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RESEARCH PROJECT B (NBBS 2106)

LOWER BACK PAIN AMONG NURSES

IN HOSPITAL SULTANAH AMINAH

JOHOR BAHRU, JOHOR

By:

MAIZATUL AKMAR IBRAHIM

MATRIC NO: 720618145398001

Submitted in fulfillment of the requirements for the Degree of

BACHELOR NURSING SCIENCE WITH HONOUR

SUPERVISOR: MRS. MANIKA

SEMESTER MAY 2012

TABLE OF CONTENT

CONTENTS PAGE

ACKNOWLEDGEMENTSABSTRACT

CHAPTER 1 : Introduction1.0 Background of study 1.1 Problem statement1.2 Significant of study1.3 Objective of study1.4 Lower Back Pain

CHAPTER 2 : Literature Review

CHAPTER 3 : Research Methodology3.0 Study setting3.1 Research design3.2 Sample3.3 Research instrument3.4 Data collection and procedure 3.5 Ethical consideration3.6 Limitations of study3.7 Pilot test

CHAPTER 4 : Data Analysis And Interpretation Of Data4.0 Data analysis and interpretation of data4.1 Research findings

Maizatul Akmar Ibrahim/ NBBS 2106

CHAPTER 5 : Discussions And Implications 5.0 Discussions of research findings5.1 Implications of research findings5.2 Recommendations of research 5.3 Conclusions of research

CHAPTER 6 : References

CHAPTER 7 : Appendix

ACKNOWLEDGEMENTS

Firstly, thanks a lot to God because give me the opportunity to finish this research project. I

would like to express my appreciation and thanks to Madam Manika as a supervisor Research

Project B for her endless support, encouragement, guideline and teaching. I extend my thanks to

all my friends for their support, ideas and opinions. Special thanks to my beloved and

understanding husband that gave me a lot of moral support to finish this research project. I wish

to thank the ethical Committee Research Study (CRC) for giving me approval and permission

to conduct the study. With this completed of research project, I wish to share the knowledge with

all my friends.

Edited by:

Maizatul Akmar Ibrahim

Semester May 2012


LOWER BACK PAIN AMONG NURSES

IN HOSPITAL SULTANAH AMINAH, JOHOR BAHRU, JOHOR

ABSTRACT

Introduction: Nursing is an occupation associated with high risk of developing lower back pain

due to their nature of work practices. The aim of this study was to determine the incidences of

lower back pain among nurses working in Hospital Sultanah Aminah Johor Bahru, Johor.

Methods: A structured questionnaire was the tool of data collection. The study population and

sample included all nurses in orthopedic ward and orthopedic clinic. A total of 50 nurses

participated in the study. The first set requested socio-demographic data, followed by the Roland

Morris Low Back Pain Questionnaire which examined lower back pain prevalence. Descriptive

statistics were employed to summarize the demographic data of the study sample, which were

presented using frequency tables and expressed as percentages, means and standard deviations.

Results:

Conclusion:

Keywords: Lower back pain, nurses, work factors


CHAPTER 1

INTRODUCTION

1.1 Background of Study

Lower back pain is one of the most common causes of job-related disability and a leading

contributor to missed work. It is often caused by injuries to the back or as a result of a disorder such as

arthritis. Symptoms include shooting or stabbing pain, limited flexibility, and an inability to stand

straight. Back pain is the second most common neurological ailment in the United State, second only

to headache. Nearly everyone at some point will have lower back pain that interferes with work,

routine daily activities, or recreation. Americans spend at least 50 billion dollars each year on lower

back pain relief. For some fortunate people, pain in the lower back may be resolved by itself or with

the aid of medication within two to four weeks. However, there are some cases of lower back pain that

may last for more than a few weeks, during which case that condition is termed as ”chronic” and

“progressive”, meaning it can only grow worse over time. Moreover, 60% to 80% of those patients

who suffer their first episode of lower back pain may experience recurring pain within one year. Most

people will have lower back pain at some point in their lives. Men and women are equally affected,

and lower back pain occurs most often between age 30 and 50 years old, due in part to the aging

process, but also as a result of sedentary life styles with too little exercise or sometimes punctuated by

too much exercise. The risk of experiencing lower back pain from disc disease or spinal degeneration

increases with age. Different situations, such as age or pregnancy, determine what risk factors may be


present as well as the principle measures to take in order to prevent or avoid back pain. Construction

workers, warehouse personnel, delivery good drivers, nurses, shopkeepers and farm workers, most of

these occupations suffer the highest incidence of back injuries, because the work involves a lot of

bending and lifting. But nursing is the riskiest occupation for back injuries. In facts, nursing has the

second highest incidence of all types of non-fatal work-related injuries in the U.S.A. In all industries

combined, Bureau of Labor Statistics, 1998, injury data show that nearly 12 out of 100 nurses in

hospitals, and 17.3 out of 100 nurses working in nursing homes report work-related musculoskeletal

injuries, including back injuries, which is about double the rate for all industries combined.

1.2 Problem Statement

Polit & Beck (2004) indicated problem statement as an expression of dilemma or

disturbing situation that needs investigation for the purpose of providing and direction. Martin, 1994

(in Nieswiadomy, 2002) suggested that a good problem statement helps the researcher to move

through the steps of research process. Lower back pain (LBP) is a very frequently occurring

phenomenon. Among adults in the general population, 70-85% was believed to experience at least one

episode of low back pain at some time during their lives. The direct and indirect costs of LBP in terms

of quality of life, productivity, and employee absenteeism are enormous, making this common

condition the single largest contributor to musculoskeletal disability worldwide. LBP is associated

with multiple risk factors, including gender, age, lifestyle, and psychosocial profile, physical demands

of the workplace, social support, and pain perception. Hospital workers seem to have higher rate of

LBP compared to the general population due to physical and emotional factors involved in their

occupation, such as stress. These rates are not well established in Malaysia. Hence, the purpose of this

study was to estimate the prevalence of LBP among hospital workers in a hospital, query as to its

consequences and to identify the risk factors associated with the LBP in this population. There was a

high prevalence of LBP among hospital staff, resulting in significant medical and socio-professional

consequences. Many risk factors were identified that would necessitate multidisciplinary involvement

to reduce the LBP incidence and related costs.

1.3 Significant of Study

Preventing work related Lower Back Pain is humanitarian issue, and efforts to address the


controllable risk factors are essential and such injuries incur a great expense to taxpayers. Most

individuals that suffer Lower Back Pain carry on with their normal activities after a few days, but in

about 7% of cases, the pain persists and worsens, limiting daily activity and work. About 70% worker

compensation costs are generated by the cases in which the absence from lasts 6 months or longer. So,

the best thing for everyone is to prevent disabilities, and the best way to do this is to prevent causation

of the injuries. The purpose of this study is to recognize the risks factors of lower back pain in nurses,

establish what impact these implications have on nurses. Nurses and work factors was chosen as the

subject to review as this was quite a problematic issue that was found on a recent work placement. The

study was conducted to determine the prevalence and factors associated with back pain among nurses

working in hospital. The study can raise awareness of this problem by improving working conditions

and educating nurses about how to reduce the number of work-related Low Back Pain injuries that

they suffer, because right now the incidences of Lower Back Pain among nurses are way too high.

