Adaptation strategies for nurses with musculoskeletal pain in hospital work: a systematic review

Tuz-Colli, Jorge Gabriel; Flores-Peña, Yolanda; Santos, Heloisa Ehmke Cardoso dos; Rocha, Fernanda Ludmilla Rossi; Marziale, Maria Helena Palucci

doi:10.1590/1518-8345.7812.4725

person Jorge Gabriel Tuz-Colli

Study concept and design · Obtaining data · Data analysis and interpretation · Drafting the manuscript · Critical review of the manuscript as to its relevant intellectual content · All authors approved the final version of the text

schoolUniversidad Autónoma de Nuevo León, Facultad de Enfermería de Nuevo León, Monterrey, Nuevo León, México.schoolUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.

0000-0002-1710-1428

person Yolanda Flores-Peña

Study concept and design · Data analysis and interpretation · Drafting the manuscript · Critical review of the manuscript as to its relevant intellectual content · All authors approved the final version of the text

schoolUniversidad Autónoma de Nuevo León, Facultad de Enfermería de Nuevo León, Monterrey, Nuevo León, México.

0000-0001-6200-6553

person Heloisa Ehmke Cardoso dos Santos

Study concept and design · Obtaining data · Data analysis and interpretation · Drafting the manuscript · Critical review of the manuscript as to its relevant intellectual content · All authors approved the final version of the text

schoolUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.

0000-0001-5232-5876

person Fernanda Ludmilla Rossi Rocha

Study concept and design · Data analysis and interpretation · Drafting the manuscript · Critical review of the manuscript as to its relevant intellectual content · All authors approved the final version of the text

schoolUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.

0000-0002-0911-3728

person Maria Helena Palucci Marziale

Study concept and design · Obtaining data · Data analysis and interpretation · Drafting the manuscript · Critical review of the manuscript as to its relevant intellectual content · All authors approved the final version of the text

schoolUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.

0000-0003-2790-3333

personCorresponding author: Yolanda Flores-Peña E-mail:
yolanda.florespe@uanl.edu.mx https://orcid.org/0000-0001-6200-6553

Conflict of interest:

the authors have declared that there is no conflict of interest.

Associate Editor:

Maria Lúcia Zanetti

PubMed/MEDLINE

(“Nursing Assistant*” OR “Personnel nursing” OR Nurse* OR “nursing worker*” OR “nursing professional*”) AND (“Musculoskeletal Pain”[Mesh] OR “Musculoskeletal Pain” OR “muscle pain”)

Web of Science

(“Nursing Assistant*” OR “Personnel nursing” OR Nurse* OR “nursing worker*” OR “nursing professional*”) AND (“Musculoskeletal Pain” OR “muscle pain”)

Scopus

(“Nursing Assistant*” OR “Personnel nursing” OR Nurse* OR “nursing worker*” OR “nursing professional*”) AND (“Musculoskeletal Pain” OR “muscle pain”)

Cochrane

((MeSH descriptor: [Nursing NEXT Assistant*] explode all trees) OR (Personnel NEXT nursing) OR Nurse OR Nurses OR (nursing NEXT worker*) OR (nursing NEXT professional*)) AND ((MeSH descriptor: [Musculoskeletal Pain] explode all trees) OR “Musculoskeletal Pain” OR “muscle pain”)

CINAHL

(“Nursing Assistant*” OR “Personnel nursing” OR Nurse* OR “nursing worker*” OR “nursing professional*”) AND ((MH “Musculoskeletal Pain”) OR “Musculoskeletal Pain” OR “muscle pain”)

