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On-line version ISSN 1518-8787
Rev. Saúde Pública vol.35 no.4 São Paulo Aug. 2001
Evaluation of a program to reduce back pain in nursing personnel*
Avaliação de programa para reduzir dores nas costas em trabalhadores de enfermagem
Neusa Maria C Alexandrea, Marco Antonio A de Moraesb, Heleno R Corrêa Filhoc and Silvia Angélica Jorged
aDepartamento de Enfermagem da Faculdade de Ciências Médicas, Universidade Estadual de Campinas (Unicamp). Campinas, SP, Brasil. bCentro de Saúde da Comunidade da Unicamp. Campinas, SP, Brasil. cDepartamento de Medicina Preventiva e Social da Faculdade de Ciências Médicas da Unicamp. Campinas, SP, Brasil. dHospital das Clínicas da Unicamp. Campinas, SP, Brasil
Back pain, therapy.# Occupational health program.# Exercise.# Nurses aides.# Program evaluation. Ergonomics (environmental health). Occupational diseases, prevention and control.
Dor nas costas, terapia.# Programa de saúde ocupacional.# Exercício.# Auxiliares de enfermagem.# Avaliação de programas. Ergonomia (saúde ambiental). Doenças ocupacionais, prevenção e controle.
Musculoskeletal disorders are an important public health problem. Among them are back conditions, a complex problem for certain occupational groups, such as nursing personnel.10 Historically, back pain has been a major complaint, and nursing professionals are one at the highest risk.3
Risk factors for back pain can be either of individual origin or related to the workplace. The main occupational risk factors are: lifting and handling of patients, uncomfortable and immobile postures, inadequate equipment, improper workplace design, heavy physical work, and inadequate work organization.2,12 Other studies include factors such as physical activity, muscular weakness, smoking, obesity and psychological factors.6 Back pain most often has a multifactorial origin. Therefore, strategies to reduce musculoskeletal disorders have included an ergonomic approach, which attempts to integrate equipment, tasks, personnel, and the work environment. The most common strategies include education, training in patient transfer and handling techniques, use of mechanical devices, stretching and exercise programs, learning relaxation techniques, better work conditions, and changes in work organization and life style.
Given that, it was established a specific exercise program with an educational ergonomic approach for nursing personnel at a university hospital. The purpose of the study was evaluated whether this program reduced the frequency and intensity of back pain in female nursing aides.
Subjects and setting **
The study was conducted in a 412-bed public teaching hospital. Volunteers were selected and did not represent a probabilistic sample of each hospital unit.
Enrolled personnel were first evaluated to assure they were qualified to participate in the program.
The study participants were female nursing aides who had back pain for at least six months. The reference population consisted of nursing aides who had one year of nursing education. The sample population included all nursing aides working at the hospital's supply service division, intensive care unit and inpatients and outpatients clinical, surgical and emergency facilities (except for obstetrics and gynecology care). Their main activities were patient care, transportation, bedside drug administration, and handling of medical instruments. Inclusion criteria were: age less than 50 years; shift-work in the selected areas; self-reporting of back pain; and interest in volunteering for the study. Exclusion criteria were either severe spinal disorder with medical restriction to exercising or history of spinal surgery. A public call for enlisting in the study was made and the list was closed once the calculated sample size was reached. The sample population was 670 nursing aides. All participants signed informed consent forms, and they were randomly divided into control group (n=29) and intervention group (n=27). The control group received only a 45-minute class during working time on subjects such as anatomy of the spine and patient transfer technique.
The educational approach was based on previous studies and research in ergonomics.1-3,14 The educational sessions were planned after assessing the hospital's workplace and the nursing personnel's specifics tasks. The program's educational component for the intervention group consisted of six modules, of an hour each, twice a week for four months. Two of the study's authors were in charge of giving a fifteen-minute slide presentation, followed by a set if exercises and relaxation. The program content was:
Recommendations about back conditions were given, the importance of regular exercise, pain relieve measures, and the effects of sports on the musculoskeletal system were stressed.
