title: Early intervention for back-injured nurses at a large Canadian tertiary care hospital: an evaluation of the effectiveness and cost benefits of a two-year pilot project. Work factors as predictors of intense or disabling low back pain; a prospective study of nurses’ aides A study of work stress, patient handling activities and the risk of low back pain among nurses in Hong Kong. A dynamic 3D biomechanical evaluation of the load on the low back during different patient-handling tasks. Risk Factors for Work-Related Low Back Pain in Registered Nurses, and Potential Obstacles in Using Mechanical Lifting Devices Patient-Handling Skill, Back Injuries, and Back Pain: An Intervention Study in Nursing Dose-response relations between occupational exposures to physical and psychosocial factors and the risk of low back pain Biomechanical analysis of peak and cumulative spinal loads during simulated patient-handling activities: a substudy of a randomized controlled trial to prevent lift and transfer injury of health care workers. The role of causal criteria in causal inferences: Bradford Hill's "aspects of association" Electromyography as a measure of peak and cumulative workload in intermediate care and its relationship to musculoskeletal injury: an exploratory ergonomic study. Evaluation of a program to reduce back pain in nursing personnel. Patient handling with and without slings: an analysis of the risk of injury to the lumbar spine. Personal risk factors for first-time low back pain. Back pain and associated factors in French nurses The accident process preceding overexertion back injuries in nursing personnel. PROSA study group. New low back pain in nurses: work activities, work stress and sedentary lifestyle. Workplace Prevention and Musculoskeletal Injuries in Nurses The secondary prevention of low back pain: a controlled study with follow-up Work related characteristics of back and neck pain among employees of a Swiss University Hospital. Personal and job-related factors as determinants of incidence of back injuries among nursing personnel. The role of physical workload and pain related fear in the development of low back pain in young workers: evidence from the BelCoBack Study; results after one year of follow up Primary Prevention of Back Symptoms and Absence from Work: A Prospective Randomized Study Among Hospital Employees Biomechanical evaluation of assistive devices for transferring residents. Identification of Modifiable Personal Factors That Predict New-onset Low Back Pain: A Prospective Study of Female Nursing Students A Randomized Controlled Trial to Prevent Patient Lift and Transfer Injuries of Health Care Workers Flexion and Rotation of the Trunk and Lifting at Work Are Risk Factors for Low Back Pain: Results of a Prospective Cohort Study Physical and psychosocial risk factors for musculoskeletal disorders in New Zealand nurses, postal workers and office workers Reducing back stress to nursing personnel: an ergonomic intervention in a nursing home. A comprehensive analysis of low-back disorder risk and spinal loading during the transferring and repositioning of patients using different techniques. Prospective cohort study of predictors of incident low back pain in nurses Isokinetic Lifting Strength and Occupational Injury: A Prospective Study Manual handling activities and risk of low back pain in nurses. The GRADE approach and Bradford Hill's criteria for causation
abstract: This study evaluated a two-year multidisciplinary early intervention pilot programme for back-injured nurses employed at a large teaching hospital , using a pre- versus post-programme analysis . The purpose was to ascertain whether this programme could reduce the incidence , morbidity , time lost and cost due to  back injuries in the 250 nurses employed on ten targeted high-risk wards . Injuries in the remaining 1395 nurses employed on the other 45 wards were monitored concurrently for comparison . The programme consisted of prompt assessment , treatment and rehabilitation through modified work . Evaluative data were gathered by one research nurse on st and ardized forms at the time of injury , weekly until return to work , and at a six-month follow-up . Time lost and cost data for up to one-year post-injury were derived from workers ' compensation statements . Compared to the two years prior to introduction of the programme , the rates of back injuries and lost-time back injuries decreased by 23 % and 43 % , respectively , on the targeted wards , while these increased on the control wards . Combined expenditure was 32 % lower per injury and 34 % lower per lost-time injury for those in the targeted group who consented to take part in the programme compared to their counterparts on the control wards , as the increased assessment and treatment costs per case attributable to the programme were more than offset by the savings in lower compensation ( wage loss ) costs . This programme thus reduced the incidence and time lost due to back injuries and was cost-beneficial Aims : To identify the work factors that predict  intense low back pain ( LBP ) and LBP related sick leaves in nurses ’ aides . Methods : The sample comprised 4266 r and omly selected Norwegian nurses ’ aides , not bothered or only a little bothered by LBP during the previous three months , and not on sick leave when completing a mailed question naire in 1999 . Of these , 3808 ( 89.3 % ) completed a second question naire 3 months later and 3651 ( 85.6 % ) completed a third question naire 15 months later . Intensity of low back symptoms and certified sick leaves attributed to LBP during the observation period were assessed by self reports at the follow ups . Results : After adjustments for LBP during the three months prior to baseline , baseline health complaints , demographic and familial factors , and a series of physical , psychological , and social work factors , logistic regression analyses revealed the following associations : intense low back symptoms were predicted by frequent positioning of patients in bed , perceived lack of support from immediate superior , and perceived lack of pleasant and relaxing culture in the work unit . LBP related sick leaves were predicted by frequent h and ling of heavy objects , medium level of work dem and s , perceived lack of supportive and encouraging culture in the work unit , working night shifts , and working in a nursing home . Long term LBP related sick leaves were associated with changes of work or work tasks during the observation period that result ed in a perceived reduction of support and encouragement at work . Conclusions : Not only frequent mechanical exposures , but also organisational , psychological , and social work factors , such as night shift work , perceived lack of support from superior , and perceived lack of a pleasant and relaxing or supporting and encouraging culture in the work unit , are associated with an increased risk of intense low back symptoms and LBP related sick leaves in nurses ’ aides RATIONALE Low back pain ( LBP ) remains a common and costly problem among the nursing profession . Several studies have indicated that LBP is attributed to mentally straining or dem and ing work , fatigue or exhaustion or general work satisfaction . AIMS This study aims to measure the magnitude of LBP among Hong Kong nurses and its association with the work-related psychological strain and patients h and ling activities . RESEARCH METHODS AND MEASURES : A cross-sectional study of Hong Kong hospital nurses was conducted . Three hundred and seventy-seven