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. 

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References

1.

Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006 Apr;88 Suppl 2:21-4. [PubMed: 16595438]

2.

Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G, Smith E, Vos T, Barendregt J, Murray C, Burstein R, Buchbinder R. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014 Jun;73(6):968-74. [PubMed: 24665116]

3.

Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976). 2006 Nov 01;31(23):2724-7. [PubMed: 17077742]

4.

Dieleman JL, Baral R, Birger M, Bui AL, Bulchis A, Chapin A, Hamavid H, Horst C, Johnson EK, Joseph J, Lavado R, Lomsadze L, Reynolds A, Squires E, Campbell M, DeCenso B, Dicker D, Flaxman AD, Gabert R, Highfill T, Naghavi M, Nightingale N, Templin T, Tobias MI, Vos T, Murray CJ. US Spending on Personal Health Care and Public Health, 1996-2013. JAMA. 2016 Dec 27;316(24):2627-2646. [PMC free article: PMC5551483] [PubMed: 28027366]

5.

Yassi A, Lockhart K. Work-relatedness of low back pain in nursing personnel: a systematic review. Int J Occup Environ Health. 2013 Jul-Sep;19(3):223-44. [PubMed: 23885775]

6.

Engst C, Chhokar R, Miller A, Tate RB, Yassi A. Effectiveness of overhead lifting devices in reducing the risk of injury to care staff in extended care facilities. Ergonomics. 2005 Feb;48(2):187-99. [PubMed: 15764316]

7.

Smedley J, Egger P, Cooper C, Coggon D. Manual handling activities and risk of low back pain in nurses. Occup Environ Med. 1995 Mar;52(3):160-3. [PMC free article: PMC1128180] [PubMed: 7735387]

8.

Burdorf A, Jansen JP. Predicting the long term course of low back pain and its consequences for sickness absence and associated work disability. Occup Environ Med. 2006 Aug;63(8):522-9. [PMC free article: PMC2078120] [PubMed: 16849528]

9.

Huntington A, Gilmour J, Tuckett A, Neville S, Wilson D, Turner C. Is anybody listening? A qualitative study of nurses' reflections on practice. J Clin Nurs. 2011 May;20(9-10):1413-22. [PubMed: 21414055]

10.

Cohen-Mansfield J, Culpepper WJ, Carter P. Nursing staff back injuries: prevalence and cost in long term care facilities. AAOHN J. 1996 Jan;44(1):9-17. [PubMed: 8694975]

11.

Aiken LH, Clarke SP, Sloane DM, Sochalski JA, Busse R, Clarke H, Giovannetti P, Hunt J, Rafferty AM, Shamian J. Nurses' reports on hospital care in five countries. Health Aff (Millwood). 2001 May-Jun;20(3):43-53. [PubMed: 11585181]

12.

Richardson A, McNoe B, Derrett S, Harcombe H. Interventions to prevent and reduce the impact of musculoskeletal injuries among nurses: A systematic review. Int J Nurs Stud. 2018 Jun;82:58-67. [PubMed: 29605754]

13.

Coggon D, Ntani G, Palmer KT, Felli VE, Harari R, Barrero LH, Felknor SA, Gimeno D, Cattrell A, Serra C, Bonzini M, Solidaki E, Merisalu E, Habib RR, Sadeghian F, Kadir M, Warnakulasuriya SS, Matsudaira K, Nyantumbu B, Sim MR, Harcombe H, Cox K, Marziale MH, Sarquis LM, Harari F, Freire R, Harari N, Monroy MV, Quintana LA, Rojas M, Salazar Vega EJ, Harris EC, Vargas-Prada S, Martinez JM, Delclos G, Benavides FG, Carugno M, Ferrario MM, Pesatori AC, Chatzi L, Bitsios P, Kogevinas M, Oha K, Sirk T, Sadeghian A, Peiris-John RJ, Sathiakumar N, Wickremasinghe AR, Yoshimura N, Kielkowski D, Kelsall HL, Hoe VC, Urquhart DM, Derrett S, McBride D, Gray A. The CUPID (Cultural and Psychosocial Influences on Disability) study: methods of data collection and characteristics of study sample. PLoS One. 2012;7(7):e39820. [PMC free article: PMC3391206] [PubMed: 22792189]

14.

