Khatu Pranam – Yoga Exercise Sequence Effective in Prevention of Back Pain in Nurses
Department of Physiatry, Balneology and Therapeutic Rehabilitation /FBLR/ of the F.D. Roosevelt University Hospital /FNsP/, Banská Bystrica, Head Physician Gabriela Majeríková, M.D.
Trnava University, Faculty of Health and Social Work, Department of Nursing, Trnava, Head of Department Associate Prof. PhDr. Botíková, Ph.D.
The original publication available only in Slovakian language in PDF format. It contains the referred pictures and graphs.
Subject of this study was to find options for prevention of vertebrogenic algic syndrome in nurses. In the F.D.Roosevelt Univesity Hospital /FNsP F.D.R./ 63% of nurses suffer from back pain and 68% of nurses carry out some physical activities in leisure time . Nurses´ motivation to regular physical activity revealed their intent of obtaining inner peace and energy in 68%, which, in rehabilitation, is met by psychosomatic exercises. These, however, occur in nurses only sporadically. Based on these results we developed a preventive program for nurses.
Prospective study was attended by 60 nurses working for more than 5 years at in-patient wards of the FNsP F.D.R. in Banská Bystrica. The control group (n=30) was instructed about back school and handling less mobile patients; the exercise group (n=30) was instructed similarly and practiced 3 times per week for 20 minutes: short relaxation, proper breathing exercise and a set of exercises Khatu Pranam from the System Yoga in Daily Life.
After 3 months of exercising 3 times per week in the exercise group a significant decrease in pain occurred by 36.67%, p=0.003. In the exercise group significantly improved the ability to maintain balance, breathing stereotype and range of spine motility, typically shortened muscles were brought to normal and weak muscles strengthened.
The study confirmed effectiveness of the proposed preventive program against back pain for nurses, but it needs to complete yoga exercises to develop lateroflexion, shortened m. levator scapulae, m.scalenus, m.quadratus lumborum and weak abdominal muscles. The back school and training aimed at handling less mobile patients as such seem to be insufficient.
Key words: back pain in nurses, exercises for nurses, Khatu Pranam, System Yoga in Daily Life.
Roman BEDNÁR1, Gabriela Majeríková2, 1,2Department of Rehabilitation, F.D.Roosevelt Univesity Hospital in Banská Bystrica, Slovakia
Preventive program of back pain in nurses
Options for prevention of vertebrogenic algic syndrome in nurses.
Khatu Pranam – Yoga Exercise Sequence Effective in Prevention of Back Pain in Nurses
Department of Physiatry, Balneology and Therapeutic Rehabilitation /FBLR/ of the F.D. Roosevelt University Hospital /FNsP/, Banská Bystrica, Head Physician Gabriela Majeríková, M.D.
Trnava University, Faculty of Health and Social Work, Department of Nursing, Trnava, Head of Department Associate Prof. PhDr. Botíková, Ph.D.
Incidence of back pain in nurses is high. The worldwide prevalence is about 17%, annual prevalence is 40-50% and lifetime prevalence is 35-80% (17). In the FNsP Hospital in Banská Bystrica suffer 63.33% of nurses from average back pain, an average intensity of pain in nurses is 3.24 , SD ±1.6772 and 19.32% use analgesics. In the group of nurses working at the patient´s bedside 64.20% reported back pain with an average pain intensity of 3.29, SD±1.661, in the outpatient department 60.0% suffered from back pain with an average pain intensity of 3.4, SD±1.569 (1). Usual prevalence of back injury in employed nurses is 44%, acute back pain is 19%, chronic back pain is 17% and lumbar hernia is 8% (21). According to Yip from Hong Kong annual prevalence of lumbar back pain in nurses is 40-60%. Of these, 94-98% experienced lumbar back pain lasting one and less than 14 days and 5-2% had pain for at least 14 days in the last twelve months. More than 50% have more than 5 episodes of pain in lumbar spine during the last twelve months (26). Byrns et al. state that almost 84% of nurses had a history of back pain caused by work and 36.2% experienced back pain which limited their mobility or their ability to perform routine work. In the pain scale from 1 to 10 a mean score was 3.5. Age, BMI or type of work were not significantly associated with the incidence of back pain. Those who reported exercising at least 20 or more minutes each week, experienced significant decrease in back pain compared to those who have not exercised p=0.028. (7). Horneij et al. present that 75% of health workers have damage to the lumbar spine. Their study indicated that damage to the spine in the lower back and a history of sick leave were the strongest predictors of future sick leave due to damage to the neck, shoulders and lower back in the group of working nurses and assistants. The authors emphasize the importance and multifactorial approach of early prevention programs in order to reduce future sick leave rate due to damage to the neck, shoulders or lower back in a group of women working as nurses or assistants (12). Erikson et al. found that regular physical activity, such as brisk walking, aerobics or other exercise lasting 20 or more minutes at least once a week for 3 to 15 months predict a lower sick leave rate among nurses (12).
