One of the overarching goals of Healthy People 2020 is to help Americans achieve longer, quality lives—unencumbered by preventable diseases, disabilities, injuries, and premature death (U. S. Department of Health and Human Services [USDHHS], 2010). Debilitating or chronic back pain is a public health concern as it is often associated with negative health consequences and status. As such, reducing the prevalence of chronic back pain is a health topic identified and prioritized by Healthy People 2020 (USDHHS, 2010).
In 2013, musculoskeletal disorders (MSDs), which included sprains and strains from repetitive motion, accounted for 33% of all nonfatal occupational injuries and illnesses (U. S. Department of Labor [USDOL], 2014). Nursing assistants experienced the highest MSDs in 2013, followed by warehouse workers, truckers, stock clerks, and registered nurses (USDOL, 2014). It is troubling to think that 53% of all the total cases incurred by nursing assistants were MSDs (USDOL, 2014).
Of the various MSDs, low back pain (LBP) is a prevalent health problem affecting nursing personnel (Yassi & Lockhart, 2013; Qin, Kurowski, Gore & Punnet, 2014). The lifetime prevalence of LBP in the general working population is between 60% and 70% (World Health Organization [WHO], 2013). In comparison, that figure is slightly greater in nursing, varying between 56% and 90% as mentioned in Maul, Laubli, Klipstein, and Krueger’s (2003) seminal paper that described the course of LBP among nurses across eight years.
In spite of the various environment health initiatives and safety measures aimed at reducing and preventing back injuries among nursing personnel, compensation claim rates for work-related back injuries remain disproportionately high in this group than any other occupation or industry (American Nurses Association “Safe Handling,” n. d. ). The significance and burden of low back pain A review of the literature on this health topic found that LBP is not an issue pertaining to modern societies or industrialized countries only; rather, it is a global phenomenon.
A 2010 longitudinal (The Global Burden of Disease) study led by the Institute of Health Metrics and Evaluation showed that LBP was among the world’s top ten diseases and injuries that accounted for the largest number of disability-adjusted life years (WHO, 2013). Significantly, LBP was ranked third in the U. S. –after ischemic heart disease and chronic obstructive pulmonary disease, respectively—in this regard (U. S. Burden of Disease Collaborators, 2013).
Without a doubt, LBP imposes a considerable burden on individuals as well as nations. It not only interferes with activities of daily living, quality of life, and work performance, but is also the leading cause of activity limitation and work absences throughout much of the world (WHO, 2013). In this country alone, an estimated 149 million work days are lost each year because of LBP, with total costs of US$100 to US$200 billion per year—of which, two thirds are from lost wages and lower productivity (WHO, 2013).
Management of LBP, risk factors, and the role of FNP In medical terms, LBP is defined as pain, muscle tension and stiffness localized below the costal margin and above the inferior gluteal folds, with or without sciatica (Chou, 2011). It can be further described as acute (usually self-limiting; less than a month), subacute (between 2 and 3 months) and chronic (greater than 3 months) (Delitto et al, 2012). Although LBP is not a disease per se, it can, nevertheless, be a difficult and complex disorder to manage.
Non-specific LBP can challenge or vex even the most seasoned medical clinician. Manchikanti and Hirsch (2015) points to LBP as “a multifactorial disorder with many possible etiologies, risk factors and co-morbidities. ” Common etiologies seen in the vast majority of patients with LBP include lumbar strains/sprains, disc herniation, or degenerative conditions, such as lumbar osteoarthritis, spinal stenosis, and spondylolysis to name a few (National Institute of Neurological Disorders and Stroke [NINDS] “Low Back Pain,” 2014).
However, there will be a small percentage of patients, whose back pain could be indicative of something serious, such as spinal infection, cancerous tumor, cauda equina syndrome, compression fractures and abdominal aortic aneursym (Delitto et al. , 2012). In the general population, the risk factors for predicting LBP are individual (e. g. , genetics, age, gender, body build, strength and flexibility) and activity-related, such as work, leisure, and sedentary lifestyle (Delitto et al. , 2012).
Those same risk factors exist among health care workers as well. However, there are also risk factors specific to, or associated with, the nature of nursing duties. Yassi and Lockhart (2013) found that a “large proportion of excess risk of back disorders” stem from physically demanding patient-handling tasks. These include, but are not limited to, adjusting patients in bed, performing hygiene care (bathing and dressing), transporting patients in wheelchairs, and transferring patients (Yassi & Lockhart, 2013).
In addition, nursing personnel who frequently handled patients had four times the risk of LBP than those who infrequently handle them (Yassi & Lockhart, 2013). Qin et al. (2014) noted that high job strain (from rapid and continuous physical motion) and other psychosocial variables (poor social support from coworkers and supervisors, inadequate staffing, stress, and management’s attitude towards health and safety) also increase risk and contribute to the prevalence of LBP in health care workers.
In treating LBP in the primary care setting, the nurse practitioner (NP) must always obtain a complete medical history to identify the likely cause of the patient’s back pain—including onset, site, severity, radiation of pain, limitations in mobility, changes to bowel/bladder dysfunction, history of previous episodes, and any pertinent psychosocial factors that could be related to this pain (Delitto et al. , 2012; NINDS, 2014). A detailed history and a throughout physical exam help to uncover serious conditions that may warrant a more comprehensive diagnostic workup (NINDS, 2014).
The NP needs to inspect for spinal deformity and/or swelling to the lower back; palpate for tenderness; assess for range of motion, and test for neurological deficits (NINDS, 2014). Intervention and evaluation The management of LBP in adults generally depends on its presentation (whether acute, subacute, or chronic), but treatment, however, should be based on national guidelines established by the Institute for Clinical System Improvement (ICSI) to standardize care. These guidelines provide quality of evidence and strength of recommendation that is helpful to the NP.
The core treatment plan recommended by ICSI (2012) are as follows: Have a discussion on the multiple causes of LBP and always address fear avoidance. Patient education on back care and back pain prevention; reassurance regarding the prognosis of LBP with resolution of pain and symptoms after two to four weeks. Encourage exercise and/or staying active with daily activities instead of bed rest, which can be ineffective and even harmful. use of heat application as an adjunct pain therapy, and analgesics, such as acetaminophen or non-steroidal anti-inflammatory drugs, for short term pain.
Diagnostic imaging in the absence of “ red flag findings” in non-specific LBP should be reduced or eliminated. Narcotics are rarely indicated. The risk of harm versus benefit must be carefully considered when prescribing narcotics, and their use should be limited, particularly in patients with active or past substance abuse issues. There are several screening tools that the NP can use to measure a patient’s functional status, One such tool is the Keane StarT-Back, whcreated to help general practitioners in the United Kingdom identify patients at greatest risk of chronic back pain.
