment, the individual's response to treatment and adherence to recommendations, and the individual's job requirements or leisure activities.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals with severe sprains and/or strains whose jobs require extensive lifting or bending may require temporary reassignment to more sedentary duties. Use of prescribed medications for management of pain and inflammation may require review of drug policies. Safety issues may need to be evaluated. Education and awareness regarding proper lifting and moving, particularly while performing heavy labor, can help prevent recurrence.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual have continued pain and disability after an adequate course of treatment?
  • Have other conditions, such as diseased internal organs, bone disease, tumor, muscle disease, or psychological stress, been ruled out?
  • Has MRI or x-ray been done to rule out disc herniations or fractures?
  • Has individual experienced any complications such as fractures, dislocations, avulsion injuries, or bleeding into a muscle?
  • Is individual obese?
  • Does individual suffer from alcoholism, hypochondriasis, or depression? Is individual a smoker?
  • Does individual have an underlying condition that may be affecting recovery

Regarding treatment:

  • Did individual follow recommendations for activity restrictions and limited bed rest?
  • Has individual avoided lifting, bending, or twisting?
  • If individual was prescribed bed rest for more than 2 days, what were the extenuating circumstances?
  • Did individual take medications such as nonsteroidal anti-inflammatory drugs or muscle relaxants, as prescribed?
  • Did individual ask for more pain relievers or muscle relaxants than injury warranted?
  • Was individual able to receive comprehensive rehabilitation?

Regarding prognosis:

  • Were workplace accommodations made to allow injury to heal completely?
  • What additional treatment options are available?
  • Given that back pain is one of the most common conditions in which somatization and seeking of secondary gain is found, has a psychological evaluation been done?
  • Would individual benefit from counseling?
  • If individual is obese, would weight reduction counseling be appropriate?

Source: Medical Disability Advisor



References

Cited

Bigos, S., et al. "Acute Low Back Problems in Adults." Clinical Practice Guidelines. 14th ed. Rockville, MD: Agency for Healthcare Policy Research (AHCPR), 1994.

El Abd, Omar. "Low Back Strain or Sprain." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Hills, Everett C. "Mechanical Low Back Pain." eMedicine. Eds. J. Michael Wieting, et al. 28 Jun. 2006. Medscape. 11 Feb. 2009 <http://emedicine.medscape.com/article/310353-overview>.

Kendall, N., S. J. Linton, and C. J. Main. Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-term Disabilities and Work Loss. Wellington, New Zealand: The National Health Committee, 1997.

Loisel, P., et al. "A Population-based, Randomized Clinical Trial on Back Pain Management." Spine 22 24 (1997): 2911-2918.

Malmivaara, A., et al. "The Treatment of Acute Low Back Pain--Bed Rest, Exercises, or Ordinary Activity?" New England Journal of Medicine 332 6 (1995): 351-355.

van Tulder, M. W., et al. "Behavioral Treatment for Chronic Low Back Pain: A Systematic Review within the Framework of the Cochrane Back Review Group." Spine 26 3 (2001): 270-281.

Source: Medical Disability Advisor