BVS – LILACS

(“Profissional de enfermagem” OR “Profissionais de enfermagem” OR “Profissionais da enfermagem” OR “Técnico de enfermagem” OR “trabalhadores da enfermagem” OR “trabalhador da enfermagem” OR “trabalhador de enfermagem” OR “trabajadores de enfermería” OR “trabajador de enfermería” OR “Assistentes de Enfermagem” OR “Auxiliar de Enfermagem” OR “Auxiliar do Enfermeiro” OR “Auxiliares de Enfermagem” OR “Auxiliares de Enfermeiros” OR “Asistentes de Enfermería” OR “asistente de enfermería” OR “auxiliar de enfermería” OR “auxiliar del enfermero” OR “auxiliares de enfermeros” OR “auxiliares de enfermería” OR enfermeri* OR Enfermero* OR Enfermera* OR “Healthcare Assistant*” OR “Nursing Assistant*” OR “Personnel nursing” OR “nursing professional* OR Nurse* OR”nursing worker*” OR “nursing professional*” OR Enfermagem OR Enfermería OR Nursing) AND (“Dor Musculoesquelética*” OR “Dores Musculoesqueléticas*” OR “Dor muscular*” OR “Dores musculares” OR “Dor Osteomuscular*” OR “dolor osteomuscular*” OR “Dolor Musculoesquelético” OR “Musculoskeletal Pain” OR “muscle pain”)