nurses were recruited from six district hospitals . They were registered nurses or enrolled nurses working full-time for at least 1 month in the current ward . One hundred and seventy-eight ( 47.2 % ) study subjects were r and omly selected from two district hospitals and 199 ( 52.8 % ) study nurses made up the convenience sample . Possible bias from psychological distress , socio-demographics and lifestyle factors was controlled for . Data were collected by face-to-face interviews . The data included work factors ( both psychological stress and patient h and ling activities related to work ) , demographics , psychological distress and lifestyle factors and the occurrence of LBP . RESULTS 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 [ adjusted odds ratio ( OR ) 2.07 ] , where frequent manual repositioning of patients on the bed was required ( adjusted OR 1.84 ) and where they were required to assist patients while walking ( adjusted OR 2.11 ) after adjustment for other potential confounders . CONCLUSION The results indicate that an association exists between work stress , manual lifting and LBP prevalence . The main route to prevention of LBP among nurses is likely to lie in improved ergonomics and psychological health in their work place . Good posture and correct transferring techniques in ward situations should be reinforced with h and s-on practice performed on nurses ' common types of clients The objective of this study was to investigate the low-back loading during common  patient-h and ling  tasks . Ten female health care workers without formal training in patient h and ling performed nine patient-h and ling tasks including turning , lifting and repositioning a male stroke patient .  The low-back loading was quantified by net moment , compression , and shear forces at the L4/L5 joint , measured muscle activity ( EMG ) in erector spinae muscles and rate of perceived exertion ( RPE ; Borg scale ) . The experiments were videotaped with a 50Hz video system using five cameras , and the ground and bedside reaction forces of the health care worker were recorded by means of force platforms and force transducers on the bed . The biomechanical load was calculated using a dynamic 3D seven-segment model of the lower part of the body , and the forces at the L4/L5 joint were estimated by a 14 muscles cross-sectional model of the low back ( optimisation procedure ) . Compression force and torque showed high task dependency whereas the EMG data and the RPE values were more dependent on the subject . The peak compression during two tasks involving lifting the patient ( 4132/4433N ) was significantly higher than all other tasks . Four tasks involving repositioning the patient in the bed ( 3179/3091/2932/3094N ) did not differ , but showed higher peak compression than two tasks turning the patient in the bed ( 1618/2197N ) . Thus , in this study the patient-h and ling tasks could be classified into three groups-characterised by lifting , repositioning or turning-with different levels of peak net torque and compression at the L4/L5 joint Back pain disability is a serious and costly problem affecting the nursing profession . The purpose s of this study were to determine risk factors for  work-related low back pain ( WRLBP ) in registered nurses and to record the reported use or reasons for nonuse of mechanical lifts . Our hypothesis was that workers who attributed the cause of WRLBP to their own actions would be knowledgeable about back safety , would be more likely to use lifts , and would report less WRLBP . A r and om sample of 270 registered nurses was selected from two acute care hospitals in central Illinois to identify WRLBP risk factors . This cross-sectional study gathered information on individual , physical workload , psychological , and organizational factors that may present a risk for WRLBP . Information was also collected on the use of  safety devices and back pain symptoms . The response rate was 50.4 % . Nearly 84 % of respondents had  WRLBP  in the past , and 36.2 % had WRLBP in the past year that limited movement or interfered with routine activities . Among the risk factors significantly associated with WRLBP were more years worked in nursing , frequent lifting , and low social support . Only 11 % reported that they routinely used mechanical lifting devices , and the primary reason given for failure to use lifting equipment was unavailability of equipment . The reasons for the lack of use of mechanical lifts should be investigated and addressed The aim of this Intervention was to evaluate the effect of training on patient-h and ling skills and prospect ively to assess the effect of skill on subsequent back pain and back injuries  in nursing . Of a total of 255 nurses , 199 were assessed for their skill in patient-h and ling .  One-half (  control  group ) received traditional training in patient-h and ling , and the other half ( trained group ) received a curriculum of instruction totaling 40 hours . The skills of both groups were assessed on graduation . The control group was rated as less competent in patient-h and ling .  Nurses in both groups were question ed about the prevalence of back pain and incidence of back injuries in the first year after graduation . In multiple regression analysis , the major risk Indicators for back injuries were poor patient-h and ling skill , low numbers of repetitions in the sit-up test , and high work-load scores . High score on the hysteria scale of Middlesex Hospital Question naire was a risk Indicator for all kinds of back pain . Though back pain was Independent of patient-h and ling skill , those rated as “ bad ” or “ poor ” had more back injuries ( 24 % ) than those who had been rated as “ good ” or “ excellent ” ( 2 % ) ( P < 0.001 ) , but the difference between the trained and control groups was not statistically significant . It was concluded that back Injuries may be prevented by the teaching of patient-h and ling skills Aims : To assess dose-response relations between occupational exposures to physical and psychosocial factors and the risk of  low back pain .  Methods : A cohort of 523 subjects , working in nursing homes and homes for the elderly , was followed prospect ively for one year . Physical load for different occupations was assessed by quantitative observations at the workplace . Information on low back pain and other factors was gathered with question naires administered at baseline and at one year . Two outcome measures of low back pain incidence were used : any new episode of pain lasting for at least a few hours during follow up ( LBP ) ; and any new episode of disabling pain that interfered with daily activities during follow up ( LBP/D ) . Hierarchical regression analysis with a spline function was used to estimate dose-response relations . Results : The risk of LBP was not associated with physical factors , controlling for confounders ; but this outcome was inversely associated with age and weakly , though imprecisely , associated with two psychosocial factors — low decision authority and high work dem and s. In contrast , the risk of LBP/D was positively associated with age and not associated with the psychosocial factors . Trunk flexion over 45 degrees was monotonically associated with the risk of LBP/D ; the estimated relative risk was 3.18 ( 95 % CI 1.13 to 9.00 ) for 1 hour and 45 minutes of bending per week ( 90th centile ) , relative to 30 minutes per week . The hierarchical estimates of effect were more stable than were the maximum likelihood estimates . Conclusion : Occupational