Subjective and Objective Categorization of Chronic Low Back Pain in Professional Nurses

Subjective and Objective Categorization of Chronic Low Back Pain in Professional Nurses
Introduction
Nursing is a challenging profession and staff nurses are entrusted with the responsibility of extending and safe and quality healthcare. Safe and quality healthcare is essential for ensuring positive health outcomes in patients. Hence, nurses should be physically, physiologically and psychologically competent for ensuring safe and quality healthcare services. Chronic low back pain has been recognized as one of the major factors that limits the professional competence of staff nurses. The presence of CLBP or LBP decreases the productivity and physical competence of staff nurses. Hence, the present study would be conducted to objectively categorize CLBP or LBP amongst nursing professionals.
Literature Review
The literature review for the proposed research was based on keyword search strategy. The keywords were linked through Boolean connectors for selecting the appropriate articles. The keywords and the Boolean connectors that were used are “Chronic Low back Pain” OR “Neuropathic Pain” OR “Nociceptive Pain” AND “Subjective categorization” OR “Objective Categorization” AND “Nurses” OR “Women”. The keywords were used to visit different clinical and nursing databases. These databases were “OVID online” “Medline Search” “Pubmed Central” “Cochrane database” and “Google Scholar”. The literature review indicated different articles related to chronic low back pain in nurses. However, no studies categorized chronic low back pain in nurses either subjectively or objectively.

These findings provided the guiding framework for the proposed research.
Freynhagen and Baron (2009) reported that the prevalence of CLBP is very high in Western societies. Epidemiological studies have indicated that a neuropathic component is prevalent in 20% to 35% cases of chronic low back pain. It has been estimated that chronic lumbar radicular pain is the most common form of neuropathic pain that accounts for CLBP.
Ghadvani et al (2016) indicated that low back pain is the most prevalent behavior related health hazard in professional nurses. The authors implicated that low back pain should be evaluated through a validated multi-factorial questionnaire. The multi-factorial questionnaire should be aligned with the social cognitive theory.
Yassi and Lockhart et al (2013) conducted a systematic review to evaluate the causative factors for CLBP amongst nursing professionals. The authors evaluated 987studies and 89 studies were finally included for the analysis. Manual handling of patients was strongly associated with the genesis of CLBP amongst professional nurses. However, the other nursing duties were also responsible for the development of CLBP. The risk of CLBP amongst nurses ranged from 1.2 to 5.5 (p<0.001) compared to their control counterparts.
Eqhbali et al. (2012) evaluated the role of reflexology in alleviating the intensity of chronic low back pain amongst professional nurses. The authors indicated nursing represents the top ten careers that impose the risk of WMSDs.
3. Methodology
Study Design and Site of Study
The study would be conducted as a prospective, randomized, controlled trial. The study participants were selected from 4 tertiary care hospitals. The NNT (number needed to treat) framework would be used for selecting the sample size for the study. NNT would be selected in such a manner, so as to achieve a power of 90% for the proposed study. The study participants would be exposed to Stratified Random Sampling. Stratified Random Sampling would be based on specialty of nursing. Age-matched controls would be selected from the same department/specialty. The age-matched controls should not belong to the nursing profession. The control subjects may be selected from the field of administration, patient counselors, consulting physicians and/or psychotherapists/psychologists.
Procedure
The study participants would be selected after appropriate screening for diabetes mellitus/history of accidental injury/ history of depressive disorders/ or history of anxiety. Hb1Ac levels would be assessed for diagnosing diabetes mellitus. History of accidental injury would be evaluated from the verbatim of the study participants. However, the history of accidental injury would be evaluated through radiological findings and gait analysis. The presence of depressive disorders would be screened through the “Prime-MD” tool. On the other hand, the “State Trait Anxiety Scale” would be used to assess the presence of anxiety disorders in an individual. The study participants (both experimental subjects and their age-matched control) would be subjectively and objectively assessed for presence of chronic low back pain. The Visual Analogue Scale would be used for subjective assessment of chronic low back pain. “Pain Detect” tool would be implemented for objective assessment of chronic low back pain..
Statistical Tests for the Proposed Research
Different statistical measures would be implemented for analyzing the results of the study. Student’s-t test would be conducted for the different comparison analysis..
Research Questions
The proposed study would evaluate 3 research questions. These questions are:
1st Research Question: Whether the risk of neuropathic pain is significantly higher in nurses compared to their age-matched controls?
2nd Research Question: Whether objective pain score is significantly higher in nurses compared to their age-matched controls?
