1

Back pain is a major health problem. An estimated

80% of the population will experience low back pain
at some time during their lifetime. Impairment of the
back and spine are the third leading cause of disability
of people in their employment years.
Low back pain may be caused by a large variety of
conditions. Most low back pain is caused by
musculoskeletal problems, for example, acute
lumbosacral strain, unstable lumbosacral ligaments
and week muscles, osteoarthritis of spine, spinal
stenosis, intervertebral disc problems, and inequality
of leg length.
Other causes include kidney disorders, pelvic
problems,
retroperitoneal
tumors,
abdominal
aneurysms, and psychosomatic problems.
Most back pain due to musculoskeletal disturbances is
aggravated by activity, whereas pain due to other
considerations is not influenced by activity.
According to a survey published this year(2000)
almost half of the adult population of the United
Kingdom(49%) report low back pain lasting for at
least 24 hours at some time during the year. In a
similar survey carried out 10 years earlier just over
one third of the population complained of such back
pain. In l998 almost one in five adults (18%)
experienced low back pain for the first time It is

estimated that up to four out of five people (80%) will

experienced back pain lasting more than a day at
some time during their life.
In 1998 in over half of those people who reported
back pain the episode lasted for over 4 weeks ----affecting 8 million people and in the case of 2,5
million of these the back pain lasted throughout the
year.
Young people are more likely to have brief acute
episodes of back pain while chronic pain is more
characteristic of older people. There is little difference
in the occurrence in men and women.
(Low back pain, kumpulan referensi dari sumber
internet)
Low back pain is extremely common. By middle life,
50-70% of adults will report having experienced
low back pain at some time. As many as 25% of
adults report experiencing low back pain in a given
year. Like headache, it is the norm to experience low
back pain.
Some 90% of reported cases of acute low back pain
settle within 6 weeks. For most people, a simple
back strain is an interruption to life which gradually
settles and return to normal function occurs quickly.

For a small number of low back pain starts with a

physical problem which may lead to psychological
disturbances.
Simple distress is a common
accompaniment to low back pain. Anxiety and
depression and other psychosomatic symptoms may
develop later.
(Guidelines for the management of employees with
compensable low back pain, l996)
Manual handling describes any activity requiring
the use of forced exerted by a person to lift, push, pull,
carry or otherwise more or restraint any animate or
inanimate object.
Where manual handling tasks involve repetitive
actions, forceful movement, and/or sustained awkward
postures, they may result in type of injury called OOS
(Occupational overuse syndrome). These injuries
may be characterized by discomfort or persistent pain
in muscles, tendons, and other soft tissues.
MECHANICAL
DISORDERS
OF
THE
LUMBOSACRAL SPINE
Mechanical disorders of the lumbosacral spine are the
most common cause of low back pain. Mechanical
low back pain may be defined as pain secondary to
overuse of a normal anatomic structure (muscle
strain) or pain secondary to injury of deformity of

an anatomic structure (herniated nucleus

pulposus).
Mechanical disorders are local disorders of the
spine, that is, the processes that cause pain are
limited to the structure of the lumbosacral spine.
Mechanical disorders are truly musculoskeletal
diseases. Systemic complications with involvement of
other organ systems (except the nervous system) are
not associated with mechanical disorders.
Back strain
Frequency of back pain ------- very common
Location of back pain --------- low back, buttock,
posterior thigh
Quality of back pain ----------- ache, spasm
Symptoms and signs -----------pain increases with
activity, increased muscle tension
Laboratory and X-ray tests --- none
Treatment ----------------------- controlled physical
activity, medication
.
Prevalence and pathogenesis
Back strain can be defined as non radiating low back
pain associated with mechanical stress to the
lumbosacral spine. The exact number of patients with
back strain is difficult to determine. Most people with
back pain (90%) have it on a mechanical basis. Of
patients with mechanical low back pain, back

strain may account

abnormalities.

for

60%

to

70%

of

The etiology of back strain is not always clear but may

be related to ligamentous or muscular strain
secondary to either a specific traumatic episode or
continuous mechanical stress.
In summary, muscle pain in low back pain patients
may be caused by four different mechanisms:
1. Pain is associated with muscle strain that is
related to muscle disruption from indirect
trauma such as excessive stretch or tension.
2. Another possible source of muscle pain is
muscle fatigue associated with overuse.
3. Muscle spasm is associated with persistent
contraction of muscle.
4. Paraspinous muscles become deconditioned
after injury.
(David G. Borenstein, Low Back , pp. 183-186)
Menurut Dieter Breithecker , ketua tim peneliti dari
Federal Work Association for Posture and Movement
di Jerman, proses kemunduran fungsi tulang pada
tubuh dan system pergerakan(locomotion system)
pada saat ini telah menjadi masalah kesehatan yang
serius bagi semua kelompok usia. Dari hasil
penelitiannya, didapatkan bahwa 80% populasi