exposure to trunk flexion over 45 degrees appears to be a risk factor for low back pain with disability among persons employed in nursing homes and homes for the elderly in the Netherl and Back injuries are a serious problem for nursing personnel who perform frequent patient-h and ling activities . Common prevention strategies include body mechanics education , technique training , and ergonomic interventions such as the introduction of assistive equipment . This investigation assessed and compared the effectiveness of two patient-h and ling approaches to reducing injury risk . One strategy involved using improved patient-h and ling technique with existing equipment , and the other approach aim ed at eliminating manual patient h and ling through the use of additional mechanical and other assistive equipment . Both intervention arms received training in back care , patient assessment , and use of the equipment available on their particular wards . An analysis of compliance with interventions and the effects of patient-h and ling methods on both peak and cumulative spinal compression and shear during various tasks was conducted . Results showed greater compliance with interventions that incorporated new assistive patient-h and ling equipment , as opposed to those consisting of education and technique training alone . In several tasks , subjects who were untrained or non-compliant with interventions experienced significantly higher peak spinal loading . However , patient-h and ling tasks conducted with the aid of assistive equipment took substantially longer than those performed manually . This , along with variations in techniques , led to increases in cumulative spinal loading with the use of patient-h and ling equipment on some tasks . Thus , the use of mechanical assistive devices may not always be the best approach to reducing back injuries in all situations . No single intervention can be recommended ; instead all patient-h and ling tasks should be examined separately to determine which methods maximize reductions in both peak and cumulative lumbar forces during a manoeuver As noted by Wesley Salmon and many others , causal concepts are ubiquitous in every branch of theoretical science , in the practical disciplines and in everyday life . In the theoretical and practical sciences especially , people often base cl aims about causal relations on applications of statistical methods to data . However , the source and type of data place important constraints on the choice of statistical methods as well as on the warrant attributed to the causal cl aims based on the use of such methods . For example , much of the data used by people interested in making causal cl aims come from non-experimental , observational studies in which r and om allocations to treatment and control groups are not present . Thus , one of the most important problems in the social and health sciences concerns making justified causal inferences using non-experimental , observational data . In this paper , I examine one method of justifying such inferences that is especially widespread in epidemiology and the health sciences generally – the use of causal criteria .  I argue that while the use of causal criteria is not appropriate for either deductive or inductive inferences , they do have an important role to play in inferences to the best explanation . As such , causal criteria , exemplified by what Bradford Hill referred to as " aspects of [ statistical ] associations " , have an indispensible part to play in the goal of making justified causal cl aims Injury rates in Intermediate Care ( IC ) facilities are high and the factors related to these injuries are unclear . The objectives of this exploratory sub- study , which is part of a large multi-faceted study in 8 IC facilities are to : ( 1 ) evaluate  EMG measured over a full-shift in the back and shoulders of 32 care aides ( CAs ) as an indicator of peak and cumulative workload ( n = 4 x 8 facilities ) ; investigate the relationship between EMG measures and injury indicators ; and explore the relationship between EMG measures and other workload measurements . Lumbar EMG  was converted to predicted cumulative spinal compression  and ranged in CAs from 11.7 to 22.8 MNs with a mean of 16.4 MNs . Average compression was significantly different during different periods of the day ( p < 0.001 ) with highest compression during pre-breakfast when CAs assist most with activities of daily living . Significant differences were found in average compression between low and high injury facilities for 3 of 5 periods of the day ( p < 0.010 ) . Peak compressions exceeding 3400 N occurred for very little of the workday ( e.g. 11.25s during the 75 min period pre-breakfast ) . Peak neck/shoulder muscle activity is low ( 99 % APDF ranged from 8.33 % to 28 % MVC ) . Peak and cumulative spinal compression were significantly correlated with lost-time and musculoskeletal injury rates as well as with total tasks observed in the CAs ( p < 0.01 ) . Perceived exertion was only correlated with peak compressions ( p < 0.01 ) . Facilities with low injury rates provided significantly more CAs ( p < 0.01 ) to meet resident needs , and subsequently CAs performed fewer tasks , result ing in less peak and cumulative spinal loading over the day OBJECTIVE To evaluate the effectiveness of a program design ed to reduce back pain in nursing aides . METHODS Female nursing aides from a university hospital who had suffered episodes of back pain for at least six months were included in the study . Participants were r and omly divided into a control group and an intervention group . The intervention program involved a set of exercises and an educational component stressing the ergonomic aspect , administered twice a week during working hours for four months . All subjects answered a structured question naire and the intensity of pain was assessed before and after the program using a visual analogue scale ( VAS ) . Student 's t-test or the Wilcoxon Rank Sum Test for independent sample s , and Chi-square test or the Exact Fisher test for categorical analysis , were used . The McNemar test and the Wilcoxon matched pairs test were used to compare the periods before and after the program . RESULTS There was a statistically significant decrease in the frequency of cervical pain in the last two months and in the last seven days in the intervention group . There was also a reduction in cervical pain intensity in the two periods ( 2 months , 7 days ) and lumbar pain intensity in the last 7 days . CONCLUSIONS The results suggest that a program of regular exercise with an emphasis on ergonomics can reduce musculoskeletal symptoms in nursing personnel Health professionals h and ling patients are known to be at risk of sustaining work related low back injuries . It is not known whether the use of lifting slings reduces the risk of injury to the lumbar spine for patient h and lers . This study used kinematic variables and subjective ratings of body part stress and lifter preference as measures of relative risk for three two-person techniques for carrying a patient from one chair to another chair . The techniques used no slings , one and two slings respectively .  