Prevalence and Risk Factors of Low Back Pain Among Nurses in Four Tertiary Care Hospitals at King Fahad Medical City, Riyadh, KSA

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1 Med. J. Cairo Univ., Vol. 78,. 2, June: , Prevalence and Risk Factors of Low Back Pain Among Nurses in Four Tertiary Care Hospitals at King Fahad Medical City, Riyadh, KSA MOSTAFA A.F. ABBAS, M.D.*,**; LAMIAA Z. ABU ZAID, M.D.*,**; LAMIAA A. FIALA, Ph.D.*,*** and NASSER A. ALHAMDAN, M.D.** The Departments of Community & Occupational Medicine*, Faculty of Medicine, Suez Canal University, Ismailia, Egypt; Community Medicine**, Faculty of Medicine, KSAU-HS, King Fahad Medical City, KSA and Community Health Sciences***, Applied Medical Sciences College, King Saud University, KSA. Abstract Background: Low Back Pain (LBP) is a common health problem among health care workers; leads to disability, absence and loss of resources on treatment, investigation and rehabilitation. Aim: This study aimed to assess the prevalence of and risk factors for Low Back Pain among nurses in four tertiary hospitals at KFMC, Riyadh, Saudi Arabia. Subjects and Methods: A cross sectional study in which all nurses for LBP has been surveyed using questionnaire including the occupational factors and the characters of LBP; with other variables such as age group, gender, job category, country of origin, previous LBP episodes and prognosis for it. rdic questionnaire for LBP has been used. Results: A total sample of 937 nursing staff returned the filled questionnaire out of 1300 distributed (72% response rate). 576 (61.5%) of nursing staff reported current attacks of episodes of LBP, 611 (65%) reported at least one attack of LBP during past 12 months and 375 (40%) of them reported to have at least one attack during life time. LBP was highest among younger age group who are less than 30 years old, 269 (64.4%) compared to older nurses (>49 years old) 30 (50.8%). Female nurses had less rate of LBP 498 (60.5%) compared to male nurses who were 78 (88.4%). Inpatient nurse, outpatient nurse and nurse assistant had consistently higher rates of low back pain; 253 (63.9%); 160 (63.5%) and 95 (62.9%) compared to administrative nurses 68 (49.3%). Middle Eastern nurses had the highest rates of LBP compared to other nationalities 48 (66.7%). Using a patient lifting device was associated with higher rates of LBP 198 out of 285 (69.5%) p<0.05; OR=1.65 (1.21<95% CI <2.25). Carrying patients had a higher rate of LBP 442 out of 664 (66.6%) p<0.05; OR=2.07 ( ); same for nurses who move or support patients and also nurses who push wheels of patients had also higher rates of LBP. LBP was severe enough to visit a doctor among 329 (57.1%) and 329 (57.1%) had to take medication, 84 (14.6%) had to Correspondence to: Dr. Mostafa A.F. Abbas, The Department of Community Medicine, Faculty of Medicine, KFMC, Riyadh, KSA, moustafafouad@yahoo.com. have X-ray and 63 (10.9%) had to take a sick leave because of LBP. Eighty five percent of those who had current LBP reported that their pain was related to work incidents. Nevertheless, only 11.5% had changed their duty because of their back pain. Conclusion: The prevalence of LBP among nursing staff at KFMC is high. Certain patient transfer tasks seemed to play important role in LBP. Key Words: Low back pain Health care workers Prevalence Risk factors. Introduction LOW back pain (LBP) is an important public health problem in all industrialized nations. It is associated with major cost, in terms of health resource usage and worker disability and absenteeism [1]. Most epidemiological data concerning (LBP) are related to developed and industrialized countries and there is little information about LBP in the general or working population in developing countries. This lack of research leaves a profound gap in what is known about LBP in a large part of the world, where the bulk of the world's working population resides [2]. Low back pain remains a common and costly problem among the nursing profession. Many studies report higher prevalence of back pain and occupational back injuries for nurses compared with other occupational groups [3-7]. Swedish statistics show a six fold excess risk of overexertion back injuries among assistant nurses compared with other employed women in Sweden [7]. These injuries can lead to sick-leaves [7] persistent medical problems [8] or job changes [5]. Most injuries occur during patient transfer [9,10]. 219

