BACKSCHOOL
On completion of this program, you will be able to:
Section I: Overview
Demographics
Low back pain affects 60-80% of us at some point in our lives. Up to 50% of us will have back pain some time this year! Symptoms of back pain are among the top 10 reasons for visits to physician's offices, outpatient departments, and emergency rooms. Even though symptoms are usually temporary, low back pain often recurs, and becomes chronic in 5-10% of patients.
Job satisfaction and psychosocial status are more direct predictors of job-related back injuries than the amount of lifting required in the job! If you want to reduce the risk of injury, you must control stress, depression, work conditions and job satisfaction. Knowledge and improved lifting techniques only go so far.
Why Nurses?
While there are the occasional and unpreventable accidents, most nurses injure themselves because of attitudes and failure to utilize good self-care habits.
Costs
This country pays $20-$25 BILLION annually in direct care costs for on-the-job back injuries! 20-30% of all worker compensation claims are related to back injuries consuming 40-50% of the dollars paid out in claims.
Many of us do not even think of the secondary losses that occur with back injury. When pain and immobility become significant factors in your life, participation and enjoyment of most daily, recreational and social activities are impacted.
Let's Take a Look
Nurses complain of back fatigue and pain from too much lifting, not enough help, lack of equipment, lack of time - and the list goes on. Nurses seldom complain about lack of training. Ask yourself these questions:
Break the Cycle
The reality is nurses are always in a hurry. We are our own worst enemy. We leave equipment in the closet, ignore posture, don't have time for physical fitness and think cheating on our use of proper body mechanics won't hurt us. We are inconsistent in using help because we are thinking "I can do it," or "everyone else is too busy."
The reasons and excuses are endless but the responsibility for self-care is yours - on and off the job! Back pain may be common, but it is not inevitable. You can break the cycle! Choose to take care of yourself and reduce the wear and tear on your back.
Education and ergonomics can decrease risk of injury in the short run. A change in attitude and approach is required for long term changes. All too often, the effects of training disappear within 2-3 months and most people revert to old habits.
SECTION II: SELF ASSESSMENT
Take Care of Yourself
Knowing your risk factors and taking care of yourself is the first step toward reducing your risk of back injury. Start by doing an HONEST assessment of your knowledge, habits and self-care.
Guess Who's Back is Under YOUR Care?
If you did not answer yes to all of the previous questions, there is opportunity for improvement. You can reduce your risk by:
Identify Your Risks
The most common cause of low back or neck pain is poor posture.
Back supports have become popular in recent years as employers increase their efforts to prevent back injuries. According to NIOSH (National Institute for Occupational Safety and Health), there have been no studies that reliably suggest the use or disuse of back belts. There is little evidence that they provide adequate support to a normal back during the variety of stresses caused by lifting or they function to remind workers to lift properly. In fact, they are concerned the belts may increase risk by providing a false sense of security. They support a strong ergonomics program combined with safe lifting techniques. (NIOSH-94-127)
Check your posture by using a full-length mirror or a friend with a camera, assess your posture while standing, sitting, lying down and lifting. How do you sit while watching TV, charting, driving, eating, or working on the computer? What did you do different because you were being observed? Do you maintain your natural curves and stabilize your pelvis while lifting patients, your child, your groceries, your bowling ball (or doing other household and recreational activities)?
Poor lifting techniques increase pressure on discs.
Bending your knees alone is not enough to decrease pressure on your back while lifting. When you back is rounded, the pressure on your discs is much higher than when your back is held upright with proper alignment.
Seldom do single lifting events cause a back injury. It is incorrect movements and lifting all day long during work, home and recreational activities that create cumulative damage to the back. Remember: You are at risk for a sudden injury if you are lifting a heavy object incorrectly.
Strains and sprains are often caused by using improper body mechanics during everyday activities.
Evaluate the effects of everyday strains on your back:
Exercise and conditioning, combined with proper body mechanics, can significantly decrease everyday stress and strains on your back.
Back pains occurring several hours after strenuous activities, such as gardening, may be the result of the posture assumed for the rest rather than from strain during the activity. Thoroughly exercised joints of the spine distort easily if place in a slouched position for long periods.
(McKenzie, 1997)Stress can actually cause muscle spasms!
Controlling your stress is critical to your success and recovery if you do have back pain. Ask any employee health nurse and they will tell you those employees who have a chronically stressed lifestyle and are having difficulty coping are those who are primed for injury and have the most difficulty with compliance and recovery.
The effects of aging affect us all.