1.4 Objective of Study

General objective

The study done to determine incidence of Lower Back Pain among nurses working at Hospital

Sultanah Aminah, Johor Bahru, Johor.

Specific Objective

1. To identify the contributing factors of acute Lower Back Pain among nurses.

2. To identify level of knowledge among nurses about evaluation and management of

Lower Back Pain.

3. To identify the skills among nurses to prevent Lower Back Pain.

4. To identify the interventions with proven efficacy that prevent back pain and back

injury among nurses.

1.5 Research questions/ hypothesis.

Did the nurses have knowledge and awareness about lower back pain?

Was there are relationship between education level and years of experienced in nursing to


prevent back pain and back injury among nurses?

Was there are relationship between places of working and working shift that contributing lower

back pain among nurses?

What are the factors that contributing lower back pain among nurses?

1.6 About Lower Back Pain

1.6.1 Prevent and Treat Back Pain among Nurses

The back is a sturdy structure, made out of resistant bone and powerful muscle. Back pain

is most often the result not of an illness of the spine, but rather a dysfunction in the back muscles and

the influence of certain risk factors. The best way to prevent and to treat back pain is by exercising and

keeping physically fit, following the norms for posture hygiene, avoiding bed rest and having a

positive mental attitude towards pain. Following are some of the effective measures that nurses can

take to prevent back pain and reduce the risk of permanent disability:

Avoid fear of back pain and the evasive, pessimistic behavior that this produces. You should

know that work-related back pain is normally due to temporary malfunctioning of the back

muscles and not to a serious lesion or illness. Therefore, the prognosis is in principle good, and

unless you repose or take other erroneous action, it will tend to improve and disappear without

any ill consequences.

Know and observe the rules of postural hygiene. These teach you how to adopt everyday

postures and movements that involve the least burden for your spinal column and muscles.

Know and make proper use of the ergonomic facilities available at your work. These will help

you to do your job with minimum loading on your spinal column and muscles.

Create a good working atmosphere with your co-workers and management. It has been

demonstrated that this reduces the risk of back pain, and where back pain does occur, it


http://www.espalda.org/asp_kovacs/english/higiene.aso

reduces the risk of the pain persisting and leading to disability.

Keep as physically active as possible. Besides being effective in preventing back pain, regular

physical activity can help channel off stress and minimize its impact. It may take as little as

getting used to making day-to-day journeys on foot rather than sitting in the car, metro or bus,

or taking the stairs up a few flights rather than always taking the elevator. If possible, it is even

better to do some aerobic sports like running or swimming. With 20 or 30 minutes on alternate

days, you will begin to note a considerable difference. If you are going to start doing a sport

regularly, you should first consult a doctor to assess your general condition and you should

observe the rules of postural hygiene in sport, with which you can do almost any of them with

less risk to your back.

Maintain and develop the back muscles. Training of the muscles involved in back function

reduces the risk of spasm. If done correctly and regularly, some aerobic exercises like

swimming may be enough to keep your back muscles and your general physical condition in

good shape. Specific exercise programs for the back are only effective for these muscles and

not for general fitness, but they require less time and can be alternated with aerobic exercises

when you have time.

If pain does occur, the following have proven effective:

Avoid repose and sick leave, since both have been shown to increase the risk of the pain

lasting longer and reappearing more readily, and the probability of permanent disability of

some kind.

For the health of the nurse, it is better to reduce the physical effort that the job demands for a

few days but to carry on working than to take sick leave and repose.

Exceptionally, if the pain is so great that you cannot move or work for a few days, you should

make the repose and sick leave as brief as possible. Reposing for 4 days is enough to produce

negative effects on your back muscles, which will have to be rehabilitated afterward.

Stay as physically active as possible, including at work.

Apply the right treatment.


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1.6.2 Understanding the Back

The human spine consists of 33 vertebrae. The 7 cervical, 12 thoracic and 5 lumbar vertebrae

are separated by intervertebral discs corresponding 23. The sacral 5 are fused, like the 4 coccygeal,

forming sacrum and coccyx bones. The back is an intricate structure of bones, muscles, and other

tissues that form the posterior part of the body’s trunk from the neck to the pelvis. The centerpiece is

the spinal column, which not only support the upper body’s weight, but also houses and protects the

spinal cord, the delicate nervous system structure that carries signals that control the body’s

movements and convey its sensations. Stacked on top of one another are more than 30 bones, the

vertebrae that form the spinal column, also known as the spine. Each of these bones contains a round

hole that, when stacked in register with all the others, creates a channel that surrounds the spinal cord.

The spinal cord descends from the base of the brain and extends in the adult to just below the rib cage.

Small nerves (roots) enter and emerge from the spinal cord through spaces between the vertebrae.

Because the bones of the spinal column continue growing long after the spinal cord reaches its full

length in early childhood, the nerve roots to the lower back and legs extend many inches down the

spinal column before exiting. This large bundle of nerve roots was dubbed by early anatomists as the

cauda equina, or horse’s tail. The spaces between the vertebrae are maintained by round, spongy pads

of cartilage called intervertebral discs that allow for flexibility in the lower back and act much like

shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue

known as ligaments and tendons hold the vertebrae in place and attach the muscles to the spinal

column.

Starting at the top, the spine has four regions, which include:

The 7 cervical or neck vertebrae (labeled C1 through C7)

The 12 thoracic or upper back vertebrae (labeled T1 through T12 )

The 5 lumbar vertebrae (labeled L1 through L5), which known as the lower back. The lumbar

region of the back, where most back pain is felt, supports the weight of the upper body.

The sacrum and coccyx, a group of bones fused together at the base of the spine.

If you look from the front, the vertebrae are aligned and form a perfectly vertical. However, in profile,


forming curves. The upper-cervical area-and lower-back-in are concave back and are called cervical

and lumbar lordosis, respectively. The middle curve is concave toward forward and is called dorsal

kyphosis. This arrangement allows the column to be very resistant to the load applied in vertical

direction, because their curvatures give flexibility. If the load is very important, the curvatures can

transiently increase, dampening the pressure on the vertebrae. So in some countries was traditional

carry the load on the head. Furthermore, in so doing maintaining the center of gravity on the axis of

the column, so that the musculatures of the back just have to work. Basically, the back serves to:

Support the body. Therefore, the back must be solid in order to support the body. It is

composed of very sturdy bones and powerful muscles.

Allow movement. Therefore, the spine must be flexible to allow for movement. This is why it

is not composed of one solid bone, but 33 separate vertebrae, which are set one on top of the

other and connected by a system of muscles and ligaments.

Contribute to maintaining a stable center of gravity at rest and, especially, when in motion. In

order to maintain a stable center of gravity, back muscles should be strong so they may act as a

counterweight and able to contract in order to compensate for body movements.

Protect the spinal cord with a bony encasement. To protect the spinal cord, vertebrae have a

special shape, with a foramen or canal to house the cord.