Study of Freitag et al. with CUELA measuring system has shown that during shift nurses assume a lot of unsuitable postures which potentially leads to high levels of physical stress up to the critical levels according to standards and this is not only during transport of patients. An average of 1,131 times of trunk bending forward more than 20 degrees occurred during each shift. This translates to a frequency of 3.5 per minute. Totally 237 of these forward bends took more than 4 seconds. Totally 72 minutes were spent in more than 20 degrees bend forward position. Though the average time spent on moving patients and heavy material lasted only 2 minutes per shift. Positions with the trunk bending forward more than 60 degrees were present 175 times. These were mostly associated with bed adjustment activities 21%, primary health care 16% and cleaning and washing 16% (10).
The best known intervention program aimed at primary, secondary and tertiary prevention of back pain is called Back School. It represents a medical-pedagogical instruction activity which aims to explain the backgrounds of the back pain and motivate an individual to actively participate in maintaining the good condition of the musculoskeletal system. The back school consists in implementation of economic movement and an appropriate compensation of static overloading. It accentuates the need to give the body time to recover from tiredness by repeated minimal muscle movements that are not loaded during usual activities. (9). Dawsan compared several studies and found that manual handling, as an isolated intervention for the prevention of back pain in nurses, is ineffective. In their studies aimed at low back pain prevention by training in manual handling as an isolated strategy Knibbe, Smedley, Best, Dehlin, Wood, Videman, Hellsing and Dawson have found its ineffectiveness. We published handling techniques in the second issue of the journal Rehabilitace a fyzikální lékařství /Rehabilitation and Physical Medicine/ in 2011. European guidelines report a high level of evidence to recommend physical exercise as an intervention for the prevention of back pain in working population. However, it is not known which type of exercise is most effective (8). Studies presented by Byrns, Gundewall, Dehlin aimed at preventing the pain in lower back in nurses by using exercises confirmed the significance of this intervention. As for the type of exercise, however, there are conflicting evidence (7). Today, sophisticated movement methods (Pilates, McKenzie, Feldekreis, Spiral dynamics, yoga, spinal exercises, Vojta method, DNS , etc.) are offerred. To a varying degree of effectiveness these cen restore and maintain musculoskeletal system in good shape and prevent occurrence and relapses of vertebrogenous algic syndrome. McKenzie method is indicated in frequent relapses or in cases of poor effect of the classical physiotherapy (11). Currently, there are exercise programs aimed at segmental stabilization first described by Richardson. This approach focuses at re-education and precise co-contraction of patterns of deep trunk muscles: mm.transversi abdominis and lumbar mm.multifidi. (18). Horneij´s high quality study tested the effectiveness of stress management interventions and provided a moderate evidence that his intervention in isolation is ineffective in preventing back pain in nurses. This could lead to the assumption that stress is not a risk factor for back pain. There is an uncertain evidence for the link between work stress and back pain in nurses. Lack of repeated studies undermines the credibility of the conclusions that can be drawn regarding the stress management effectiveness in the prevention of injury and back pain in nurses (8). According to Yip, the prevention of back pain in nurses lies with the training of high-risk work activities and an ergonomic determination of difficult working postures. Furthermore, relaxation and workshops on teamwork are recommended for nurses. Especially for those who are relatively new in the ward (27). In recent decades, nursing associations have developed and advocate a „No Lifting Policy“ and prefer using lifting equipment and manual lifting is excluded except for extraordinary circumstances. Currently there is no evidence available which would expressly support the widespread application of „No Lifting“. Australian and American studies supporting the „No Lifting“ theory showed certain design deficiencies. Other studies, however, did not specify that manual lifting should by avoided (8).