Specific ergonomic orientation
Photographs were used to orient nursing personnel about their workplace: work surface height, workspace, and height of reach.8 The purpose was to offer elevant information regarding the anatomy of the spine; Body mechanics; Situations that may cause back pain. Photographs were taken of the nursing personnel at work, while they were performing their main tasks at their units. Then ergonomic findings were associated with musculoskeletal disorders. Complicated situations were presented to them to develop a critical sense about the effect of the workplace environment on their health. The presentation was divided in two sections: main general factors causing musculoskeletal disorders; and ergonomic risk factors specifically related to hospital equipment and environment.
First, the patient's condition was evaluated, then the equipment, the environment, and nursing personnel were prepared and then the task of moving and transferring the patient was performed.
Randomized treatment allocation was done in an attempt to reduce unbalanced risk factors between the work settings. During the study, the treatment group underwent a 45 minute exercise program, twice a week, including strength and flexibility exercises, conducted during working hours for four months. It also included a set of exercises to be performed after working hours. Two authors were in charge of teaching sessions, which were offered at the beginning of the program at the university's community health center that provides comprehensive care to the university's employees, academic staff, and students.
A questionnaire was prepared and assessed in a pilot survey.3,13 Pain intensity was assessed through self-reporting of symptoms, and visual analogue scale (VAS). The questionnaire was completed before and after completing the program. Back pain frequency and intensity was checked at two distinct retrospective periods (the last two months and the last seven days) and in different regions of the spine: neck (cervical), upper back (thoracic), and lower back (lumbar).
The Epi Info program was used in the descriptive analysis to characterize the groups. Student's t-test or the Wilcoxon Rank Sum Test for independent samples were used to compare the variables between groups of independent samples. Chi-square test or exact Fisher test was applied for categorical analyses. The McNemar test and Wilcoxon matched pairs test were used to compare data before and after the program.
One of the participants in the intervention group dropped out due to an unexpected surgery. The study ended with 26 individuals in the intervention group and 29 in the control group.
Both groups were homogeneous for the three variables shown in Table 1 (p>0.05). There was no difference in the proportion of married personnel between the groups (p = 0.11; Chi-square test).
Table 2 exhibits the difference in cervical and lumbar back pain.
Before starting the program, back pain frequency in different regions of the spine in the last two months and the last seven days was assessed in both groups.
Cervical and lumbar complaints were more common than thoracic ones. Alexandre et al3 (1996) studied a hospital nursing team and observed that these individuals suffered mainly from lower back and cervical pain, as well as from diffuse back pain. This fact is particularly relevant since most studies focus only on lower back pain.
Back pain complaints was similar in both groups prior to the program, but after its completion, there was a significant difference in relation to cervical pain in the last two months and in the last seven days, and lumbar pain in the last seven days.
The frequency of back pain in the intervention group was reduced in all regions of the spine, but there were no changes in the control group either in the last two months or in the last seven days. There was a statistically significant reduction in the frequency of cervical pain in the last two months and in the last seven days in the intervention group.
Before the program, control and intervention groups referrred similar pain intensities as assessed using the Wilcoxon Rank Sum Test for independent samples. However, at the end of the program, there was a significant difference in cervical pain for both periods. Lumbar pain in the last seven days showed a p-value of 7%, which could be attributed to the significance value in the 93% confidence interval.
Table 3 presents indicators of the severity of back pain referred, associated with other aspects involving the participants' working life during the study.
This study established an education program with an ergonomic approach and specific exercises for nursing aides within the hospital setting. This group was chosen due to their irregular working schedule and to the fact that most aides have a second job to increase their income given their low salaries in the hospital. Their low socioeconomic status prevent them to participate in activities such as sports and leisure time. The program was well accepted by nursing aides and had excellent support from the hospital management. From now on it will be offered in the gymnasium of the university's community health center. Back pain complaints decreased significantly, and the subjects reported a feeling of well being during the program.