1.6.3 Back Pain

Back pain occurs due to a neurological mechanism, usually of an unknown origin, which

causes pain, inflammation and muscle contraction. The primary methods for diagnosis are clinical

examination and history, and only rarely are such tests as radiography or blood analysis, magnetic

resonance or neurophysiological tests of any use. There are scientifically evaluated scales to assess

objectively the intensity of the pain and the degree of disability that the back pain may produce. To

prevent back pain or to treat it, the highest level of activity possible should be maintained. Bed rest

should be avoided. Most cases are treated favorably with medication, neuroreflexotherapy or other

non-surgical treatments. Surgery is indicated only in a very small number of cases and only when

there are clear signs that guarantee its success. In the past, it was believed that pain occurred because

there was an abnormality in the structure of the spine, such as scoliosis or a herniated disc. The advent


of pain is due to a neurological process that involves the activation of pain-transmitting nerves and

episodes of muscular contracture and inflammation. It can also sometimes signify nerve root

compression. This process can be triggered by an alteration in the structure of the spine, such as a

herniated disc or significant degeneration of the facet joint. In most cases, however, it is not possible

to determine the initial cause, and it is attributed to pain from the contracture or overburdening of the

muscles. Back pain occurs and is perpetuated through a neurological process:

a. Specific nerve fibers know as Ad and C, or "capsaicin sensitive" or "pain nerves" are activated.

b. The activation of these nerves causes pain, inflammation, and muscle contracture.

c. A vicious circle is initiated because inflammation and muscle contracture maintain the

activation of the pain nerves.

d. Research studies reveal that if activation of Ad-C fibers persists over a period of time, other

biochemical processes are initiated that could perpetuate their activation indefinitely. In this

occurs pain will persist although its initial cause has disappeared.

This neurological process that causes pain, inflammation and muscle contracture:

May be initiated by any structural injury. For example, a herniated disc will activate the pain

nerves in the external layers of the disc by being in contact with inner substances. In this

case, magnetic resonance imaging (MRI) would show the ruptured fibrous ring and would

permute the identification of the cause of pain.

May develop without a structural injury. For instance, a sustained faulty posture may

overburden a muscle group and provoke contracture, thereby activating pain nerves.

If a patient's musculature is weak or asymmetric, there may be on overload of effort

maintained for a long period of time or repeated periodically. In cases like this, no radiological

tests would show an injury causing pain.

The following are accepted causes for back pain:

Disc fissures, protrusions or herniations, which allow contact of the nucleus pulposus with pain

nerves located in the fibrous ring.


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Relevant deterioration of the facet joint.

Muscle contracture, caused by faulty posture, effort, or spinal curve alterations. This latter

assumption includes scoliosis of over 60º.

Nerve root compression caused by a herniated disc, spinal stenosis or grade III spondylolisthesis or

grade IV spondylolisthesis.

1.6.4 Types of Lower Back Pain

Acute or short term, low back pain generally lasts from a few days to a few weeks. Most acute back

pain is mechanical in nature, which means that it is the result of trauma to the lower back or a disorder

such as arthritis. Pain from trauma may cause by:

A sports injury

Work around the house or in the garden

A sudden jolt, such as a car accident or other stress on spinal bones and tissues.

Symptoms of lower back pain can range from:

Muscle ache to shooting or stabbing pain

Limited flexibility and range of motion

An inability to stand up straight

Occasionally, pain felt in one part of the body may “radiate” from a disorder or injury elsewhere in the

body. Some acute pain syndromes can become more serious if left untreated. Chronic back pain is

measured by duration. Pain that persists for more than 3 months is considered chronic. Chronic lower

back pain is often progressive, and the cause can be difficult to determine.


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1.6.5 Causes of Lower Back Pain

Lower back pain is often the result of an injury or trauma to the back. However, in some cases, the

pain may be the result of a degenerative condition, osteoporosis, or congenital abnormalities of the

spine. In other cases, irritation to joints and discs causes the condition. Other causes of lower back

pain include obesity, smoking, and weight gain during pregnancy.

Common Causes of Lower Back Pain:

Injury or Trauma

As people age, bone strength, muscle elasticity, and tone tend to decrease. The discs in the

back begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae.

Lower back pain can occur when someone lifts something too heavy or overstretches, causing

a sprain, strain, or spasm in one of the muscles or ligaments in the back. If the spine become

overly strained or compressed, a disc may rupture or bulge outward. This rupture may put

pressure on one of the more than 50 nerves rooted to the spinal cord that control body

movements and transmit signal from the body to the brain. When these nerve roots become

compressed or irritated, this results in lower back pain.

Degenerative Conditions

In most cases, lower back pain follows injury or trauma to the back, but other lower back pain

causes include:

a) Degenerative conditions, such as arthritis or disc disease

b) Osteoporosis or other bone diseases

c) Viral Infections

d) Irritation to joints and discs

e) Congenital abnormalities in the spine

Lifestyle

Lower back causes related choices include:

a) Obesity

b) Smoking

c) Weight gain during pregnancy

d) Stress


e) Poor physical condition

f) Posture inappropriate for the activity being performed

g) Poor sleeping position

In addition, scar tissue created when the injured back heals itself does not have the strength or

flexibility of normal tissue. Buildup of scar tissue from repeated injuries eventually weakens

the back and can lead to a more serious injury.

Medical Conditions

Conditions that may cause lower back pain and require treatment by a physician or other health

specialist can include:

a) Bulging disc

b) Cauda equine syndrome

c) Sciatica

d) Spinal degeneration

e) Spinal Stenosis

f) Osteoporosis

g) Skeletal Irregularities

h) Fibromyalgia

i) Spondylitis.

1.6.6 Lower Back Pain Relief

Specific suggestions for the relief of lower back pain include alternating ice and heat, minimal bed

rest, and exercise. Other therapies for relieving back pain may need to be tried, such as interventional

therapy, spinal manipulation, or acupuncture. In most cases, lower back pain can be treated without

surgery. Relief for lower back pain typically involves:

Using pain medicine

Reducing inflammation

Restoring proper function and strength to the back

Preventing recurrence of the injury.

Most people with back pain recover without residual functional loss. However, a healthcare provider


should be consulted if there is no noticeable relief after 72 hours of self-care.

Specific suggestions for lower back pain relief include:

Ice and heat

Minimal bed rest

Exercise

Medications

Complementary and alternative methods

Surgery.

1.6.7 Relieving Low Back Pain through ice and heat

Although ice and heat which the use of cold and hot compresses have never been scientifically proven

to quickly resolve lower back pain, compresses may help reduce pain and inflammation and allow

greater mobility for some individuals. As soon as possible following trauma, patient should apply a

cold pack or a cold compress, such as a bag of ice or bag of frozen vegetables wrapped in a towel to

the tender spot several times a day for up to 20 minutes. After 2 to 3 days of cold treatment, patient

should then apply heat such as heating lamp or hot pad for brief periods relax muscles and increase

blood flow. Warm baths may also help relax muscles. Avoid sleeping on a heating pad, which can

cause burns and lead to additional tissue damage.

1.6.8 Relief of Lower Back Pain through bed rest

Patient who has lower back pain should limit their bed rest to 1 to 2 days. A Finnish (1996) study

found that people who continued their activities without bed rest following the start of lower back pain

appeared to have better back flexibility than those who rested in bed for a week. Other studies

suggested that bed rest alone may make back pain worse and can lead to secondary complications,

such as:

Depression

Decreased muscle tone


Blood clot in the legs.

People should resume activities as soon as possible. Some healthcare providers recommend that at

night or during rest, people should lie on one side with a pillow between their knees or lie on their

back and put pillow beneath their knees.

