Continuing Education Activity

Low back pain (LBP) is common among healthcare professionals with prevalence of low back pain among health care workers being greater than among those working in heavy industries. In most cases, low back pain is short lived but when it becomes chronic, it can cause significant disability, suffering and societal costs. Costs of low back pain are both from direct care and from loss of productivity. This activity reviews the evaluation and management of lower back pain in healthcare professionals and highlights the role of individuals and that of administration in preventing low back pain.

Objectives:

• Identify the etiology of lower back pain in healthcare professionals.
• Describe strategies to prevent lower back pain in healthcare professionals.
• List the management options available to prevent the occurence of lower back pain in healthcare professionals.
• Employ interprofessional team strategies for improving coordination and communication to advance the prevention and management of lower back pain in healthcare professionals.

Introduction

Low back pain (LBP) is widely prevalent in the general population and is one of the main reasons individuals seek medical care [1]. It is a leading cause of disability worldwide, placing a significant medical and economic burden on society [2]. The lifetime prevalence of low back pain is approximately 70%, costing the US healthcare industry $87 billion annually [3] [4]. While LBP is an issue in the general population, the problem is even more among healthcare professionals and nurses. Nursing is an occupation most at risk from LBP, with rates exceeding heavy industry workforces [5] [6]. Furthermore, the lifetime prevalence of low back pain in nurses is higher than in the general population, with reports as high as 90% [7]. Additionally, LBP recurrence rates in nurses exceed 70% [8]. Lower back pain causes adverse effects on nurses, affecting their wellbeing, job satisfaction, and overall quality of life [9]. Other detrimental effects include increased risk of chronicity, associated personal and economic costs, reduced workforce efficiency, increased work absence, and burnout [10]. This high risk of LBP and associated adverse effects cause many nurses to consider leaving their job. In a 2001 survey, containing responses from over 40000 nurses from five different countries, 39% said they planned to leave their occupation within one year due to the physical challenges of the job [11]. 

Etiology

Nursing involves a large amount of heavy lifting when repositioning or moving patients [12]. Research has shown nursing to be the occupation with the highest prevalence of heavy lifting [13]. For nurses, heavy lifting is the most significant risk factor for the development of musculoskeletal injuries, particularly in the lower back [14]. One study found that nurses who regularly manually reposition, transfer, or lift their patients are more at risk from LBP than nurses who do not carry out these duties [15]. Long work and overtime increase exposure to physical demands. With this, the threat of musculoskeletal problems also increases [16].  High psychosocial demands, combined with low social support and reduced job control, also contribute to LBP occurrence [17]. 

Furthermore, a systematic review of 89 studies conducted by Yassi & Lockheart identified a causal link between nursing activities, such as patient care (dressing and bathing patients), and low back pain [5]. These researchers also noted that patient care, unloaded standing & walking and miscellaneous tasks account for 80% of cumulative lumbar compression in nurses while heaving lifting accounts for only 10%. Therefore, these frequent activities confer increased risk and should be considered risk factors for LBP, despite them not being overtly strenuous [18].

Furthermore, 24.4% of nurses experience poor sleep due to fatigue, psychosocial stress, perceived exhaustion, and musculoskeletal pain. Consequently, insufficient sleep has significantly contributed to an increased risk of LBP in healthcare workers [19]. The aging workforce may also be a contributory factor. A registered nurse in the United States is about 47 years old [20]. Obesity is also an issue among nurses, highlighting this as a potential cause for the high rates of low back pain in healthcare professionals [21]. Smoking is not an unusual social habit among healthcare professionals, especially among nurses. Several studies indicate an association between low back pain and smoking [22]. In most cases, the most significant contributing factors for the development of low back pain in nurses are the physical demand associated with long working hours, patient handling, and demanding schedules.