Twenty-two nurses performed five trials each of the three techniques . Kinematic measures of angular displacement , velocity and acceleration were obtained using the lumbar motion monitor and visual analogue scales were used to obtain measures of body part stress for seven body parts . Angular displacement , velocity and acceleration were significantly greater ( p < 0.05 ) in the frontal , sagittal and transverse planes for the no sling technique compared to techniques using slings . Comparatively small yet significant differences between techniques using slings were recorded for sagittal flexion and rotation . There was no significant difference between one and two sling techniques for other dependent variables . Mean total body stress rating was higher for the no sling technique and all subjects indicated that their first preference was for slings . Although all three measures of risk rated the no sling technique as carrying a higher level of risk than the techniques using slings . No single measure adequately captured all aspects of relative risk . The elimination of manual patient h and ling is thought to be the best option for the reduction of work related back injuries in patient h and lers . Where re sources or technology are not yet adequate to provide practical alternatives and where the use of manual technique for a seat to seat task is unavoidable , the use of patient h and ling slings will reduce the risk STUDY DESIGN A prospect i ve study of personal risk factors for first-time low back pain . OBJECTIVES To construct and vali date a multivariate model to predict low back pain . SUMMARY OF BACKGROUND DATA Various physical and psychological factors have been reported to increase the risk of low back pain , but conflicting results may be attributable to inaccurate " clinical " measures and to poorly vali date d statistical models . METHODS A total of 403 health care workers aged 18 - 40 years volunteered for the study . None had any history of " serious " back pain requiring medical attention or time off work . The volunteers completed the following question naires : the modified somatic perception question naire , the Zung depression scale , and the Health Locus of Control .  Anthropometric factors were quantified using st and ard techniques . The 3Space Isotrak device ( Polhemus , VT ) was used to measure lumbar curvature and hip and lumbar spine mobility . Leg and back strength and back muscle fatiguability were measured in functional postures . Postal follow-up question naires , sent after 6 , 12 , 18 , 24 , 30 , and 36 months , inquired about back pain , and multivariate logistic regression was used to identify risk factors at each follow-up . RESULTS The response rate fell from 99 % at 12 months to 90 % at 36 months , at which time 90 volunteers reported " serious " back pain and 266 reported " any " back pain . The following were consistent predictors of serious back pain : reduced range of lumbar lateral bending , a long back , reduced lumbar lordosis , increased psychological distress , and previous nonserious low back pain . Only the latter three were consistent predictors of " any " back pain . Physical factors had the most influence in a sub- population of volunteers who were new to the job . CONCLUSIONS Personal risk factors explained up to 12 % of first-time low back pain The aim of this study was to assess , in a prospect i ve cohort of nurses , the risk factors associated with six back pain indicators : back pain ( BP ) , chronic or recurring BP ( occurring often or lasting for more than 3 months ) ,  cervical ( CP )  ,  dorsal ( DP ) and lumbar ( LP ) pain and medical treatment for BP . In 1980 , a sample of 469 nurses was r and omly selected from six public sector hospitals . They were followed up and interviewed in 1980 , 1985 and 1990 .  BP indicators  were assessed on the basis of the nurses ' self-reports during the 12 months before question naire administration in 1990 . The data collected were subjected to cross-sectional analysis in 1990 , to study the associations between the six BP indicators and the risk factors . In a longitudinal analysis , the 1990 BP indicators were analysed in relation to the risk factors present in 1985 among the 210 nurses who were still working in hospitals in 1990 and had not suffered from musculoskeletal disorders ( MSDs ) between 1980 and 1985 . Of the 310 nurses still working in hospitals in 1990 , 57.9 % had suffered from BP within the previous 12 months , 23.6 % of them from CP , 23.0 % from DP and 41.1 % from LP , 40.5 % had suffered from chronic or recurring BP , 31.1 % had undergone treatment and 7.4 % had taken sick leave for BP . In 1990 , BP accounted for 35.8 % of the total number of days of sick leave . The results of the 1990 cross-sectional analysis showed that : ( a ) BP was more frequent among nurses who smoked , experienced symptoms of psychological disorders and had reported stressful factors relating to physical work load ; ( b ) chronic or recurring BP was associated with symptoms of psychological disorders ; ( c ) the frequency of CP increased with age and previous MSDs ; ( d ) DP was more frequent among nurses with children under 3 years and was related to tobacco consumption ; ( e ) LP was associated with symptoms of psychological disorders and physical work load ; and ( f ) treatment for BP was related to symptoms of psychological disorders and fewer of the nurses treated for BP practised a sport . The logistic regressions of the 1985 - 90 longitudinal analysis showed that : ( a ) age was associated with CP ; ( b ) psychosocial factors at work were related to CP ; ( c ) physical work load was associated with chronic or recurring BP ; ( d ) tobacco consumption increased the frequency of BP and DP ; and ( e ) commuting time to work ( ⩾ 1 h/day ) was associated with CP and LP . These results underline the importance of age , tobacco consumption , commuting time to work and work load in the occurrence of BP and also of longitudinal studies in investigating the factors associated with musculoskeletal disorders OBJECTIVES This prospect i ve dynamic- population -based study investigated factors involved in the accident process preceding overexertion back injuries  among nursing personnel . METHODS The study covered all reported occupational overexertion back injuries due to accidents among of the approximately 24 500 nurses in the Stockholm County hospitals during 1 year . It was assumed that several factors interact in the accident process . Detailed information was obtained for each injury by interviews with the injured nurse and head nurse . Risks in the physical environment were identified using an ergonomic checklist . RESULTS During the study 136 overexertion back injuries were reported . Of the 130 nurses participating in the study , 125 had been injured in connection with patient work . Cluster analysis yielded 6 clusters and their pattern of contributing factors . The most frequent injury occurred during patient transfer in the bed or to or from the bed , without the use of transfer devices , when the patient suddenly lost his or her balance or resisted during the transfer and the nurse had to make a sudden movement . However , there were physical conditions , such as shortcomings in the physical work environment or a lack of a transfer device , that compelled the nurses to perform the tasks under unsafe conditions . CONCLUSIONS The clusters showed a complexity of different kinds of accidents and indicated that the measures for preventing accidents , or for blocking an accident process once started , have to be of different kinds and placed at several different levels in the organization of a workplace BACKGROUND Low back pain is common among nurses . Previous studies have shown that the risk of low back pain increases rapidly with greater amounts of physical work and psychological stress , but is