Back to Basics
To prevent musculoskeletal injuries in the workplace, nurses should adopt safe lifting techniques

By Anne Federwisch
January 28, 2005

If you have an aching back, you’re not alone. An estimated 52% of nurses complain of chronic back pain, according to the American Nurses Association, with 20% requesting assignment transfers and up to 12% leaving the profession as a result of back injuries.

Because back pain affects so many nurses, it’s important that “you be aware you’re at risk,” says Lori Schaumleffel, RN, COHN-S. As coordinator of employee services at Mercy Hospital of Folsom (Calif.), she often deals with nurses who have back pain.

“If we lose nurses to back injuries, we’re losing a valuable resource,” Schaumleffel says. “While it may not knock you out of your career, it can be a hindrance throughout your life.”

Perhaps 80% to 90% of the time, the origin of back pain cannot be pinpointed precisely, estimatesMaj. John Childs, PT, PhD, a senior physical therapist and director of research at Wilford Hall Medical Center at Lackland Air Force Base, Texas, who has studied back pain and treatment extensively.

But certain risk factors increase the likelihood of back problems.

The physicality of many nursing jobs puts caregivers at high risk. Nursing aides, orderlies, and attendants ranked No.1 in the Bureau of Labor Statistics’ most recent (2002) compilation of the number of musculoskeletal injuries involving days away from work.

RNs came in seventh, following closely behind construction workers, assemblers, janitors, nonconstruction laborers, and truck drivers.

“Patients are sicker and bigger than they’ve been historically,” explains Schaumleffel, making nurses’ jobs more dangerous to their own health. The frequency of manual labor on the job also increases the risk throughout a career. “Back injuries are microtraumas — the damage accumulates over time,” she says. The more you work in awkward postures or lift heavy loads, the greater your risk.

But just getting older doesn’t necessarily bode poorly for your back. The prime incidence of the onset of back pain occurs between ages 30 and 50, Childs says. After age 50, the spine becomes stiffer, actually reducing the onset of back pain, assuming no arthritis is involved.

Bad habits also can increase the incidence of back problems. Although smoking itself does not cause back pain, it has been shown to be an independent risk factor associated with back pain, increasing its likelihood and delaying recovery, Childs says.

Being overweight and out of shape compounds the danger as well. “In general, most back pain is caused by your back being out of shape,” according to Childs.

Psychosocial factors also can affect the back. “Research shows that under stress, in certain personalities, muscles around the back will contract, causing back pain,” says Nancy Menzel, RN, PhD, APRN, COHN-S, assistant professor at the University of Florida College of Nursing, who has studied the psychosocial components of back pain in nurses. “In many instances, pain and stress are intertwined.”

Dealing with back pain

Although the incidence of back pain is high, particularly in the nursing profession, “the good news is that most people with back pain are going to be fine,” Childs says.

Bed rest may be indicated for the first 24 hours after onset of acute back pain, but “bed rest beyond two or three days has not been shown to be efficacious when compared to maintaining activity as tolerated,” advises Eunice Lau, MD, a board-certified physiatrist at Kaiser Permanente’s Hayward & Fremont Medical Centers and the spine clinic at their Union City Medical Office.

Inactivity can cause reduced muscle tone, decreased exercise tolerance, and weakening of the back muscles, compounding the problem, rather than improving the situation.

Acute lower back pain flare-ups are generally treated with nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen, Lau says. Muscle relaxants such as Flexeril (cyclobenzaprine) or Robaxin (methocarbamol) also can be prescribed in the acute phase.

In addition to medication use, a conservative treatment regimen includes activity modification, maintaining proper body posture, stretching exercises of the lower back and legs, and gradual transitioning to a lumbar strengthening exercise (LSE) program.

Research has shown that LSEs (generally prescribed in a clinical setting) can help reduce recurrence of back pain, according to Childs. “The theory is that spine muscles act as guide wires for the back,” Childs says. By working on strengthening your back, you improve the guidance system. “Almost all my patients go home with some trunk exercises and aerobic exercise suggestions.”

Other exercise may help, but has not been clinically researched as to its specific effect on reducing back pain. Aerobic exercise improves overall fitness and helps keep your weight down. Core exercises (low back/abdominal strengthening exercises) or Pilates (strengthening and flexibility exercises emphasizing proper body alignment and correct breathing) are similar to LSE in strengthening abdominal and back muscles.

Spinal manipulation remains controversial. Some studies show no difference between manipulation and conventional treatment. For some patients, spinal manipulation may reduce back pain. Childs just published a study in the Annals of Internal Medicine indicating that patients treated with high-velocity thrust spinal manipulation who met four out of five predictive criteria had a 92% chance of substantial reduction in pain within a week.

Work-hardening programs may assist people in returning to their jobs despite back pain by actively simulating work-related tasks in a clinical setting, increasing endurance and decreasing fear of movement.

More passive programs, like back schools that just teach information in a classroom setting, generally tend to be less effective, Childs says. Addressing psychosocial factors may play a role in protecting your back as well, according to Menzel. She completed a pilot study in 2004 that showed that the use of cognitive-behavioral training in conjunction with the use of mechanical lifting aids was promising for reducing back pain in nurses compared to the use of the lifting devices alone.

