Management of Occupational LBP in Health Care Professionals

Introduction

In 1998 alone low back pain (LBP) alone cost £12.3 billion[1]. It has also been recognised that (LBP) is the most common problem among hospital workers[2]

LBP can be classified as either acute, recurrent or chronic. Chronic pain is the costliest health problem in the UK[1] and contributes to increased rates of mental illness, mortality, unemployment and social exclusion.

LBP can specifically be split into either Non-specific which accounts for 90% of all cases or Specific which accounts for the remaining 10%[3]. Non-specific LBP is diagnosed based on the exclusion of all specific pathologies and is usually mechanical in its nature. Specific LBP is attributed to a specific pathology such as:

Epidemiology

Hospital workers experience more occupational health problems than other professional groups, the most common being (LBP)[2]. LBP is responsible for high treatment costs, frequent sick leave, prolonged back pain and potentially sometimes job loss which may lead to psychological problems like depression[4]. The majority of the literature reports the prevalence of LBP to be high in both Nurses and Physiotherapists as compared to other health care professions. However, the prevalence of LBP within these professions varies significantly between different countries.

The lifetime prevalence of LBP in Nurses has been reported as 63% in Iran[5], 59.1% in Bangladesh[6] , 61.7% in Saudi Arabia[7], 59% in South Africa[8], 55.3% in Nigeria[9] and 77.1% in Turkey[2]. In contrast the lifetime prevalence of LBP in Physiotherapists has been reported as 35% in Australia[10], 73.7% in Slovenia[11], 60.8% in Bangladesh[12], 49.2% in Canada[13], 33.3% in Nigeria[9] and 72.7% in Turkey[2] .

However only two of these studies directly compared the prevalence of LBP in Nurses to Physiotherapists. These studies reported a prevalence of 77.1% & 55.3% in Nurses compared to 72.7% & 33.3% in physiotherapists across Hospitals in Turkey[2] and Nigeria[9] .

Aetiology

Correct technique to lifting heavy objects (Dr. Kirstie, 2019)

The majority of cases (78.3%) of LBP among Nurses and Physiotherapists are reported to have occurred after starting work[2]. The likely cause of LBP is therefore attributed to the common actions and movements involved with these professions. These include:

  1. Lifting of heavy objects/patients including patient manual handling [2][6][7][8][9][10][11][13]
  2. Frequent bending/trunk flexion[10] [13]
  3. Pulling patients up the bed[8][10] [13]
  4. Prolonged positioning/bad posture[6][8][9][10]
  5. Standing for long hours[9]
  6. High workload/Treating an excessive number of patients in 1 day[10]
  7. Performing manual therapy[10]
  8. 6-month rotational roles (76%) have an increased prevalence compared to 12-month rotational roles (16%)[8]

Risk Factors

Lack of team-work and assistive transfer devices, as well as the number of patient transfers, appeared to be relevant risk factors associated with LBP in the healthcare populations. Although it is to note that association does not mean causation and the intrinsic risk factors may skew the effects of the extrinsic risk factors.

But, what we can take from these factors, may explain LBP in the health-care work-force and managers should identify these risks to install preventive measures to protect their staff. It should be the manager's role to ensure, excellent team-work and collaboration to help with manual handling tasks. As well as the number of patient transfers done per day safely, with the appropriate assistive transfer devices. All of these are practically avoidable.

Risk Factors .png

Yoshimoto et al, (2019) found in a comparative cross-sectional study, looking into low back pain risk factors[14]. That previous episodes of low back pain, kinesiophobia, and insomnia were all significantly associated with severe disabling low back pain. 718 nurses completed survey questionnaires, where 15% of them had low back pain. They found the above factors had the greatest correlation, despite physical flexibility and workload differences. Interestingly no association was found between low back pain and physical parameters such as trunk flexibility and work-related lifting frequency. Unfortunately, the population sample is confined to one medical center in Japan, limiting the generalizability of the study as well. And due to the cross-sectional design, causality cannot be defined.

Boughattas et al, (2017) approximately 58% of the 208 nurses in this study had low back pain[15]. Unfortunately, the authors of this study use outdated literature to discuss important explanations of why these risk factors may impact on the nurse populations.

Andersen et al (2019) looked into the incidence of back-related injury, during patient transfer, something healthcare workers do multiple times a day[16]. This was a prospective cohort study using a survey questionnaire (n=2080) 17 different hospitals in Denmark, were sent a questionnaire every 14 days for one year. There were associated incidence of back injury of which was associated significantly with the number of patient transfers. 1-4 = Odds ratio 3.58, 5-8 OR = 7.60 and >9 OR = 12.27 - Lack of assistive devices were a common phenomenon amongst these injuries including slide sheet (30%) intelligent beds (19%) and walking aids (18%).