Osteoarthritis is part of aging and most of us cannot avoid it. However, osteoarthritis occurs in varying degrees and often goes unnoticed. As this, too, is a wear and tear condition, managing your risks throughout your life can decrease the significance of this process on your older body.
Do you think about the long-term consequences and cumulative effects of the choices you are making now?
Osteoarthritic pain results from narrowing of the discs and the development of bony spurs on the vertebra in the spine. Spondylosis is another degenerative disease process resulting from one vertebrae shifting forward on the one below it, narrowing the spinal canal.
SECTION III: YOUR BODY
Your Spine (Cervical, Thoracic, & Lumbar Curve)
The healthy spine aligns itself in three natural curves. It supports your upper torso, protects your spinal cord and provides a point of attachment for your muscles and ligaments. It is flexible, balanced and pain free. It is supported by strong back, abdominal, buttock and leg muscles.
The lower back has adapted to upright posture through the development of larger vertebrae throughout the lumbar curve (L1-5) which are able to bear the body's weight.
You need to remember that you really do need to support balanced alignment of your spine in all positions: sitting, standing, lying down, lifting, moving, etc…
Take A Closer Look
Let's take a closer look at the spine:
Ruptured discs cause severe pain due to the pressure placed on the spinal nerves and are often disabling. If the pressure continues, nerve damage occurs, resulting in numbness and weakness.
Maintaining Those Curves…
The key to preventing most back pain is maintaining your natural curves. Proper posture is key to maintaining a balanced spine and avoiding strain to supporting ligaments and muscles. Posture supports the natural curves of your back when a straight line can be drawn through your ear, shoulder, hip and ankle while standing. It allows the lumbar spine to bear the weight of the upper body and transmit this weight through the pelvis and lower extremities. This weight distribution sets up your pelvis and lumbar spine to function as a fulcrum during lifting activities. By setting your pelvis, you stabilize the fulcrum and decrease stressors on the lower back.
Setting your pelvis prepares and protects your back from strain during lifting activities. Learn to set your pelvis by standing with your feet shoulder width apart, your knees slightly bent and:
Bearing the weight…
When you increase weight loads by picking something up, your trunk muscles contract to provide stabilization and support to your spine - not to provide lifting power! How you choose to lift the load determines the relationship of the lever (your arms) to the fulcrum (your pelvis) and the amount of force required to lift it. One of the best things you can do for your back is to increase the strength of your abdominal muscles so they can provide support to your spine.
May the Force Be With You…
An object held further away from your body requires more force to lift. In addition, your lower back (the point of the fulcrum) must take more stress to compensate for the long lever arm. This generates a tremendous amount of strain on the lower back area. In addition, your trunk and pelvic muscles must work hard to maintain your balance and keep you from falling forward due to your posture and the weight of the object you are lifting.
Test it out! Experience lifting force:
1) Grab a textbook.
2) Hold it against your abdomen and analyze how hard your arm muscles are working to keep that book in place.
3) Compare the amount of strength required to hold the same book at arm's length.
Fully extended, the amount of work required to hold the book increases exponentially-taking up to 10 times the work of holding the book close to your body.
Remember the greater the distance between you and the object, the more force required. The maximum torque of that force occurs at the point where the lever sits on the fulcrum; your lumbar spine. Rounding your back instead of keeping it in its natural curves also increases the stress on your lower back. Squatting and using your legs means the lever is shorter and stronger!
SECTION IV: BODY MECHANICS
Proper Body Mechanics
Learning to use proper body mechanics is like learning any other motor skill. It requires practice and may feel odd and uncomfortable until the skills are developed. A good place to start is learning to support your natural curves by using good posture during lifting, standing, walking, sitting, and sleeping activities.
Standing and Walking
Stand with your back against a wall. There should be only minimal space between your back and the wall. Both slouched postures and standing at attention (military stance) alter the natural curves and strain your back.
You can decrease back fatigue when standing for long periods by changing positions and propping a foot up 6-8 inches (which encourages natural lordosis of the lumbar spine).
Sitting and Driving
Most furniture does not support your body's natural curves. When buying furniture or cars, consider lumbar support in the style and make of the products. Anyone who spends a lot of time in a chair is at particular risk for development of back pain.
Develop
a good sitting posture, sit on a stool (or sideways on a chair) and perform the following exercises. Good sitting posture results from maintaining lumbar lordosis just short (10-15%) of the extreme position achieved during the exercise. If you are experiencing back discomfort, a lumbar roll will support your back in this position when seated in a chair. (Mckenzie, 1997)You can rest your back and relieve stress placed on your spine from extended sitting or standing by doing stretching and resting exercises.