Hypothesis Testing and Statistical Inference
Hypothesis Testing For Evaluating the Prevalence of Neuropathic Pain
The null hypothesis contends that the prevalence of neuropathic pain is not significantly higher in nurses compared to age-matched controls. The null hypothesis is accepted if the p-value for the statistical test of inference is greater than 0.05 (p>0.05). The alternative hypothesis is accepted if the p-value for the statistical test of inference is less than 0.05 (p<0.05).
b. Hypothesis Testing For Evaluating the Risk Factors for Neuropathic Pain
The null hypothesis contends that objective pain score is not significantly higher in nurses. The null hypothesis is accepted if the p-value for the statistical test of inference is greater than 0.05 (p>0.05). The alternative hypothesis is accepted if the p-value for the statistical test of inference is less than 0.05 (p<0.05).
Statistical Software
The results for the proposed study would be represented and analyzed through MS-excel software.
Ethical Approval
The ethical approval for the proposed research would be obtained from the research and ethical committees of the respective healthcare organizations.
4. Proposed Outcomes of the Study
Till date, no studies have been conducted for objective categorization of CLBP or LBP in nursing professionals. Classification and categorization of CLBP or LBP would be highly beneficial for planning intervention strategies. Appropriate interventions should be implemented for mitigating the prevalence and intensity of CLBP or LBP amongst nursing professionals. Alleviation of CLBP is essential for ensuring productivity amongst staff nurses. The study would help to deploy nursing professionals in their practice settings. Appropriate deployment of nurses is essential for ensuring safe and quality healthcare in patients.
References
Eghbali M, Safari R, Nazari F, Abdoli S. (2012)The effects of reflexology on chronic low
back pain intensity in nurses employed in hospitals affiliated with Isfahan University of
Medical Sciences. Iran J Nurs Midwifery Res.  17(3),239-43.
Freynhagen R, Baron R. (2009) The evaluation of neuropathic components in low back pain.
Curr Pain Headache Rep.  13(3):185-90.
Ghadyani L, Tavafian SS, Kazemnejad A, Wagner J (2016)Development and Psychometric
Evaluation of Nursing Low Back Pain Predictor Questionnaire Focusing on Nurses
Suffering from Chronic Low Back Pain in Iran. Asian Spine J. 10(4),697-704
Yassi, A & Lockhart K. (2013) Work-relatedness of low back pain in nursing
personnel: a systematic review International Journal of Occupational and
Environmental Health 19(3), 223-244
Subjective and Objective Categorization of Chronic Low Back Pain in Professional Nurses: A Research Study
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Subjective and Objective Categorization of Chronic Low Back Pain in Professional Nurses
Introduction
Nursing is a challenging profession and staff nurses are entrusted with the responsibility of extending and safe and quality healthcare. Different studies have confirmed the presence of chronic low back pain in nursing professionals. Moreover, such studies have also implicated that the prevalence and intensity CLBP varies from one nursing specialty to another. Most authors have recognized the presence and prevalence of low back pain in nursing professionals. Work related musculoskeletal disorders are recognized as major causes for the development of chronic low back pain. Such studies have been conducted on subjective ratings based on individual verbatim and/or use of Visual Analogue Scale. However, these studies were unable to provide a gold standard for diagnosis of etiology of CLBP. Till date, no studies have been conducted for objective categorization of CLBP or LBP in nursing professionals. Classification and categorization of CLBP or LBP are highly significant for planning intervention strategies. Appropriate interventions should be implemented for mitigating the prevalence and intensity of CLBP or LBP amongst nursing professionals. The present study was conducted to objectively categorize CLBP amongst nursing professionals.
Literature Review
Freynhagen and Baron (2009) reported that the prevalence of CLBP is very high in Western societies. Epidemiological studies have indicated that a neuropathic component is prevalent in 20% to 35% cases of chronic low back pain. It has been estimated that chronic lumbar radicular pain is the most common form of neuropathic pain that accounts for CLBP. Freynhagen and Baron (2009) endorsed that the pathophysiology of CLBP is complex. This is because CLBP might occur either due to a neuropathic component or nociceptive component. Moreover, CLBP may involve both the components of neuropathic pain and nociceptive pain. The involvement of both these components leads to the genesis of mixed pain syndrome. Neuropathic pain is caused by the lesions in nociceptive sprouts that occur within the degenerated discs. Neuropathic pain is also caused due to mechanical compression of nerve roots. Mechanical compression of the nerve roots in the vertebral column is referred as radiculopathy.