mengalami masalah punggung sesuati dengan

tingkatan usia. Sedangkan 50% populasi mengalami
masalah punggung yang terjadi minimal setahun
sekali dan 25% populasi menderita sakit punggung
kronis. Hanya 15% dari kasus keluhan nyeri punggung
disebabkan oleh penyakit tertentu, sisanya disebabkan
karena kurang gerak badan yang posisi duduk yang
salah dan berlangsung dalam waktu yang lama..
Age
Spondyloarthropathies,
including
ankylosing
spondylitis, Reiters syndrome spondylitis associated`
with inflammatory bowel disease, and benign tumors
of the spine(osteoid osteoma, aneurismal bone cyst,
osteoblastoma), occurs between the third and fourth
decades, Diseases of middle age include diffuse
idiopathic skeletal hyperostosis (DISH), gout,
pagets disease, and ostomyelitis. A different set of
diseases occurs more commonly during and following
the sixth decade, which includes malignant metastasis,
colon
cancer,
prostatic
cancer,
metabolic
(osteoporosis), and degenerative diseases(expanding
abdominal aortic aneurysm). Approximately 80 % of
patients with malignant disease affecting the lumbal
spine are over 50 years of age.
Sex

Back pain occurs predominantly in men.

Occupational exposure to heavy-duty labor explains
some of the increased prevalence of this symptom.
Many illnesses including the spondyloarthropathies,
infections, and malignant and benign tumors also
occur more commonly in men. Endocrinologic
disorders, including osteoporosis and parathyroid
disorders, and muscle disease (polymyalgia
rheumatica and fibromyalgia) are more likely to
appear in women. Psoriatic spondylitis, spondylitis
associated with inflammatory bowel
disease,
hemangioma, Gauchers disease, pituitary disease,
and subacute bacterial endocarditis occur with
equal frequency in both sexes.
Family history
Familial predisposition does occur in certain medial
illnesses that are associated with back pain. A prime
example is the spondyloarthropathies. In the presence
of a particular Histocompatibility Locus Antigen
(HLA-B27), members of a family are at risk of
developing ankylosing spondylitis, Reiters syndrome,
psoriatic spondylitis and spondylitis associated with
inflammatory
bowel
disease.
Other
spondyloarthropathies, such those occurring in
familial Mediterranean people and Whipples disease,
occur more commonly in family members without any

specifically associated genetic factor. The etnic

background of the family may predispose members
to specific illnesses. Caucasian women of Northern
European extraction are at greatest risk of
developing osteoporosis.
Occupational/social history
The occupational history is essential for evaluating the
patient risk of developing mechanical low back pain.
Workers doing heavy lifting at their job are at risk of
developing mechanical low back pain. However, this
symptom also occurs in sedentary workers. Lifting a
light object from a rotated position or stretching far
overhead to reach an object on a shelf may be
associated with the onset of low back pain. The
relationship of work and onset of pain is important in
evaluating the patient in regard to compensation.
Whether the symptoms of back pain are work-related
of not, it is important to discuss their association from
the patient viewpoint.
Social history also includes quantification of
consumption of alcohol, coffee, and recreational
drugs and cigarette smoking are associated with
osteoporosis, while illicit drugs results in
immunosuppression
and
predisposition
to
infection. Smoking may also be associated with
increased risk for herniated intervetebral disc and low

back pain.(Borenstein D.G., Wiesel S.W., and Bodeb

S.D. 1995) hal : 64-67
Back and neck pain is one of the leading causes of
lost work time, second only the common cold. It
affects 65-85% of the population of the United States
at some point on their lives. The most common cause
is sprain, strain or spasm usually brought on by
poor lifting techniques, improper posture, or an
unhealthy ergonomic environment. Another
common cause is disc problems brought on by injury,
wear and tear, or age. Other causes include spinal
stenosis, osteoarthritis, osteoporosis, and other
conditions.(kumpulan referensi dari sumber internet,
hal: 1 dari 4)
Types of back and neck pain
Acute pain
Acute pain can be defined as severe short-term pain.
Post-operative pain is an example. Acute pain is selflimiting, which means the pain acts to warn you to
cease or limit activity that could cause additional
tissue damage. The more intense and prolonged an
acute pain episode is, the more likely it will lead to
chronic pain. This makes sense given the information
that we are beginning to learn about how the central
nervous system changes in response to instant pain. As
a result of intense pain, neurons in the spinal cord that

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help to prevent pain transmissions actually die. At the

same time, pain-transmitting neurons grow more
connections to other nerves, become more sensitive,
and react more strongly to painful stimulus.
Chronic pain
Rather than being the symptoms of a disease process.
chronic pain is itself a disease process. Chronic pain
is unrelenting(tidak menjadi lunak) and not selflimiting. It can persists for years and even decades
after the initial injury. There many factors that affect
the development of chronic pain such as age, level of
disability, depression or the presence of nerve damage.
Persons with chronic low back pain are frequently
obese. Some studies suggest that they may have
problems dealing with stress and exhibit depressed,
dependent personalities. Some patients with chronic
low back pain develop a dependence on alcohol or
analgesics.
Patients with muscle strain have back pain as their
main complaint. The pain can be limited to a small
local area or can cover a diffuse area of the
lumbosacral spine but does not radiate to the lower
extremities. At times, there may be a referral of pain to
the buttocks or posterior thigh, since the mesenchymal
structures in the lower back, buttocks, and posterior
thigh all originate from the same embryonic tissues.