The following exercises can be used to stretch and rest your back:
Sleeping
A good night's sleep is good for you, your body and your brain. Soft, saggy mattresses, couches and lounge chairs encourage swaybacks and increase back strain. Use a firm, supportive mattress instead. Sleep on your side with knees bent, back and neck in alignment, head supported in a neutral position. If you are sleeping on your back, place a pillow under your legs to take the stress off of your lower back.
Most Americans and Europeans are sleep deprived and have been becoming progressively more so since the advent of the light bulb followed by assembly lines and shift work. Even small amounts of sleep deprivation impair our mental functioning and tolerance to everyday stresses and strains. Getting as little as 6.5 hours of sleep per night increases your risk of poor judgement and injury. Consider this as you pass your meds and drive home from work.
Those who work day and evening shifts are sleep deprived from shorting sleep time to complete projects, socialize and get chores done. Those of us who rotate shifts seldom prepare for the rotation and sleep just enough to get by. It is suggested you will generate less sleep debt if you rotate forward rather than backward (days to eves rather than eves to days).
Night shift workers should avoid rotating, staying consistently on nights, to be healthy and alert. If you have to rotate to night shifts and have trouble sleeping and staying awake, try taking a nap for two hours before you go in and go to bed when you feel drowsy the next day. Night shift workers will sleep better if the sleeping environment is dark, quiet and uninterrupted. Interruptions interfere with the quality of deep sleep that is necessary for rejuvenation of your mental functioning. They will also be healthier, happier and will function at their full capacity if they make sure they consistently sleep at the same time each day - even on their days off!
And a word of warning to those of you on 12 hour shifts; studies have shown a considerable sleep debt is developed during the workweek. Fatigue and decreased alertness are common during each shift (you know that) and they become worse as the workweek progresses. Performance decreases, and errors increase after 10 hours of work. Workers miss bits of information and have difficulty processing information that presented no difficulty earlier in the shift. Errors in judgement, impaired concentration and a higher susceptibility to accidents are common.
Get enough rest before your shift to decrease risk of injury, poor judgement and excess fatigue. It may not be only the patient at risk. Your error in judgement or slow response time may cost you dearly.
(Coren, 1996)Lifting
You have all heard this before; think through lifting activities before doing them to make sure you have the resources to do them safely. Position your feet for a broad base of support.
Set your pelvis so that natural curves are kept and supported. Lift with your legs; those muscles are stronger anyway. Hold objects close to your body. Avoid added stress on your back by not lifting heavy items above your chest. Hold the item close to you and use a stool to avoid reaching over your head. Nurses have a very difficult time applying the concept of holding objects close to their body when the object is a patient. If you are afraid of contamination, wear appropriate protective clothing and get in there where you belong when you are doing transfers.
Plan ahead by using equipment and assistive aids appropriately. Set your pelvis, bend your knees, while keeping your back straight and avoid twisting at the waist. "Lift only what you can't pull and pull only what you can't push."
Exercise and Conditioning
Cardiovascular fitness provides many benefits. Strength and flexibility training not only helps protect your back, it heightens your reactions and increases bone density.
Your Target Heart Rate
Calculate your target heart rate with the following formula:
220-(your age) = answer (answer) * .80 = your target heart rate
The American College of Sports Medicine recommends exercising at 60-90% of your maximum heart range. The .80 indicates your target at 80% of your maximum range. To determine your heart rate range for cardiovascular conditioning, multiply by .60 and .90 respectively.
It is suggested you do stretching exercises before every shift (and other physical activities and exercises) to decrease the risk of muscle injuries.
The following exercises can be used to stretch and strengthen your back and increase your flexibility. They are easy, fast and require no extra equipment. When done for 15 minutes 3-5 times per week, they will assist you in staying conditioned and balanced. Always warm up by stretching and limbering your body. Try lying on your back and alternately moving each extremity, tightening and relaxing muscles. Include cardiovascular conditioning exercises for a well-rounded workout!
Elbow Props:
From a starting position of lying on your stomach with your arms at your side, lie with your head turned to one side and relax for 3-5 minutes. Turn your head and repeat on other side. Then prop yourself up on your elbows and relax for 2-3 minutes for a slow stretch of your lower back. Return to the starting position and relax for a minute. Repeat the process up to 5 times while keeping your lower back relaxed.