The main limitations of the study were the difficulties found with a non-probabilistic sample due to volunteering, and the need to work sometimes with test power below 80% (60-75%). The inclusion criteria did not provide a balanced distribution for the three subsets of cervical, thoracic and lumbar pain. Therefore lumbar back pain could not reach a significant 5% alpha error threshold for retrospective report for the both the period of the last seven days and the last two months. Despite that, the point estimate for lumbar pain at the last treatment day is significant, and it is possible to have a better understading of the non-parametric retrospective difference between the groups when evaluating the box-plots.
The sparcity of clinical trial studies on back pain among nursing professionals in Brazil impaired the comparability aspects, due to lack of validated methods in Portuguese for standardizing diagnosis and classification of spinal disorders and back pain. Another difficulty was the practice of controversial prevention methods described in the literature. Back pain is, by definition, symptomatic and definite diagnoses are rarely possible. Pain assessment is complex and may be possible through measures of its severity, frequency and disability caused. This study tried to overcome these limitations by estimating severity using the VAS.
Gates7 (1988) stated that muscular disability is one of the main causes of back pain among nursing personnel. Physical activity and exercise are known to have beneficial effects on the musculoskeletal system.Training in patient lifting procedures and education in body mechanics were initially proposed to avoid back pain in nursing personnel. Stubbs et al16 (1983) emphasized that training alone would not solve the problem since the training effectiveness cannot be assessed without knowing the environment and individual's concerns.
Few studies have dealt with programs consisting only of exercises designed to reduce back pain. Gundewall et al9 (1993) reported a decrease in lower back pain complaints and pain intensity in a group of nurses after implementing an exercise program during working hours. Skargren & Oberg15 (1996) suggested that a moderate weekly exercise program directed to nursing personnel can modify the physical capacity and reduce musculoskeletal symptoms in non-regular exercisers, and probably in subjects over 40 years of age.
The current tendency is to combine different approaches in a single program since various inter-related factors may cause spinal lesions. Thus, recent studies have evaluated programs that simultaneously use different strategies, such as training in lifting and handling patients, with work alteration, life style orientation, organizational changes at the workplace, use of mechanical devices, exercises and relaxation.5,18
The prevalence of back pain among nursing professionals stresses the need for further studies to better understand the problem and provide effective approaches for dealing with this condition.
Programs based on ergonomics and postural aspects for patient's lifting and handling can prevent back impairment and improve patient management skills.11,17 Such training has become requisite in health institutions in countries with occupational health concerns. In Brazil, schools and health institutions are not particularly concerned about training nursing personnel in moving and transferring patients and there is no specific legislation relating nursing personnel education.
The present study indicates that there is a need of an educational program with emphasis on ergonomics for health workers. Its results should also encourage more research on the evaluation of specific training projects to reduce back pain among nursing personnel.
Researchers and organizations worldwide are looking for solutions regarding musculoskeletal disorders seen in nursing personnel. In Brazil, this is a particularly important problem and active measures are needed.3,4
As a conclusion, this study indicated that the frequency and intensity of back pain among nursing aides, mainly in the cervical (p<0.05), and lumbar regions (p=0.07) decreased more significantly in the intervention group. This suggests that a program of exercises conducted twice a week with an ergonomic approach could reduce musculoskeletal symptoms in nursing personnel.
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Heleno R Corrêa Filho
Departamento de Medicina Preventiva e Social
Faculdade de Ciências Médicas, Unicamp
13084-270 Campinas, SP, Brasil
* Supported by FAPESP (Process n. 1997/05744-3). Presented to 4th International Conference on Ocupational Health for Health Care Works, Montreal, 1999.
Received on 11/8/2000. Reviewed on 12/4/2001. Approved on 22/5/2001.
** The study was approved by Ethics Committee and hospital personnel were informed notified about it.