Epidemiology

Of all healthcare workers, nurses and operating room staff have the highest rates of back pain. The annual and lifetime prevalences in these groups are 40-50% and 80%, respectively [23] [24]. Mohamed and colleagues conducted an investigation in 2019 into the weekly prevalence of LBP in healthcare professionals. The study found that the one-week prevalence of LBP was highest in nurses (57%), followed by physicians (50%) and physical therapists (36%) [25]. A study of 1163 nurses investigated the prevalence of LBP in nurses in the U.S., 47% of participants reported having experienced back problems within the last year [26]. A cross-sectional study conducted in 2014 investigated the prevalence of LBP in nurses in various countries and identified that Australia, England, the U.S., and France had an annual LBP prevalence of 29% and 59%. For comparison, in the Philippines, the one-year prevalence of LBP among nurses was 80%. These results reveal a disparity between developed and developing countries regarding LBP prevalence among nurses [27].

The equipment and resources available to nurses affect the epidemiology of LBP. One study by Lee and co-workers found that nurses whose facilities employed lift teams were less likely to report low back pain than nurses who did not have such resources [28]. A further study comparing LBP rates among 114 nurses found that nurses who had not received any education on low back pain had higher pain scores than those who received an education. Furthermore, nurses who work in internal medicine and pediatric intensive care units had higher average pain scores than nurses who worked elsewhere. Female nurses reported higher pain scores than males. Nurses over the age of 34, with a chronic disease or abnormal BMI had higher average pain scores [29]. Unfortunately, it is difficult to know the exact number of nurses with LBP. Many employees may underreport symptoms for fear of losing their job, reprisal, and believing pain to be an expected consequence of work and age [30].

Pathophysiology

Low back pain can occur following an acute traumatic event or from repetitive trauma. Repetitive compressing, twisting, and loading of the disc in the flexed posture increases the risk for internal disc disruption and annular tears [31].

In addition, the lack of muscle strength contributes to low back pain, even in the absence of degeneration [32]. This is because weakness in muscles leads to segmental instability, which causes back pain even when no structural defects exist [33]. Furthermore, deprived control of the spinal structures leads to repetitive trauma and degeneration of the soft tissues and joints [34]. These findings refer to the concept of lumbar stability. This concept divides the back into a neutral and elastic zone. The neutral zone refers to the normal functional range of movement, while the elastic zone is at the extremes of motion [35]. Lumbar stability is the ability to maintain the spinal neutral zone during routine functional activity without causing pain or venturing into the elastic zone [36]. This is essential in preventing injury, as entrance into the elastic zone (extremes of motion) increases the threat of injury to the back under loading.

Weakness or dysfunction in the multifidus muscle causes the larger spinal muscles (erector spinae) to contract before they are due to, in an attempt to increase the stiffness of the spine. The earlier activation of the erector spinae creates abnormal forces across the back, resulting in back pain [37]. Therefore, muscle weakness and lack of coordination among the muscles significantly contributes to the occurrence of LBP.

History and Physical

The history should explore the eight features of pain. They are Site, Onset, Characteristics, Radiation, Associated factors, Timing, Exacerbating Factors, and Severity. These eight features are easily remembered by the acronym SOCRATES[38].

Besides this, the presence of red flags (signs and symptoms suggestive of serious pathology) should be excluded by eliciting a history of trauma, cancer, weight loss, night pain, age >50, fever, IV drug use, recent infection, previous surgery, urinary retention, saddle anesthesia, osteoporosis, corticosteroids, morning stiffness, improvement with exercise, pain down the leg, pseudo claudication and pain relieved by sitting [39]. 

The Start Back Tool [40] or the Orebro Short Musculoskeletal questionnaire [41] can identify the presence of yellow flags or psychological barriers to recovery

The physical examination should include assessment of symmetry in both the sagittal and coronal plane, gait, muscle atrophy, flexibility (flexion, extension, lateral flexion and rotation), touch and pinprick sensation in all relevant dermatomes, muscle power, deep tendon reflexes, Babinski, clonus, tenderness, straight leg raising, femoral stretch test and FABER's test [42].