inversely related to leisure activities . However , these previous studies were predominantly retrospective in design and not many took account of three factors simultaneously . AIMS This 12-month prospect i ve study examined the relationships between work activities , work stress , sedentary lifestyle and new low back pain . METHODS A total of 144 nurses from six Hong Kong district hospitals completed a face-to-face baseline interview , which was followed-up by a telephone interview . The main study measures were demographic characteristics , work activities , work stress , physical leisure activities and the nature of new low back pain during the 12-month follow-up period . Level of work stress , quality of relationships at work , level of enjoyment experienced at work , and work satisfaction were self-reported . RESULTS Fifty-six ( 38.9 % ) nurses reported experiencing new low back pain . Sedentary leisure time activity was not associated with new low back pain . Being comparatively new on a ward ( adjusted relative risk 2.90 ) , working in bending postures ( adjusted relative risk 2.76 ) and poor work relationships with colleagues ( adjusted relative risk 2.52 ) were independent predictors of new low back pain . CONCLUSION The findings of this study suggest that low back pain is a common problem in the population of nurses in Hong Kong . Being comparatively new on a ward , bending frequently during work and having poor work relationships with colleagues are independent predictors of new low back pain . Training for high-risk work activities and ergonomic assessment of awkward work postures are essential . Moreover , relaxation and team-building workshops for nurses , especially those who are less experienced in the type of work on their current ward , are recommended Objective The purpose of this study was to describe the availability of preventive devices and training in relation to neck , shoulder , and back musculoskeletal injuries/disorders ( MSD ) in registered nurses . Summary background data Nurses have one of the highest rates of MSD of any occupation . Studies have shown that mechanical lifting devices and lifting teams can reduce MSD rates and associated costs . Methods Data from 1163 r and omly selected currently working nurses ( 1 + years on the current job ) were collected in anonymous mailed surveys ( 74 % response rate ) . MSD cases had neck , shoulder , and /or back symptoms for at least 1 week , or at least monthly , and moderate or more pain , in the past year . Results Nurses with mechanical lifting devices available were significantly less likely to have neck or back MSDs . Back injury was less likely when lifting teams were available . However , adjustable beds and transfer sheets were associated with greater odds of back MSD . Training in workstation adjustment was associated with significantly lower MSD prevalence , though postural training was not . Conclusions Though use of mechanical devices and lifting teams was limited in nursing workplaces , these prevention strategies were related to reduced odds of MSD . Nursing administrators can use these findings to consider workplace changes & NA ; The current investigation studied the effectiveness of a secondary prevention program for nurses with back pain who were deemed at risk for developing a chronic problem . A 2 × 3 repeated measures design was employed with 2 groups and 3 assessment periods . The treatment group received an intervention design ed to reduce current problems , but above all to prevent reinjury and minor pains from becoming chronic medical problems , and it included a physical and behavioral therapy package . The control group was placed on a waiting‐list . Results indicated that the treatment group had significantly greater improvements than the control group for pain intensity , anxiety , sleep quality and fatigue ratings , observed pain behavior , activities , mood , and helplessness . These differences were generally maintained at the 6 month follow‐up . In addition , the treatment group broke a trend for increasing amounts of pain‐related absenteeism , while the control group did not . Taken as a whole , the results suggest that a secondary prevention program aim ed at altering life style factors may represent an effective method for dealing with musculoskeletal pain problems OBJECTIVES 1 ) To explore the staff- and work-related risk factors for spinal pain among hospital employees , 2 ) to investigate the effect of staff- and work-related variables on the consequences of spinal pain , such as doctor visits and sick leave . METHODS A mailed survey was carried out in a r and om sample of 2700 employees stratified for occupational categories ( administration staff , nurses , nurse assistants , physicians , support staff and allied health professionals ) . The question naire measured self-reported spinal pain , consequences of pain , and work characteristics . RESULTS The response rate was 48.1 % ( 1298/2700 ) . The one-year prevalence of spinal pain was 67.3 % , highest among nurses ( 75.6 % ) and lowest among support staff ( 54.9 % ) . Reported work characteristics associated with spinal pain included frequent work at a poorly adapted work station ( odds ratio ( OR ) 1.90 [ 1.24 - 2.93 ] ) and having to maintain a position for a long time ( OR 1.71 [ 1.25 - 2.34 ] ) . No significant correlations were observed with lifting , patient h and ling , material h and ling , or working on nightshift . Sickness leave due to spinal pain was significantly associated with duration of pain episode ( OR 4.08 for>3 months compared to less than 10 days ) , and with work categories ( OR 2.58 for nurse assistants compared to nurses ) . CONCLUSION In this population of hospital employees , being a nurse , working at a poorly adapted work place , and having to maintain positions for a long time were related independently to spinal pain . Nurse assistants had a higher risk of work absenteeism The purpose of this multicenter prospect i ve cohort study was to assess personal and job-related factors as determinants of incidence of reported  back injuries among nurses . The study population included 5,649 nurses who were surveyed by question naire  and then observed for a 12-month study period . An annual injury rate of 4.9 % was observed . Four factors were found to be significant ( P less than .01 ) predictors of back injury . All four factors -- service area , lifting , job category , and previously reported back injury -- maintain significance when a forward stepping model of logistic regression is applied . The adjusted odds ratios observed are 4.26 for service areas where lifting occurs most as compared with areas where lifting occurs least ; 2.19 for daily lifters v light , occasional , and nonlifters ; 1.77 for nursing aides v registered nurses and supervisory personnel ; and 1.73 for individuals who have previously reported back injury v those who have not reported previous injury . These findings strongly suggest that job-related rather than personal characteristics are the major predictors of back injury in nurses Aims : To study the influence of work related physical and psychosocial factors and individual characteristics on the occurrence of  low back pain among young and pain free workers . Methods : The Belgian Cohort Back Study was design ed as a prospect i ve cohort study . The study population of this paper consisted of 716 young healthcare or distribution workers without low back pain lasting seven or more consecutive days during the year before inclusion . The median