Back Safety

Article Author:
Steve Bhimji
Article Editor:
Tammy Toney-Butler
Updated:
11/15/2018 3:35:13 PM
PubMed Link:
Back Safety

Introduction

Today, complaints of low back pain (LBP) are a common occurrence amongst healthcare professionals. Of all the professions, health professionals have an extremely high-risk for a back injury. In most cases, low back pain is preventable when precautions are used. When back pain becomes chronic, it can cause significant disability and suffering. The literature reveals that even mild back pain has an association with reduced quality of life and marked loss of function. More important, low back pain frequently causes a person to miss work, leading to decreased productivity and significant economic loss for the healthcare institution.

The cost of managing back pain in healthcare institutions is measured in billions of dollars each year. Physicians, nurses, and nursing assistive personnel have a high prevalence of LBP, resulting in time off work and sometimes, even needing a change in the career. It is an estimation that nearly 8% to 12% of nurses have left or are considering leaving the healthcare profession because of LBP. Once low back pain develops, there is an increased risk of visiting the emergency department and even the need for hospitalization. Many nurses are so distressed about the constant pain that they see a variety of healthcare professionals, including orthopedic surgeons, and end up needing surgery.[1][2][3]

Etiology

Activities Often Associated with LBP in Health Professionals

  • Rotating patients
  • Moving patients in bed
  • Shifting patients in and out of the bed
  • Positioning patients
  • Dressing patients
  • Bathing patients
  • Carrying medical devices
  • Lifting patients
  • Tidying and making beds
  • Moving patients for procedures

The two most common causes of low back pain are lifting heavy patients and carrying medical equipment.[4][5]

Risk Factors

Numerous risk factors for low back pain include the following categories.

Occupational factors

  • Number of hours worked per week
  • Handling of patients
  • Time of shift
  • The lifting of heavy patients
  • Long shifts (12 hours)

Psychological factors

  • Tendency for somatization
  • Mental health issues
  • Ignoring pain
  • Work dissatisfaction
  • Monotonous work
  • Negative work culture
  • Lack of support at work
  • Passive coping methods

Physical factors

  • History of low back pain
  • Limited range of motion
  • Physically inactive

Lifestyle factors

  • Sedentary lifestyle
  • Smoking
  • Diet
  • Obesity
  • Lack of sleep
  • Demographic factors
  • Gender
  • Age

Factors that Exacerbate Low Back Pain

  • Working long hours
  • Excessive workload
  • Inadequate personnel
  • Lack of lifting equipment
  • Inadequate breaks
  • Standing up for long periods
  • Poor posture
  • Poor eating habits
  • Poor sleep

Epidemiology

Back pain among healthcare workers is not a novel phenomenon. Ever since the evolution of modern-day medicine, healthcare workers have developed a variety of musculoskeletal problems while moving, lifting, and rotating patients. Over the past 40 years, it is increasingly apparent that the role of physically managing patients has a downside - the development of musculoskeletal problems including low back pain. Among the healthcare professionals, nurses report the highest rates of chronic low back pain, and this is not only an American phenomenon. Low back pain affects nurses globally. The global prevalence of low back pain among nurses has been reported to be anywhere from 30% to 90%, but in the USA, surveys indicate that at least 50% of nurses have at one time reported low back pain. Low back pain can result in significant pain, disability, and time off of work. Low back pain also occurs in the highest rates of workers' compensation claims among nurses. Data indicate that nearly one-third of United States nurses have reported occupational-related low back pain that is so severe it requires time off of work and another 10% to 20% have had to change employment.[6][7][8]

The exact number of nurses who have low back pain is not known because a significant amount never sees a health care provider, choosing instead to self-manage the problem. From surveys, it appears that low back pain is a common problem both in rural and urban hospitals. It generally is more common in females compared to males; this may be in part because there are more females in nursing. The numbers range from 30% to 80 percent. In healthcare settings, low back pain has been reported in nurses working in all medical and surgical specialties but is most common on the general medical floor and the intensive care units.

Data in 2012, from the US Bureau of Labor Statistics, reveal that nurses with back injuries required at least 7 days to recuperate. In 2009, the average compensation for work-related back pain was $10,700. These numbers have tripled over the past decade. Over the past three decades, obesity has significantly increased among nurses and other allied healthcare workers. Also, poor sleep and diet also contribute to lower back pain. When working long hours, nurses often complain that they have no time to eat because of staffing challenges. Many do not have time to exercise and, consequently, gain weight. Also of importance is that among healthcare professionals, smoking is a widespread social habit, especially among nurses. Several studies indicate an association between low back pain and smoking.

