1 116167 Fear-avoidance beliefs, perceived lumbar exertion, musculoskeletal fitness, and multi-site pain contribute to pain intensity, physical functioning, and perceived ability to work in female health-care personnel with recurrent low back pain Annika Taulaniemi 1 , MSc Lotta Kuusinen 2 , MD Kari Tokola 1 , MSc Markku Kankaanpää 2 , PhD Jaana H. Suni 1 , DSc 1 UKK Institute for Health Promotion Research 2 Tampere University Hospital short title: Descriptors of low back pain in nursing personnel
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1
116167
Fear-avoidance beliefs, perceived lumbar exertion, musculoskeletal fitness, and
multi-site pain contribute to pain intensity, physical functioning, and perceived
ability to work in female health-care personnel with recurrent low back pain
Annika Taulaniemi1, MSc
Lotta Kuusinen2, MD
Kari Tokola1, MSc
Markku Kankaanpää2, PhD
Jaana H. Suni1, DSc
1 UKK Institute for Health Promotion Research
2 Tampere University Hospital
short title: Descriptors of low back pain in nursing personnel
2
Abstract
Objective: To study associations between physical and psychosocial risk factors for chronic low
back pain (LBP) and outcomes representing various domains of the ICF model, assessed through
pain intensity, physical functioning, and work ability
Design: Cross-sectional study
Subjects: 219 female health-care workers with recurrent non-specific LBP
Methods: Associations between several risk factors and outcomes of bodily pain and pain
interfering with normal work, physical functioning, and ability to work were studied. Bivariate
correlations between risk factors and outcome variables were studied first. Secondly, variables with
statistically significant correlation (p<0.05) were set within a generalised linear model to analyse
their contribution to each outcome.
Results: Work-induced lumbar exertion (p<0.001), multi-site pain (p<0.001), and work-related
fear-avoidance beliefs (FAB-W) (p=0.02) were associated with bodily pain. Multi-site pain
(p<0.001), perceived lumbar exertion (p=0.005), FAB-W (p=0.01), and physical performance in
figure-of-eight running (p=0.01) and modified push-ups (p=0.05) were associated with physical
functioning; FAB-W (p<0.001), lumbar exertion (p=0.003), depression (p=0.01), and recovery after
work (p=0.03) were associated with work ability. In addition, there was an association between
lumbar exertion and poor physical performance.
Conclusion: FAB-W and perceived lumbar exertion contribute to pain, physical functioning, and
work ability. Good physical performance capacity may reduce work-induced lumbar exertion.
Keywords: Lower Back Pain; International Classification of Functioning, Disability and Health;
Low back pain (LBP) is a bio-psychosocial, multidimensional, complex, and costly problem and is
a leading cause of years lived with disability(1). In the majority of low back pain patients (85–
90%), the pain is classified as non-specific low back pain (NSLBP). After an acute pain episode,
most recover, but in 50–70% the pain recurs within the following year and in 10% it becomes
chronic (2). The prevalence of LBP varies between occupational groups. Workers in physically
demanding jobs are known to have increased risk (3). Among health-care workers, the one-year
prevalence of LBP has been found to be as high as 45–77% (4), which is high in comparison to
other occupations.
Preventing new LBP episodes (i.e., recurrence) is considered to be of importance for prevention of
persistent pain. Low back pain is often a long-term or recurrent condition wherein individuals
experience repeated pain episodes that are not independent of each other (5). Longer-time follow-up
studies (6, 7) indicate that the majority of people with LBP indeed experience back pain off and on
over an extended span of time.
Risk factors for development of chronic disability from LBP are related more closely to
psychosocial and psychological factors than to spine condition itself (8, 9). Fear-avoidance beliefs
(FAB), job satisfaction, and anxiety are known to be associated with the problem of chronicity (10).
On the other hand, there is also increasing evidence that low performance levels for several
components of physical fitness are risk factors for LBP (11, 12), although scientific evidence about
those associations is still partly conflicting. Nursing duties include large amounts of heavy physical
work and psychosocial stress, which are known to be risk factors for LBP (13).
The World Health Organization (WHO) has presented the International Classification of
Functioning, Disability and Health (ICF) model, aimed at providing a scientific basis for
Kommentar [KJ1]: Please give references
4
understanding and studying health and health-related states, outcomes, and determinants (14). There
are ICF Core Sets developed for various health conditions, including LBP (15).
The ICF model comprises five main components: (i) body structures and functioning, (ii) activities,
(iii) participation, (iv) environmental factors, and (v) personal factors. Each of these main domains
can be subdivided into chapters and further categories (14). The ICF is a useful tool in structuring
numerous bio-psychosocial measurements into logical and understandable entities and for analysing
their associations with various outcomes.