age was 26 years with an interquartile range between 24 and 29 years . At baseline , these workers filled in a question naire with physical exposures , work related psychosocial factors and individual characteristics . One year later , the occurrence of low back pain lasting seven or more consecutive days and some of its characteristics were registered by means of a question naire . To assess the respective role of predictors at baseline on the occurrence of low back pain in the following year , Cox regression with a constant risk period for all subjects was applied . Results : After one year of follow up , 12.6 % ( 95 % CI 10.1 to 15.0 ) of the 716 workers had developed low back pain lasting seven or more consecutive days . An increased risk was observed for working with the trunk in a bent and twisted position for more than two hours a day ( RR 2.2 , 95 % CI 1.2 to 4.1 ) , inability to change posture regularly ( RR 2.1 , 95 % CI 1.3 to 3.5 ) , back complaints in the year before inclusion ( RR 1.7 , 95 % CI 1.1 to 2.8 ) , and high scores of pain related fear ( RR 1.8 , 95 % CI 1.0 to 3.1 ) . Work related psychosocial factors and physical factors during leisure time were not predictive . Conclusion : This study highlighted the importance of physical work factors and revealed the importance of high scores of pain related fear in the development of low back pain among young workers The personnel at a geriatric hospital were r and omized into two groups . One group was allowed to exercise during working hours to improve back muscle strength , endurance , and coordination . The other group did not participate in the exercise program and received no further advice or information . After 13 months , the training group had increased back muscle strength . One subject had been absent from work 28 days in the training group whereas 12 subjects had been absent 155 days from work because of low back pain in the control group ( P<0.004 ) . The back pain complaints and intensity of back pain in the training group also decreased in a statistically significant way . Every hour spent by the physiotherapist on the training group reduced the work absence among the participants by 1.3 days , result ing in a cost/benefit ratio greater than 10 This is the first of two articles to report a biomechanical evaluation and psychophysical assessment of nine battery-powered lifts , a sliding board , a walking belt , and a baseline manual method for transferring nursing home residents from a bed to a chair . The objectives of the biomechanical evaluation were : ( 1 ) to investigate the effects of transfer method and resident weight on the biomechanical stress to nursing assistants performing the transferring task , and ( 2 ) to identify  resident-transferring methods that could reduce the biomechanical stress to the nursing assistants . Nine nursing assistants served as test subjects ; two elderly persons participated as residents . A four-camera motion analysis system , two force platforms , and a three-dimensional biomechanical model were used to measure biomechanical load . The results indicate that transfer method and resident weight affect a nursing assistant 's low-back loading . The basket-sling and overhead lift devices significantly reduced the nursing assistants ' back-compressive forces during the preparation phase of a resident transfer . In addition , the use of basket-sling , overhead , and st and -up lifts removed about two-thirds of the exposure to low-back stress ( lifting activities per transfer ) as compared to the baseline manual method . Thus , the use of these devices reduces biomechanical stress , and thereby will decrease the occurrence of  resident-h and ling-related low-back injuries . Furthermore , lifting device maneuvering forces were found to be significantly different and a number of design /use problems were identified with various assistive devices . The second article will detail the psychophysical assessment of the same resident-transferring methods Objectives Prevention of occupational low back pain ( LBP ) in nurses is a research priority . Recent research suggests intervening before commencing nursing employment is ideal ; however , identification of modifiable risk factors is required . The objective of this study was to investigate modifiable personal characteristics that predicted new-onset LBP in nursing students . Methods This prospect i ve study was conducted on female nursing students ( n=117 ) without LBP at baseline to predict new-onset LBP ( an episode of significant LBP during the follow-up period ) . At the 12-month follow-up , participants with ( n=31 ) and without new-onset LBP ( n=76 ) were compared across baseline social or lifestyle , psychologic ( distress , back pain beliefs , coping strategies , and catastrophising ) , and physical ( spinal postures and spinal kinematics in functional tasks , leg and back muscle endurance , spinal repositioning error , and cardiovascular fitness ) characteristics . Results Participants response rate at follow-up was excellent ( 91 % ) . After controlling for earlier LBP , age , and BMI , regression analysis showed that modifiable social or lifestyle , psychologic and physical characteristics ( namely , smoking , increased physical activity , higher stress , reduced back muscle endurance , greater posterior pelvic rotation in slump sitting , and more accurate spinal repositioning in sitting ) were significant and independent predictors of new-onset LBP at follow-up . Inclusion of these factors in multivariate logistic regression analysis , with significant new-onset LBP as the outcome , result ed in a substantial model R2 of 0.45 . Discussion Modifiable personal characteristics across multiple domains are associated with new-onset LBP in female nursing students . These findings may have implication s for the development of prevention and management interventions for LBP in nurses Study Design . R and omized controlled trial ( RCT ) . Objectives . To compare the effectiveness of training and equipment to reduce musculoskeletal injuries , increase comfort , and reduce physical dem and s on staff performing patient lifts and transfers at a large acute care hospital . Summary of Background Data . Back injury to nursing staff during patient h and ling tasks is a major issue in health care . The value of mechanical assistive devices in reducing injuries to these workers is unclear . Methods . This three-armed RCT consisted of a “ control arm , ” a “ safe lifting ” arm , and a “ no strenuous lifting ” arm .  