Retsas A, Pinikahana J. Manual handling activities and injuries among nurses: an Australian hospital study. J Adv Nurs. 2000 Apr;31(4):875-83. [PubMed: 10759984]

15.

Smedley J, Egger P, Cooper C, Coggon D. Prospective cohort study of predictors of incident low back pain in nurses. BMJ. 1997 Apr 26;314(7089):1225-8. [PMC free article: PMC2126588] [PubMed: 9154024]

16.

Trinkoff AM, Le R, Geiger-Brown J, Lipscomb J, Lang G. Longitudinal relationship of work hours, mandatory overtime, and on-call to musculoskeletal problems in nurses. Am J Ind Med. 2006 Nov;49(11):964-71. [PubMed: 16691609]

17.

Bernal D, Campos-Serna J, Tobias A, Vargas-Prada S, Benavides FG, Serra C. Work-related psychosocial risk factors and musculoskeletal disorders in hospital nurses and nursing aides: a systematic review and meta-analysis. Int J Nurs Stud. 2015 Feb;52(2):635-48. [PubMed: 25480459]

18.

Holmes MW, Hodder JN, Keir PJ. Continuous assessment of low back loads in long-term care nurses. Ergonomics. 2010 Sep;53(9):1108-16. [PubMed: 20737336]

19.

Vinstrup J, Jakobsen MD, Andersen LL. Poor Sleep Is a Risk Factor for Low-Back Pain among Healthcare Workers: Prospective Cohort Study. Int J Environ Res Public Health. 2020 Feb 05;17(3) [PMC free article: PMC7036951] [PubMed: 32033339]

20.

Grover E, Porter JE, Morphet J. An exploration of emergency nurses' perceptions, attitudes and experience of teamwork in the emergency department. Australas Emerg Nurs J. 2017 May;20(2):92-97. [PubMed: 28196705]

21.

Kelly M, Wills J. Systematic review: What works to address obesity in nurses? Occup Med (Lond). 2018 May 23;68(4):228-238. [PubMed: 29579241]

22.

Alkherayf F, Agbi C. Cigarette smoking and chronic low back pain in the adult population. Clin Invest Med. 2009 Oct 01;32(5):E360-7. [PubMed: 19796577]

23.

Edlich RF, Winters KL, Hudson MA, Britt LD, Long WB. Prevention of disabling back injuries in nurses by the use of mechanical patient lift systems. J Long Term Eff Med Implants. 2004;14(6):521-33. [PubMed: 15698378]

24.

Bin Homaid M, Abdelmoety D, Alshareef W, Alghamdi A, Alhozali F, Alfahmi N, Hafiz W, Alzahrani A, Elmorsy S. Prevalence and risk factors of low back pain among operation room staff at a Tertiary Care Center, Makkah, Saudi Arabia: a cross-sectional study. Ann Occup Environ Med. 2016;28:1. [PMC free article: PMC4731917] [PubMed: 26835129]

25.

Al Amer HS. Low back pain prevalence and risk factors among health workers in Saudi Arabia: A systematic review and meta-analysis. J Occup Health. 2020 Jan;62(1):e12155. [PMC free article: PMC7382437] [PubMed: 32710807]

26.

Trinkoff AM, Lipscomb JA, Geiger-Brown J, Storr CL, Brady BA. Perceived physical demands and reported musculoskeletal problems in registered nurses. Am J Prev Med. 2003 Apr;24(3):270-5. [PubMed: 12657347]

27.

Rezaee M, Ghasemi M. Prevalence of low back pain among nurses: predisposing factors and role of work place violence. Trauma Mon. 2014 Nov;19(4):e17926. [PMC free article: PMC4310160] [PubMed: 25717449]

28.