In most cases, the most significant contributing factors in the development of low back pain in nurses are the physical demand associated with long working hours, patient handling, and demanding schedules. Also, the aging workforce may also be a contributory factor. The average age of a registered nurse in the United States is about 47 years old.[9]

Healthcare Professionals Most At Risk for Back Injury

While anyone can develop back injury, the healthcare workers who usually move or lift patients are at the highest risk; i.e., bedside nurses, nursing assistive personnel (NAP), and unlicensed assistive personnel (UAP). Physicians in the emergency room may help move a patient and are also susceptible to back injury.

In other healthcare workers, the onset of pain may get delayed for a few days. After lifting a heavy patient, these individuals may only have mild discomfort but over the next few days may develop an odd ache which gradually starts to get more intense. It also may be associated with numbness or radiating pain to the lower extremities.

Pathophysiology

Mechanical LBP usually occurs following an acute traumatic event but can also occur from repetitive trauma, which is common in the workplace. The pathophysiology of LBP is multifaceted and complex. Many structures may be affected including the ligaments, bone, disks, tendons or the muscle. Most of these components of the spine have sensory innervation that generates pain signals as a result of tissue damage. Other causes of low back pain may be neuropathic or in chronic cases may be both neuropathic and nociceptive.[10][11]

The damage to the lower back may be a due to compressive muscular forces that increase intradiscal pressure. Repetitive compressing loading of the disc when the individual is in flexion can also increase the risk for internal disc disruption and annular tears. Further, any torsion or rotational force can generate shear forces that can cause tears in the annulus and then this results in the central contents (nucleus pulposus) leaking through the tears.

Ligaments Commonly Injured in LBP

  • Interspinous
  • Supraspinous
  • Intracapsular
  • Ligamentum flavum
  • Anterior longitudinal ligament
  • Capsular ligaments

Over time, the disk space may narrow, and some may even develop spondylolisthesis.

History and Physical

When a healthcare worker sustains a back injury while lifting a patient, the symptoms may be acute or chronic. In some cases, the low back pain may develop suddenly and can be incapacitating. When healthcare workers suffer a back injury, it may present as one of the following:

  • Persistent low back pain
  • Herniated disc with or without sciatica
  • Strained muscles
  • Torn or pulled ligaments
  • Disc degeneration due to repeated and excessive strain

Other symptoms may include numbness in the legs, arms, or the back. When the pain is severe, ambulation decreases because it exacerbates the pain. The majority of nurses or nursing assistive personnel present with a history of an inciting event that immediately caused the low back pain. Other commonly reported complaints in the history include:

  • Twisting and or lifting of a heavy patient or medical equipment
  • Prolonged sitting at the desk
  • Injured by a heavy piece of equipment like the elevator door or a patient bed
  • Falling while trying to lift the patient

History taking also should involve the following:

  • Age of nurse
  • Current work status
  • Onset of symptoms
  • Rating the intensity of pain
  • What influences the pain (e.g., exercise standing, sitting)
  • How does pain influence sleep, eating, mood, work and perming daily living activities
  • Quality of life

Past medical history should rule of prior injury to the spinal cord, motor vehicle accidents, and metabolic disorders like osteoporosis. Any previous surgery on the back, use of medication, and psychiatric history should be noted. It is also important to ask if the individual about smoking and alcohol use.

Review of systems should assess if the low back pain has affected the following:

  • Libido
  • Bowel and bladder function

Psychosocial factors need including in the evaluation of all healthcare workers with low back pain. One should determine the following:

  • Job satisfaction
  • Depression
  • Personality trait
  • Coping styles
  • Stress
  • Prior history of a work-related injury

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.[12]

Treatment / Management

The treatment of low back pain is not simple, primarily because in most cases there is a multifactorial etiology.[13][14][15]

Before one starts treatment, consider the following:

  • Modifiable risk factors
  • Non-modifiable risk factors
  • Lifestyle
  • Demographics
  • Age
  • Occupational factors
  • Physical factors
  • Psychological factors
  • Psychosocial factors

Because the cause of low back pain in nurses has multiple etiologies, no one remedy works best for everyone. What may work in one nurse may not always work in another nurse. Most studies indicate that a multidisciplinary approach that involves biopsychosocial improvement and rehabilitation is more effective than physical treatment in lowering disability and pain in nurses.

Prevention of work-related LBP

Unlike in the past, many risk factors for low back pain have been identified and thus reducing or eliminating the risk factors is of primary importance when managing back pain.