Freynhagen and Baron (2009) also pointed out that diagnosis and management of CLBP remains an enigma. This is because there is no gold standard that could categorize CLBP either subjectively or objectively. Subjective and objective categorization of chronic low back pain is essential for addressing the clinical dilemma associated with its management. Appropriate screening methods and diagnostic tests are highly mandated for effective management of CLBP. The burden of chronic low back pain impairs the productivity of an individual. Hence, it is essential to detect and categorize the causative component (neuropathic or nociceptive) of CLBP. Management of neuropathic and nociceptive pain is distinctly different from each other. NonSteroidal Anti-inflammatory Drugs (NSAIDS) and physical exercise could alleviate the prevalence of nociceptive pain. On the other hand, management of neuropathic pain is difficult and challenging (Freynhagen & Baron, 2009).
Neuropathic pain is usually managed with the help of GABA (gamma amino butyric acid) agonists and lifestyle interventions. NSAIDS inhibits cyclooxgenase-2 (Cox-2) enzymes. Cox-2 is responsible for the conversion of arachidonic acid to prostaglandins. Prostaglandins are potent inflammatory mediators. Hence, NSAIDS prevents nociceptive pain by reducing inflammation. On the other hand, GABA agonists’ increases the permeability of chloride channels in the post-synaptic neurons associated with the transmission of pain impulse. The influx of chloride ions leads to hyperpolarization of post-synaptic neurons. Hyperpolarization of the post-synaptic neurons prevents the transmission of neuropathic pain.
Ghadvani et al (2016) indicated that low back pain is the most prevalent behavior-related health hazard in professional nurses. The authors implicated that low back pain should be evaluated through a validated multi-factorial questionnaire. The multi-factorial questionnaire should be aligned with the social cognitive theory. Ghadvani et al (2016) conducted a cross-sectional study based on a 50-item questionnaire. The 50-item questionnaire was based on the social cognitive theory. The study was conducted on 500 professional nurses engaged in different healthcare organizations in Tehran. Exploratory factor analysis was undertaken to determine the causative factors for low back pain. The tool (50-item questionnaire) was validated through Cronbach’s alpha. The exploratory factor analysis involved six factors. These factors were observational learning, outcome expectations, emotional regulation, self-efficacy, and self-regulation in overcoming the challenges of the working environment. The different exploratory variables accounted for 67.12% variance in behavior change. The Cronbach’s alpha exhibited an excellent internal consistency (alpha=0.91). The test and retest analysis at two weeks interval indicated a correlation coefficient of 0.94. The authors concluded that multi-factorial questionnaires are effective tools that may be used to predict the work-related factors associated with the genesis of low back pain amongst nurses.
Yassi and Lockhart et al (2013) conducted a systematic review to evaluate the causative factors for CLBP amongst nursing professionals. The authors evaluated 987studies and 89 studies were finally included in the analysis. Amongst these studies, 23 studies were descriptive in nature (involving biomechanical/ergonomic end-points), and 9 studies were systematic reviews. The systematic review indicated that nurses are predisposed to the risk of developing chronic low back pain. CLBP and back disorders occurred irrespective of the nursing technique, personal characteristics and work-related factors. Manual handling of patients was strongly associated with the genesis of CLBP amongst professional nurses. However, the other nursing duties were also responsible for the development of CLBP. The risk of CLBP amongst nurses ranged from 1.2 to 5.5 (p<0.001) compared to their control counterparts.
Eqhbali et al. (2012) evaluated the role of reflexology in alleviating the intensity of chronic low back pain amongst professional nurses. The authors indicated nursing represents the top ten careers that impose the risk of WMSDs. Different pharmacological and non-pharmacological interventions are implemented for managing the prevalence of CLBP amongst nurses. Reflexology is a type of non-pharmacological intervention that is used for the management of CLBP. Eqhbali et al. (2012) conducted a double-blind study across 50 male and female nursing professionals. The study participants were segregated into two groups. One group received intervention with reflexology, while the other group was intervened with non-specific massage. The responses of the study participants based on the interventions were collected through structured questionnaire. The feedback o the study participants were collected for two weeks. Pain intensity was evaluated through the numerical analog scale for pain. The pain intensity was measured before and after implementation of respective non-pharmacological interventions. The results indicated that reflexology significantly reduced the intensity of pain amongst study participants compared to the control group (p<0.01). However, the non-specific massage was equally effective in reducing the intensity of back pain amongst study participants.
3. Methodology
Study Design and Site of Study
The study was conducted as a prospective, randomized, controlled trial. Thirty-eight nurses within the age group of 30 to 45 years participated in the study. However, eight nurses were excluded from the study as they did not match inclusion criteria. The detailed inclusion and exclusion criteria for the proposed study were:
Inclusion Criteria
Professional nurses with working experience of > 5 years
Nurses with chronic low back pain
Nurses belonged to one of the four specialties; cardiac care, intensive care, orthopedic care and psychiatric care.
The study participants were willing to participate in the study.
