Cognitive Functional Therapy in nurses with persistent low back pain: an intervention based on an individualised multidimensional evaluation

Nurses perform essential healthcare tasks within our healthcare system and adequate nursing health is crucial for the provision of effective, empathic and efficient health care. However, occupational Low Back Pain (LBP) is very common among nurses. Lifetime prevalence ranges from 35 to 84% and annual prevalence is approximately 70%. LBP is worldwide the leading cause of disability and has a significant personal, social and economic impact. The problem of persistent LBP (PLBP) in nurses and beyond is still an increasing and urgent public health problem. Management approaches for LBP in nurses to date are mostly isolated interventions based on the belief that LBP results from a physical injury and focussing on physical nursing characteristics (lifting, transferring). They show very limited efficacy and no consistent evidence is presently available to support their widespread application. Better strategies to manage LBP in nurses is warranted and there is a clear need for individualised multimodal non-pharmacological interventions incorporating the biopsychosocial understanding of LBP, where it is acknowledged that a complex interaction between modifiable and non-modifiable factors across the multidimensional domain play a role. Further, management for LBP in nurses should target misconceptions around LBP. More specifically, it should not only focus on lifting and transferring tasks and ergonomics but should also assess the nominated painful postures and movements. Additionally, it should stimulate self-management and integrate high-value and guideline-based care. There is increasing evidence that this can lead to better outcome. However, integrating these promising principles in nurses with PLBP is currently lacking. The general aims of this doctoral project were: (1) to get a better understanding of the biopsychosocial characteristics in nurses with PLBP and (2) to evaluate an individualised Cognitive Functional Therapy (CFT) intervention in working nurses with PLBP within a specific occupational nursing setting. Firstly, a systematic review to evaluate the efficacy of current interventions for LBP in nurses was conducted (Chapter 1). With only four included low risk of bias studies, this systematic review revealed the limited presence of low risk of bias randomised controlled trails evaluating relevant interventions for LBP in nurses. From this systematic review it could be concluded that there is no strong evidence for any intervention in treating nor preventing LBP in nurses. While the high-quality studies in this systematic review actually had a good design and good methodology, they only compared unidimensional interventions, known to have effects that are small to moderate at best. These results confirmed the urgent need for other management approaches for LBP in nurses. Secondly, a cross-sectional study was performed evaluating multidimensional characteristics of nurses with PLBP (Chapter 2). Psychological (emotional distress, beliefs about LBP and self-efficacy) and lifestyle (physical activity and sleep) factors were evaluated among 42 nurses (28 nurses with PLBP and 14 pain-free controls). Furthermore, functional lumbar kinematics were monitored and compared during five functional tasks among 36 nurses (28 with PLBP, 8 pain-free controls) and between LBP subgroups (defined a-priori and based on clinical examination). Nurses with PLBP reported significantly more overall emotional distress (due to higher stress and anxiety levels), poorer self-efficacy (psychological behaviour) and poorer sleep (lifestyle behaviour), in addition to higher pain and disability. The nurses with LBP moved in a similar manner to those without LBP (physical behaviour). However, when analysed as two distinct LBP subgroups (Flexion Pattern (FP) and Extension Pattern (AEP)), the FP LBP subgroup were significantly more flexed than the AEP LBP subgroup for all functional tasks. Compared to the pain-free group, the AEP LBP subgroup differed significantly (more lumbar extension) for two (usual sitting, transferring a 5kg box from the ground to the table and back) of the five functional tasks and the FP LBP subgroup for one (sit-stand-sit) of the five functional tasks (more lumbar flexion). These results supported the biopsychosocial nature of LBP in working nurses with PLBP. Thirdly, a case-series pilot study was performed to longitudinally evaluate (three years follow-up) LBP-related absenteeism, pain, disability, healthcare seeking and several psychological and lifestyle behaviours in 30 nurses with PLBP following an individualised CFT intervention (Chapter 3). This case-series pilot study consisted of three phases; a baseline phase with two baseline measurements with 6 months in between, a CFT intervention for 14 weeks and a follow-up period with six follow-up measurements (immediately after, three, six and nine months after and one and three years after the CFT intervention). For absenteeism, follow-up measurements where at one, two, three and four calendar years after the intervention. Days of absenteeism due to LBP were significantly reduced in the first and second calendar year after the CFT intervention, but not the third and fourth. Disability and pain were significantly reduced for up to one year after the CFT intervention, but not at six months and three years follow-up. Total healthcare seeking (consults and proportion of subjects) was significantly reduced at all follow-ups (only measured until one year after the intervention) after the intervention. All psychological (emotional distress, back beliefs, self-efficacy and pain-related fear) and lifestyle variables (sleep), except for one (physical activity level), demonstrated significant improvements at all follow-ups (only measured until one year after the intervention). Fourthly, a secondary analysis was conducted on the same case-series pilot study of 30 nurses from Chapter 3, and evaluated some modifiable physical factors (lumbar kinematics and back- and leg- muscle endurance) in nurses with PLBP following an individualised CFT intervention (Chapter 4). Lumbar kinematics during five functional tasks (with a kinematic device, BodyguardTM) and back- and leg- muscle endurance were measured at baseline, immediately after the CFT intervention and one year later. Outcomes were compared between two subgroups (FP and AEP, defined a-priori) within the LBP population. Results revealed significant differences in lumbar kinematics between the two LBP subgroups. After the CFT intervention these kinematic differences were not evident at any follow-ups. Lumbar kinematics in one of the LBP subgroups (FP) significantly changed (less end-range flexion) after CFT during all of the five functional tasks and all follow-ups. No significant between- or within-group differences for back- and leg- muscle endurance were found after CFT. Chapter 3 and Chapter 4 demonstrated promising results for an individualised CFT intervention in nurses were PLBP is a major problem. Further high-quality research with stronger methodology is warranted to further explore the efficacy of an individualised CFT intervention in nurses with PLBP. Fifthly, two case reports provide a clear insight in and implementation of the multidimensional clinical reasoning process used to identify unhelpful behaviours across the multidimensional domain in nurses with PLBP. And further, how this process guided an individualised CFT intervention and how this intervention was practically implemented (Chapter 5). These two cases further showed that the personalised CFT intervention was flexible and assisted the two cases in a different way to improve their PLBP and showed promising changes in a wide range of outcome measures (clinical, physical, psychological and lifestyle). This doctoral project was a first step in the exploration of PLBP in nurses within an individualised, multidimensional understanding of pain. A CFT intervention showed promising results in a case-series of 30 nurses with PLBP with three years follow-up. The results of the studies in this doctoral project have to be interpreted in the context of their methodological limitations. These limitations are clearly discussed in the respective Chapters and general discussion, together with directions for essential future research. Future large prospective studies should further explore the biopsychosocial characteristics in nurses with PLBP and their causal relation with the onset and development of PLBP. It is also warranted to search for and evaluate other measures that can evaluate the impact of LBP in this specific population of working nurses with PLBP. Additionally, analysing the causal relationship between changing movement patterns and change in clinical status with mediation analysis seems interesting to unravel whether change in movement pattern is necessary to change the clinical status. Furthermore, Single Case Experimental Design studies should explore in detail the individual processes of change that occurs following an individualised CFT intervention. Last but not least, evaluating the efficacy of a CFT intervention compared with other guidelines-based care in a large randomised controlled multicentre trial is essential.

Publication year:2020

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