Lee SJ, Lee JH, Gershon RR. Musculoskeletal Symptoms in Nurses in the Early Implementation Phase of California's Safe Patient Handling Legislation. Res Nurs Health. 2015 Jun;38(3):183-93. [PubMed: 25914203]

29.

Ovayolu O, Ovayolu N, Genc M, Col-Araz N. Frequency and severity of low back pain in nurses working in intensive care units and influential factors. Pak J Med Sci. 2014 Jan;30(1):70-6. [PMC free article: PMC3955545] [PubMed: 24639834]

30.

Pransky G, Snyder T, Dembe A, Himmelstein J. Under-reporting of work-related disorders in the workplace: a case study and review of the literature. Ergonomics. 1999 Jan;42(1):171-82. [PubMed: 9973879]

31.

Vergroesen PP, Kingma I, Emanuel KS, Hoogendoorn RJ, Welting TJ, van Royen BJ, van Dieën JH, Smit TH. Mechanics and biology in intervertebral disc degeneration: a vicious circle. Osteoarthritis Cartilage. 2015 Jul;23(7):1057-70. [PubMed: 25827971]

32.

Sjölie AN, Ljunggren AE. The significance of high lumbar mobility and low lumbar strength for current and future low back pain in adolescents. Spine (Phila Pa 1976). 2001 Dec 01;26(23):2629-36. [PubMed: 11725246]

33.

Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ., Orthopaedic Section of the American Physical Therapy Association. Low back pain. J Orthop Sports Phys Ther. 2012 Apr;42(4):A1-57. [PMC free article: PMC4893951] [PubMed: 22466247]

34.

Farfan HF. Muscular mechanism of the lumbar spine and the position of power and efficiency. Orthop Clin North Am. 1975 Jan;6(1):135-44. [PubMed: 123048]

35.

Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992 Dec;5(4):383-9; discussion 397. [PubMed: 1490034]

36.

Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord. 1992 Dec;5(4):390-6; discussion 397. [PubMed: 1490035]

37.

van Dieën JH, Selen LP, Cholewicki J. Trunk muscle activation in low-back pain patients, an analysis of the literature. J Electromyogr Kinesiol. 2003 Aug;13(4):333-51. [PubMed: 12832164]

38.

Sayma M, Williams HR. A new method for teaching physical examination to junior medical students. Adv Med Educ Pract. 2016;7:91-7. [PMC free article: PMC4762462] [PubMed: 26937208]

39.

Nordin M, Randhawa K, Torres P, Yu H, Haldeman S, Brady O, Côté P, Torres C, Modic M, Mullerpatan R, Cedraschi C, Chou R, Acaroğlu E, Hurwitz EL, Lemeunier N, Dudler J, Taylor-Vaisey A, Sönmez E. The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities. Eur Spine J. 2018 Sep;27(Suppl 6):816-827. [PubMed: 29492717]

40.

Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011 Oct 29;378(9802):1560-71. [PMC free article: PMC3208163] [PubMed: 21963002]

41.

Linton SJ, Nicholas M, MacDonald S. Development of a short form of the Örebro Musculoskeletal Pain Screening Questionnaire. Spine (Phila Pa 1976). 2011 Oct 15;36(22):1891-5. [PubMed: 21192286]

42.

Davenport D, Colaco HB, Kavarthapu V. Examination of the adult spine. Br J Hosp Med (Lond). 2015 Dec;76(12):C182-5. [PubMed: 26646344]

43.

Alqarni AM, Schneiders AG, Hendrick PA. Clinical tests to diagnose lumbar segmental instability: a systematic review. J Orthop Sports Phys Ther. 2011 Mar;41(3):130-40. [PubMed: 21289452]

44.

Strand SL, Hjelm J, Shoepe TC, Fajardo MA. Norms for an isometric muscle endurance test. J Hum Kinet. 2014 Mar 27;40:93-102. [PMC free article: PMC4096102] [PubMed: 25031677]

45.