11

Such referral of pain does not necessarily

connote(mengandung
arti)
any
mechanical
compression of the neural elements and should not be
called sciatica.
The patients may experience pain simultaneously
with an injury. The pain increases in intensity and
grows larger in its distribution after a few hours. He
change in pain is associated with increasing edema in
the injured structure along with the reflex contraction
of surrounding muscles that limit motion. The patient
may be able to continue to be active for a few hours.
However, marked pain and stiffness occur the next day
after sleeping. Flexion or extension of the spine may
cause pain. Pain occurs with the motion that contract
the injured muscle. Certain motions may be painless,
while others cause incapacitating pain. In general,
muscle strain will be increased with activity and
relieved with rest.
Pathophysiology
The spinal column can be considered as an elastic rod
constructed of rigid units (vertebra) and flexible
units (intervertebral discs) that are held together by
complex facet joints, multiple ligaments and
paravertebral muscles. The unique constraction of the
back allows for flexibility while providing maximum
protection for the spinal cord. The spinal curves
absorb vertical shocks from running and jumping. The

12

trunk helps to stabilize the spine. The abdominal and

thoracic muscles are important in lifting activities.
Lack of use weakens these supporting structures.
Obesity, postural problems, structural problems, or
overstretching of the spinal supports may result in
back pain.
Low back pain remains a symptom of vague
etiology. Numerous terms prevails in the literature
along with nonspecific mechanisms and, therefore
nonspecific treatment regimes. Terms such as
lumbosacral strain, unstable back, facet syndrome,
iliolumbar ligamentous strain, quadratus lumbar pain,
myofascitis, spinal stenosis, degenerative disc disease,
latissimus dorsi syndrome, abnormal transforaminal
ligaments, and a great many more enjoy current
vogue(mode, sedang digemari)
An enigma(teka-teki) remains in that there is no
universality or standardization of low back pain
disorders. The term syndrome must remain in todays
terminology without clarification or universal
understanding.(Cailliet R., 1981)
Low back pain considered to have excited less than 2
months can be termed acute. Chronic back pain, like
any chronic pain, may persist in the absence of any
clinical findings or confirmatory test. (Cailliet R,
1981).

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Risk factors associated with manual material

handling injuries
1. Personal factors
-

Age
Gender
Anthropometry(body weight and height)
Physical fitness and training
Lumbar mobility
Strength
Medical history
Years of employment
Smoking
Psychosocial factors
Anatomical abnormality
Marital status

2. Environmental factors
-

Humidity
Lighting
Noise
Vibration
Air temperature

3. Job-related factors

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Location of load relative to the worker

Distance object is moved
Frequency and duration of handling activity
Weight of object or force required to move object
Bending and twisting
Stability of the load
Postural requirements
(Amit B., James D. and Mcglothlin 1996)
(Occupational Ergonomics, hal. 331)

A more recent report by National Safety Council

indicated that overexertion(kerja keras/aktivitas fisik
yang berat) is the most common cause of occupational
injury, accounting for 31% of all injuries. The back,
moreover, is the body part most frequently
injured(22% of 1,7 million injuries) and the most
costly to workers compensation system.
Work-related (MSIs) musculoskelethal injuries are
typically attributed to a direct trauma, a single
exertion(overexertion),or
multiple
exertion(repeated trauma). It is not always
possible, however, to determine the specific cause of
the injury, and the pathophysiology of many types of
MSIs is poorly understood.
Sixty-seven percent(67%) of overexertion injuries
claims involve lifting, while 20% involve pulling or
pushing. Sixty percent(60%) of people with low back
pain report that overexertion was the cause. The

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likelihood of identifying a specific cause for a

patients low back pain is approximately 5-10%; a
defined structural diagnosis can be reached in
no more than 50% of all cases. Another major cause
believed relevant to low back pain includes the
degenerative disease of the spine.
Mechanical low back pain
The spine is a mechanical structure that supports the
individual from the day of birth throughout his or her
life. The spine defies(menentang/melawan) gravity, or
at least is in balance with gravity. It supports mankind
in standing and sitting and allows an individual to
bend, stoop, squat, twist, turn, and in other manners,
function throughout the activities of daily living.
The lumbar spine contains five vertebrae and forms a
normal curve in the erect posture called lordosis. This
lordosis
is
also
frequently
called
the
sway(lenggang/goyangan) of the low back. Between
vertebrae are the discs and behind the discs emerge the
nerves that descend into the legs. The five lumbar
vertebrae balanced upon the sacrum. The sacrum is
contained between two broad bones of the pelvis,
called ilia. One of the ilia is called an ileum and
connects to the sacrum by the sacroiliac joint. Both
ilia contain sockets into which the hip joins fit. These
ball-and-socket joints permit movement of the ilia,