2 220 Prevalence & Risk Factors of Low Back Pain Among Nurses A recent study conducted in Taiwan [11] and aimed to assess the prevalence and risk factors for different measures of LBP among nursing aides in Taiwan, results revealed that the prevalence rates for pain lasting for at least one day, seeking of medical care, intense pain, sick leave, and chronic pain were 66.0%, 43.9%, 38.1%, 10.7%, and 8.6%, respectively. In the same study, multiple logistic regression analyses indicated that the risk factors varied with different measures of LBP, at least one high-risk patient-handling task and one psychosocial factor were observed to be associated each LBP related measure. Three risk factors, including manual transfer of patients between bed/wheelchair and bath cart, perceived physical exertion, and psychological demands, were consistently associated with different measures of LBP. Besides, age was found to be associated with an increased risk of only chronic pain. A cross-sectional study of Hong Kong hospital nurses [12] was aimed to measure the magnitude of LBP among Hong Kong nurses and its association with the work-related psychological strain and patient handling activities. Results showed that of the 377 nurses interviewed, 153 (40.6%) reported having LBP within the last 12 months. With symptoms of LBP as the outcome, risks were increased where nurses self-reported that they only occasionally or never enjoyed their work, where frequent manual repositioning of patients on the bed was required, and where they were required to assist patients while walking after adjustment for other potential confounders. To investigate the risk factors for LBP in hospital nurses, a cross-sectional study was conducted at Southampton General Hospital [13]. Results showed that the lifetime prevalence of back pain was 60% and the one year period prevalence 45%. 10% had been absent from work because of back pain for a cumulative period exceeding four weeks. After adjustment for non-musculoskeletal symptoms, significant associations were found with frequency of manually moving patients around on the bed, manually transferring patients between bed and chair, and manually lifting patients from the floor. Subjects and Methods Aim of this study was to assess the prevalence and associated risk factors for Low Back Pain among nurses in four major hospitals at KFMC, Riyadh, Saudi Arabia. The current study is a cross sectional study using rdic questionnaire definition for LBP [14]. Using a Comprehensive sample for the nurses in the four major hospitals at KFMC in Riyadh over the last 12 months who were about 1300 nurses. All nurses were included, except those with previous history of musculoskeletal or bone disorder. The questionnaire had a section on demographic characteristics for nursing staff, work characteristics, low back pain if any, currently (Point Prevalence), past 12 months (Annual Prevalence) and any LBP attack during lifetime; and impact of LBP on the nursing staff in terms of need for doctor visit, medication, X-ray, and sick leave. Univariate analysis for all variables with LBP results for identifying significant independent variables. Results A total number of 1300 questionnaires were distributed and an overall response rate of (n=937) 72% was achieved. From Table (1); about half of nursing staff (n=460) 49.1% were at the age group of 30 to 49 years old. Most of them were females (n=823) 87.8%. About one third had work experience less than or equal to 5 years (n=302) 32.2%. Asians represented more than half of the nursing staff (n=525) 56%. The highest percentage of them were inpatient nurse (n=396) 42.3%. Table (1): Socio-demographic characteristics of study population. Study population. % Age group in years: < >_ Gender: Female Male Working Experience yrs: > Nationality: Saudi Middle East Western Indian Asian Job Type: Inpatient-Nurse Outpatient -Nurse HCA-Health Care Assistant Administrative Nurse Total %

3 Mostafa A.F. Abbas, et al. 221 From Table (2); showed that (n=576) 61.5% of nursing staff reported having current attacks of LBP; (n=611) 65.2% reported to have attack of LBP during past 12 months; (n=375) 40% of them reported to have at least one attack of LBP during lifetime. As shown in Table (3), the highest percentage of nurses (n=269) 64.4% having current attacks of LBP was at the age group of less than 30 years, while about (n=30) 50% of the age group equal to or more than 50 years were suffering from current attack of LBP. Regarding lifetime prevalence of LBP we found that about one third (n=151) 36.1% of nurses at age group less than 30 years had at least one attack of LBP during their lifetime compared to (n=32) 54.2% of the age group equal