The majority of low back pain do not have an identifiable diagnosis.  Also, the standard battery of tests during physical examination may not identify the strength and endurance of the paraspinal muscles, which plays a significant role in low back pain.  The following tests could identify the weakness in these muscles

The prone instability test [43] The patient starts by standing on one end of the examination couch. While continuing to stand on the foot end of the couch, the patient lowers his / her torso on to the couch.  The patient can hold onto the couch's sides for support. The examiner then palpates the lower lumbar spine to elicit tenderness. The patient then holds onto the couch and lifts his / her feet off the ground tensing the paraspinal muscles. Less pain and tenderness on repeat palpation of the lower lumbar spine while the feet are off the floor is considered positive. 

Prone Plank/Bridge [44] The patient is prone and elevates his / her entire body off the couch/mat on forearms and tips of toes. The body should be parallel to the couch/mat. With adequate muscle strength, men should maintain this position for 124 +/- 72s and Women for 83 +/- 63s.

Supine Bridge [45] The patient is supine and flexes the hip and knee to keep the feet flat on the couch/mat. The arms are flexed to position the hands beside the ears. The lower part of the torso and pelvis is lifted off the couch/mat, to maintain the trunk and the thigh in a straight line. With adequate muscle strength, men should maintain this position for 188 +/- 45s and Women for 152 +/- 30s. 

Evaluation

In most cases of LBP, a physical examination will suffice if there are no red flags. Plain x-rays of the spine contribute very little and should not be ordered unless there is trauma. The study of choice for evaluation of LBP in patients with neurological deficits is an MRI [46]. Patients with spondyloarthropathy like ankylosing spondylitis [47] need to be identified earlier as there is a usual delay in the diagnosis of these conditions. Patients exhibiting insidious onset of back pain for more than 3 months with early morning stiffness and relief with NSAIDs should be evaluated further with HLA B27, C Reactive Protein, and normal X-rays or MRI scans of the sacroiliac joint. 

Treatment / Management

Prevention makes up a large part of the treatment of lower back pain. Prevention itself can be separated into five separate categories – primordial prevention, primary prevention, secondary prevention, tertiary prevention, and quaternary prevention[48].

Primordial Prevention - This is focused on reducing risk factors for the entire population, in order to reduce the incidence of disease. It is targeted towards adapting lifestyle behaviors and social conditions that can go on to cause disease. With regard to low back pain, primordial prevention techniques involve providing walkways, cycle pathways, open spaces for recreational activities, gyms to exercise, and health education about diet, weight, alcohol, and tobacco control.

Primary Prevention - This is focused on reducing incidence among a population who are deemed susceptible to the disease, and the aim is to prevent the disease occurring in the first place. The target population is otherwise healthy individuals, and the methods are specific to each disease. With regard to low back pain, primary prevention techniques in vulnerable groups like health workers involve risk assessment, provision of lifting aids, training in manual handling, and provision of dedicated lifting teams.

Secondary Prevention – This is concentrated on early diagnoses in those members of the population who appear well, when they are actually displaying very early signs of the disease. Methods are primarily focused on screening, as screening often picks up those who have subclinical signs rather than those who display more obvious symptoms. With regards to low back pain, secondary prevention involves analysis and action following adverse incidents like lifting accidents, provision of early rehabilitation for injuries or symptoms, and prevention of presenteeism. Absenteeism is a sickness absence due to disease. Presenteeism is attendance even in the presence of disease. Some studies show that presenteeism is more costlier than absenteeism. 

Tertiary Prevention – This has an emphasis on reducing the symptoms of disease once the disease has progressed. The aim is to reduce the effects of disease on a person’s lifestyle and productivity. With regard to low back pain, the tertiary prevention techniques involve the provision of physical rehabilitation, cognitive behavior therapy, and modification of job roles to prevent recurrence.

Quaternary Prevention [49]  – This is a fairly new category, with a focus on preventing harm from medical interventions. With regards to low back pain, quaternary prevention involves avoiding needless investigations and harmful procedures in persons who do not have the disease but are worried (the worried well) or who have early self-limiting disease. These individuals need protection from interventions that may have more negative outcomes than positive ones. MRI scanning and many corticosteroid injections have negative outcomes on back pain. MRI scans may just identify age-related changes and may cause psychological distress [50]. The majority of mechanical low back pain is due to the lack of muscle strength. Corticosteroids destroy collagen and thereby the building blocks of muscles. Corticosteroid injections into the facet joint and disc spaces are not recommended[51].