16

and hence the pelvis and the lumbar spine. The sacrum
continues down to form the tailbone(the coccyx). The
sacrum is a flat bone between the two pelvic
bones(ilia). The coccyx is formed by several small
bones that resemble a tail.
Disc injuries
For reasons that are still unknown, intervertebral discs
may degenerate and lose their strength : they become
flattened and in advanced cases the viscous fluid may
even be squeezed out. The degenerative processes
impair the mechanics of the vertebral column and
allows tissues and nerves to be strained and
pinched(terjepit), leading to various back trouble,
most commonly lumbago(painful muscle cramps),
and sciatic troubles, and even
in severe
instances to paralysis of the legs.(Grandjean E. l988)
The most severe problem involves the spine and the
muscles of the back, which in many sitting positions
are not merely not relaxed, but are positively stressed
in various ways.

Most back pain comes from the muscles, ligaments

and joints in your back.

17

The back is made up of the bony spinal column and

the ligaments and muscles that support and move the
spine. The bones of the spine, called vertebrae,
support the weight of the body. There are 24 of these
blocks of spongy bones. Each of the blocks has wing
like projections that surround and protect the spinal
cord and the nerves. The joints between the vertebrae
allow flexible movement. In the joint between each
pair of vertebrae are cushions called discs, which are
kept tense by their special structure.
Peak muscle strength for both men and women is
reached between the age of 25 and 35 years old.
Older workers aged between 50 and 60 can
produce only about 75-85% as much muscular
strength. (Grandjean E., 1988)
Beginning at ages 30-40, the ligaments that encase
the disc start to dry out and become less elastic.
When they are dried out, a person can
snap(menjepit) or break them by suddenly rotating
or bending the spine. If the ligament mesh
surrounding the disc has been torn(robek), the
pulpy core of the disc may squeeze through it. This
is called a rupture disc, and it may cause pain by
pressing on the nerves that enter and leave the
spinal cord.
Most people with back pain or backache do not
have any damage in their spine. Very few people
with backache have a slipped disc or a trapped

18

nerve. Even then a slipped disc usually gets better

by itself.
For most people, a simple back pain is an interruption
to life which gradually settles and return to normal
function occurs quickly. For a small number, low back
starts with a physical problem which may lead to
psychological disturbances. Simple distress is a
common accompaniment to low back pain. Anxiety
and depression and other psychosomatic symptoms
may develop later.
Some 90% of reported cases of acute low back pain
settle within
six weeks. The challenge for treating practitioners is
the cases which do not settle quickly. Many studies
have suggested factors other the severity of the injury
or problem are associated with delayed recovery..
Low back pain will have substantial financial,
domestic and social consequences. Those the person
needs to be assessed in the context of what their
physical problem means to their life.
Ergonomic advice should include care with lifting; for
example holding and object as close to the body as
possible, and standing as close as possible to the
workstation. Patients should be advised to change
positions frequently, especially avoiding prolonged

19

sitting or fixed flexion. Patients should be advised that

good lumbar support and seating is often helpful.
Chronic pain
Chronic pain requires a different approach to
management than acute pain. Physical problems may
contribute a part of the disability while psychological
distress and social interactions reinforce behavior. The
combination of these problems can result in a fixed
disabled state, often preventing usual activities.
Features suggesting this condition will be :
-

History of protracted low back pain and disability

Lack of response to any treatment
Increasing symptoms
Use of words such as excruciating(menyiksa) or
agonizing(mengerikan) in situations where it is
inappropriate
- Where most activities are being avoided because
of the pain
- Where most activities are being avoided because
of the problem
The loading on the vertebral column increases from
above downwards, and is at its greatest in the lowest
five lumbar vertebrae.