A medical , surgical , and rehabilitation ward were each r and omly assigned to each arm . Both intervention arms received intensive training in back care , patient assessment , and h and ling techniques . Hence , the “ safe lifting ” arm used improved patient h and ling techniques using manual equipment , whereas the “ no strenuous lifting ” arm aim ed to eliminate manual patient h and ling through use of additional mechanical and other assistive equipment . Results . Frequency of manual patient h and ling tasks was significantly decreased on the “ no strenuous lifting ” arm . Self-perceived work fatigue , back and shoulder pain , safety , and frequency and intensity of physical discomfort associated with patient h and ling tasks were improved on both intervention arms , but staff on the mechanical equipment arm showed greater improvements . Musculoskeletal injury rates were not significantly altered . Conclusions . The “ no strenuous lifting ” program , which combined training with assured availability of mechanical and other assistive patient h and ling equipment , most effectively improved comfort with patient h and ling , decreased staff fatigue , and decreased physical dem and s. The fact that injury rates were not statistically significantly reduced may reflect the less sensitive nature of this indicator compared with the subjective indicators Study Design . A 3-year prospect i ve cohort study among workers of 34 companies in the Netherl and s. Objectives . To investigate the relation between flexion and rotation of the trunk and lifting at work and the occurrence of low back pain . Summary of Background Data . Previous studies on work-related physical risk factors for low back pain either lacked quantification of the physical load or did not take confounding by individual and psychosocial factors into account . Methods . The study population consisted of 861 workers with no low back pain at baseline and complete data on the occurrence of low back pain during the 3-year follow-up period . Physical load at work was assessed by means of analyses of video-recordings . Information on other risk factors and the occurrence of low back pain was obtained by means of self-administered question naires . Results . An increased risk of low back pain was observed for workers who worked with the trunk in a minimum of 60 ° of flexion for more than 5 % of the working time ( RR 1.5 , 95 % CI 1.0–2.1 ) , for workers who worked with the trunk in a minimum of 30 ° of rotation for more than 10 % of the working time ( RR 1.3 , 95 % CI 0.9–1.9 ) , and for workers who lifted a load of at least 25 kg more than 15 times per working day ( RR 1.6 , 95 % CI 1.1–2.3 ) . Conclusions . Flexion and rotation of the trunk and lifting at work are moderate risk factors for low back pain , especially at greater levels of exposure Objective To investigate the association of physical and psychosocial risk factors with musculoskeletal disorders ( MSDs ) in New Zeal and nurses , postal workers and office workers . Design A cross-sectional postal survey asking about demographic , physical and psychosocial factors and MSDs . Participants A total of 911 participants was r and omly selected ; nurses from the Nursing Council of New Zeal and data base ( n=280 ) , postal workers from their employer 's data base ( n=280 ) and office workers from the 2005 electoral roll ( n=351 ) . Outcome Measures Self-reported pain in the low back , neck , shoulder , elbow , wrist/h and or knee lasting more than 1 day in the month before the survey . Results The response rate was 58 % , 443 from 770 potential participants . 70 % ( n=310 ) reported at least one MSDs . Physical work tasks were associated with low back ( odds ratio ( OR ) 1.35 , 95 % CI 1.14 to 1.6 ) , shoulder ( OR 1.41 , 95 % CI 1.17 to 1.69 ) , elbow ( OR 1.14 , 95 % CI 1.13 to 1.83 ) and wrist/h and pain ( OR 1.39 , 95 % CI 1.15 to 1.69 ) . Job strain had the strongest association with neck pain ( OR 3.46 , 95 % CI 1.30 to 9.21 ) and wrist/h and pain . Somatisation was weakly associated with MSDs at most sites . Better general and mental health status were weakly associated with lower odds of MSDs . Conclusions In injury prevention and rehabilitation the physical nature of the work needs to be addressed for most MSDs , with modest decreases in risk seemingly possible . Addressing job strain could provide significant benefit for those with neck and wrist/h and pain , while the effects of somatisation and the promotion of good mental health may provide smaller but global benefits A prospect i ve epidemiologic study was conducted in two units ( 140 beds and 57 nursing assistants ) of a nursing home to demonstrate the efficacy of an ergonomic intervention strategy to reduce  back stress to nursing personnel . The total programme involved the following : determining patient h and ling tasks perceived to be most stressful by the nursing assistants ( NAs ) ; performing an ergonomic evaluation of these tasks ; and conducting a laboratory study to select patient transferring devices perceived to produce less physical stress than existing manual patient-h and ling methods . The intervention phase included training NAs in the use of these devices , modifying toilets and shower rooms , and applying techniques to patient care . Immediately after completing the intervention programme , a post-intervention analysis ( which lasted eight months in unit 1 and four months in unit 2 ) was performed . A biomechanical evaluation of the physical dem and s required to perform stressful patient-h and ling tasks showed that the mean compressive force on the L5/S1 disc , the mean h and force required to make a transfer , and the strength requirements ( expressed as percentage female population capable ) were 1964 N , 122 N , and 83 % after intervention as compared to 4751 N , 312 N , and 41 % before intervention . Subjectively , the mean rating of perceived exertion was less than ' very light ' after intervention as compared to between ' somewhat hard ' and ' hard ' before intervention . Overall , the mean acceptability rates for the walking belt and the mechanical hoist were 81 % and 87 % for patient transfers . The incidence rate for back injuries prior to the intervention , 83 per 200,000 work-hours , decreased to 47 per 200,000 work-hours after the intervention . There were no injuries result ing in lost or restricted work days during the last four months of the post-intervention . It is concluded that an appropriate ergonomic intervention programme offers great promise in reducing physical stress and risk of low-back pain to nursing personnel . However , large-scale studies in different nursing homes are needed to confirm the above findings Although patient h and lers suffer from low-back injuries at an alarming rate worldwide , there has been limited research quantifying the risk for the specific tasks performed by the patient h and lers . The current study used both a comprehensive evaluation system ( low-back disorder risk model ) and theoretical model ( biomechanical spinal loading model ) to evaluate risk of LBD of 17 participants ( 12 experienced and five inexperienced ) performing several patient h and ling tasks . Eight of the participants were female and nine were male . Several patient transfers were evaluated as well as  repositioning of the patient in bed ; these were performed with one and two people . The patient transfers were between bed and wheelchair ( fixed and removable arms ) and between commode chair and hospital chair . A ' st and ard ' patient ( a 50 kg co-operative female ; non-weight bearing but had use of upper body ) was used in all patient h and ling tasks . Overall , patient h and ling was found to be an extremely hazardous job that had substantial risk of causing a low-back injury whether with one or two patient h and lers . The greatest risk was associated with the one-person transferring techniques with the actual task being performed having a limited effect . The repositioning techniques were found to have significant risk of LBD associated with them with the single hook method having the highest LBD risk and spinal loads that exceeded the tolerance limits ( worst patient h and ling job ) . The two-person draw sheet repositioning technique had the lowest LBD risk and spinal loads but still had relatively high spinal loads and LBD risk . Thus , even the safest of tasks ( of the tasks evaluated in this study ) had significant risk . Additionally , the current study represented a ' best ' case scenario since the patient was relatively light and co-operative . Thus , patient h and ling in real situations such as in a nursing home , would be expected to be worse . Therefore , to have an impact on LBD , it is necessary to provide mechanical lift assist devices Abstract Objective : To assess the impact of h and ling patients and indicators of individual susceptibility on risk of  low back pain in nurses . Design : Prospect i ve cohort study with follow up by repeated self administered question naires every three months over two years . Setting : NHS university hospitals trust . Subjects : 961 female nurses who had been free from low back pain for at least one month at the time of completing a baseline question naire .  