to or more than 50 years. Table (2): Prevalence of current LBP, last 12 month LBP and lifetime LBP attacks among Nursing staff at KFMC, Riyadh KSA. Study population (n=937). % Current attack(s) of LBP: Last 12 month attack (s) of LBP: Lifetime attack(s) of LBP: Table (3): Current LBP, past 12 months LBP and Lifetime LBP attack(s) relationship to demographic characteristics. Current LBP (n=576) LBP last year (n=611) LBP in life time (n=375)... (%) * Age groups: < >_ (64.4) 277 (60.2) 30 (50.8) OR=1.75 ( ) (62.7) 310 (67.4) 39 (66.1) (36.1) 192 (41.7) 32 (54.2) OR=4.74 ( ) 0.07 Gender: Females Males 498 (60.5) 78 (88.4) 522 (63.4) 89 (78.1) OR=2.05 ( ) 326 (39.6) 49 (43) 0.49 Job Type: Inpatient-Nurse Outpatient -Nurse HCA-Health Care Assistant Administrative Nurse 253 (63.9) 160 (63.5) 95 (62.9) 68 (49.3) OR= 1.82 ( ) OR=1.79 ( ) OR=1.75 ( ) 247 (62.4) 172 (68.3) 109 (72.2) 83 (60.1) OR=1.72 ( ) 141 (35.6) 107 (42.5) 67 (44.4) 60 (43.5) Nationality: Saudi Middle East Western Indian Asian 36 (59.0) 48 (66.7) 20 (46.5) 141 (59.7) 331 (63.0) OR=2.30 ( ) OR=1.96 ( ) 35 (57.4) 53 (73.6) 23 (53.5) 122 (51.7) 378 (72.0) OR=2.43 ( ) OR=2.24 ( ) 15 (24.6) 29 (40.3) 16 (37.2) 77 (32.6) 238 (45.3)

4 222 Prevalence & Risk Factors of Low Back Pain Among Nurses Table (4): Present LPB attack(s) and working characteristics. Lifting device: Carry patient: Move support: Push wheel: BMI group: <25 25-< of Study group (69.5) 378 (58.0) 442 (66.6) 134 (49.1) 523 (64.5) 53 (42.1) 541 (64.8) 35 (34.3) 400 (62.6) 136 (62.4) 40 (50.0) Current LBP (n=576). Visit doctor: 189 (32.8) 387 (67.2) Medication: 329 (57.1) 247 (42.9) X-ray: 84 (14.6) 492 (85.4) Sick leave: 63 (10.9) 513 (89.1) Admit hosp: 8 (1.4) 568 (98.6) Change duty: 66 (11.5) 510 (88.5) Work incident: 492 (85.4) 84 (14.6) Current LBP OR=1.65 ( ) OR=2.07 ( ) OR=2.5 ( ) OR=3.52 ( ) OR=1.67 ( ) Table (5): Burden of LBP among nursing staff at KFMC, Riyadh. The same table showed that males had a higher rate of current attacks of LBP, (n=78) 88.4% compared to females who were (n=498) 60.5%. While administrative nurses had the least rate of LBP (n=68) 49.3% compared to Health Care Assistants (HCA), (n=95) 62.9% p<0.05; OR=1.75 ( ). Almost the same percentages of inpatient nurses and outpatient nurses had current attacks of LBP (n=253) 63.9% and (n=160) 63.5% respectively which was consistently higher than HCA and administrative nurses. Middle eastern nurses had the highest rate of current attacks of LBP (n=48) 66.7%; also Asians represent the bulk of LBP current attacks (n=331) 63% p<0.05; OR 1.96 ( ) when compared to western nurses as reference group. In Table (4); having a patient lifting device was not protective against LBP; since it was actually associated with higher rate of current attack of LBP (n=198) 69.1% p<0.05; OR=1.65 ( ). It is observed that high percentages of current attacks of LBP were recorded among groups of nurses who performed certain patient transfer tasks. These tasks include carrying patients, moving or supporting patients and pushing wheels; (n=442) 66.6%; (n=523) 64.5% and (n=541) 64.8% respectively. Also those who had a lower BMI had higher rate of current attack of LBP, (n=400) 62.6% among <25 BMI compared to those who have a BMI >_30. From Table (5) it is noticed that about one third (n=189) 32.8% of nurses who have current attacks of LBP visited doctors offices and more than half of them (n=329) 57.1% used medications for these attacks. Only (n=84) 14.6% had perform X-ray for investigation of their condition, meanwhile, the majority of them (n=513) 89.1% did not get sick leave for their LBP, and only (n=66) 11.5% had to change their duty because of pain attacks. Most of nurses (n=492) 85.4% related the episodes of LBP to work incidents. Discussion Low Back Pain is a major occupational health problem and represent a huge burden on nursing staff and on the health care system. This study aimed at describing prevalence of LBP among nursing staff and its risk factors. In this study prevalence of current attacks of LBP (Point Prevalence) was (n=576) 61.5% among nursing staff and this figure is comparable to multiple international studies [11,12,13]. Even much higher figures were reported in other studies, such as the work done by de Castro