20

Degeneration of the discs first affects the margin of

the disc, which is normally tough and fibrous. A tissue
change is brought about by loss of water, so that the
fibrous ring becomes brittle and fragile, and loses its
strength. At first the degenerative changes merely
make the disc flatter with the risk of damage to the
mechanics of the spine, or even of displacement of the
vertebrae. Under these conditions quite small actions,
such as lifting a weight, a slight stumble(tersandung)
or similar incidents, may precipitate severe backache
and lumbago.
When degeneration of the disc has progressed further,
any sudden force upon it may sqeeze the viscous
internal fluid out through the ruptured outer ring, and
so exert pressure either on the spinal cord itself or on
the nerves running out from it. This is what happens in
a case of a slipped disc or disc herniation. Pressure
on nerves, narrowing of the species between vertebrae,
pulling and sqeezing at adjoining tissues and
ligaments of the joints are the causes of the variety of
aches, muscular cramps and paralysis including
lumbago and sciatica which commonly accompany
disc degeneration.
Lifting, handling and dragging loads involve a
good deal of static effort, enough to be classified as
heavy work. The main problem of these forms of
work, however, is not the heavy loads on the muscles,

21

but much more the wear and tear on the intervertebral

discs, which the increased risk of back troubles.
Back troubles are painful and reduce ones
mobility and vitality. They lead to long absences
from work, and in modern times are among the
main causes of early disability. They are
comparatively common in the age group 20-40, with
certain occupations(laborer, farmer, nursing staff, etc.)
being particularly vulnerable to disc troubles.
(Grandjean E. l988)
Patients with muscle strain have back pain as their
main complaint. The pain can be limited to a small
local area or can cover a diffuse area of the
lumbosacral spine but does not radiate to the lower
extremities. At times, there may be a referral of pain to
the buttocks or posterior thigh, since the mesenchymal
structures in the lower back, buttocks, and posterior
thigh are all originate from the same embryonic tissue.
Such referral of pain does not necessarily connote any
mechanical compression of the neural elements and
should not be called sciatica.(connote=mengandung
arti)
Muscle strain results from overuse or
overstretching of a muscle. On physical examination,
any active motion of the involved muscle against
resistance will cause pain. Muscle pain in low back

22

pain patients may be caused by four different

mechanisms :
1. Pain is associated with muscle strain that is
related to muscle disruptions from indirect
trauma such as excessive stretch of tension.
2. Another possible source of muscle pain is muscle
fatigue associated with overuse. Fatigue has a
metabolic component manifested by increased
concentrations of lactic acid, a byproduct of
anaerobic metabolism.
3. Muscle spasm is associated with persistent
contraction of muscle. The absence of blood flow
with accumulation of metabolic byproducts may
stimulate pain receptors within blood vessels.
4. Paraspinous muscles become deconditioned
after injury. Radiographic evaluation of crosssectional views of patients with back pain
demonstrate decreased muscle mass in
paraspinous and psoas muscles. Decreased
muscle mass results in decreased muscle power
that puts individuals at risk for persistent muscle
injury.(Borenstein D., Wiesel S.W., Boden S.D.,
1995)
The usual physical findings are limited to local
tenderness over the involved area with limited
motions; However, the attacks will vary in intensity
and can conveniently be divided into three
categories : mild, moderate and severe.

23

a. The mild is associated with subjective pain

without objective findings, and patients
usually are able to return to customary
activity in less than a week.
b. The moderate is characterized by a limited
range of spinal motion and paravertebral
muscle spasm as well as pain, and patients
frequently resume full activity in under two
weeks.
c. The severe may cause patients to tilt forward
or list(miring) to one side. These patients
have trouble ambulating(dapat berjalan) and
can take up to three weeks to recover full
function.
Low back pain is very common in developed
countries, especially in adults of working age. Low
back pain is characterized by a range of symptoms
which include pain, muscle tension or stiffness, and
is localized between the shoulder blades and the
folds of the buttocks, with or without spreading to
the legs(sciatica).
Low back pain is commonly categorized into acute,
sub-acute and chronic. Acute low back pain is
usually defined by a period of complaint of six
weeks or shorter, sub-acute low back pain as a
period between six and twelve weeks, and chronic
low back pain as a period of complaint longer

24

than twelve weeks. Low back pain is often selflimiting so may resolve with or without treatment.
Menurut Dieter Breithecker, ketua tim peneliti dari
suatu riset yang dilakukan oleh Federal Work
Association for Posture and Movement di Jerman,
proses kemerosotan fungsi tulang dan system
pergerakan(locomotive system) pada saat ini telah
menjadi masalah kesehatan yang serius untuk semua
kelompok usia. Hasil penelitiannya menunjukan
bahwa 80% populasi mengalami masalah pinggang
sesuai dengan tingkatan usia. Sedangkan 50 % dari
populasi mengalami masalah pinggang yang dialami
minimal satu tahun sekali, dan 25% populasi
menderita sakit pinggang kronis. Hanya 15% dari
kasus keluhan nyeri pinggang disebabkan oleh
penyakit tertentu, sisanya disebabkan oleh kurang
gerak badan dan posisi duduk yang salah dan
berlangsung dalam waktu yang lama.(kumpulan
internet,..).