There is moderate evidence from several studies that back pain preventive intervention is only effective in multidimensional strategy and training of isolated manual lifting is inefficient. As for all other interventions (exercise, lumbar support, stress management, manual lifting equipment and training) there are contradictory evidence or are implemented as isolated studies. Back pain is complex and multifaceted and application of multidimensional intervention is recommended by others. There are permanently positive findings supporting the efficacy of multidimensional strategy for the prevention of back pain in nurses (8).
Yoga exercises are the oldest from among today´s exercises and methods. Nevertheless, they are still relevant and many of the contemporary exercise methodologies are based on yoga principles or irrespective of their origin they approached it. The current trend in the exercises called „body mind“, a conscious connection of body and mind is nothing else but the most basic principle of thousands of years old yoga exercises. Currently, yoga is thoroughly elaborated and explained according to modern scientific knowledge. Its applications are elaborated for particular diagnoses, such as yoga for back pain, yoga for joint pain, yoga for rheumatism, yoga for asthma patients, yoga for eyes, yoga and multiple sclerosis, use of yoga for selected psychiatry diagnoses and others. In the former Czechoslovakia a research under the guidance of academician C. Dostálek was held at the Institute of Physiological Regulations of the Academy of Sciences in Prague. He and his colleagues published numerous works both at home and abroad scientifically clarifying the effects of yoga. Dostálek´s explanation of the mechanism of effect of yoga was well accepted in Europe and even in India. It was supported also by working relationships of the Institute of Physiological Regulations and the Lonavla Yoga Institute, the Varanasi University and the All India Institute of Medical Sciences in New Delhi. Through this collaboration several Indian scholars and yoga teachers visited Czechoslovakia. They were Dr. Mukhunda Bhole from the Lonavla Yoga Institute and prominent yoga teachers Swami Gitananda and Swami Maheshwarananda. Maheshwarananda elaborated yoga exercises and techniques and masterfully connected the original Indian yoga with the needs of Western man. He is the author of the System Yoga in Daily Life, one of the currently most widely used yoga systems, which has been used in the Czech Republic and Slovakia for 40 years. Academician Ctibor Dostálek repeatedly visited Indian workplaces engaged with therapeutic use of yoga and research in this area. These workplaces were visited also by V.Doležalová, M.D., from Prague and Associate Professor J.Motajová, M.D., from Bratislava who engaged in research into yoga in cardiac patients. Associate Professor Votava should also be mentioned, who led the section for utilization of yoga in rehabilitation for many years. Yoga exercises start from simple preparatory exercises suitable for the sick and beginners. Yoga movement is slow, conscious and synchronized with breathing, which is something we are not used to in the normal gym exercises. Proper breathing and learning what is called full yoga breath are crucial. Regular practice of yoga brings a gradual release of shortened muscles, strengthening of muscle groups, it restores the full extent of joints and spine motions and regulates the correct stereotype. Only after mastering the preparatory exercises one can proceed to asanas – positions. Asana has a phase of assuming the position and a phase of holding the position. The exerciser should relax in the asana in a concentrated and non-violent way in order to achieve harmony without feeling exhausted. Only the muscles necessary to maintain the asana should be activated while consciously breathing. Asana performed in this way has a deeper effect and thus it can more significantly influence the autonomic nervous system. Each asana specifically influences the sympathetic or parasympathetic nervous system, as confirmed by Kolísko, who measured asanas using the HRV method (heart rate variability). As is known, at the beginning of practice when certain activities are learned, in the movement also some unnecessary muscles are involved. Therefore, the aim is to relax muscles and muscle fibers that are not involved in keeping the position or making the movement. This is called differentiated relaxation. Differentiated relaxation is done deliberately in most yoga techniques, but mainly in asanas and preparatory exercises. After some time the exerciser is able to shift this ability into his or her everyday life. People have much more experience with how their muscles stretch than how they relax (23). In patients with cortical plasticity disorders and related somatognostic and stereognostic functions we recommend, during specific training of stabilization functions, to also perform simple exercises with a maximum awareness of posture and movement. In this context, practicing yoga, Tai Chi or Feldenkrais seem to be very useful (13). If the overall excitability of the system is increased and there is a