1.6.9 Lower Back Pain relief through exercise

Exercise may be the most effective way to provide relief from lower back pain, speed recovery, and

help strengthen back and abdominal muscles. Maintaining and building muscle strength is particularly

important for people with skeletal irregularities. Doctors and physical therapists can provide a list of

gentle exercises that help keep muscle moving and speed the recovery process. A routine of back-

healthy activities may include:

Stretching exercises

Swimming

Walking

Yoga, which gently stretches muscles and eases pain

Movement therapy to improve coordination and develop proper posture and muscle balance.

Any mild discomfort felt at the start of these exercises should disappear as muscles become stronger.

However, if pain is more than mild and lasts more than 15 minutes during exercise, you should stop

exercising and contact your doctor.

1.6.10 Medication used to relieve Lower Back Pain

Medications are often used for lower back pain relief. Effective relief may involve a combination of

prescription drugs and over-the-counter remedies. People should always check with their healthcare

provider before taking drugs to relieve low back pain. Certain medicines, even those sold over-the-


counter are:

Be unsafe during pregnancy

Conflict with other medications

Cause side effects, including drowsiness

Lead to liver damage.

Medications that are commonly used for Lower Back Pain include:

Pain medicines

Counterirritants

Anticonvulsants

Antidepressants

Opioids.

1.6.11 Complementary and Alternative Therapies for Lower Back Pain relief

When back pain does not respond to more conventional approaches, people may consider the

following complementary and alternative therapies for relieving lower back pain:

Spinal manipulation

Acupuncture

Biofeedback

Interventional therapy

Traction

Transcutaneous electrical nerve stimulation

Ultrasound


1.6.12 Relieving Lower Back Pain through surgery

In the most serious cases, when other therapies prove unsuccessful, surgery may provide lower back

pain relief caused by back problems or serious musculoskeletal injuries. While some surgical

procedures may be performed under local anesthesia, others require hospitalization. It may be months

following surgery before the person is fully healed, and people may suffer permanent loss of

flexibility. Since invasive back surgery is not always successful, it is generally only performed in

people with progressive neurologic disease or damage to the peripheral nerves.

1.6.13 Lower Back Surgery

Surgery may provide relief from pain that caused by back problems or by serious musculoskeletal

injuries that do not respond to other types of treatment. Types of surgery on the lower back include;

Discectomy, Foraminotomy, Intradiscal electrothermal therapy, Spinal fusion, Laminectomy. Since

surgery is not always successful, it is often only done in people with progressive neurologic disease or

damage to the peripheral nerves.

In most cases, lower back pain can treated without surgery by:

Using analgesics

Reducing inflammation

Restoring proper function and strength to the back

Preventing recurrence of the injury

1.6.14 Tips to a Healthier Back

Following any period of prolonged inactivity, begin a program of regular low-impact exercises. Speed

walking, swimming, or stationary bike riding 30 minutes a day can increase muscle strength and

flexibility. Yoga can also help stretch and strengthen muscles and improve posture. Ask your

physician or orthopedist for a list of low-impact exercises appropriate for your age and designed to

strengthen lower back and abdominal muscles.


Always stretch before exercise or other strenuous physical activity.

Don’t slouch when standing or sitting. When standing, keep your weight balance on your feet.

Your back supports weight most easily when curvature is reduced.

At home or work, make sure your work surface is at a comfortable height for you.

Sit in a chair with good lumbar support and proper position and height for the task. Keep your

shoulders back. Switch sitting positions often and periodically walk around the office or gently

stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of your

back can provide some lumbar support. If you must sit for a long period of time, rest your feet

on a low stool or a stack of books.

Wear comfortable, low-heeled shoes.

Sleep on your side to reduce any curve in your spine. Always sleep on a firm surface.

Ask for help when transferring an ill or injured family member from a reclining to a sitting

position or when moving the patient from a chair to a bed.

Don’t try to lift objects too heavy for you. Lift with your knees, pull in your stomach muscles,

and keep your head down and in line with your straight back. Keep the object close to your

body. Do not twist when lifting.

Maintain proper nutrition and diet to reduce and prevent excessive weight, especially weight

around the waistline that taxes lower back muscles. A diet with sufficient daily intake of

calcium, phosphorus, and vitamin D helps to promote new bow growth.

If you smoke, quit. Smoking reduces blood flow to the lower spine and causes the spinal discs

to degenerate.


CHAPTER 2

LITERATURE REVIEW

Review of literature is a key step in the research process. Review of literature refers to an

extensive, exhaustive and systematic examination of publications relevant to the research project.

Review of literature for the study of “Lower Back Pain Among Nurses” has been organized under

the following headings:

2.1 Low Back Pain

Bend. Lift. Push. Pull. Stoop. Stand. Walk. 8, 10, 12 hours in a row, day in and day out.

No wonder nurses have the highest rate of workers’ compensation claims for back injuries. A

literature review of 80 studies conducted over three decades indicates an annual prevalence of 40% to

50% for Low Back Pain (LBP) and a lifetime prevalence of 35% to 80% among nurses. Among the

general population, LBP is the second most common reason for a visit to a primary care provider and

the third most frequent reason for surgery. LBP affects 5.6% of adults each day in the United States,

while 18% reported having had back pain within the past month. About 8 in 10 people in developed

countries will experience back pain at some point in their lives. LBP occurs most commonly between

the ages of 35 and 55 years old, and is the leading cause of disability in those under age 45 years old.

According to the American Nurses Association, patient-handling tasks, such as frequent manual lifting

and transferring of patients, are the primary causes of the escalating rate of LBP in nurses. For


example, 98% of the time, nurses lift patients by grasping them under the axillae and then “tossing”

the patient to another location. This technique is banned in many institutions because it is has been

found to be harmful to nurses and is painful for patients. According to the Department of Labor,

Bureau of Labor Statistics, in 2007, nursing aides, orderlies and attendants had the highest incidence

of musculoskeletal disorders (MSD), such as back and shoulder injuries, among United States

workers. These healthcare professionals were found to have an incidence rate of 249 cases per 10,000

workers. That rate is seven times the national musculoskeletal disorders average for all occupations in

the United States. The 2007 study also found that emergency medical personnel ranked second in

MSD rates. Environmental factors that increase a nurse’s risk of back injury by interfering with proper

body mechanics include space limitations, medical equipment around the patient, transfer surfaces that

are not flush and nonadjustable beds, chairs and commodes. Examine the statistical impact of back

injuries among nurses; 52% of nurses complain of chronic back pain, 38% of nurses experienced a

back injury severe enough to require that they take time off from work, 12% of nurses that leave the

profession report back pain as a major contributing factor. The estimated total direct and indirect costs

for the treatment of LBP are in the billions of dollars annually.