Schellenberg KL, Lang JM, Chan KM, Burnham RS. A clinical tool for office assessment of lumbar spine stabilization endurance: prone and supine bridge maneuvers. Am J Phys Med Rehabil. 2007 May;86(5):380-386. [PubMed: 17303961]

46.

Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK., Clinical Efficacy Assessment Subcommittee of the American College of Physicians. American College of Physicians. American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 02;147(7):478-91. [PubMed: 17909209]

47.

Magrey MN, Danve AS, Ermann J, Walsh JA. Recognizing Axial Spondyloarthritis: A Guide for Primary Care. Mayo Clin Proc. 2020 Nov;95(11):2499-2508. [PubMed: 32736944]

48.

Kisling LA, Das JM. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 1, 2023. Prevention Strategies. [PubMed: 30725907]

49.

Pandve HT. Quaternary prevention: need of the hour. J Family Med Prim Care. 2014 Oct-Dec;3(4):309-10. [PMC free article: PMC4311333] [PubMed: 25657934]

50.

Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, Benzel EC. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005 Nov;237(2):597-604. [PubMed: 16244269]

51.

Chou R, Loeser JD, Owens DK, Rosenquist RW, Atlas SJ, Baisden J, Carragee EJ, Grabois M, Murphy DR, Resnick DK, Stanos SP, Shaffer WO, Wall EM., American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009 May 01;34(10):1066-77. [PubMed: 19363457]

52.

Theis JL, Finkelstein MJ. Long-term effects of safe patient handling program on staff injuries. Rehabil Nurs. 2014 Jan-Feb;39(1):26-35. [PubMed: 23780793]

53.

Anyan W, Faraklas I, Morris S, Cochran A. Overhead lift systems reduce back injuries among burn care providers. J Burn Care Res. 2013 Nov-Dec;34(6):586-90. [PubMed: 24217002]

54.

Schoenfisch AL, Lipscomb HJ, Myers DJ, Fricklas E, James T. A lift assist team in an acute care hospital-prevention of injury or transfer of risk during patient-handling tasks? AAOHN J. 2011 Aug;59(8):329-34. [PubMed: 21800796]

55.

Kindblom-Rising K, Wahlström R, Nilsson-Wikmar L, Buer N. Nursing staff's movement awareness, attitudes and reported behaviour in patient transfer before and after an educational intervention. Appl Ergon. 2011 Mar;42(3):455-63. [PubMed: 20965495]

56.

Garg A, Kapellusch JM. Long-term efficacy of an ergonomics program that includes patient-handling devices on reducing musculoskeletal injuries to nursing personnel. Hum Factors. 2012 Aug;54(4):608-25. [PubMed: 22908684]

57.

Al-Tannir MA, Kobrosly SY, Elbakri NK, Abu-Shaheen AK. Prevalence and predictors of physical exercise among nurses. A cross-sectional study. Saudi Med J. 2017 Feb;38(2):209-212. [PMC free article: PMC5329636] [PubMed: 28133697]

58.

Nicholls R, Perry L, Duffield C, Gallagher R, Pierce H. Barriers and facilitators to healthy eating for nurses in the workplace: an integrative review. J Adv Nurs. 2017 May;73(5):1051-1065. [PubMed: 27732741]

59.

Blake H, Patterson J. Paediatric nurses' attitudes towards the promotion of healthy eating. 2015 Jan 22-Feb 11Br J Nurs. 24(2):108-12. [PubMed: 25615996]

60.

Kyle RG, Wills J, Mahoney C, Hoyle L, Kelly M, Atherton IM. Obesity prevalence among healthcare professionals in England: a cross-sectional study using the Health Survey for England. BMJ Open. 2017 Dec 04;7(12):e018498. [PMC free article: PMC5719305] [PubMed: 29203505]

61.

Ficarra MG, Gualano MR, Capizzi S, Siliquini R, Liguori G, Manzoli L, Briziarelli L, Parlato A, Cuccurullo P, Bucci R, Piat SC, Masanotti G, de Waure C, Ricciardi W, La Torre G. Tobacco use prevalence, knowledge and attitudes among Italian hospital healthcare professionals. Eur J Public Health. 2011 Feb;21(1):29-34. [PubMed: 20219867]

62.