relative tendency to get a „shortening“, it is necessary to use appropriate relaxation techniques of yoga as a basic approach that complements other individual practices according to the type of disorder (22). In yogic exercises there should be only as much tension in muscles, as is necessary for that particular movement or posture. However, we are able to achieve this only when our perception of the body is deep enough to capture various tensions in the body and release those which are unnecessary (15). Relaxation exercises can also be used in patients. E.g. Savasana (relaxation in the back-lying position) has proved to be a suitable aid in the treatment of high blood pressure. Udupa and his colleagues observed a similar effect in Savasana as with using diazepam. Therefore some exercises can reduce application of synthetic pharmaceuticals having side effects (24). Yoga is a system of exercises leading to the organism´s resistance to stress so the resulting steady state is not disturbed by stressors in such an extent as in untrained individuals (25). According to Lewit, from the prevention point of view yoga exercises are suitable, movements are not swift but smooth, body unfolds in a round shape, strengthening alternates regularly with relaxation and proper breathing technique is adhered to. (14). According to statistics from 2002 in the USA 14 million people practice yoga, of which 1 million use it against back pain. Yoga is effective for treatment of chronic back pain. In a randomized controlled trial it was scored better than other conventional exercises or exercises taken from the book Spine Care. The authors also confirmed that the 12-week yoga classes brought about more lasting improvement than the conventional 12-week exercise. As for reduction of pain after 26 weeks yoga proved to be better than exercise and also after 26 weeks in the yoga group the most significant reduce occurred in analgesics consumption to 21% compared to conventional exercise group reduction to 50% and reduction to 58% in exercises according to the book (19).
The research aimed at creating a compensatory program for nurses which is effective against back pain. Our hypothesis suggests that in the majority of nurses the back pain subsides and the functional status of the spine improves after completing a three-dimensional program.
Characteristics of Group of Patients and Methodology
Clinical research objectifies the effectiveness of compensatory exercises and the back school with principles of proper handling the less mobile patients with nurses working at seventeen inpatient wards (Table 1). 60 female nurses were included in the clinical study. Their mean age in the control group (n=30) was 46 years (min. 28 years, max. 57 years) and in the exercise group (n=30) was 45 years (min. 23 years, max. 59 years). BMI in the control group was 25.01 SD 0,928 and in the exercise group it was 24.76 SD 1,235 . In the study, 16.67% of nurses were university graduates and 83.33% were secondary school graduates. They all worked in a three-shift operation at the inpatient wards of the FNsP Hospital in Banská Bystrica.
According to Dawson, isolated stress management program does not function as prevention for back pain in nurses (8). According to Bednár and Majeríková´s study assessing mental stress of nurses influencing the back pain, no direct effect of stress on the onset of pain has been confirmed, but it is an important factor supporting the onset and continuation of pain (4). Systematic reports on the role of occupational stress for back pain in the general population are uncertain. Linton found strong evidence that stress relates to future back pain. Lack of repeated studies undermines the credibility of the conclusions that can be drawn regarding the stress management effectiveness in the prevention of injury and back pain in nurses (8). According to Yip, the prevention of back pain in nurses lies with the training of high-risk work activities and an ergonomic determination of difficult working postures. Furthermore, relaxation and workshops on teamwork are recommended for nurses. Especially for those who are relatively new in the ward (27). Effective prevention of pain and back injury in nurses lies in a multilevel intervention (8). Therefore, in our prospective study we have chosen the three-dimensional intervention.
At the beginning, each nurse attended a 60-minute workshop on back school, handling less mobile patients and practiced a 30-minute compensatory exercise program. Thereafter they voluntarily decided whether they wanted to continue the exercises. The ethics committee proposed to randomize nurses only after one month of exercise, which was practically impossible. Therefore, we finally decided to let it up to nurses to decide about joining the exercise group. In the study participated nurses working more than five years in hospital´s inpatient wards, had a history of back pain in the compensated stage and in the entry form they indicated an absence of structural changes in the spine: scoliosis, kyphososcoliosis, intervertebral disc damage, status after vertebrae fractures, spondylolisthesis, spinal canal stenosis and rheumatic diseases.