2.2 Resolving Back Pain in Nurses

The high incidences of back pain among nurses are well documented. Dozens of books,

studies and articles exist on the subject. According to the U.S. Department of Labor Bureau of Labor

Statistics, nurses and other medical attendants accounted for roughly 20% of all days away from work

in 2006, mainly as a result of sprains and strains to the torso muscles. Nurses offer care and comfort,

but they often end up with a pain in the back for their efforts. Most often, nurses hurt their backs while

turning bed-ridden patients or transferring them among stretchers, beds and chairs. Orthopedic and

Intensive Care Unit (ICU) nurses have the highest rates of low back pain among all nurses. According

to the study, 65% of orthopedic nurses and 58% of ICU nurses develop debilitating low back pain at

some point in their careers. If patients are unconscious, nurses will try to turn him every 2 hours to

prevent him from getting bed sores and the amount of lifting in one shift adds up a lot. Also ward

rooms or cubicle are often small, and nurses have to move bed or furniture around so they can do their

job. Most individuals that suffer low back pain carry on with their normal activities after a few days,

but in about 7% of cases, the pain persists and worsens, limiting daily activity and work. About 70%


of worker compensation costs are generated by cases in which the absence from work lasts 6 months

or longer. So, the best thing for everyone is to prevent disabilities, and the best way to do this is to

prevent causation of the injuries. Recurring back pain resulting from improper body mechanics or

other non-traumatic causes is often preventable. A combination of exercises that don’t jolt or strain the

back, maintaining correct posture, and lifting objects properly can help prevent injuries.

Many work-related injuries are caused or aggravated by stressors such as heavy lifting, contact stress

(repeated or constant contact between soft body tissue and a hard or sharp object, such as resting a

wrist against the edge of a hard desk or repeated tasks using a hammering motion), vibration,

repetitive motion, and awkward posture. Applying ergonomic principles – designing furniture and

tools to protect the body from injury – at home and in the workplace can greatly reduce the risk of

back injury and help maintain a healthy back. More companies and homebuilders are promoting

ergonomically designed tools, products, workstations, and living space to reduce the risk of

musculoskeletal injury and pain. The use of wide elastic belt that can tighten to “pull in” lumbar and

abdominal muscles to prevent low back pain remains controversial. A landmark study of the use of

lumbar support or abdominal support belts worn by persons who lift or move merchandise found no

evidence that the belts reduce back injury or back pain. The 2 year study, reported by the National

Institute for Occupational Safety and Health (NIOSH) in December 2000, found no statistically

significant difference in either the incidence of worker’ compensation claim for job-related back

injuries or the incidence of self-reported pain among workers who reported they wore back belts daily

compared to those workers who reported never using back belts or reported using them only once or

twice a month.

2.3 The Incidence of Low Back Pain among Theatre Nurses

International Association for the Study of Pain defined pain as an unpleasant sensory and

emotional experience associated with actual or potential tissue damage, or described in terms of such

damage. It is a major symptom in many medical conditions, and can significantly interfere with a

person’s quality of life and general functioning. In the past decades, there has been increasing interest

in occupational health issue relating to musculoskeletal system. One of these is a low back pain (LBP),

a phenomenon with particularly high prevalence all over the world. Low back pain not only

considered to be the most common reason for functional disability, worldwide, but also estimated to


affect almost 90% of the universal population. Moreover, low back pain is said to be among the

leading musculoskeletal disorders that predominantly affect the working population in developed as

well as in developing countries. Nurses, as professionals, have serious incidents of occupational Low

Back Pain and traumas in the lumbar area, as their profession is unique with heavy emotional and

physical work, and are exposed to a combination of mechanical and psychosocial stress at work.

Working positions often are uncomfortable either due to lack of space or movement restriction caused

by special circumstances, such as in dialysis unit, operating theatre, and intensive care unit. It has been

found that nurses have to walk and stand up during their shift more than warehouse workers a lot of

times more than 6 hours a day. Engels J.A et al (1996) found that physical variables which seem to

elicit symptoms of low back pain in subjects the most, were lifting (65%), and working in awkward

postures (47%), stooping (34%) and poor ergonomic layout of the ward (53%). The prevalence of low

back pain was 87% in ICU nurses and 64% in nurses working in the wards. The compressive force

on the disc between the L5 and S1 vertebrae was seen to be the highest during observation of drainage,

lifting and transferring of patients in bed, injection and suctioning. Several high risk activities have

been identified for nurses in the hospital especially in relation to low back pain. The most important

factor related to workload is rapid movement combined with poor body posture especially when

nurses perform duties under time pressure. Time pressure activities include emergency nursing care,

operating rooms, unplanned or unexpected work within hospital units. It is generally accepted that

nursing staff belong to the group of high-risk professions with regard to the occurrence of

musculoskeletal injuries, and data on the prevalence of LBP among operating room nurses is not much

and considering in their significance in nursing system, more information and knowledge needs to be

disseminated therefore the statement of the problem is to investigate into the causes, effects and

incidence of Lower Back Pain (LBP) among theater nurses.

2.4 Nurses and Preventable Back Injuries

Every single day in the United States, 9000 healthcare workers sustain a disabling injury

while performing work-related tasks. Disabling back injury and back pain affect 38% of nursing staff.

In evaluating studies related to back injury, Owen (2000) reported that “twelve percent of all nurses

intending to leave nursing permanently cited back pain as either a main or contributing factors.” In the

1998, Bureau of Labor Statistics ranking of the professions at the highest risk for the back pain injury,


healthcare workers accounted for 6 of the top 10 positions. An obvious conclusion would be that these

injuries are contributing, at least in part, to the current nursing shortage. The consensus is that nurses

are being injured primarily while transferring patients or when lifting patients, either by cumulative

injury, by lifting over and over day after day (year after year), or by a direct injury such as lifting or

transferring a 135kg (300lb) patient alone. The National Institute of Occupational Safety and Health

recommended a weight limit of 20.7kg (46lb) for women. This weight limitation was based on a box

that was 35.6cm (14in) wide, with handles. The box was lifted for a total of 25.4cm (10in), beginning

with it at knuckle height while the person lifting it was standing. This compact box with handles that

weighs only 20.7kg in no way resembles a patient, yet this limitation is the one recommended.

University of Ohio investigators measured spinal load pressure biomechanically during various routine

tasks related to handling patients which moving patients from wheelchair to bed or from bed to

wheelchair and from commode to hospital chair or from hospital chair to commode. Various transfer

techniques were evaluated on a 49.5kg (110lb) subject which 1-person hug, 2-person hook and toss, 2-

person gait belt and various in-bed repositioning techniques which manual 2-person draw sheet

method, manual 2-person hook, and manual 2-person thigh-and-shoulder method. All of this

movement is familiar to nurses. In the Ohio State University investigation, all the methods of

transferring a repositioning that were studied placed the nurse in the high-risk group for back injury. In

fact, “even the safest of tasks (of the tasks evaluated in this study) had significant risk.” Take note that

the “test subject” weighed only 49.5 kg and was alert, oriented, and cooperative - not an average

patient. This study indicates that use of the proper body mechanics that we were all taught does very

little to prevent cumulative or direct back injuries. Can these injuries be prevented? The answer is a

resounding yes. Several investigators have evaluated the usefulness of lift items in an acute care

setting.

Charney (2000) found that having lift teams who were responsible for all total body transfers

and used proper mechanical lift equipment led to reduced rates of injury. Fewer lost days, and fewer

modifications of duty associated with lifting patients. At the end of a 1 year pilot studies of a lift team.