Main outcome measures : Incidence of new low back pain during follow up and of pain leading to absence from work . Results : Of 838 women who provided data suitable for analysis , 322 ( 38 % ) developed low back pain during follow up ( mean 18.6 months ) , including 93 ( 11 % ) whose pain led to absence from work . The strongest predictor of new low back pain was earlier history of the symptom , and risk was particularly high if previous pain had lasted for over a month in total and had occurred within the 12 months before entry to the study ( incidence during follow up 66 % ) . Frequent low mood at baseline was strongly associated with subsequent absence from work for back pain ( odds ratio 3.4 ; 95 % confidence interval 1.4 to 8.2 ) . After adjustment for earlier history of back pain and other potential confounders , risk was higher in nurses who reported frequent manual transfer of patients between bed and chair , manual repositioning of patients on the bed , and lifting patients in or out of the bath with a hoist . Conclusions : Of the indicators of individual susceptibility that were examined , only history of back trouble was sufficiently predictive to justify selective exclusion of some applicants for nursing posts . The main route to prevention of back disorders among nurses is likely to lie in improved ergonomics . Key messages A history of back trouble , particularly if recent and prolonged , is highly predictive of new episodes of back pain There are grounds for excluding nurses with recent and prolonged back pain from the most physically dem and ing jobs Age , height , and weight are not sufficiently discriminatory for risk of back pain to influence selection and appointment of nurses Back pain is more common in nurses who lift and move patients frequently without the use of mechanical aids Controlled trials are needed to assess the benefits of ergonomic intervention aim ed at prevention of back pain in One hundred seventy – one nurses had their back strength evaluated on an isokinetic lifting device and filled out an epidemiologic question naire . They were then followed prospect ively for 2 years to determine the incidence of job – related low – back injuries . The data were analyzed to determine if the injury incidence correlated with any of the strength or epidemiologic variables collected during the original evaluation . Average peak force measured during the isokinetic lift was 63.8 kg + 13.6 kg at a lift speed of 30.5 cm/sec and 59.1 kg + 14.9 kg at a lift speed of 45.7 cm/sec . Sixteen nurses reported an occurrence of job – related low – back pain or injury during the 2–year prospect i ve period . Discriminate statistical techniques showed that none of the strength or epidemiologic variables correlated with the incidence of pain or injury or explained significant amounts of variance when the variables were regressed on strength or work calculated from the lift force/lift height data . It was concluded that in this high risk population , in which loads are heavy and lifting postures are variable , the use of low – back strength or prior history of pain or injury are poor predictors as to subsequent low – back pain or injury OBJECTIVE --To investigate the risk factors for low back pain in hospital nurses , with particular emphasis on the role of specific nursing activities . METHODS --A cross sectional survey of 2405 nurses employed by a group of teaching hospitals was carried out . Self administered question naires were used to collect information about occupational activities , non-occupational risk factors for back symptoms , and history of low back pain . RESULTS --The overall response rate was 69 % . Among 1616 women , 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 . Rates in men were generally similar to those in women . In women back pain during the previous 12 months was weakly associated with height , and was significantly more common in those who reported frequent non-musculoskeletal symptoms such as headache and low mood . After adjustment for height and 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 . In contrast , no clear increase in risk was found in relation to transfer of patients with canvas and poles , manually lifting patients in and out of the bath , or lifting patients with mechanical aids . Confirmation of these findings is now being sought in a prospect i ve study of the same population . CONCLUSIONS --This study confirms that low back pain is highly prevalent among nurses and is associated with a high level of sickness absence . People who often report non-musculoskeletal symptoms were significantly more likely to report low back pain . Specific manual h and ling tasks were associated with an increased risk of back pain ; however , no such association was found with mechanised patient transfers This article describes how the Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach to grading the quality of evidence and strength of recommendations considers the Bradford Hill criteria for causation and how GRADE may relate to questions in public health . A primary concern in public health is that evidence from non-r and omised studies may provide a more adequate or best available measure of a public health strategy 's impact , but that such evidence might be grade d as lower quality in the GRADE framework . GRADE , however , presents a framework that describes both criteria for assessing the quality of research evidence and the strength of recommendations that includes considerations arising from the Bradford Hill criteria . GRADE places emphasis on recommendations and in assessing quality of evidence ; GRADE notes that r and omisation is only one of many relevant factors . This article describes how causation may relate to developing recommendations and how the Bradford Hill criteria are considered in GRADE , using examples from the public health literature with a focus on immunisation
target: Overall studies showed that nursing activities conferred increased risk for , and were associated with back disorders regardless of nursing technique , personal characteristics , and non-work-related factors .
  Patient h and ling appears to confer the highest risk , but other nursing duties are also associated with elevated risk , and confound dose – response assessment s related to patient h and ling alone .
  A threshold of nursing activities below which the risk of back disorders is not elevated has not been established .
background: Abstract Background : Although non-specific low back pain ( LBP ) is known to be multifactorial , studies from across the globe have documented their higher prevalence in nurses .
  This systematic review was conducted to ascertain whether this much-documented association constitutes a causal relationship , and whether there is a discernible threshold of exposures associated with this elevated risk .