For preventing new episodes of LBP and pain chronicity it is essential to understand these links
between several biological and psychosocial factors influencing the early stages of recurrent LBP,
especially in a population performing physically demanding work.
The purpose of the cross-sectional study was to assess predictors of sub-acute outcomes of LBP in
a sample of female health-care personnel with recurrent non-specific LBP, with the ICF model as
the framework. More specifically, it examined associations between bio-psychosocial risk factors
that might influence bodily pain and pain interfering with normal work, physical functioning, and
ability to work.
MATERIALS AND METHODS
Study design and participants
The cross-sectional study was part of a randomised controlled trial (the NURSE RCT, clinical trial
registration NCT04165698) aimed at reducing pain, movement-control impairment, and fear-
avoidance beliefs in working female health-care personnel with recurrent non-specific LBP. The
study was approved by the Ethics Committee of Pirkanmaa Hospital District, Finland (ETL code
R08157). Data from the baseline measurements in the NURSE RCT were analysed in the study
reported upon here.
Gelöscht: cross-sectional
5
The target population was female health-care personnel working in wards with bed patients or other
nursing tasks that include lifting patients, transfer, or other postures that are awkward for the lower
back. To be eligible, individuals had to meet the following criteria: (i) being a woman aged 30–55
who (ii) had worked in her current job for at least 12 months and (iii) experienced LBP of intensity
2 or above on the numeric rating scale (NRS; 0–10) (16) within the preceding four weeks. The
exclusion criteria for the study were (i) a serious earlier back injury (fracture, surgery, or disc
protrusion), (ii) chronic LBP as diagnosed by a physician or self-reporting of continuous LBP over
the past seven months or longer, (iii) a serious other disease or symptoms limiting participation in
moderate-intensity neuromuscular exercise, (iv) engaging in neuromuscular-type exercise more than
once a week, and (v) pregnancy or recent delivery (<12 months).
More precise information on recruitment in its three sub-studies is available in the protocol article
on the NURSE RCT (17). The total sample consisted of 219 health-care workers, working in
community- or university-hospital wards, old people’s homes, home service, and public health-care
units in the city of Tampere, Finland. Figure 1 summarises the recruitment process.
Study procedures and measurements:
The measurements for all three sub-studies were conducted in 2011–2013 at the UKK Institute for
Health Promotion Research, in Tampere. Informed consent was obtained in writing from all
participants on the first visit. Specially educated personnel with a long work history conducted all
measurements. Health screening was performed before fitness testing, in accordance with the safety
model of the Health-related Fitness Test Battery for Middle-aged Adults (18). The measurement
battery consisted of questionnaires, assessment of health-related fitness tests’ results, and
objectively measured physical activity / sedentary time over one week. The description of
measurements used in the study is presented in line with the ICF model.
Outcome measures (dependent variables):
Kommentar [KJ2]: and
Kommentar [KJ3]: demanding
Kommentar [KJ4]: Were all measures taken at one single session?
6
Body structures and functioning: Bodily pain and pain interfering with normal work (sum score
from the two questions concerning pain in the RAND-36 Health Survey (19), which consists of one
five-point-scale and one six-point-scale rating. Ratings were re-coded in accordance with
predetermined numbers, with the sum scores for the recoded values being 0 (very severe pain and
extreme difficulties) to 100 (no pain and no difficulties).
Activities: Physical functioning (sum score from 10 questions from the RAND-36 survey) (19). The
item consists of 10 ratings on a three-point scale (limited a lot, limited a little, not limited at all).
Ratings were recoded to predetermined numbers, with the sum score interpreted thus: 0 = limited a
lot … 100 = not limited at all.
Participation: Self-assessed current and future ability to work (sum score from four questions, 3–27
scale (3 = poor … 27 = the best possible) (20).
Risk factors for low back pain (independent variables):
Body structures and functioning:
Number of musculoskeletal pain sites.
Body mass index (BMI), in kg/m2.
Depression; Beck Depression Inventory, short form (sum score from nine questions with a 1–4
rating scale) (21), where high values indicate higher levels of depression.
Flexibility (trunk lateral flexion; cm) (22).
Perceived recovery from work (on a five-point scale: 1 = recovering well … 5 = not recovering).
Ratings were re-coded to tertiles.
Kommentar [KJ5]: How did you compute the 0-100 score?
Kommentar [KJ6]: give reference or explain
Kommentar [KJ7]: same remark here. Please try to clarify. The aim is that readers can repeat the procedure. Looking at the reference, it seems you did not use the work ability index WAI. This is one of the primary outcomes so use some sentences to explain. Give questions and responses (e.9. 1= ... -9=...)