Risk factors for low back pain

Low back pain typically begins in young adulthood,
affecting the most productive years of life in an
industrial workers. There is a rising prevalence with
age until the fourth and fifth decades, after which

25

there is a leveling off or decrease. Attacks of low back

pain seem to be more common among those who have
had previous back pain episodes.
Buckle and colleagues found that of 68 patients, over
70% reported at least one previous episode. Rowe
similarly noted that 85% of low back pain patients had
a history of intermittent episodes.(Borenstein D. G. et
al, hal. 665)
Several studies have examined differences in relation
to the risk of low back pain injury. Women represent
about 40% of the working population but develop
only 20% of the industrial low back problems. This
may be because women typically are employed in
less physically demanding jobs.
In a review of 31.000 employees from one
manufacturer, Bigos and associates found that women
had statistically fewer injuries than men
But had an increased risk of making a high-cost injury
claims.
Magora reported that in occupations
demanding strenuous physical efforts, women had a
higher incidence of low back pain than men. Other
investigators report equal prevalence of back pain in
men and women.(Borensstein D.G. et. al., hal 665).
At least two studies have found ow back pain to be
more prevalent in cigarette smokers than in
nonsmokers. It is not clear whether this association
is a result of increased intradiscal pressure from
chronic coughing and straining or whether nicotine

26

itself has a direct biochemical

pathophysiology of back injury.

role

in

the

Poor physical fitness may be a predisposing factor

for back pain. Cady and associates, in a prospective
study of firefighters found that the least fit group of
employees was 10 times more susceptible to develop
back pain than the most fit group.
One of the better-studied risk factors for industrial low
back pain is job type; however the data are
inconsistent. The Bureau of Labor Statistics has
identified construction and mining as the industries
with highest incidence of back injuries, followed
closely by the trucking industry and the nursing
profession.
In a retrospective study of 2000 workers, Rowe found
that 35% of sedentary workers and 45% of heavy
handlers had made visits to physicians for low back
pain within a 10-year period. Eastrand reported a
survey of Swedish workers that suggested that the
number of years spent doing heavy labor have a
cumulative effect on predisposition to low back
problems.(Borenstein D.G., hal 66)
Despite contradictory data, it does seem likely that
certain tasks in the workplace are important in the

27

development of low back pain. Snook and associates

found that handling tasks were responsible for
70% of low back injuries, and Clein and associates
later reported similar findings. The weight of the
object lifted has been implicated in lifting injuries. In
one study, more than half the injured workers had
lifted objects weighing at least 60 pounds. The risk of
low back pain is thought to be increased by prolonged
sitting and exposure to vibration. Less physically
stressful, but boring and repetitive jobs(assembly
line work) also have been linked to increased
incidence of back pain.
It is imperative to understand the distinction between
physical impairment and physical disability. Physical
impairment is an objective anatomic or pathologic
dysfunction leading to loss of normal body ability.
Permanent impairment is an objective assessment of
functional abnormality or loss after the acute injury
phase and after maximal medical rehabilitation.
Physical disability is a measure of reduced capacity
to engage in gainful everyday activity as a result of
some impairment.
Very heavy work is that which involves lifting
objects weighing more than 100 pounds at a time,
with frequent lifting or carrying of objects
weighing 50 pounds or more.

28

Heavy work involves lifting no more than 100

pounds at a time, with frequent lifting or carrying
of objects weighing up to 50 pounds.
Medium work is defined as lifting of no more than
50 pounds at a time, with frequent lifting or
carrying of objects weighing up to 25 pounds.
Workers with 5% or less back-related permanent
partial physical impairment can qualify in this
category, but those with higher ratings cannot.
Light work is described as lifting of no more than 20
pounds at a time, with frequent lifting or carrying
of objects weighing up to 10 pounds. Applicants
with between 10 % and 15% permanent partial
physical impairment because of a low back problem
should be able to do this type of work.(Borenstein et.
al., hal 674).

Anatomi and patofisiologi pinggang

Secara anatomic, yang disebut pinggang adalah
keseluruhan daerah vertebra lumbal dan sakrum, yang
diperkuat oleh beberapa ligamen dan otot yang
terdapat disekitar daerah tersebut. Ligamen yang

29

dimaksud
adalah
ligament
longitudinal
anterior(melekat pada tiap lorpus vertebra bagian
depan/ventral, dan berfungsi untuk mengontrol gerakn
ekstensi batang tubuh/trunk), ligament longitudinal
posterior(melekat pada korpus vertebra bagian dorsal,
dan berfungsi untuk mengendalikan gerakan fleksi
batang tubuh), ligamentum plavum(terletak pada
bagian dorsal kolumna vertebralis dan merupakan
bagian dari kanalis vertebralis, berfungsi untuk
melindungi medulla spinalis), dan ligamentum
interspinosum(melekat
pada
prosesus
yang
memanjang dari proksimal ke distal).
Gambar letak ligamentum(gambar .)
Sedangkan otot yang berpengaruh
baik secara
langsung maupun tidak langsung pada nyeri pinggang
secara umum dapat dibedakan menjadi dua tipe yaitu :
Tipe I : adalah otot yang berfungsi mempertahankan
sikap tubuh. Kelainan pada otot tipe ini adalah
cenderung untuk menjadi tegang dan memendek.
Tergolong otot tipe ini adalah m. quadratus lumborum,
grup otot ekstensor batang tubuh diantaranya terdiri
dari m. erector spinae, m. longisimus thorasis,
m.rotatores, m.multifidus, dan grup fleksor panggul
yang meliputi m. iliopsoas, m.tensor fasia latae,
m.rektus femoris, serta grup eksorotasi panggul
meliputi m.piriformis, adductor panggul, grup
hamstring, m. gastroknemius dan soleus.