Press Ups:
This is an advanced strengthening exercise. If you are currently suffering from back pain, please check with your physician or therapist before continuing. From a starting position of lying on your stomach with palms flat at your shoulders, do a partial push-up while keeping your pelvis on the floor. Hold it for a 5 count and then slowly return to the floor. Repeat 5 times while relaxing your lower back and legs.
Hamstring Stretch:
From a starting position of sitting with your legs extended with heels less than 6 inches apart, bend from the hips in an easy stretch and hold it for a 20 count. Repeat 5 times, stretching farther each time trying to touch your toes.
Knee to Chest Raise:
From a starting position of lying on your back with your knees bent and feet flat on the floor, raise your right knee to your chest for a 5 count then lower it. Repeat 5-10 times. Do the same with the left leg and then with both legs.
Partial Curl-up or Half Sit-ups:
From a starting position of lying on your back with knees bent and feet flat on the floor, slowly reach forward with your hands while curling head (keep your head in line with your shoulders) and neck to chest and hold for a 5 count. Slowly return to starting position. Repeat 5-10 times.
Pelvic Tilt:
From a starting position of lying on your back with your knees bent and feet flat on the floor, press lower back into the floor by tightening your abdomen and buttocks and hold for a 5 count. Repeat 5-10 times.
Straight Leg Raise:
From a starting position of lying on your stomach with hands on hips, stiffen and raise one leg slowly from the hip and return to floor. Don't lift your pelvis in order to raise your leg and keep your leg straight. Repeat 5-10 times and switch to other leg.
If you are going to short cut and skip exercising, at least:
If Your Back Hurts
If you should develop a backache, take care of it with rest, icing, anti-inflammatories and slow stretches. Stop and determine the causative factors. If your posture, technique or conditioning are at fault, correct it once the pain has diminished in order to prevent reoccurrence and more wear and tear on your back.
References
Agency for Health Care Policy and Research. Clinical practice guideline, acute low back problems in adults. Washington, DC: Department of Health and Human Services, 1994. (Publication no. 95-0642.)
Coren, Stanley. Sleep Thieves: An Eye-Opening Exploration into the Science and Mysteries of Sleep. New York, NY: Free Press. 1996
Daltroy, LH, Iverson, MD, Larson, MG, et al. Teaching and social support: effects on knowledge, attitudes, and behaviors to prevent low back injuries in industry. Health Education Quarterly. 1993. (20)43-62.
Dehlin, O, Berg, S, Hedinrud, B, et al. Muscle training, psychological perception of work and low back symptoms in nurses aides. Scandinavian Journal of Rehabilitation Medicine. 1978. (10)201-209.
Gundewall, B, Lijeqvist, M, Hansson, T. Primary prevention of back symptoms and absence from work. A prospective randomized study among hospital employees. SPINE. 1993. (18)587-594.
McKenzie, Robin. Treat Your Own Back. Spinal Publications New Zealand LTD. 1997
McKenzie, Robin. Treat Your Own Neck. Spinal Publications New Zealand LTD. 1997
National Institute for Occupational Safety and Health. Back belts: do they prevent injury? Washington, DC: National Institute for Occupational Safety and Health, 1994. (DHHS (NIOSH) Publication no. 94-127.)
Videman, T, Rauhala, H, Asp, S, et. al. Patient handling skill, back injuries, and back pain: an intervention study in nursing. SPINE. 1989. (14)148-156.
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Continuing Education Questions:
You know you are using good posture when:
The amount of force required to lift the load is minimized when you hold the object close to you because the distance between the line drawn through the point of the fulcrum and the line drawn through the object being lifted are:
Your pelvis and lumbar spine function as a fulcrum during lifting activities which means:
You can tell if your standing posture is correct by identifying whether a straight line can be drawn through your:
Most furniture:
You can improve your posture and decrease strain on your back when sitting for extended periods of time by:
Consistently failing to get enough sleep (8 or more hours per night):
The most common factor contributing to back pain is:
You can significantly reduce your risk of back injury by:
You can decrease your risk of back injury by:
Spinal nerves:
Back injury prevention is:
A good sleeping surface is firm enough to support your body in good spinal alignment. It is suggested that you:
Back pains occurring several hours after strenuous activities may be the result of:
One quick way to check your standing posture is to:
Most nurses:
The lumbar vertebrae are larger and stronger because they.
The most direct predictors of job-related back injuries are:
Intervertebral discs:
If you are chronically stressed at home or on the job:
If you know you will be doing a lot of standing and walking, you can decrease the strain on your back by:
How many natural curves are there in your back?
In addition to good posture and proper body mechanics, you can decrease your risk by:
Most back pain results from:
Foundation skills for proper body mechanics include:
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