Meittunen et.al (1999) reported that nurses surveyed indicated high satisfaction with the transfer team

and that the total number of restricted (light-duty) days was reduced by 361%. What is needed is an

approach to handling patient that involves (1) reduction of the nursing staff, (2) a well-trained lift

team, (3) modern mechanical lifting, and (4) policies and procedures that clearly mandate a new

method of handling patients. To be successful, a lift team must be well trained not only how to use


modern mechanical lift equipment but also in the various needs of patients, for example, patient in

traction with hip precaution or patients having heart monitoring. The sole job of the lift team is to lift

and transfer. The members of the team must be readily available and must work closely with nursing

staff. Nurses are sustaining preventable back and neck injuries. It is time to end the behavior that

results in these injuries. The agencies employed to protect workers must begin to do just that.

Responsible agencies include the individual hospitals, the Occupational Safety and Health

Administration, the Nurses Association, and the nursing unions. Freeing nursing staff from lifting and

transferring will not only prevent needless disabling injuries and keep more nurses on the job; it will

also allow nurses to spend more time nursing, which is why most of us entered the nursing profession.

2.5 Prevalence of Back Pain among Nurses Working in Government Health Clinic and Hospital

in Port Dickson, Malaysia.

Workplace, including physical and psychosocial factors and their interaction, are strong

determinants of back pain. Psychosocial risk factors at work such as perceived high pressure on time

and workload, low job control, job dissatisfaction, monotonous work, and low support from co-

workers and management appear to independently increase the risk of hospitalization for back

disorders. Other factors such as heavy physical work, night shifts, lifting, bending, twisting, pulling,

and pushing have often been associated with Low Back Pain (LBP). Back symptoms are the most

common cause of disability for person under age 45 year old. Many back injuries are occupational in

nature. Occupational back injury is clearly related to lifting and repeated activities. Persons in

occupations that require lifting such as nursing are especially at risk. Patient transfer involves

adjusting the patient in bed, transferring a patient from bed or chair to toilet. These maneuvers have

consistently been related to low back injuries in nurses, and are perceived to be the most stressful tasks

performed by these occupations. Not surprisingly, efforts have been made to prevent low back injuries

following lifting techniques, ergonomic interventions and mechanical equipment and individually

designed physical training programs and stress management. Low back pain is a major public health

problem throughout the world, and the prevalence of low back pain appears to be even higher for

nurses than for woman of similar age in the general population. Back pain is defined as any discomfort

or pain at the back in the past 12 months. Several authors report annual prevalence of low back pain in

nurses varying between 45% to 58%. Despite this high prevalence of low back pain among nurses, the


etiology and the nature of back pain are not yet well understood. Many studies have been performed

in various occupational settings, indicating a strong association between musculoskeletal disorders and

work related factors. This was also found among nurses. The contribution of psychosocial factors and

work pressure was also evident, but not as clear as has been shown for the physical factors.

Risk indicator for back pain includes sex, age, weight, height, right or left handed, number of children,

smoking habits, regular physical exercise, driving time, job, duration of work time, work time a week,

manual lifting of weight heavier than 10kg, and uncomfortable working positions. In summary, risk

factors of back pain can be divided into 3 groups which are socio demographic factors (Age, gender,

education level, smoking, body mass index, number of children), physical and work factors (static and

awkward body position, heavy physical, night shift, lifting, bending, twisting, pulling and pushing)

and psychosocial factors (Perceived high pressure on time and workload, low job control, job

dissatisfaction, monotonous work and low support from co-workers and management. This study was

conducted to determine the prevalence and factors associated with back pain among nurses.

2.6 Interventions to Prevent Back Pain and Back in Nurses.

Nurses play an important role within the health care system, providing and assisting in the

provision of primary, secondary and tertiary level health care. Typically, their work is physically

demanding. Nurses frequently assist patients to mobilize, transfer between positions and perform other

activities of daily living such as toileting and showering. Nurses have an increased risk of back

trouble. Compared with other professions, they have an increased risk of back pain and a six times

higher prevalence of back injury. Nurses and related medical worker lead all other occupations for risk

of herniated lumbar intervertebral discs requiring hospitalization in women. Furthermore, hospitals

and nursing and residential care facilities lead all industries for workplace injury and illness.

Numerous factors have been found to increase nurses’ risk of back pain. Physical load and work

posture play a role, as do psychosocial factors such as personality and the presence of psychosomatic

symptoms. Work task and work organizational factors have been shown to be significant risk in

individual studies, although when all trials are considered the evidence is inconsistent. Nursing

qualifications are important, with nursing assistants at greater risk for back pain than registered nurses.

Years in the nursing profession may also be relevant, with a growing body of evidence suggesting that


younger nurses are at greatest risk. Identification of physical predictors of back pain is more clusive.

Prospective studies find predominantly non-significant relationships or inconsistent results. However,

reduced lateral bending of the spine has been identified as a risk factors in two studies. Back Pain and

injury have a major impact on the efficiency of the nursing workforce. Registered nurses rank seventh

and nursing aides and orderlies are highest ranked across all occupations for back injuries involving

days away from work in private industry. Back injuries and resultant workers’ compensation claims in

nurses are expensive. In long-term care facilities in the United States, nurses’ back injuries are

estimated to cost over US$6 million in indemnity and medical payments. Nurses’ compensation for

back injury comprises 56.4% of all indemnity costs and 55.1% of all medical costs. In one Australian

state, nurses back injury claims accounted for $A2.39 million expenditure in one financial year. The

primary objective of this study was to systematically review the literature to determine whether there

are interventions with proven efficacy that prevent back pain and back injury in nurses. A review

focusing specifically on nurses was considered necessary due to the unique nature of nursing work.

2.7 The Problem of Lower Back Pain in Nursing Staff and Its Effect on Human Activity

Today, musculoskeletal disorders are one the most frequent health related directly to

working conditions. Intensification of work, changes in scheduling and organization of the workplace,

rising demands on employees as well as new technologies lead to situations characterized by

additional pressure and stress. As a result, more and more occupational or work-related diseases have

appeared, as are musculoskeletal problems, stress, occupational burnout, chronic exhaustion and

depression. According to studies carried out by the European Foundation for the Improvement of

Living and Working Conditions, poor working conditions, rising demand and strict timetables and

deadlines lead to significant changes in the daily lives of members of the workforce, e.g.; sleeping

disorders, increased exhaustion, backaches, muscle pain, fractures and cramps. The European

Foundation for the Improvement of Living and Working Conditions (in its European Occupational

Diseases Statistics-EOSD) states that the most significant health problems faced today by the

workforce are musculoskeletal disorders, with a percentage of 35%, stress with a percentage of 28%

and general exhaustion with a percentage of 23%. Lately, the scientific community has been using the

concept of occupational exhaustion syndrome or burnout more and more frequently in order to denote

fatigue and depression among members of the workforce. Particularly vulnerable professional groups


are deemed to be physicians, especially oncologists, heart surgeons, neurosurgeons and general

surgeons, as well as other health professional such as nursing staff, social worker, psychologist, etc.

Injuries to the lumbar spine are painful, chronic an in most cases non-reversible conditions, and the

individuals suffering from them are unable to attend to their social, occupational and other activities.