The cognitive behavioral training group received instruction in muscle relaxation, job-stress management, cognitive restructuring (learning to change the perception of pain), conflict resolution, distraction and pain-coping strategies, as well instruction in and use of the lifting equipment. The control group received only instruction in and use of the lifting equipment.

Surgical options

For certain specific pathologies, surgery may be warranted to reduce back pain if conservative treatment fails to garner results, Lau says. In a microdiscectomy, some of the inner content of a herniated disk is removed through a small incision to relieve impingement on the nerves. In a laminectomy, the posterior part of the vertebra is removed, giving more room for the disk itself.

Intradiscal electrothermal therapy (IDET) is a minimally invasive technique used to treat significant wear and tear on the outer ring of the disk. A probe heats the disk wall, causing it to thicken and seal, reducing herniation.

A surgeon may recommend spinal fusion, actually connecting adjoining vertebrae by use of a bone graft or synthetic material. This increases the stability of the spine, but consequently reduces flexibility.

Flexibility may be maintained by replacing a damaged disk with an artificial one. The prosthetic devices, first approved by the FDA in June, use material similar to those in artificial knees and hips and allow normal movement of the spine.

No matter what the treatment advised for back pain, occupational health nurse Schaumleffel and others emphasize a positive attitude in dealing with the problem. “In learning to live with back pain, you have to stress the living part,” she says.

Your achin’ backs

Number (in thousands) of work-related musculoskeletal disorders involving days away from work and median days away from work by selected occupation (2002)

Occupation: Nursing aides, orderlies, attendants
No. of injuries: 44.4
Days lost: 6

Occupation: Truck drivers
No. of injuries: 36.8
Days lost: 12

Occupation: Laborers, nonconstruction
No. of injuries: 24.9
Days lost: 8

Occupation: Janitors, cleaners
No. of injuries: 15.2
Days lost: 7

Occupation: Assemblers
No. of injuries: 15.2
Days lost: 14

Occupation: Construction laborers
No. of injuries: 11.1
Days lost: 10

Occupation: Registered nurses
No. of injuries: 10.8
Days lost: 6

Occupation: Sales supervisors
No. of injuries: 9.9
Days lost: 7

Occupation: Cashiers
No. of injuries: 9.3
Days lost: 8

Occupation: Stock handlers, baggers
No. of injuries: 8.8
Days lost: 5

Occupation: Assemblers
No. of injuries: 7.8
Days lost: 7

Source: Bureau of Labor Statistics. “Lost-worktime Injuries and Illnesses: Characteristics and Resulting Time Away from Work, 2002. www.bls.gov

Not your grandfather’s handling techniques

Experts agree that the best way to treat back pain is to prevent it in the first place. But the “proper body mechanics” taught in nursing schools and at employee orientations may not be so proper after all in a patient care setting.

“If proper body mechanics were enough to protect a 120-pound nurse lifting a 250-pound patient, we wouldn’t have so many injuries,” says Nancy Menzel, RN, PhD, an assistant professor at the University of Florida College of Nursing who has studied back pain in nurses.

The problem, explains Butch de Castro, RN, PhD, MSN/MPH, senior staff specialist for occupational health and safety at the American Nurses Association, is that traditional lifting techniques are based on outdated studies that focused on men lifting 50-pound boxes with handles straight off the ground.

“But our patients don’t weigh 50 pounds, don’t have handles, and we’re not lifting them straight off the ground,” he says, so the techniques “have no practical application to nursing care in terms of patient handling.”

A safer way to reduce the risk of injury associated with moving patients is to eliminate manual patient handling altogether, he says. Nurses should lift or transfer patients using only assistive patient handling equipment such as ceiling lifts, transfer chairs, sliding boards, gait belts, or inflatable, mechanical, or friction-reducing lateral-assist devices.

This “no-lift” policy is the hallmark of the ANA’s “Handle with Care” campaign launched in September 2003, a comprehensive effort aimed at preventing back and other musculoskeletal injuries in nurses by effecting changes in practice through modifications in administration, legislation, and education.

“Safe patient handling prevents nurses’ injuries, improves patient care, and saves employers money in terms of workers’ compensation costs,” de Castro says.

The United States lags behind other nations such as the United Kingdom and Australia, which have had no-lift policies in place for nurses for more than 10 years, resulting in a significant reduction in incidence of back pain and injury in nurses.

The United States is moving forward, though. The Smart Patient Handling policy at Mercy Hospital of Folsom requiring that ancillary devices must be used for anything other than minimal assist “has decreased the incidence of back pain and injury due to patient handling,” attests Lori Schaumleffel, RN, COHN-S, coordinator of employee services.

The idea of reducing or eliminating manual transfers is catching on throughout the country.

“We’re seeing more health care administrators taking safe patient handling to heart,” de Castro says, noting that more nurses are trying to alter policies in their facilities. “It just takes one champion within a health care facility to create change.”

For more information about safe patient handling, visit:

• American Nurses Association Handle with Care Campaign, www.nursingworld.org/handlewithcare
• Department of Veterans Affairs, VHA Patient Safety Center,
  www.patientsafetycenter.com

Anne Federwisch

Editor’s note Visit Education/CE at http://nsweb.nursingspectrum.com/ ce/ce283.htm to view our self-study module on lower back pain.

Anne Federwisch is a freelance writer.