There is considerable overlap between the interventions listed above. The interventions can be further split into those which can be enforced by the individual and those which can be brought about by the administration of the health facility.

INTERVENTIONS THAT CAN BE SET UP BY THE ADMINISTRATION OF THE HEALTH FACILITY

TRAINING IN MANUAL HANDLING – The aim here is to educate healthcare professionals on how to reduce the chance of injury whilst at work. Theis and Finkelstein established that a program focused on safe patient handling resulted in a significant reduction in the incidence of injuries. They went onto conclude that every dollar spent on training, resulted in a $3.71 profit[52].

PROVISION OF LIFTING EQUIPMENT – There has been a lot of evidence to suggest that the use of technical equipment to assist with patient handling, can decrease the incidence of physical injuries in the healthcare environment. Anyan and co-workers found that the installation of overheard lifting systems resulted in a significant reduction in the number of claims made by healthcare professionals as well as the rate of absenteeism and staff injuries [53].

LIFTING TEAM – A lift team consists of a group of people specially trained in lifting techniques. The lift team spends their time rotating around the healthcare setting in order to aid the lifting of patients. A lift-assist team was welcomed by nursing personnel and decreased the injury among direct care providers but what is not known is whether the risk of handling has been transferred to members of the lift assist team[54].

WORKPLACE EDUCATION - An education program directed at healthcare professionals to improve their own body awareness and enhance communication with patients decreased injuries. Instructing patients to participate in transfers is a skill that needs to be acquired. The educational intervention enhanced the competence of health professionals in guiding patients to move independently and thereby helped to reduce strain on themselves and on their patients [55].

ERGONOMIC ASSESSMENT AND IMPLEMENTATION - Work by Garg and co-workers shows that a comprehensive ergonomic program and patient devices decreased patient handling injuries by 59.8%, lost workdays by 86.7%, and workers compensation costs by 90.6% [56].

INDIVIDUAL

LIFESTYLE HEALTH PROMOTION – Nurses are in the frontline of medical care but may not be able to practice the principles of healthy living which they understand and want to promote. Work schedules, social eating practices, staff shortages, workload, stress at work, and shift patterns all interfere with practicing healthy lifestyle choices [57] [58].

DIET - The national guidelines in the United Kingdom suggest eating five portions of fruit and vegetables each day as part of a healthy diet. A survey in a pediatric unit identified that 79% of the nurses did not consume five portions of fruit and vegetables every day. The nurses felt that their lack of adherence to national guidelines was a barrier in promoting a healthy diet to their patients[59].

WEIGHT REDUCTION - A national survey in the United Kingdom identified that 25% of English nurses were obese (BMI> 30). Obesity in nurses was significantly higher than among other healthcare professionals but the highest prevalence of obesity was in unregistered care workers[60].

SMOKING - A cross-sectional study in Italy conducted across seven hospitals identified a high proportion of smokers among health professionals. The prevalence of smoking among health professionals was higher than among other professions. 44% of the 1082 healthcare workers were smokers. Among them 33.9% were physicians, 49.8% were nurses 41.1% were technicians and 50.4% were auxiliary employees[61]. However policy, pharmaceutical, and behavioral interventions have shown a positive effect on smoking cessation among healthcare workers[62].

STRETCHING / PHYSICAL EXERCISE - Chen and co-workers reported that 127 nurses who had been experiencing low back pain for a period of six months were randomized into an experimental group and control group. The experimental group performed a stretching exercise program for 50 minutes three times a week. The control group was instructed to continue with usual activities for 50 minutes three times a week. The visual analog scale of pain showed statistically significant improvement in the experimental group at two, four, and six months. The authors concluded that a stretching exercise program was an effective and safe intervention for treating low back pain in nursing personnel [63].

CBT - A small randomized control trial showed a weekly stress and pain management therapy for 6 weeks decreased pain intensity scores [64].