Pain in the lumbar spine and systematic drug intake become a part of the daily routine of these

persons, and usually they will accompany them from the third decade of their lives onward. According

to the results of studies carried out in the United States, lower back pain is the most frequent reason

for temporary disability among the population at large in the age group under 45 years old, and in

persons aged 45 to 56 years old, it is the third most frequent reason leading to the restriction of

physical activity of individuals having suffered heart trouble and rheumatic diseases. It is generally

accepted that nursing staff belong to the group of high-risk professions with regard to the occurrence

of musculoskeletal injuries, especially in the area of the lumbar spine.

In 1976 in Sweden, Dehlin et.al in a study carried out at a geriatric hospital; found that the

prevalence of lower back pain in assistant nursing staff came close to 47%. In 1983, Stubbs et.al in the

U.K were able to prove that over the course of a year, lower back pain afflicted 43.1% of all nursing

staff. In 1986, Arad et.al, in a study carried out at the Royal North Hospital of Australia amongst 1033

nurses, found an 87% incidence an a 42 % prevalence for lower back pain. The prevalence of

musculoskeletal condition among nursing staff, according to Smith et.al, reached 70% in 2004, while

the percentage for lumbar spine pain was 56.7%. In Greece, in a study carried out by

A.Vassiliadouet.al in 1995 with 407 female nurses at a major Athens hospital, the researchers showed

that prevalence was 63% and 67% for time periods of two weeks and six months respectively. Quite a

few studies seem to point to the relation between lower back pain and changes in human behavior.

Psychological disposition, interpersonal relations, as well as simple daily activities and habits such as

walking, sleeping, and sexual relation would seem to change significantly when this problem occurs.

Many researchers, among them, Yip et.al in 2001, and Smedley J et.al in 2003 and 2004 found that

stress in the workplace is one of the most significant factors leading to the occurrence of lower back

pain.

2.8 Top 5 Back Pain Treatment


According to current research, there are certain muscles in the back that work to

stabilize the spine. When the spine or the back suffers an injury, these muscles are reflexively

inhibited or shutdown. Worse still, these muscles do not spontaneously recover, and this is true even if

patients do not feel pain and are able to return to normal activity level. Because the neurological

system is complex, it is difficult to pinpoint the exact cause of back pain. The causes of back pain are

divided into categories such as mechanical, injuries, acquired disorders or diseases, infections or

tumors. Mechanical causes; these are problem with how the spine works. For example,

Spondylolistesis (deterioration of the disc one vertebrae to slip forward over another, causing the

vertebrae to rub together, therefore causing pain). Other mechanical problems are fracture, herniated

discs, spinal stenosis, spinal degeneration an sciatica. Injuries; this category includes common forms

of back pain due to injury to the spine or the ligaments an muscles involves with spine. Sprains, for

example, result if a ligament that supports the spine is pulled or torn due to improper lifting or body

mechanics, even twisting the wrong way. Fractures can occur from osteoarthritis which causes the

bones to become brittle and weak. Severe injuries can result from an accident or fall. Acquired

disorders; these are medical problems that you might have been born with such as scoliosis (an

abnormal curvature of the spine) to other problems that you acquired, such as arthritis (osteoarthritis

and rheumatoid arthritis) which can lead to fractures; musculoskeletal pain syndromes such as

fibromyalgia, spinal stenosis (narrowing of the spinal canal putting pressure on spine or nerves), and

even pregnancy. Infection or tumors; infection, although not common, can cause pain if it involves the

vertebrae. Two example of this are osteomyelitis (infection and inflammation of the vertebrae) and

discitis (infection in the discs). Tumors, although rare, can also cause back pain. These can cause back

pain. These can be benign or cancerous, but usually result from the tumor that has spread from another

area of the body. Because 95% of lower back pain reported is not “nonspecific”, that is, not related to

serious underlying medical conditions such as disease, infections or fractures, muscles are the first

place considered for back pain relief. Muscles don’t start to hurt for no reason, so something must be

causing that pain, Reducing the pain is the first step. Over-the-counter pain reducers and anti-

inflammatory medications are very helpful to take the edge off an injury. Next, the physical damage

should be addressed. Rest of the back is important, and should be situated in a comfortable position for

2-3 days. Ice is a great back pain relief when use with caution. No more than 20 minutes at a time,

every other hours. During this period, it is important to not remain immobile. This can cause stiffness

and lengthen recovery. Slowly moving the back in normal positions such as sitting upright, standing


and slight twisting if tolerated is recommended. Deep massage and designated exercises to pinpoint

the pain are necessary to get the back into pain free living. Targeted massage will disrupt the

adhesions and chemical bonds that hold the back muscles in pain. Depending on your condition,

specific exercises will stretch and rebuild the muscles causing pain that produce pain-blocking

impulses. Back supports are also designed to hold your back in position and support your back as you

recover. Sometimes back pain can come from more serious conditions. If you have suffered recent

trauma, have a history of osteoporosis, cancer, diabetes or kidney complications, or have pain that is

worse when lying down or at night, have bowel or bladder issues or unexplained fever or weight loss

or gain, you must seek back pain relief from a qualified medical professional. The good news is that

less than two percent of neck and back pain complaints are attributable to a serious cause.

2.9 Low Back Pain Fact Sheet

If you have lower back pain, you are not alone. Nearly everyone at some point has back

pain that interferes with work, routine daily activities, or recreation. Americans spend at least $50

billion each year on low back pain, the most common cause of job-related disability a leading

contributor to missed work. Back pain is the second most common neurological ailment in the United

States - only headache is most common. Fortunately, most occurrences of low back pain go away

within a few days. Others take much longer to resolve or lead to more serious conditions. Acute or

short-term low back pain generally lasts from a few days to a few weeks. Most acute back pain is

mechanical in nature – the result of trauma to the lower back or a disorder such as arthritis. Pain from

trauma may be caused by a sports injury, work around the house or garden, or sudden jolt such as a car

accident or other stress on spinal bones and tissues. Symptoms may range from muscle ache to

shooting or stabbing pain, limited flexibility and or range of motion, or an inability to stand straight.

Occasionally, pain felt in one part of the body may “radiate” from a disorder or injury elsewhere in the

body. Some acute pain syndromes can become more serious if left untreated. Chronic back pain is

measured by duration – pain that persists for more than 3 months is considered chronic. It is often

progressive and the cause can be difficult to determine. The National Institute of Neurological

Disorder and Stroke, a component of the National Institutes of Health (NIH) within the U.S

Department of Health and Human Services, is the nation’s leading federal funder of research on

disorders of the brain and nervous system and one of the primary NIH components that supports


research on pain and pain mechanisms. Other institutes at NIH that support pain research include the

National Institute of Dental and Craniofacial Research, the National Cancer Institutes, the National

Institute on Drug Abuse, the National Institute of Mental Health, the National Center for

Complementary and Alternative Medicine, and the National Institute of Arthritis and Musculoskeletal

and Skin Diseases. Additionally, other federal organizations, such as the Department of Veterans

Affairs and the Center for Disease Control and Prevention, conduct and studies on low back pain.

Scientists are examining the use of different drug to effectively treat back pain, in particular daily pain

that has lasted at least 6 months. Other studies are comparing different health care approaches to the

management of acute low back pain (standard care versus chiropractic, acupuncture, or massage

therapy). These studies are measuring symptom relief, restoration of function, and patient satisfaction.

