CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION For nurses with low back pain and poor body posture, will a spinal training program (Back School), as compared to passive physiotherapy treatment, decrease pain intensity and improve body posture? Jaromi, M., Nemeth, A., Kranicz, J., Laczko, T. & Betlehem, J. (2012). Treatment and ergonomics training of work-related lower back pain and body posture problems for nurses. Journal of Clinical Nursing, 21(11-12), 1776 1784. http://dx.doi.org/10.1111/j.1365-2702.2012.04089.x CLINICAL BOTTOM LINE: The results of this randomized controlled trial, which included testing the efficacy of a structured intervention program for reducing back pain in nurses, show promise for reducing pain and improving body posture in health care professions. Results of the study indicated that both s of subjects tested reported and demonstrated significant improvement in back pain intensity reduction and improved body posture, although subjects in the experimental showed a more significant improvement overall. The experimental took part in ergonomic training with six sessions of follow-up training. The follow-up training included education on ergonomics, theory, workstation education, and lifting. In addition, subjects in the experimental engaged in redesigning their workstations and body strengthening that included musculature of the anterior thorax, lower extremity, back, shoulder, and abdomen. Occupational therapy and nursing, in particular, within the physical dysfunction practice can have similar responsibilities in regards to client handling and transferring. As indicated by Jaromi and colleagues (2012), the intervention of ergonomic training and Back School could be implemented as an in-service or other continuing education opportunity within a variety of physical dysfunction facilities in which occupational therapists are employed in efforts to prevent or remediate dysfunction in health care professionals. RESEARCH OBJECTIVE(S) List study objectives. To test the effectiveness, meaning the degree to which Back School aids in the relief of chronic back pain and improves posture in nurses when compared to other methods such as passive physiotherapy. 1
DESIGN TYPE AND LEVEL OF EVIDENCE: Level 1: Randomized controlled trial, including a 6-month and 12-month follow-up Limitations (appropriateness of study design): Was the study design type appropriate for the knowledge level about this topic? Circle yes or no, and if no, explain. SAMPLE SELECTION How were subjects selected to participate? Please describe. The subjects were randomly assigned to the control and the experimental. The subjects were nurses working in the inpatient clinics of the University of Pecs in Hungary; the exact method of recruitment was not reported. Inclusion Criteria Less than 60 years of age, having experienced more than 3 months of lower back pain with or without referred pain, and had an active diagnosis of chronic low back pain. Exclusion Criteria Pregnancy, previous spinal surgery, current nerve root entrapment with significant neurological deficit, spinal cord compression, tumors, structural deformities or severe instability, osteoporosis, inflammatory disease of the spine, spinal infection, severe cardiovascular or metabolic disorder, depression or connective tissue disorder (p. 1778). SAMPLE CHARACTERISTICS N= % Dropouts 11.7% #/ (%) Male 18 (16%) #/ (%) Female 93 (84%) Ethnicity NA Disease/disability diagnosis Chronic low back pain and body posture problems Check appropriate : <20/study 20 50/study 51 100/study 101 149/study 150 200/study INTERVENTION(S) AND CONTROL GROUPS Add s if necessary 2
Group 1: Control Brief Description This included 55 nurses (8 males, 47 female) who received passive control physiotherapy (electrical stimulation, heat therapy, massage and osteokinematic mobilization) Setting Who Delivered? Frequency? Duration? Group 2: Intervention Department of Orthopedics and the Institute of Physiotherapy at the University of Pecs in Hungary Physical therapists Once per week, 50-minute session 6 weeks Brief Description This included 56 nurses (10 males, 46 females) attended ergonomic training and Back School, which consists of both an educational and a skill component in which participants are taught about various aspects regarding the back and pain, then complete exercises targeted at strengthening the back and abdominal muscles. Setting Who Delivered? Frequency? Duration? Department of Orthopedics and the Institute of Physiotherapy at the University of Pecs in Hungary Physical therapists Once per week, 50-minute session 6 weeks Intervention Biases: Circle yes or no and explain,if needed. Contamination There is a possible contamination risk as all the subjects were recruited from the same hospital and have opportunities to encounter each other in the workplace. Co-intervention Timing Neither was given other therapies based on medical recommendations and were recommended to continue in their physical activity choices. Jaromi et al. (2012) indicated that the subjects leisure activities did not affect the interventions. Site 3
Use of different therapists to provide intervention The amount of therapists involved in the study was not reported. MEASURES AND OUTCOMES Complete for each relevant measure when answering the evidence-based question: Name of measure, what outcome was measured, whether the measure is reliable and valid (as reported in article yes/no/nr [not reported]), and how frequently the measure was used. Visual Analog Scale was used to assess pain intensity, spinal functions and level of impairment. The psychometric properties of the scale were not reported within the article. The measure was used prior to interventions, after the interventions were complete, and at both 6- and 12-month follow-up visits with a physical therapist. Name of measure, what outcome was measured, whether the measure is reliable and valid (as reported in article yes/no/nr [not reported]), and how frequently the measure was used. Zebris WinSpine three-dimensional ultrasonic biomechanical movement analysis system used to assess body posture and lumbar lordosis angle. The psychometric properties of the device were not reported within the article. The system was used prior to interventions, after the interventions were complete, and at both 6- and 12-month follow-up visits with a physical therapist. Measurement Biases Were the evaluators blind to treatment status? Circle yes or no, and if no, explain. In assessing body posture, therapists were not given information regarding the type of intervention the participants were receiving. Recall or memory bias. Circle yes or no, and if yes, explain. Others (list and explain): RESULTS List results of outcomes relevant to answering the focused question Include statistical significance where appropriate (p < 0.05) The results from this study indicated that subjects who participated both the Back School program and in passive physiotherapy demonstrated a statistically significant reduction in back pain at the conclusion of their respective 6 week program (p = 0.000) as measured by the Visual Analog Scale. Those subjects in Back School reported continued relief of pain at both the 6- (p = 0.000) and 12- (p = 0.000) week follow-up, which was not the case for those that participated in the passive physiotherapy program. 4
With regard to body posture and lumbar lordosis angle, subjects in the experimental (Back School) demonstrated statistically significant (p = 0.000) improvements in body posture and lumbar lordosis angle at all measurement times, including 6- and 12- week post-intervention. The control showed no statistically significant improvements in body posture or lumbar lordosis angle immediately after intervention, 6 or 12 weeks post-intervention. Was this study adequately powered (large enough to show a difference)? Circle yes or no, and if no, explain. Were appropriate analytic methods used? Circle yes or no, and if no, explain. Were statistics appropriately reported (in written or table format)? Circle yes or no, and if no, explain. CONCLUSIONS State the authors conclusions that are applicable to answering the evidence-based question. Jaromi et al. (2012) concluded that participation in the Back School programming resulted in a significant decrease in lower back pain and body postures problems when compared to passive physiotherapies. The authors also concluded that the information and techniques learned through participation in the Back School had long-term effects on the nurses perceived pain intensity and body posture as it relates to the diagnosis of lower back pain. This work is based on the evidence-based literature review completed by Renae H. Witta, OTS, Alyssa A. Jenkins, OTS, and Anne M. Haskins, PhD, OTR/L, Faculty Advisor, University of North Dakota in Grand Forks, ND. CAP Worksheet adapted from: Critical Review Form Quantitative Studies Law, M., Stewart, D., Pollack, N., Letts, L., Bosch, J., & Westmorland, M., 1998, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA.Contact: www.copyright.com 5