First author, year, country	Study design	Level of evidence/ Methodological quality	Participants	Intervention	Outcomes
Moreira, et al., 2021 ( ³⁶ ) ; Brazil	Experimental, randomized controlled clinical trial, single-blind, parallel-group with allocation concealment	Level II 3	IG*: 46 nursing assistants; and 44 from the CG ^†	The program was applied twice a week for 30 minutes per session. The training consisted of exercises for spinal stabilization. Each session was divided into three steps: 1) Five minutes of warm-up exercises; 2) 20 minutes of therapeutic exercises; 3) Five minutes of hamstring stretching and cool-down exercises at the end of the session.	The participants showed improvements in trunk flexor muscle strength with an effect size of 0.77 ( p =0.002) and in the control of lower back symptoms by 6.25 ( p =0.002) after the therapeutic exercise program. The positive association between exercise exposure and symptom improvement was 2.04 times higher for the IG* than for the CG ^† (OR ^‡ =2.04; 95% CI ^§ 1.82-2.72).
Taulaniemi, et al., 2020 ( ³⁷ ) ; Finland	Experimental, four-arm randomized controlled clinical trial	Level II 3	IG*: 165 healthcare workers and 54 in the CG ^† . Of these, 87% were nurses	A Pilates-based exercise program focused on controlling the neutral posture of the spine, divided into three stages. Stage 1. Supervised neuromuscular exercise classes. Stages 2 and 3: One supervised class and one home session with the aid of a DVD or a study-specific booklet. During this stage, the participants were allowed to exercise in supervised group sessions.	Practicing Pilates with good adherence reduced work-related fear-avoidance beliefs (FABs) and decreased low back pain intensity ( r =0.16, p =0.05). The study identified that motivational strategies should target individuals with low schooling levels, lower physical fitness and high FAB levels to achieve better exercise adherence.
Oka, et al., 2019 ( ³⁸ ) ; Japan	Analytical, prospective, randomized, parallel-group, multicenter study with centralized evaluations	Level II 3	4,767 nurses 1799 in group A, 1420 in group B, and 1548 in Group C from 12 hospitals	Group A served as the Control Group. The participants in groups B and C received an exercise manual detailing how to perform the standing back extension exercise “One Stretch,” along with a 30-minute seminar. In Group B, participants only attended the 30-minute seminar. In Group C, both physical and psychological approaches were incorporated into the treatment of low back pain.	The standing back extension exercise called “One Stretch” effectively improved and prevented low back pain. The improvement rates were 13.3%, 23.5% and 22.6% in groups A, B and C, respectively. The pain worsening rates were 13.0%, 9.6% and 8.1%, respectively, decreasing as the intervention level increased (p<0.001).
Imai, et al., 2021 ( ³⁹ ) ; Japan	Experimental, randomized controlled parallel-group trial	Level II 3	104 participants 53 in the IG* and 51 in the CG ^† , including healthcare workers such as nurses	The program consisted of a six-month plan involving progressive exercises and pain neuroscience education (PNE). The stretching sessions lasted 20 minutes and the walking sessions lasted approximately 30 minutes, performed 3-4 times per week. The Control Group received general feedback after completing a questionnaire.	The study demonstrated that a combination of PNE and exercise yielded better outcomes for patients, including reduced presenteeism ( F =12.87, p <0.001, η²=0.94), lower pain intensity ( F =11.0, p <0.001, η²=0.1), decreased physical stress and improved psychological status and quality of life.
Lopes, et al., 2019 ( ⁴⁰ ) ; Brazil	Experimental, prospective, open-label trial with repeated measures	Level II 2	IG*: 64 nursing technicians No CG ^† was included	An adapted mindfulness program, consisting of weekly 60-minute sessions over 8 consecutive weeks. The participants were guided to practice daily meditation at home for 20 minutes, incorporating mindfulness into their daily routines and activities as an informal practice. During face-to-face meetings, exercises focused on pain management, breathing techniques, body scan, mindful walking, mindful movements with light body postures, sitting, lying down and meditation.	The mindfulness program demonstrated significant reductions in musculoskeletal symptoms, anxiety, depression and catastrophic pain ( p <0.001). A particularly significant finding was the reduction in catastrophic pain levels (η²=0.203; p <0.001) and MSP (η²=0.200; p <0.001). The positive effects were observed after 8 weeks and remained stable through the 12-week follow-up period.
Morais, et al., 2023 ( ⁴¹ ) ; Brazil	Experimental, randomized clinical trial, triple-blind (patient, statistician and outcome evaluators)	Level II 5	IG*: 34 workers; CG ^†: 33 workers, including healthcare personnel (e.g.: Nursing staff) diagnosed with chronic spinal pain	The participants received eight sessions of seed-based auriculotherapy, administered twice a week and lasting a mean of 10 to 15 minutes per session. The workers were instructed to leave the seeds in place for three days, manually stimulating them at least three times a day, applying pressure 15 times on each auricular point.	Seed-based auriculotherapy demonstrated positive therapeutic effects in reducing pain intensity among healthcare workers with chronic spinal pain. The IG* showed a significant 34% reduction in pain when compared to the CG ^† ( p =0.007). Regarding pain interference in daily living activities, a reduction in mean values was observed in both groups ( p <0.05). Additionally, a significant reduction in medication use was noticed ( p =0.013).
Soler-Font, et al., 2019 ( ⁴² ) ; Spain	Experimental, cluster-randomized controlled trial with two arms and a control group	Level II 3	IG*: 138 nurses CG ^†: 119 nurses	The intervention incorporated components targeting all three prevention levels. The primary prevention included: 1) Occupational risk factors to protect healthy workers from MSDs and MSD-related absenteeism. through participatory ergonomics; and 2) Promotion of healthy lifestyles at work (physical activity, emotional well-being and diet). Secondary and tertiary prevention involved a case management service for the early identification of MSPs.	The intervention was effective in reducing pain by up to 63% (OR ^‡ =0.37; 95% CI ^§: 0.14-0.96) in the neck, shoulders and upper back among Nursing staff. A non-statistically significant reduction in lower back pain was observed in the Intervention Group when compared to the Control Group. Work functioning remained stable over the 12-month follow-up period in the Intervention Group, whereas a decline was noticed in the Control Group ( p <0.05).
Sezgin & Esin, 2018 ( ⁴³ ) ; Turkey	Pre-experimental study with pretest and posttest for non-equivalent control groups	Level II 2	61 nurses, 30 in the IG* and 31 in the CG ^†	The Ergonomic Risk Management Program (ERMP) consisted of two components: 1) A two-week video-based training focused on musculoskeletal risks for ICU nurses, complemented with preventive exercises; and 2) Personal interviews with nurses aimed at identifying predisposing, reinforcing and facilitating factors for behavioral change.	ERMP was effective in increasing exercise frequency ( p =0.017) and reducing musculoskeletal pain ( p =0.017) as well as ergonomic risk levels among ICU nurses ( p <0.05).

