Original article
Back Pain in Direct Patient Care Providers: Early Intervention with Cognitive Behavioral Therapy

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Abstract

Back pain and injury are a widespread problem for direct care providers and can lead to disability and job loss. Although most intervention studies focus on the number of reported injuries as the outcome variable, pain is a leading indicator of impending injury. More secondary prevention interventions focusing on early detection and treatment of pain are needed to reduce injuries. The primary aim of this study was to assess the feasibility and effect size of a cognitive behavioral therapy (CBT) intervention to reduce the measures of back pain, stress, and disability in direct care providers working with back pain. The secondary aim was to assess the association between affect and outcome variables, particularly unscheduled work absence, which is a component of disability. This randomized clinical trial recruited 32 registered nurses and nursing assistants with a history of back pain in the past year and assigned them to either an intervention or a control group. The CBT intervention was a weekly stress and pain management session over 6 weeks led by a clinical psychologist. Data for both groups were collected at baseline and at 6 weeks, with work absence data caused by back pain self-reported for 12 weeks. Pain intensity scores declined in the intervention group, indicating a large effect. However, stress scores increased. Depression scores accounted for one-third of the variance in hours absent because of back pain. Although there was a high dropout rate in the intervention group, a cognitive-behavioral intervention shows promise as a secondary prevention intervention.

Section snippets

Multifactorial cause of back pain and injury

One of the major difficulties in reducing back pain and WMSDs is their multifactorial cause (National Institute for Occupational Safety and Health 1997, National Research Council and Institute of Medicine 2001, World Health Organization 1985). Many studies have identified biomechanical load (e.g., lifting heavy patients) as a risk for back injury (Ulin et al 1997, Winkelmolen et al 1994, Zhuang et al 1999).

However, there is also evidence that psychosocial stress has a risk similar to that of a

Cognitive behavioral therapy for pain and disability

WMSDs are associated with both pain and disability, concepts that are often related but not synonymous. Pain has sensory, affective, and cognitive dimensions. Its clinical assessment is through subjective reports. “Disability is restricted function and can be assessed reliably by clinical interview, questionnaire, or work loss” (Waddell, Newton, Henderson, Somerville, & Main, 1993). Although disability is almost always based on physical impairment, with chronic low back pain there may be no

Research aims

The primary aim of this study was to assess the feasibility and effect size of a cognitive behavioral intervention to reduce the outcome variables of stress, pain, and disability in RNs and NAs working with WMSDs. Unlike other studies before 2003 that had assessed CBT as a treatment for those with chronic pain undergoing rehabilitation during work loss or modification (tertiary prevention) (Kole-Snijders et al 1999, Linton and Andersson 2000, Turner and Jensen 1993), the focus of this study was

Sample and Setting

This randomized clinical trial used a two-group repeated-measures design. The University of Florida Health Sciences Center Institutional Review Board approved the study. The sample included 27 female and 5 male RNs or NAs at a 550-bed tertiary care academic medical center in Florida. Inclusion criteria were a history of back pain in the past year, at least 80% of work time providing direct patient care, and working at least 30 hours a week. Because of our focus on secondary not tertiary

Results

The mean age of participants was 40.3 years, and they worked an average of 42.0 hours per week. Approximately 60% were RNs, with the remainder NAs. Although 26% reported they had had low back trouble lasting only 1 to 7 days in the last year, another 26% reported they had experienced back pain every day during that time. The rest of the participants reported frequencies between these two extremes.

Although we requested that even those intervention group participants who did not attend the

Limitations

The sample size was too small to provide significance in statistical tests. The sessions were offered sequentially, not concurrently, introducing the threat of history. Different psychologists led each of the groups, reducing standardization of the intervention. The study was insufficiently funded to provide redundant sessions on different days of the week to accommodate the varying schedules of direct patient care providers. Requiring completion of 14 instruments may have been a participant

Discussion

The high dropout rate in the intervention group, coupled with the increase in stress scores in that group, indicate that these participants either found attending a session at a specific time and day of the week difficult or they judged the intervention not helpful. The lack of significant differences between the groups on the majority of measures may have been a result of the study’s short duration or shortened time for delivery of the CBT intervention. The effect of using different group

Conclusions and recommendations

Although back pain is prevalent in direct patient care providers, researchers face challenges intervening with RNs and NAs before their pain and disability get so severe that they report a work-related injury or progress to chronic pain. Primary prevention activities involving modifying the workplace with lifting equipment will assist in reducing the incidence of back pain. However, such equipment has an unknown effect on the large percentage of this workforce already experiencing pain. Given

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    This research was funded by a grant from the American Association of Occupational Health Nurses Foundation.

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