La Torre G, Tiberio G, Sindoni A, Dorelli B, Cammalleri V. Smoking cessation interventions on health-care workers: a systematic review and meta-analysis. PeerJ. 2020;8:e9396. [PMC free article: PMC7304418] [PubMed: 32587807]

63.

Chen HM, Wang HH, Chen CH, Hu HM. Effectiveness of a stretching exercise program on low back pain and exercise self-efficacy among nurses in Taiwan: a randomized clinical trial. Pain Manag Nurs. 2014 Mar;15(1):283-91. [PubMed: 23266331]

64.

Menzel NN, Robinson ME. Back pain in direct patient care providers: early intervention with cognitive behavioral therapy. Pain Manag Nurs. 2006 Jun;7(2):53-63. [PubMed: 16730318]

65.

Edlow JA. Managing Nontraumatic Acute Back Pain. Ann Emerg Med. 2015 Aug;66(2):148-53. [PubMed: 25578887]

66.

Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WD, Carey TS. The rising prevalence of chronic low back pain. Arch Intern Med. 2009 Feb 09;169(3):251-8. [PMC free article: PMC4339077] [PubMed: 19204216]

67.

Casiano VE, Sarwan G, Dydyk AM, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Dec 11, 2023. Back Pain. [PubMed: 30844200]

68.

GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016 Oct 08;388(10053):1545-1602. [PMC free article: PMC5055577] [PubMed: 27733282]

69.

Jelsma J, Mielke J, Powell G, De Weerdt W, De Cock P. Disability in an urban black community in Zimbabwe. Disabil Rehabil. 2002 Nov 10;24(16):851-9. [PubMed: 12450461]

70.

Fabunmi AA, Aba SO, Odunaiya NA. Prevalence of low back pain among peasant farmers in a rural community in South West Nigeria. Afr J Med Med Sci. 2005 Sep;34(3):259-62. [PubMed: 16749358]

71.

Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingworth W, Sullivan SD. Expenditures and health status among adults with back and neck problems. JAMA. 2008 Feb 13;299(6):656-64. [PubMed: 18270354]

72.

Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M., Lancet Low Back Pain Series Working Group. What low back pain is and why we need to pay attention. Lancet. 2018 Jun 09;391(10137):2356-2367. [PubMed: 29573870]

73.

Hartvigsen J, Natvig B, Ferreira M. Is it all about a pain in the back? Best Pract Res Clin Rheumatol. 2013 Oct;27(5):613-23. [PubMed: 24315143]

74.

Yang H, Haldeman S, Lu ML, Baker D. Low Back Pain Prevalence and Related Workplace Psychosocial Risk Factors: A Study Using Data From the 2010 National Health Interview Survey. J Manipulative Physiol Ther. 2016 Sep;39(7):459-472. [PMC free article: PMC5530370] [PubMed: 27568831]

75.

Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010 Apr 07;303(13):1295-302. [PubMed: 20371789]

76.

Hestbaek L, Leboeuf-Yde C, Kyvik KO. Are lifestyle-factors in adolescence predictors for adult low back pain? A cross-sectional and prospective study of young twins. BMC Musculoskelet Disord. 2006 Mar 15;7:27. [PMC free article: PMC1464095] [PubMed: 16539729]

77.

Engers A, Jellema P, Wensing M, van der Windt DA, Grol R, van Tulder MW. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008 Jan 23;2008(1):CD004057. [PMC free article: PMC6999124] [PubMed: 18254037]

Disclosure: Rayhan Tariq declares no relevant financial relationships with ineligible companies.

Disclosure: Jemima George declares no relevant financial relationships with ineligible companies.

Disclosure: George Ampat declares no relevant financial relationships with ineligible companies.

Disclosure: Tammy Toney-Butler declares no relevant financial relationships with ineligible companies.