Lack of team-work and support in task completion OR 3.16. Conclusion - Improving team collaboration in tasks, reducing patient transfer,s and providing necessary assistive devices are needed to reduce LBP incidence.

Simsek et al, (2017), 1682 Health care workers, including nurses, medical secretaries, physicians, allied health professionals, and caregivers. Found that being female, aged >65yrs, ^BMI, Married, lack of exercise, working more than 4hrs standing, sitting at a desk more than 4hrs, more years of service, low job satisfaction were associated with increased risk of low back pain[17]. These were all significant (P=<0.01 however, the ORs were marital status, standing time at work and computer use were all <0.02 OR meaning a misrepresentation of the practical implication of these significant values. Also, the relation to pain and age, suggests younger ages 21-35yrs female workers are in more pain 6.22 and 4.76 for female and male, and at 46-55yrs male workers have higher VAS scores 5.55 and 7.19 for female and male.

Assessment

To ensure a thorough and complete assessment of a patient with Occupational low back pain (LBP), you must assess the biological, psychological and social factors that may be contributing to a patient’s symptoms. A clinical assessment of the biological element of Low Back Pain should be completed to form a diagnosis. A psychosocial assessment tool should be used to assess the possible psychosocial risk factors that may be contributing to their back pain. Finally, an assessment of the biological risk factors of the patient’s workplace activities should be completed, this can be done in person or through video recordings.

Psychosocial Assessment

Research has suggested that there is a consistent association between exposure to psychosocial risk factors at work and musculoskeletal disorders in healthcare workers, especially nurses[18]. To assess the psychosocial factors a screening questionnaire should be used to that highlight psychosocial risk factors in your patient.

Bonneterre et al. (2008) completed a systematic review in 2008 on the reliability and validity of psychosocial risk measurement questionnaires in nurses[19]. Of the tools included in the review, some are specific to healthcare workers and some are general tools. They concluded from their review of 108 the four most commonly used questionnaires were the:

1.     Karasek’s Demand-Control questionnaire (General)

2.     Effort-Reward Imbalance questionnaire (General)

3.     The Nursing Stress Scale (Nursing specific)

4.     The Nursing work index or a derivative (Nursing specific)

They concluded there is no specific questionnaire that can satisfy all areas of internal validity required for a tool of this nature but Karasek’s Demand-Control questionnaire was capable of predicting injuries and musculoskeletal disorders in nurses[19] .

A cross sectional study by Bonnettere et al. (2011) addressed the validation of the Nursing Work Index (Extended Organisation) tool[20]. They concluded from the study that the NWI-EO had good psychometric properties demonstrated in the content validity, construct validity and reliability.

Further research is needed to complete further comparison of the tools available for screening of psychosocial risk factors for musculoskeletal disorder in healthcare workers to try to identify a gold standard assessment tool.

Assessment of Risk of Musculoskeletal Disorder in the Workplace

[21]RULA assessment worksheet
Rapid Upper Limb Assessment (RULA) is an ergonomic screening tool that assesses biomechanical and postural loading of the trunk, neck and upper limbs. It is deemed to be a suitable method of assessing posture in the workplace[22]. The RULA gives a score from 1-9 to each body part based on deviation away from the neutral position. Additional weights are given to postures according to forces/loads handled and the occurrence of repetitive/static muscular activity[23]. This is important in healthcare workers and, especially nurses as the more times a task is repeated the higher risk of musculoskeletal disorder r(MSD) will occur. The score is converted into an Action Level between 1 and 4 which determines the need for ergonomic intervention to lower the risk of MSDs and in this case LBP. This action level will indicate the tasks completed by your patient which may need to be modified to decrease their risk of LBP. Research has suggested that the RULA, compared to the rapid entire body assessment (REBA) and the Novel Ergonomic Postural Assessment (NERPA), overestimates certain risks due to providing higher risk scores for smaller angular deviation categories, this could be a weakness and must be considered when using the RULA[24]. Yazdanirad et al. (2018) compared the RULA with the loading on the upper body assessment (LUBA) and (NERPA) method and concluded that the RULA is the most effective of these methods for the assessment of MSDs[25]. However, this study was completed using Pharmaceutical workers, automotive workers and assembly industry workers therefore lowering the external validity of the study.                        
[26] REBA assessment worksheet
                                                                        

Rapid Entire Body Assessment (REBA) tool is also an ergonomic screening tool which was developed at Nottingham City Hospital, UK, for use on healthcare practitioners[27]. It is one of the most popular and commonly used assessment tools across a range of industries[28]. Similarly, to the RULA, it assesses posture factors during working tasks. Little to no training is required to use the REBA making it an easily accessible tool. The REBA method is mainly for the analysis of forced postures and is less effective at assessing the risk posed by repetitive loads[29]. The REBA produces a score between 1-15 which correlates to a risk level. There are 5 levels of risk; Negligible (1), Low (2-3), Medium (4-7), High (8-10) and Very high (11-15). As with the RULA this risk level correlates to the need for ergonomic intervention. A systematic review of the REBA concluded that further research was required to support the predictive and concurrent validity of this method[28].  During the development of REBA there was a 62-85% agreement on scoring of postural conditions except for in the upper arm suggesting a high inter-observer reliability[27].                                    