Because low back pain is affecting many healthcare workers, most hospitals have initiated primary prevention measures. There is evidence that by making changes in the workplace, a significant number of new episodes of work-related back pain are reduceable. Primary prevention includes teaching healthcare workers about the following:

  • Causes of low back pain
  • Risk factors for low back pain
  • LBP Prevention

All hospitals have adopted new lifting techniques for nurses who need to position or move patients. The other aim is to lower the physical demands of the workplace by installing mechanical lifts that can be used to lift or move patients. To date, there is no safe lifting capacity for healthcare workers; this indicates that LBP can occur even after lifting or moving thin and light patients.

Use of pre-placement strength testing, abdominal belts, physical exam of the back, and radiological screening have not been effective in preventing back pain. Even though many "back schools" have evolved, which provide practical information about posture, back care, and back exercises, there continues to be a debate about the benefits of such programs.[1][16][17]

Primary Prevention

The one intervention that has proven to be useful in the workplace is to reduce the physical demands of healthcare professionals. But this is not always easy as many hospital rooms are small, making it impossible to install lifts and hoists; plus many hospitals were built 20 to 30 years ago, causing structural changes in the workplace often prohibitively expensive. Difficulty exists in knowing what exactly needs to be changed in the workplace to ease the burden of LBP because there is a multitude of causes and risk factors.

However, the evidence does show that primary prevention aimed at preventing back injury is cost-effective, but at the same time, both the psychosocial and organizational risk factors need to be controlled.

Secondary Prevention (of Chronicity and Recurrence of Symptoms)

The majority of healthcare workers with LBP treated for their pain and disability through secondary prevention. Unfortunately, after many years of research, it still is not well known who does and does not improve. The other thing not known is why some patients recover quickly and others do not. Evidence indicates that close to three-fourths of patients with acute LBP (1 to 4 weeks) have a good prognosis even with minimal treatment and investigations. In fact, there is evidence to suggest that some patients get over-treated during this phase with excessive rest, which eventually leads to muscle atrophy and continuing pain.

Patients in the subacute phase (4 to 12 weeks) do tend to recover if the workplace demands eased. Return to work during this time is highly recommended as it is productive and can save costs.  However, data also show that the longer the patient is allowed to stay at home, the more difficult it is to get them back into mainstream work.

For those with chronic pain (symptoms persisting after 3 months), there are few well-controlled studies to determine their outcome. This group of patients best benefits from a multidisciplinary approach. Data show that modifying the workload increases the chance of these individual continuing in their job.

Tertiary Prevention (Reducing Disability)

Evidence shows that the earlier a patient can return to work, the less significant the disability. However, this also requires a flexible modified workplace. This flexible altered workplace may not be possible for small clinics and ambulatory care centers because of space, time, and money. For the most part, some rehabilitation is a recommendation for all patients with chronic LBP. Despite years of research and the accumulation of evidence about the benefits of rehabilitation, patient motivation is often low, and non-compliance rates are high. In many of these individuals, before rehabilitation gets prescribed, the psychosocial factors must be assessed and diminished to improve motivation.

Differential Diagnosis

  • Drug seeking behavior
  • Malingering
  • Multiple myelomas
  • Infection of the spinal cord
  • Myopathy
  • Connective tissue disease
  • Osteoporosis

Prognosis

Low back pain that is mechanical is not associated with mortality, but it does have high morbidity. Individuals with low back pain may not be able to work, and this can result in loss of productivity and added costs to the healthcare institution for replacement of the insured workers and paying out compensation.

For those who lose weight, discontinue smoking, and participate in an exercise program, the prognosis is excellent.

Complications

Low back pain is not a benign condition and can have the following repercussions:

For the Healthcare Worker

  • Lead to disability
  • Depression
  • Psychological problems
  • Poor quality of life
  • Loss of earning
  • Difficulties in interpersonal and interprofessional relationships
  • Loss of job or change of job

For the Employer

  • Low back in the healthcare workers can also have repercussions for the healthcare institution:
  • Loss of labor
  • Reduction in work efficiency
  • Increased financial costs to pay for the hiring of more nurses
  • Extra costs to look for nurses with back pain in terms of compensation payouts
  • Litigation costs
  • Costs to install joists or lifts
  • Costs to prevent LBP

Postoperative and Rehabilitation Care

Ergonomics Programs and Back Injury Prevention

Ergonomics is simply defined as a change of job to fit the needs and abilities of the worker rather than trying to fit the worker to the task. The workplace has to undertake steps to prevent low back pain. Most of the studies indicate that the back is not due to the lifting of patients but how the procedure is performed. Ergonomics can help move patients in a more controlled manner. Evidence indicates that an ergonomic program can help prevent injuries in the workplace. Thus, the first task is for the hospital to identify all the risk factors for low back pain and control them.