Kommentar [KJ8]: Procedure, number of sites, You may present body chart in additional file. Reference?
Kommentar [KJ9]: Fingertips to floor? How did you account for length?
Kommentar [KJ10]: Explain. E.g. ’daily after work, on average during the past week’?
Kommentar [KJ11]: how
7
Perceived exertion in various anatomical body parts after work (1–5 scale: 1 = no exertion at all …
5 = high exertion) over the preceding four weeks(23). The sum score measured exertion in eight
distinct physical parts of the body.
Perceived exertion after work in the low back (1 = no exertion … 5 = high exertion)(23). Five-
point-scale ratings were recoded to tertiles.
Tiredness and sleepiness (sum score from three questions developed by Finnish Institute of
Occupational Health; 3 = no tiredness or sleepiness… 13 = long-term, daily tiredness and
sleepiness)(24). The questions concern tiredness in the morning after woken up, and tiredness and
sleepiness during the day-time.
Activities:
Aerobic fitness assessed via a six-minute-walk test (6MWT), for maximal walking distance
(metres) in six minutes (25).
Muscle strength assessed via (i) modified push-ups, number of repetitions in 40 seconds; (ii) one-
leg squats, number of repetitions, with progressively increasing external load; and (iii) vertical
jump, cm (22).
Agility as assessed by running of a figure of eight, via running time in seconds (26).
Participation:
Health-related physical activity:
Objectively measured aerobic physical activity (using a Hookie AM20 tri-axial accelerometer, from
Traxmeet, Espoo, Finland), with recoding of data on meeting recommendations for at least three
times a week (27), yes/no.
Kommentar [KJ12]: Which? Did you use all regions? Add subscores?
Kommentar [KJ13]: Sum score? Or each muscle group was analysed?
Kommentar [KJ14]: Unclear, I assume subjects wore the accellerometers during three days the whole day or during wake hours or durinh work?
8
Meeting of recommendations for muscle-strengthening training at least twice a week (27), yes/no
(questionnaire).
Personal factors:
Fear-avoidance beliefs (FAB). Two sub-scales exist in the fear-avoidance beliefs questionnaire
(FABQ): an eight-item work (FAB-W) sub-scale (range: 0–48 points; three questions considering
long-term sick leave were excluded from the original FABQ) and a five-item physical-activity
(FAB-P) sub-scale (range: 0–30 points). High values indicate increased levels of fear-avoidance
beliefs. (28, 29)
Content and placement of risk factors and outcome measures are presented in Figure 2, according to
the ICF model.
Also, psychosocial factors at work (such as work stress) were assessed via a Finnish questionnaire
(30). Those variables were used in the study only for adjustments.
Statistical analysis
For the descriptive analyses, the mean and standard deviation (SD) were calculated for normally
distributed data, and medians (Md) and quartiles (Q1,Q3) for skewed distributions. Correlations
between interval-scale measurements were analysed via Pearson’s correlation coefficient (r) in
cases of normal distributions and via Spearman’s rank correlation coefficient (rs) in cases of skewed
distributions.
Associations between categorical and normally distributed interval-scale variables were analysed
via one-way analysis of variance (ANOVA) for tertiles and via independent-samples t-test in cases
of binominal variables. The corresponding statistical tests for non-normal distributions were the
Kruskal–Wallis test and the Mann–Whitney test.
Kommentar [KJ15]: Why not as independent variable?
9
When statistically significant associations (p<0.05) between individual factors from the ICF model
and selected main outcomes were calculated in bivariate analysis, generalised linear models (GLMs)
were used to determine the contribution of the factors and covariates to dependent outcome
measurements: bodily pain and pain interfering with normal work, physical functioning, and
perceived ability to work. After calculation of crude β-coefficients, the analyses were adjusted first
for age, BMI, and work type (shift work / regular work), and after that also for hormonal status and
work satisfaction.
All analyses were conducted with the SPSS statistical analysis package, version 22.
RESULTS
Description of the study population
Baseline characteristics of the study sample are reported in Table 1. The study subjects had worked
in their current position for, on average, 11.4 years. More than 85% of them were nurses or nursing
assistants, and 70% had irregular working hours. Most perceived their health to be average or good,
but 28% perceived their fitness to be poor in comparison to that of persons the same age and
gender. Only approximately 40% were of normal body weight, and 60% were considered to be
overweight or obese.
At the pre-study screening, the pain intensity for all people who were included in the study was
more than 2 (mean 4.7, SD 1.8), measured on NRS (1–10). Most of the study subjects (82%)
experienced LBP on a few or most days of the week but not daily, and 18% had daily LBP. The
corresponding percentages at the baseline measurement were 72% and 12%, and 16% had
recovered from pain.