                  There is no Gold Standard assessment tool for risk of Work-Related Musculoskeletal disorders (WRSMD), a systematic review that compared 30 observational tools for assessment of biomechanical exposures in the workplace, including the RULA and REBA, suggested there no tool that had a clear superiority[23].  Furthermore, there is also a lack of high-quality evidence on the effectiveness of ergonomic tools to assess back pain in healthcare workers.

Treatment

Historically the management of lower back pain has been difficult. As previously discussed, Back pain, specifically lower back pain is multifactorial in nature and can have radiculopathies involved. This has led to a myriad of treatment options. The cochrane library alone has 179 systematic reviews on treatments for low back pain. These include medication, yoga, education, manual therapy, exercise to name a few. It is a testament to how difficult this condition is to treat that there are so many studies into unique interventions.

The National Institute of Clinical Excellence (NICE) have compiled a set of guidelines for treating lower back pain based on the current best evidence based clinical knowledge (See Resources).

One of the fundamental aspects of treatment of any condition, and this is not limited to lower back pain, is the importance of building self efficacy in the patient.

The first option in the conservative management from the NICE  is self management[30]. Taking a full history from the patient and conducting a clinical examination will aid to steer a therapists treatment, however, at the forefront should be the thinking of how to empower the patient to take ownership of their rehabilitation.

Back pain education.jpg
  • Provide patients with education and information on their condition. Probe their understanding of what they think is going on, try to quell their fears and promote the importance of continuing with normal activities[30].

A 2008 Cochrane review of 24 studies on patient education for low back pain found that for individuals with acute or subacute low back pain, a 2.5 hour individual patient education session was more effective than no intervention for a faster return to work, less chronic disability and fewer recurrent problems. However, for more chronic patients the intervention was less effective than more intensive interventions[31]. One of the most popular educational packs is The Pain Toolkit which is designed around managing your symptoms, pacing exercise and grading activity to allow an individual to have control over their back pain.

The second option recommended by NICE is exercise[30]. There have been many studies into various forms of exercise, such as aerobic, strengthening, stretching, pilates to name a few. Hong et al (2017) aimed to develop an exercise guideline for the treatment of lower back pain with specific exercises[32]. They conducted a systematic review and reported that when dealing with chronic low back pain, the highest level of evidence came from general exercise. Aerobic and stabilising exercise was level B evidence and strengthening, stretching, extension, unsupervised walking came in at level C evidence. For acute low back pain the evidence was level C or lower[32].

Whilst a specific type of exercise has no consensus, what can be agreed on is that rest is not a treatment option. Cessation of activity reduces the body's tissues to deal with loads placed upon it, and increase the risk for many other health factors, not least low back pain[33].

The review by Kikuchi (2017) recommends cognitive behavioural therapy and stress reduction mindfulness. As it was low cost and displayed long term effects on pain reduction[33]. However, NICE (2016) recommends this as an option only when paired with an exercise programme[30].

All of the previously mentioned interventions allow the patient to be self reliant and should be pursued. The following interventions are passive in nature and rely on a therapist giving a treatment to the individual.

  • Manual therapy - a term that ignites ferocious debates in the physiotherapy world is recommended by NICE (2016). Again, they state that it should be in conjunction with an exercise programme and not offered alone. A 2012 systematic review by Cochrane on spinal manipulation therapy focused on three primary outcome measures, pain with the visual analogue scale, Functional status with the oswestry disability index and recovery with global improvement with a likert scale[34]. The overall conclusion was that spinal manipulation therapy is no better than standard interventions such as exercise for acute low back pain. It does however produce a clinically significant effect on pain in the short term when compared with a sham treatment. Cochrane felt this review had low quality evidence due to high risk of bias. Cochrane conducted a similar review in 2011 for chronic low back pain. The findings were that spinal manipulation therapy produces statistically significant short term effects on pain and functional status when compared with other interventions such as sham treatment[35]. However, they state that the size of the effects are not clinically relevant.
  • Acupuncture and electrotherapy are not recommended by NICE (2016)[30].

Resources

Prevention and Management of Occupational Related LBP

NICE Guidelines: Low back pain and sciatica in over 16s: assessment and management

NICE Guidelines: Low back pain in adults: early management

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