30

Tipe II : adalah otot-otot yang berfungsi untuk gerak

cepat dan kuat. Kelemahan otot tipe ini adalah
cenderung melemah dan menjadi lembek. Termasuk
otot tipe ini diantaranya adalah otot perut,quadrisep,
gluteus maksimus dan minimus, peroneal dan tibialis
anterior.
Gerakan yang terjadi pada pinggang
1. Fleksi : gerakan yang terbesar terjadi pada
vertebra lumbal 5-S1(60-75%), pada VL 4-5(1520%), dan pada VL1-4(5-10%)
2. Ekstensi : gerakannya hanya sedikit karena
dibatasi oleh ketegangan
lig. Longitudinal
anterior, posisi prosesus spinosus yang saling
berbenturan.
3. Rotasi : paling besar terjadi pada VL3-4 dan
paling kecil pada Vl5-S1, dan untuk setiap
segmen sebesar 3-7 derajat.
4. Laterofleksi(fleksi ke lateral). Bagian/sisi
cekung dari korpora saling mendeka
Penekanan/kompresi intradiskal pada berbagai
aktivitas
Berdiri
:0%
Duduk
: +30%
Berjalan
: +15%
Batuk
: +50%

31

Loncat
: +50%
Membungkuk 20 derajat kedepan
: +8%
Mengangkat benda seberat 20 Kg
: +300%
Dengan lutut sedikit menekuk
Mengangkat benda 20 Kg dengan
: +500%
Lutut lurus
Duduk bersandar > 90 derajat
: -10-20%
(Ismiati S.W., 2001)
(Pelatihan fisioterapi tiga sindroma nyeri pinggang)
Penyebab nyeri pinggang
Secara umum penyebab nyeri pinggang dapat dibagi
menjadi :
1. Kelainan congenital misalnya kelainan facet dan
kelainan pada vertebra yang meliputi sakralisasi,
lumbalisasi dan scoliosis.
2. Trauma misalnya fraktur kompresi, spondilosis,
spondilolitesis, dan subluksasi pada sendi facet.
3. Peradangan
misalnya
rematoid
arthritis,
spondilitis ankilopoitika, tuberculosis, jamur, dan
salmonella.
4. Tumor/neoplasma misalnya metastase karsinoma
payu dara, kelenjat gondok/tiroid, ginjal, paru
dan prostat.
5. Gangguan metabolic misalnya osteoporosis
dengan akibat fraktur kompresi.

32

6. Proses degenerasi misalnya spondilosis, hernia

nucleus pulposus(HNP), osteoartritis, stenosis
spinalis dan penyempitan foramen intervertebra.
7. Kelainan
biomekanik(merupakan
factor
penyebab utama).
Ditinjau dari aspek biomekanik, penyebab nyeri
pinggang dapat dibagi menjadi :
1. Nyeri pinggang static(static/postural back pain)
2. Nyeri pinggang kinetic(kinetic back pain)
Nyeri pinggang static(static low back pain)
Nyeri pinggang ini terjadi akibat deviasi dari
postur/sikap tubuh yang salah dan berlangsung dalam
waktu yang relatif lama sehingga menimbulkan
ketegangan pada ligament, dan kelelahan pada otot.
Pada posisi tegak , tubuh dipertahankan oleh ligament
iliofemoral tensor fasia latae, ligament longitudinal
anterior, ligament poplitea, dsan kontraksi minimal
dari otot gastrok dan soleus.

Kinetic low back pain

Pada nyeri pinggang kinetic, timbulnya rasa nyeri
dipengaruhi oleh gerakan/aktivitas dengan tiga
kemungkinan yaitu :

33

1. Stres abnormal pada pinggang yang normal yang

disebabkan oleh :
a. Ketidakmampuan otot karena beban terlalu
berat.
b. Mengangkat benda dengan jarak yang cukup
jauh dari tubuh.
c. Mengangkat beban/benda yang berat dalam
waktu yang lama
2. Stres normal pada pinggang yang abnormal :
a. Skoliosis struktural, dimana letak facet tidak
sejajar pada bidang simetris.
b. Degenerasi diskus yang menyebabkan fungsi
vertebra menjadi tidak normal.
c. Pemendekan otot hamstring.
d. Pemendekan otot pinggang bawah dan
ligament.
3. Stres normal pada pinggang yang normal, tetapi
tubuh tidak siap menghadapi stress tersebut.
Misalnya, seseorang mengangkat beban yang
berat tetapi yang bersangkutan menduga beban
tersebut ringan sehingga tubuh tidak siap.
Loading of the disc between the third and fourth
lumbar vertebrae in N(Newton), during various
postures and tasks
___________________________________________
Posture/activity
N