Differential Diagnosis

The differential diagnoses for low back pain include, but are not limited to, the following categories and conditions[65]

Spine Related

Injury

1. Sprains and strains
2. Fractures

Degeneration

1. Disc prolapse and radiculopathy
2. Spinal stenosis and pseudo claudication
3. Cauda equina syndrome

Inflammatory

1. Spondyloarthropathy

Cancer-related

1. Metastatic disease
2. Intramedullary tumor

Infection-related

1. Spondylodiscitis
2. Vertebral osteomyelitis

Non-spine Related

1. Aortic disease dissection,  aneurysm,
2. Genitourinary disease - Colic, tumor, and infection.
3. Gastrointestinal causes - pancreatitis and pancreatic cancer, peptic ulcer, cholecystitis, and cholangitis

Prognosis

In most cases, acute episodes of mechanical back pain resolve within 12 weeks. However, chronic symptoms may still be present in up to 33% of patients. Individuals whose acute symptoms resolve still have a 20-40% chance of recurrence in the first year and an 85% chance of lifetime recurrence[66]. 

 The various psychosocial and environmental factors that influence prognosis include[67]:

1. Depression
2. BMI > 25
3. Compensation claim
4. Smoking
5. Job dissatisfaction
6. Fear-avoidance
7. Strenuous physical workloads

Complications

The greatest complication of low back pain is the danger of the acute episode becoming chronic and disabling. Low back pain and the disability caused by it are increasing. The 2015 Global Burden of Disease study revealed that low back pain was responsible for 60.1 million years lived with disability. This was an increase of 54% as compared to 1990 [68].  In the majority of the patients with low back pain, the episode is short-lived, but in 28% of the patients, the disability becomes chronic and results in 77% of the disability caused by low back pain. Disability as a result of low back pain is highest in working age groups and the trend is similar in low and middle-income countries. A survey among urban dwellers in Zimbabwe identified that low back pain was one of the top 5 health complaints limiting activity[69]. Another study among peasant farmers in Nigeria showed that more than 50% reduced their workload because of low back pain[70]. 

The direct health care cost of low back pain in the US is estimated to be about $50-90 billion annually[71]. The total cost of low back pain both from direct care and loss of productivity is estimated at about $ 635 billion annually [72]

Unfortunately, a significant proportion of patients with chronic low back pain have concurrent pain in other body parts and in addition have other physical and mental health problems. The combined effect of the low back pain and the co-morbidity is greater than the effect of just the low back pain or the co-morbidity. This results in the need for more care and a poorer response to treatment [73].

A study that looked at the 2010 National Health Interview Survey (NHIS) in the US identified that female and older workers were at increased risk of developing low back pain. They also identified other psychosocial factors including work-family imbalance, hostile work environment, and job insecurity as potential risk factors[74].

Deterrence and Patient Education

In light of the evidence, the most effective patient recommendation in preventing back pain is maintaining a healthy BMI of less than 25. Higher BMI correlates with worse disability[75]. As fear avoidant behaviors worsen outcomes, it is recommended that patients continue to engage in physical activity. Smoking cessation is also recommended as smoking adversely affects low back pain[76]. Intensive patient education by discussing staying active, activity modification, and early return to normal activity has been found to be effective when returning to work [77].

Emphasizing the importance of maintaining proper posture and correct lifting techniques will aid in the prevention of back pain. Ergonomic modifications at the workplace by employers are essential. Other possible employer interventions include providing appropriate rest breaks and paid-time to engage in physical exercises.

Enhancing Healthcare Team Outcomes

Work-related back pain has a multifactorial etiology with numerous risk factors. LBP is very costly and leads to marked inefficiency in the delivery of healthcare. In the majority of patients, investigations are not needed unless there are red flags. Bed rest must be discouraged and early return to work should be recommended. There should also be an early referral for psychosocial support in the presence of yellow flags. Ergonomic workplace adaptations are mandatory. Low back pain has a multifactorial etiology and administration of the health facility should take an active role in reducing workplace stress and hostility.