5 Mostafa A.F. Abbas, et al. 223 et al., 2009 [15] who reported that 78.2% of nurses in the Philippines suffered from Acute recent episode during the past year. Also the current study results shows that the LBP during past 12 month (Annual Prevalence) was (n=611) 65% among nursing staff which is a comparable figure to the study done in a major Chinese hospital (56%) [16]. While in the current study males had a higher rates of LBP incidents than females, other studies reported higher rates of LBP among female nurses as the work done by Solidaki E, et al., 2010 [17]. Solidaki E, et al., found that among nurses in Crete university hospital in Greece, females reported higher rates of LBP (n=149) 40% compared to male nurses (n=72) 37%. In present study, current LBP, past 12 months LBP and lifetime LBP were 61.5%, 65.2% and 40% consecutively, while the work done by Cunningham C, et al., in 2006 [17] reported 15.5%, 30% and 46%, which are less than the figures reported by our study. This difference might be due to their small sample size (only 49 nurses). There might be underreporting of LBP episodes in the current work, the same problem reported by other researchers [19] in which they showed reluctance of health care workers to report episodes of LBP. Also, at the same time there are reports of other lower figures of LBP than the current study as the work done by Engels JA, et al., 1996 [20] who studied prevalence of LBP among nurses professionals in 4 Dutch nursing homes, and reported that LBP among nurses was 35.9%. Conclusion and Recommendation: Low back pain among nurses is prevalent and represents a challenge for occupational health physicians caring for the health of nurses, also LPB represent a major source of medical expenditure in the form of required medications, investigations and sick leave. Further large scale studies are needed to identify the awkward postures associated with higher prevalence of LBP and the ergonomic solutions for it. References 1- MANIADAKIS N. and GRAY A.: The economic burden of back pain in the UK. Pain, 84: , VOLINN E.: The epidemiology of low back pain in the rest of the world. A review of surveys in low-and middleincome countries. Spine, 22: , DEHLIN O., HEDENRUD B. and BACK J.H.: Symptoms in nursing aides in a geriatric hospital. Scand J. Rehabil Med., 8: 47-53, HARBER P., BILLET E., GUTOWSKI M., SOOHOO K., LEW M. and ADELE R.: Occupational low-back pain in hospital nurses. J. Occup. Med., 27: , HEAP D.C.: Low back injuries in nursing staff. J. Soc. Occup. Med., 37: 66-70, LJUNGBERG A-S., KILBOM and HÄGG G.M.: Occupational lifting by nursing aides and warehouse workers. Ergonomics, 32: 59-78, ENGKVIST I-L., HAGBERG M., LINDÉN A. and MALK- ER B.: Over-exertion back accidents among nurses aides in Sweden. Safety Sci., 15: , LARSSON T. and BJÖRNSTIG U.: Persistent medical problems and permanent impairment five years after occupational injury. Scand J. Soc. Med., 2: , ESTRYN-BEHAR M., KAMINSKI M., PEIGNE E., MAILLARD MF., PELLETIER A., BERTHIER C., et al.: Strenuous working conditions and musculo-skeletal disorders among female hospital workers. Int. Arch. Occup. Environ Health, 62: 47-57, JENSEN R.C.: Back injuries among nursing personnel related to exposure. Appl. Occup. Environ Hyg., 1: 38-45, FENG C.K., CHEN M.L. and MAO I.F.: Prevalence of and risk factors for different measures of low back pain among female nursing aides in Taiwanese nursing homes. BMC Musculoskeletal Disord, 25: 8-52, YIP Y.: A study of work stress, patient handling activities and the risk of low back pain among nurses in Hong Kong. J. Adv. Nurs., 36 (6): , SMEDLEY J., EGGER P., COOPER C. and COGGON D.: Manual handling activities and risk of low back pain in nurses. Occup. Environ. Med., 52 (3): , KUORINKA I., JONSSON B. and KILBORN A.: Standardized rdic questionnaire for the analysis of musculoskeletal symptoms. Appl. Ergon., , DE CASTRO A.B., CABRERA S.L., GEE G.C., FUJISH- IRO K. and TAGALOG E.A.: Occupational health and safety isuues among nurses in the Philippines. AAOHN J. April, 57 (4): , SMITH D.R., WEI N., ZHAO L. and WANG R.: Musculoskeletal complaints and psychosocial risk factors among Chinese hospital nurses. Occupational Medicine, Dec. 54 (8): , SOLIDAKI E., CHATZI L., BITSIOS P., MARAKATZI I., PLANA E., CASTRO F., et al.: Work-related and psychosocial determinants of multi-site musculoskeletal pain. Scand J. Work Environ Health, 36 (1): 54-61, CUNNINGHAM C., FLYNN T. and BLAKE C.: Low back pain and occupation among Irish health service workers. Occupational Medicine, 56: , MENZEL N.: Underreporting of musculoskeletal disorders among health care workers, research needs. AAOHN J., Dec. 56 (12): , ENGELS J.A., GULDEN J.W., SENDEN T.F. and HOF B.: Work related risk factors for musculoskeletal complaints in the nursing profession: Results of a questionnaires survey. Occupational and Environmental Medicine, Sep. 53 (9): , 1996.