34

Standing upright
860
Walking slowly
920
Bending trunk sideways 20 degree
1140
Rotating trunk about 45 degree
1140
Bending trunk forwards 30 degree
1470
Bending trunk forwards 30 degree,
2400
Supporting weight of 20 Kg
Standing upright holding 20 Kg
1220
(10 Kg in each hand)
Lifting 20 Kg with back straight, and
2100
Knees bent
Lifting 20 Kg with bent back and knees 3270
Straight
___________________________________________
(Granjean E., 1988) hal. 107
Lifting technique and disc pressure
If a person bends over until the upper part of his body
is horizontal, then the leverage effect imposes very
heavy pressure on the discs between the lumbar
vertebrae. An average weight of the upper part of the
body would be about 45 Kg and the length of leverage
about 350 mm, with a resulting moment of between
1000 and 2000 Nm. If a weight is lifted at the same
time, the force on the discs could rise to 3000-4000
Nm.

35

The effect of four postures on the intervertebral

disc pressure between the third and fouth lumbar
vertebrae
Standing
Lying down
Sitting erect
Sitting with back slightly
stooping
(Granjean E., 1988. Hal.55)

: 100%
: 24%
: 140%
: 190%

Localized fatigue and musculoskeletal troubles

Moderate static work might produce troublesome
localized fatigue in the muscles involved which can
build up to intolerable pain. If the static load is
repeated daily over a long period, more or less
permanent aches will appear in the limbs and may
involve not only the muscles but also the joints,
tendons and other tissues. Thus long lasting and daily
repeated static efforts can thereby lead to damage of
joints, ligaments and tendons. All these acute and
chronic impairments are usually summarized under
the term musculoskeletal disorders.
Several field studies as well as general experience
have shown that such static loads are associated with a
higher risk of:
1. Arthritis of the joints due to mechanical stress.

36

2. Inflammation of the tendon sheaths (tendinitis or

peritendinitis).
3. Inflammation of the attachement-point of tendons.
4. Symtoms of arthrosis (chronic degeneration of the
joints).
5. Painful muscle spasms.
6. Intervertebral disc trouble.
Persistent musculoskeletal troubles
These symptoms of overstress can be divided into two
groups : reversible and persistent musculoskeletal
troubles.
The reversible symptoms are short-lived. The pains
are mostly localized to the muscles and tendons, and
disappear as soon as the static load is relieved. These
troubles are the pains of weariness.
Persistent troubles are also localized to strained
muscles and tendons, but they affect the joints and
adjacent tissues as well. The pains do not disappear
when the work stops, but continue. These persistent
pains are attributable to inflammatory and
degenerative processes in the overloaded tissues.
Elderly employees are more prone to such
persistent troubles. According to Van
Wely,
persistent musculoskeletal troubles are commonly
observed among operators who work all the year

37

round at the same machine at which the manual

controls are either too high or too low.
Persistent musculoskeletal troubles, if supported over
years, may get worse and lead to chronic inflammation
of muscular work.
Mechanical low back pain
1. Muscle strain
20-40 years(age)
Back/unilateral(pain pattern location)
Acute(onset)
Decreased(standing)
Increased(sitting)
Decreased(bending)
Negative(straight leg)
Negative(plain x-ray)
2. Herniated nucleus pulposus
30-50 year(age)
Back/unilateral(pain pattern location)
Acute/prior episodes(onset)
Increased(standing)
Decreased(sitting)
Decreased(bending)
Positive(straight leg)
Negative(plain x-ray)

38

3. Osteoarthritis
>50 year(age)
Back/unilateral(pain pattern location)
Insidious(onset)
Decreased(standing)
Increased(sitting)
Increased(bending)
Negative(straight leg)
Positive(plain x-ray)
4. Spinal stenosis
>60 year(age)
Leg/bilateral(pain pattern location)
Insidious(onset)
Decreased(standing)
Increased(sitting)
Increased(bending)
Positive/stress(straight leg)
Positive(pain x-ray)
5. Spondylolisthesis
20 year(age)
Back(pain pattern location)
Insidious(onset)
Decreased(standing)
Increased(sitting)
Decreased(bending)
Negative(straight leg)
Positive(pain x-ray)

39

6. Scoliosis
30 year(age)
Back(pain pattern location)
Insidious(onset)
Decreased(standing)
Increased(sitting)
Decreased(bending)
Negative(straight leg)
Positive(pain x-ray)