All participating nurses were examined at the beginning. At the examinations, functional status of their spine was assessed according to standard examination techniques in rehabilitation. We measured mobility of the spine, breathing stereotype, shortened muscles, weakened muscles and balance ability. Nurses completed a short questionnaire about the current state of back pain and its history, basic data of their position and informed consent of the patient about inclusion in the study. Clinical research was approved by the ethics committee. The exercise group was instructed into the back school, the principles of proper handling the less mobile patients and compensatory training exercises which they practiced for three months. The back school and the principles of proper handling the less mobile patients for nurses were published in the journal Rehabilitation and Physical Medicine No.2 in 2011 and that is why we did not go in more detail in this article (4). The recommended frequency of workout was 3 times per week including once per week 30 minutes under the guidance of a physiotherapist and twice per week at home individually. They recorded numbers of exercises and their durations in special workout calendar. The entire home workout program took 20 minutes. The control group was instructed into the back school and the principles of proper handling the less mobile patients. Both groups were examined after three months; the results were compared and statistically evaluated. The examinations data were categorized, analyzed and process in EXCEL. Statistical testing was performed by
Student´s t-test, Wilcoxon´s one-sample test and Mann-Witney´s U-test two-samples. Muscle examinations were evaluated with the Pearson chi-square, degrees of freedom and signification.
In the Roosevelt Hospital 96% of nurses rate their work as stressful and 32% consider it very stressful (3). According to Bednár 68% of nurses in the Roosevelt Hospital in Banská Bystrica prefer motivation for regular physical activity such exercises, after which they feel refreshed, full of energy, balanced, innerly satisfied and happy, to exercises, after which they gain a nice figure, muscle strength and weight loss. These results speak of high mental stress of nurses (2). This led us to the selection of such preventive exercises that improve the spine condition and at the same time significantly reduce the mental stress. In rehabilitation, these conditions meet psychosomatic exercises. Besides acting on our body, psychosomatic exercises develop relaxation ability and gnostic functions. According to Kolář, the most suitable are yoga, taichi or Feldenkrais method (13).
For our compensatory workout we created a program for nurses that included a short relaxation, practicing proper breathing and a sequence of exercises Khat Pranam from the System Yoga in Daily Life. This sequence of exercises is practiced with compensated patients in courses against back pain and is also included in home program. For its simplicity and complexity it is popular which met the prerequisites of good compliance. In the literature we found comparative studies with other methodologies and since our department has many years of experience with yoga exercise our previous good results with this sequence of exercises brought us to include it as a suitable psychosomatic exercise together with relaxation and practicing proper breathing. The exercise sequence Khatu Pranam comprises 10 positions that systematically influence the whole spine and through the closed and open kinetic chains they activate muscle interactivity with shoulder and pelvic girdle. The sequence strengthens and stretches typical weakened and shortened muscle groups. The sequence warms-up and mobilizes the movement of spine and joints. Some positions, such as the seventh and tenth, influence the balance ability. The sequence can be practiced dynamically or statically with holding time. We used a dynamic form with precise inhalation and exhalation at specified positions and by repeating several rounds in this way we can have an aerobic training effect.
Khatu Pranam Sequence
The starting position is sitting on heels. The trunk and head are erect, hands rest on the thighs (Fig. 1). The first position: inhaling both arms go up above the head, palms are together. Pull shoulder blades together and look up towards the palms (Fig. 2). The second position: exhaling turn the palms to the front and slowly bend forward from the hips keeping the back and arms straight and in the same level. Forehead and arms touch the floor (Fig. 3). The third position: inhaling bring the upper body forward with chin on the floor until the shoulders are above fingers Toes, knees, chest, hands and chin touch the floor (Fig. 4). The fourth position: complete inhaling and hold breath. With the help of the hands lift the trunk up and lower the pelvis to the floor. Look up. The whole spine is evenly arched (Fig. 5). The fifth position: exhaling raise the pelvis / buttocks high so that the legs remain straight and the body weight is distributed between the hands and the feet. The whole foot soles should touch the floor. The head hangs relaxed and look towards the navel (Fig. 6). The sixth position, inhaling step the right foot between the hands. The left knee is on the floor. Push the pelvis forward. Raise the head and look up (Fig. 7). The seventh position: completing the inhalation extend the arms above the head and bring the palms together. Look up towards the palms. Push the pelvis forward (Fig. 8). The eighth position: this position is identical with the position number six. The ninth position: exhaling bring the left foot beside the right one and straighten the knees. Allow the head and upper body to hang downwards relaxed (Fig. 9). The tenth position: inhaling raise the head and trunk so that the movement starts from the hips. Extend the arms above the head, bring palms together and look up (Fig. 10). At this point you are in the middle of one cycle of the exercise. Now continue in reverse order, i.e. from the tenth position to the first one. In the positions 6 and 7 change the legs (6).