Other research is comparing standard surgical treatments to the most commonly used standard

nonsurgical treatments to measure changes in health-related quality of life among patients suffering

from spinal stenosis. NIH – funded research at the Consortial Center for Chiropractic Research

encourages the development high-quality chiropractic projects. The Center also encourages

collaboration between basic and clinical scientists and between the conventional and chiropractic

medical communities. Other researchers are studying whether low-dose radiation can decrease

scarring around the spinal cord and improve the results of surgery. Still others are exploring why

spinal cord injury and other neurological changes lead to an increased sensitivity to pain or a

decreased pain threshold (where normally non-painful sensations are perceived as painful, a class of

symptoms called neuropathic pain), and how fractures of the spine and their repair affect the spinal

canal and intervertebral foramena (openings around the spinal roots). Also under study for patients

with degenerative disc disease is artificial spinal disc replacement surgery. The damaged disc is

removed and a metal and plastic disc about the size of a quarter is inserted into the spine. Ideal

candidates for disc replacement surgery are the persons between the ages of 20 and 60 years old that

have only one degenerating disc, do not have a systemic bone disease such as osteoporosis, have not

had previous back surgery, and have failed to respond to other forms of nonsurgical treatment.

Compared to other forms of back surgery recovery from this form of surgery appears to be shorter and

the procedure has fewer complications.


CHAPTER 3

METHODOLOGY

3.1 Introduction.

In this chapter the type of methodology used for this research is explained. It includes place of

research, research design, population and sample, instrument, ethnic consideration, pilot study, data

collection, discussion with suggestion and limitation of study.

3.2 Study setting

According to Polit & Hungler (1999), place of research is the physical location with the situation

needs where we can get data collection throughout our study. The study was done at Hospital

Sultanah Aminah, Johor Bahru, Johor. This hospital is one of the referral hospitals in Malaysia. The

population for the study included all nurses in the Orthopedic wards and Orthopedic clinic in the

referral hospital.

3.3 Research Design.

In this research, the information related to the objective fixed to study design such as quantitative

research which was descriptive design using questionnaire and non experimental cross sectional

survey. This study design was chosen due to easy work up and enough sufficient time in collecting

data. Purpose of study design is to identify factor contributing for lower back pain among nurses.

3.4 Population

The study population and sample was conducted among nurses working in Orthopedic wards and

Orthopedic clinic in Hospital Sultanah Aminah, Johor Bahru, Johor. A total of 50 nurses are work in

the Orthopedic Department in this hospital. Considering the ethical measures, participation in the

study was voluntary, so participants had a choice to be a part of the study or refrain without giving any


reason. Self-administered questionnaire in English were used to elicit the information with regards to

respondents’ personal and socio-demographic characteristics, back pain, work characteristic and

psychosocial factors. The questions were adopted directly from previous studies.

3.5 Inclusive Criteria:

Nurses that work in Orthopedic wards and Orthopedic clinic in Hospital Sultanah Aminah,

Johor Bahru, Johor.

Questionnaire to be given to selective nurses.

3.6 Exclusive Criteria:

Nurses who were pregnant.

Nurses with known history of prolapsed inter-vertebral disc.

Newly nurses

3.7 Research Instrument

Polit & Hungler (1999) stated that instrument is the method used for researcher to collect data using

questionnaire form, observation and interview. The instrument for the study is a simple rating

structured questionnaire tagged ”Lower Back Pain Among Nurses in Hospital Sultanah Aminah, Johor

Bahru”.

The first section of the questionnaire assessed the following socio-demographic characteristics of the

nurses such as gender, age, marital status and working experience, while the second section of the

Roland Morris Disability Questionnaire was use to evaluate the prevalence of low back pain of the

participants.

3.8 Data collection procedure .

Researcher was make arrangement with the management site of the Hospital Sultanah Aminah, Johor

Bahru to collect data. Researcher get enough questionnaire form and was distribute to the nurses

working at Orthopedic wards and Orthopedic clinic. Data collection was carried out using Section 1

and Section 2. The questionnaire form consist of English language only . Consent will be obtained


from participants. The participants have been explained about the purpose of research.

3.8 Data analysis.

Study design was a cross-sectional study among nurses working at one hospital. The research will be

present in case the participants would like to clarify about the questionnaire. Researcher will give

participants 2 days to answer the questions before being recollected. The questionnaire will answer by

50 selected nurses and will be collected and checked immediately. Completed data was captured on a

spreadsheet using the Word Excel programme in preparation for analysis. The data were recorded

from question responses into meaningful prevalence variables. Double data entering was done to

ensure quality. Thereafter data was transferred into the Statistical Package for the Social Sciences

Version 17.0 (SPSS Version 17.0 system). Descriptive statistics was employed to summarize the

demographic data of the study sample. The demographic data was presented using frequency tables

and expressed as percentages, means and standard deviations.

3.9 Ethical Consideration.

Polit & Hungler (1999) stated that ethical consideration is the system with have moral value. This is

the procedure in the research that related to professional body, law and social which involved.

Researcher need to understand and follow the research procedure from beginning until end of the

research. These included preparing proposal, approval/ permission from the Director of Hospital that

we are doing our Research. Registration to Clinical Research Centre. There is no force or pressure to

my participants. Researcher should get the consent from participant and participant has right to get

information about analysis. Researchers have to prepare a cover letter together with consent form

followed by questionnaire form to my participants.

3.10 Limitation.

In my literatures review, that I have been used on this research, there are most probably cover all

over the world including hospital in Malaysia. Therefore, my research were involved the nurses at


ward and clinic in the hospital.

CHAPTER 4

ANALYSIS , PRESENTATION AND DESCRIPTION OF

THE RESEARCH FINDINGS.

4.1 Introduction

This chapter presents the data analysis, interpretation, and discussion based on responses in the

completed copies of the questionnaire on the “Lower Back Pain among nurses in Hospital Sultanah

Aminah Johor Bahru, Johor”

The data analysis was done using statistical software and the result is presented as frequencies and

percentages in tables, figures, and charts. Each analysis is presented item by item, followed by

relevant discussion in accordance with the main sections and subsections of the study questionnaire.

4.2 Data management and Analysis.

The objectives were to :

Assess the knowledge and skills of nurses about lower back pain and their prevention

Determine how concern among nurses in the ward related with incidence of lower back pain

occurs in work place.

4.2.1 Data Processing

The researcher sorted and checked the questionnaires for completeness in order to determine their


usability. Fifty copies of the questionnaire were administered . All participants have returned their

copies and majority of the questions were answered through their experiences. A total of 50

questionnaires complete and copies of the questionnaire were analyzed and participants have give

response rate 100%.

4.2.2 Data entry and data check.

The data was entry into SPSS Software Version 17.0 data analysis statistical software. The

biostatistician taught the data entry. The biostatistician who are familliar with the use of the computer

software whereby the researcher then engaged to enter the data. After entering the data into the

computer, the data was imported from the template to the data analysis statistical software. The

reseracher then conducted data checks, looking for outliers and cross checking the data collecting tool.

4.2.3 Data Analysis

Data analysis was undertaken with the assistance of the biostatistician. Descriptive statistics were used

in the analysis. Univariate analysis, which included frequency distribution of key items on the

participants knowledge regarding lower back pain among nurses were presented. Bivariate analysis

was used to described the participants and the knowledge among participants regarding intervention

and prevention of lower back pain.


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