Gelöscht: investigated
Kommentar [KJ16]: Figure 1 sows some exclusions after baseline measures. What was the reason?
Kommentar [KJ17]: Were there no missings? If yes, how did you handle missings?
10
Descriptive data for the measurements are presented in Table II. Participants perceived themselves
as having moderate bodily pain and pain interfering with normal work: mean 63.1 (SD 19.0) on a
0–100 scale (0 = very severe pain / extreme difficulties … 100 = no pain/difficulties). The median
for physical functioning was 90 (Q1=80,Q3=95, scale 0–100), and the median for self-assessed
current and future work ability was 23 (Q1=21, Q3=24, scale 3–27).
Bivariate analysis
The correlation of the various risk factors from ICF-domains (a) body structures and functioning,
(b) activities, and (c) personal factors with the outcome variables (i) bodily pain and pain interfering
with normal work, (ii) physical functioning, and (iii) work ability were calculated. These are
presented in Table III.
Associations between categorical risk factor variables and outcome variables are presented in Table
IV. Perceived lumbar exertion was associated with physical pain and pain interfering with normal
work (F=17.82, df=207, p<0.001). Those who perceived themselves very exerted in the low back
after work had more pain and pain interfering with normal work than did those who perceived little
running a figure of eighta -0.10 0.15 -0.34 <0.001 0.33 <0.001
Personal factors
FAB about physical activity -0.26 <0.001 -0.15 0.03 -0.23 0.01
FAB about worka -0.25 <0.001 -0.25 <0.001 -0.38 <0.001
r = Pearson’s correlation coefficient, rs = Spearman’s rank correlation coefficient, a = skewed distribution where rs is
used to describe the correlation, BMI = body mass index, and FAB = fear-avoidance beliefs.
Kommentar [KJ30]: Table also includes variables you use as confounders used for adjustment..
27 Table IV: Associations between risk factors for low back pain in various ICF domains: (a) body structures and functioning and (b) the participation domain, all categorical
variables and outcome variables, for (1) bodily pain and pain interfering with normal work, (2) physical functioning, and (3) perceived current and future ability to work
(statistically significant p-values are in boldface)
Body structures and
functioning:
Bodily pain
Activities:
Physical functioning Participation:
Perceived current and
future ability to work
Body structures and functioning
domain:
n
mean (SD)
p
Md (min.,
max.)
p
Md (min.,
max.)
p
Perceived lumbar exertion after
work
little exertion
exertion
high exertion
63
79
74
70.4 (18.8)
66.3 (17.4)
53.0 (17.0)
<0.001
95 (60, 100)
90 (15, 100)
80 (45, 100)
<0.001
24 (15, 27)
23 (16, 26)
21 (12, 27)
<0.001
Perceived recovery from work
recovering well
some difficulties
not recovering
90
102
21
65.4 (18.8)
62.9 (18.7)
57.3 (18.1)
0.19
90 (60, 100)
85 (15, 100)
75 (50, 100)
0.003
23 (17, 27)
22 (15, 26)
21 (16, 27)
<0.001
Participation domain
Physical activity
Aerobic activity
meeting recommendations
not meeting recommendations
Strength training
meeting recommendations
not meeting recommendations
54
156
44
174
63.0 (19.9)
63.4 (15.9)
62.6 (18.5)
63.6 (20.7)
0.89
0.76
Md (Q1, Q3)
93 (85, 95)
85 (75, 95)
95 (85, 95)
85 (75, 95)
0.05
0.02
Md (Q1, Q3)
23 (21, 24)
23 (20, 24)
23 (21, 25)
22.5 (20, 24)
0.87
0.053
28
Table V: Associations between risk factors for LBP and outcome measures (bodily pain and pain interfering with normal work, physical functioning, and perceived current
and future ability to work) with a statistically significant association in bivariate analysis, analysed via generalised linear models
Bodily pain and pain interfering with work Physical functioning Perceived current and future work ability
Β = regression coefficient; FAB-W = fear-avoidance beliefs related to work; a = adjusted for age, BMI, and work type (shift work vs. regular work);
b = adjusted for age, BMI,
work type (shift work vs. regular work), hormonal status, and work satisfaction; and LBP = low back pain.
29 Table VI: Associations between fitness-test results and perceived exertion in the low back after a work shift, analysed via ANOVA and adjusted for age (p-values reflecting
statistically significant differences are in boldface)
Mean (SD) test results for various categories of perceived lumbar exertion
after a work shift
Fitness test: little exertion exertion high exertion mean difference from