Benefits of the Khatu Pranam Positions
The starting position – sitting on heels – active involvement of postural muscles that keep the spine and head in the correct upright position. Transition from the starting position to the first position in flexion in the shoulder joint gradually involves m. deltoideus, m. coracobrachialis, m. pectoralis major, m. trapezius and m. serratus anterior. In the maximum flexion the trunk muscles cooperate and the lordosis increases. Furthermore, shoulder blade adductors and all trunk muscles become engaged. This exercise increases the range of flexion in the shoulder joint and reduces thoracic kyphosis. In the positions 1 and 19 the trunk muscles and ligaments stretch and lateral thoracic breathing deepens. Postural muscles and shoulder joint stabilizers are activated (Fig. 2). Transition from the first to the second position in flexion of the hip joints the eccentric contraction engages m. quadratus lumborum, paravertebral muscles and shoulder joint flexors. In the positions 2 and 18 all muscles are relaxed. This increases the blood supply to the head, relieves the neck and shoulder area, deepens the back chest breathing and acts as an autotraction and relaxes the spine (Fig. 3). In the transition from the second to the third position the trunk is moved forward, which activates shoulder joint extensors and abductors, shoulder blade abductors, elbow joint flexors and extensors, hand dorsal flexors, hip joint extensors and trunk muscles. Positions 3 and 17 bend and stretch the entire spine, reduce thoracic kyphosis and promote diaphragmatic breathing (Fib. 4). Transition from the third to the fourth position the trunk and head extension phase activates the deep and short head extensors, paravertebral muscles, shoulder blade adductors, m. triceps brachii, m. deltoideus, m. coracobrachialis and m. pectoralis major. Positions 4 and 16 stretch the entire spine and the front of the trunk. They strengthen the back, arm and shoulder muscles. They relax shortened hip joint flexors, m. rectus abdominis and neck flexors. They strengthen short and deep head extensors, paravertebral muscles, shoulder blade adductors, m. triceps brachii and shoulder joint flexors (Fig. 5). Transition from the fourth to the fifth position activates hip and shoulder joint flexors, abdominal muscles and shoulder blade adductors. Stretching of m. triceps surae and knee joint flexors. Positions 5 and 15 activate entire trunk muscles, shoulder joint stabilizers, stretch m. triceps surae and the knee joint flexors (Fig. 6). Transition from the fifth to sixth position unilaterally activate the hip joint flexors, contralaterally activate the hip joint extensors. The shoulder joint extensors, trunk and head extensors get activated. Positions 6 and 14 extend the back muscles and the whole spine, the muscles of the hips and pelvic floor. Hip joint flexors extend unilaterally and hip joint extensors extend contralaterally (Fig. 7). Transition from the sixth to the seventh position in flexion in the shoulder joint gradually involve m. deltoideus, m. coracobrachialis, m. pectoralis major, m. trapezius and m. serratus anterior. In the maximum flexion the trunk muscles cooperate and the lordosis increases. Furthermore, shoulder blade adductors and all trunk muscles become engaged. The spine extends. Positions 7 and 13 stretch the whole of the upper body, especially along the sides of the chest. These positions improve balance and leg stability. Hip joint flexors extend unilaterally and hip joint extensors extend contralaterally. Postural muscles and shoulder joint stabilizers get activated (Fig. 8). Positions 8 and 12 are the same as positions 6 and 14. Transitions from the eighth to the ninth position activate the leg muscles. In positions 9 and 11 the whole upper body can relax. The spine, shoulder girdle and arms are relaxed. They stretch the back muscles, knee joint flexors and m. triceps suare (Fig. 9). Transition from the ninth to the tenth position, when erect, the hip joint extensors and trunk and neck extensors get activated. Furthermore, the shoulder joint flexors and shoulder blade fixators get activated. The tenth position actively involves postural muscles that keep the spine and head in the correct upright position (Fig. 10) (6).