An effective ergonomics program in the workplace should have the following features:

Commitment by management and administration

One of the key ways to prevent back pain is for the employer to be involved in preventive programs. The administration needs to implement safety programs by providing resources and support for the workers. If there is an ergonomic program introduced, the administration should ensure that it is implemented, used and evaluated at regular intervals

Education

The key to preventing LBP is the education of the healthcare worker about the signs and symptoms of low back pain. Workers need to know the risk factors and how to minimize factors that exacerbate any pre-existing injury.

Audit of Risk Factors

All employers should understand the causes of back pain in nurses and should keep a record of the following:

  1. Number of back injuries in a given time
  2. The seriousness of the injury
  3. How much time off
  4. How many cases referred to workers' compensation
  5. Sick leave usage
  6. Recovery period
  7. How many returns to work and in what timeframe
  8. How much of the cost was reimbursed by health insurance

Methods to Identify Risk Factors for Back Pain

  • Survey healthcare workers
  • Perform a job hazard analysis to determine the risk factors
  • Assess nurses in real time when they move or lift the patient to see the technique
  • Assess how many times nurses are moving, reporting, or transporting patients
  • Assess patient characteristics like weight, cognition, and health condition
  • Assess the physical features in a room that increase the risk of back pain

Ergonomic Options for Back Pain Treatment and Prevention

  • Eliminate the hazard whenever possible. For example, if there is an obese patient on the ward who needs to use the bathroom but cannot ambulate, provide the patient with a bedside commode rather than risk injury while lifting patients.
  • Use lifts to move patients and objects (this may not always be possible as most hospital rooms are small.

Equipment to Lift and Move Patients

  • Portable total lifts
  • Overhead track lifts
  • Sit to stand lifts
  • Device to assist with a lateral transfer
  • An inflatable mattress that helps slide a patient
  • Frictionless sheets
  • Transfer boards
  • Gait belts with handles that can get tied around the patient’s waistline

Administrative Changes

  • Utilize lifting teams for moving patients. While this may be practical during the daytime, it may not always be possible at night, weekends, or on holidays when there is a shortage of staff.
  • Increase staffing: while this is a good solution, it depends on affordability and how many people to employ. Survey conduction is essential to determine how many patients actually need lifting and moving regularly. Employing staff just for this purpose may not be realistic.
  • Train workers on the use of lifting devices
  • Implement a policy that no single worker should lift a person
  • Some healthcare workers may benefit from alternative tasks that do not require lifting
  • Change the rotation of nurses so that everyone gets a break from jobs that involve patient moving or lifting

Consultations

  • The majority of LBP cases can be managed by the primary healthcare provider. If the patient has neurological deficits, then he or she should be referred to an orthopedic surgeon.
  • Referral to physical therapy is vital as it can help with recovery.
  • A dietitian consult may be helpful in those who need to lose weight.

Deterrence and Patient Education

Besides ergonomics at work, the following are also recommended for the nurse:

  • Remain stress-free
  • Participate in stress relieving exercises
  • Reduce body weight
  • Discontinue smoking
  • Eating a healthy diet
  • Exercise regularly

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. The good news it is preventable by developing a standardized approach to managing these patients. In the majority of patients, extensive investigations are not needed unless there are red flags. Bed rest must be discouraged for no more than 48 hours, and early return to work is the recommendation. The workplace should be modified to allow the worker to transition back to where there is no climbing lifting or bending. If possible, patient lift items should be utilized, and all risk factors for LBP erased.

International Guidelines to Manage Nurses with Work-Related LBP

For acute LBP (less than three months)

  • Restrict bedrest to no more than 48 hours
  • Encourage some exercise
  • Do not order unnecessary radiological studies if there are no red flags (e.g., urine retention, fecal incontinence, trauma to the lower back, infection)

For chronic LBP (more than three months)

  • Recommend physiotherapy
  • Assess all psychosocial factors and may need a referral to a mental health worker
  • Encourage swimming or some water-related activity
  • Encourage the return to work
  • Modify the workplace by reducing the workload

Outcomes

Some studies show that a multi-step core stability exercise program can help some nurses overcome low back pain and improve the quality of life, but this is not a universal observation. The difficulty is that there are many types of exercises and low back pain remedies and there is no good data to determine which works and which does not. More high-quality randomized trials are needed to determine which intervention works for nurses with LBP. [18][19][20](Level V)