Exclusion Criteria
Professional nurses with working experience of < 5 years
Nurses complaining of chronic headache/migraine/abdominal pain
Nurses suffering from diabetes mellitus, depressive disorders, and anxiety disorders.
Nurses not belonging to one of the four specialties; cardiac care, intensive care, orthopedic care and psychiatric care.
Nurses unwilling to participate in the study.
Procedure
The experimental subjects and controls subjects were selected after appropriate screening for diabetes mellitus/history of accidental injury/ history of depressive disorders/ or history of anxiety. The study participants (both experimental subjects and their age-matched control) would be subjectively and objectively assessed for the presence of chronic low back pain. The Visual Analogue Scale would be used for subjective assessment of chronic low back pain. On the other hand, the “Pain Detect” tool was implemented for objective assessment of chronic low back pain.
Statistical Tests and Software
Different statistical measures would be implemented for analyzing the results of the study. Student’s test was conducted for comparison tests. The statistical tests for the present study were conducted with MS-excel software.
Research Questions and Hypothesis
The study evaluated 3 research questions. These questions are:
1st Research Question: Whether the prevalence of neuropathic pain is significantly higher in nurses compared to their age-matched controls?
H0= Prevalence of neuropathic pain is not significantly higher in nurses compared to their age-matched controls.
Ha= Prevalence of neuropathic pain is significantly higher in nurses compared to their age-matched controls.
2nd Research Question: Whether objective pain score is significantly higher in nurses?
H0= Objective pain score is not significantly higher in nurses.
Ha= Objective pain score is significantly higher in nurses.
Results

Fig 1: Indicates the prevalence of neuropathic pain amongst nurses and age-matched controls.

Fig 2: Indicates the objective pain score amongst nurses and age-matched controls.
Discussion and Conclusion
Fig 1 indicated that prevalence of neuropathic pain is significantly higher in nurses compared to their age-matched controls (p<0.001). Fig 2 indicated that the objective pain score is also significantly higher in nurses (p<0.001). Hence, the present study implicated that neuropathic pain is significantly higher in nurses compared to their age-matched controls. Moreover, objective categorization of pain through the Pain Detect tool was appropriate.
Nurses are faced with different challenges in their practice settings. Work related postural stress is one of the major challenges that are faced by nurses in their field of practice. Postural stress results from manual handling of patients, stress arising from therapeutic interventions and prolonged standing. Work-related musculoskeletal disorders are one of the major causes of chronic low back pain amongst professional nurses. WMSDs and CLBP are strongly associated with years of experience and professional workload. Apart from that, prolonged working periods and lack of appropriate work-rest cycles increase the risk of CLBP amongst professional nurses.
Work-related musculoskeletal disorders (WMSDs) are the major cause of chronic low back pain. WMSDs are strongly correlated with the frequency of work, intensity of work, duration of work and force applied for performing a work. Inflammatory mediators like substance P and prostaglandins are also responsible for the genesis of neuropathic pain. The liberation of inflammatory mediators decreases the threshold of pain in the adjacent nerves. The adjacent nerves become hypersensitive to sympathetic stimulation. Disc prolapse is another major cause of development of neuropathic pain. In disc prolapse, the nucleus palposus (present within the vertebra) moves inward onto the spinal cord. The compression of the spinal cord leads to the genesis of CLBP. On the other hand, nociceptive pain is caused due to stimulation of nociceptors (receptors responsible for pain sensation). These nociceptors are either visceral or somatic. Nociceptors are stimulated either due to postural stress or work-related (mechanical) stress.
The study indicated that nursing profession and years of employment are predisposing risk factors for the development of neuropathic pain. Suitable mitigation strategies should be implemented in practice settings to reduce the prevalence of neuropathic pain amongst staff nurses. Reduction of neuropathic pain may increase the productivity and efficiency of nursing professionals.

References
Eghbali M, Safari R, Nazari F, Abdoli S. (2012)The effects of reflexology on chronic low
back pain intensity in nurses employed in hospitals affiliated with Isfahan University of
Medical Sciences. Iran J Nurs Midwifery Res.  17(3),239-43.
Freynhagen R, Baron R. (2009) The evaluation of neuropathic components in low back pain.
Curr Pain Headache Rep.  13(3):185-90.
Ghadyani L, Tavafian SS, Kazemnejad A, Wagner J (2016)Development and Psychometric
Evaluation of Nursing Low Back Pain Predictor Questionnaire Focusing on Nurses
Suffering from Chronic Low Back Pain in Iran. Asian Spine J. 10(4),697-704
Yassi, A & Lockhart K. (2013) Work-relatedness of low back pain in nursing
personnel: a systematic review International Journal of Occupational and
Environmental Health 19(3), 223-244