First author, year, country	Intervention/technique used	Number of sessions	Duration per session	Evaluation instrument/technique	Outcome
Moreira, et al., 2021 ( ³⁶ ) ; Brazil	Therapeutic exercise for spine muscle strength (warm-up, strengthening and stretching)	Mean of 17.5 sessions	30 minutes	Dynamometry: Strength of trunk flexor muscles; pressure pain threshold of the long dorsal muscle	Increased strength of flexor muscles Significant reduction in pressure pain threshold
Taulaniemi, et al., 2020 ( ³⁷ ) ; Finland	Pilates-type physical exercise Neuromuscular exercise	Twice a week for the first two months, then once a week for four follow-up months	60 minutes	-Fear-Avoidance Beliefs Questionnaire (FABQ) -Exercise adherence log	Reduced beliefs related to avoiding pain associated with physical activity and work Greater adherence to exercise
Oka, et al., 2019 ( ³⁸ ) ; Japan	Active spinal extension exercises called “One Stretch” Educational seminar Psychological and physical approaches	1 seminar and 6-month follow-up	30 minutes	-Keele STarT Back (SBST) low back pain screening tool -Fear Avoidance Beliefs Questionnaire (FABQ).	Subjective improvement in pain Pain reduction
Imai, et al., 2021 ( ³⁹ ) ; Japan	Progressive physical exercises and Pain Neuroscience Education (PNE)	3-4 times per week for 6 months	20-minute stretching and 30-minute walks	-Widespread Pain Index (WPI) -EuroQol 5-Dimensions (EQ5D-L) -Presenteeism Scale (WLQ)	Reduced lower back pain Reduced presenteeism
Lopes, et al., 2019 ( ⁴⁰ ) ; Brazil	Adapted mindfulness	8 sessions	60 minutes	-Nordic Musculoskeletal Questionnaire (NMQ) -Catastrophic Pain Scale -World Health Organization Quality of Life Scale (WHOQOL-BREF)	Less pain, anxiety and catastrophizing Improved quality of life perception
Morais, et al., 2023 ( ⁴¹ ) ; Brazil	Seed-based auriculotherapy	8 sessions	10-15 minutes	-Visual analog scale for pain -Brief pain inventory -Rolland-Morris Disability Questionnaire and Quality of Life SF-36	Reduced intensity of chronic spinal pain Improved quality of life perception
Soler-Font, et al., 2019 ( ⁴² ) ; Spain	Multifaceted intervention at three prevention levels: I. Participatory ergonomics: Reduction of exposure to biomechanical and psychosocial risk factors II. Health promotion: Nordic walking, Mediterranean healthy eating and Mindfulness course III. Case management: early detection of and MSDs and MSP; Multidisciplinary support for return-to-work	Variable, over 12 months	Variable depending on the component	-Adapted Standardized Nordic Questionnaire -Work role functioning was assessed using the Spanish version of the Work Role Functioning Questionnaire (WRFQ-SpV)	A reduction in pain was observed in the neck, shoulders and upper back Stable work functioning Decreased need for work rescheduling requests
Sezgin & Esin, 2018 ( ⁴³ ) ; Turkey	An ergonomic risk management program was developed based on the PRECEDE-PROCEED model. 1) Video training and educational materials (brochures and CDs), complemented with preventive exercises 2) Personal interviews focused on identifying predisposing, reinforcing and facilitating factors for behavior change	26 follow-up weeks	Two weeks	-Musculoskeletal symptoms questionnaire -Ergonomic risk report form -Rapid Upper Limb Assessment (RULA) form	Reduction in MSP Increased exercise frequency

[1] *IG = Intervention Group; ^†CG = Control Group; ^‡OR = Odds Ratio; ^§CI = Confidence Interval