Results and Discussion
Effective prevention of pain and back injury in nurses lies in a multilevel intervention (8). Therefore, in our prospective study we have chosen the three-dimensional intervention. It consists of the instruction of the back school, handling the less mobile patients and the compensatory exercise preventive program created by us. Compensatory exercises consisted in a short relaxation, practicing proper breathing and the exercise sequence Khatu Pranam – the structure was adopted from the System Yoga in Daily Life, from which the sequence itself comes. An average duration of the entire block was 20 minutes. We used the preventive program for nurses also within the hospital-wide project in the FNsP Hospital in Banská Bystrica which employs more than 800 nurses. The hospital-wide project entitled the Prevention of Back Pain in Health Professionals was created in order to reduce the incidence of back pain in nurses working at the patient´s bedside. 10 inpatient wards with 206 nurses actively participated in the project. The entire project lasted from May 2010 till June 2012 and was approved by the hospital´s management. All nurses attended a 60-minute workshop at which they received theoretical instructions and could practice the back school and the proper handling the less mobile patients. In the second session of the workshop the nurses were offered compensatory exercises; 58 nurses used this opportunity.Results of the prospective study of the proposed prevention program against back pain in nurses (n=60) working at 17 inpatient wards of the FNsP Hospital in Banská Bystrica for more than 5 years brought the following: In the exercise group (n=30) back pain decreased by 36.67% with statistical significance of p=0.003. In the control group (n=30) back pain decreased by 13.33% without significance p=0.301 (Graph 1). Comparison between the two groups showed no significant variation p=0.795. In concert with Byrns we confirmed that a 20-minute or longer workout every week significantly reduces back pain p=0.028 (7). In the exercise group at the study entry, mean pain intensity was 4.25 and at the end of the study it fell to 3.31. In the control group at the study entry, mean pain intensity was 3.56 and at the study´s end it was 3.42. The original intention to randomize the group failed and we finally let it up to the nurses to voluntarily decide about entering the study. Motivation of nurses in the exercise group may have been stronger due to more severe pain. This is the most common motivation for why patients seek Professional help, however, once the pain subsides, their interest in active approach declines, which proved to be true also in our group. By means of Sharpened Romber Test we evaluated the balance abilities. In the exercise group we observed a prolonged holding time in a tandem position by an average of 21 seconds with the statistical significance p=0.19. Matthias test that comprehensively assesses body posture and muscle imbalances, was not sensitive enough, hence was not relevant. As for assessing the breathing stereotype, breathing modified to physiological in ten out of totally 20 participants with statistical significance p=0.009. Breathing stereotype modification has, in addition to respiratory function, also an important postural function that is provided by the deep stabilizing muscle system. Here, the substantial role plays the diaphragm, the main breathing muscle, and its teammates. Incitement of correct breathing stereotype facilitates the deep stabilizing system. I fit is insufficient, the long surface back extensors get overloaded which is nowadays considered the most common cause of back pain. In the exercise group the mobility in the thoracic spine according to Otto´s inclination index improved by 1.45 cm and reclination index by 1.40 cm with statistical significance p<0,05. In the lumbar spine, the input and output mean values in both groups ranged within physiological limits, so the variances were insignificant. Thomayer´s test, however, statistically significantly improved p<0,05 only in the exercise group by 10.4 cm. As for the cervical spine, there was significant improvement of p<0,05 in all movement directions except for rotation to the right. The exercise group showed improvement in the cervical spine anteflexion by 0.883 cm while the same worsened in the control group. Retroflexion in the exercise group improved by 1.05 cm and worsened in the control group. Inclination improved in the exercise group by an average of 1.183 on the right and 1.3 on the left, while in the control group inclination worsened on the right and improved on the left by 0.486 cm. Lumbar spine lateroflexions have not changed significantly bilaterally as a consequence of absence of sideways bending positions in the sequence. When assessing the effect of the exercise on typically shortened muscles there was a statistically significant modification of m. pectoralis minor, m. sternoceidomastoideus, m. trapesius, short head extensors, paravertebral muscles and m. iliopsoas and no change occurred to m. levator scapulae, m. scalenus and m. quadratus lumborum (Graphs 2, 3, 4). These three musles were not affected probably as a result of absence of sideways bending and rotating positions in the said sequence. When practicing the sequence we did not force the backward bend of cervical spine in the backward bend positions and we omitted torsion in the position 7, which is a rotation of the trunk with arms towards the rear heel; this position is normally not included. Absence of these elements could manifest on the lack of improvement in shortened muscles and lateroflexion of the lumbar spine. In majority of shortened muscles, however, we observed release in favor of normal state potentiated also by the effect of relaxation and practicing proper breathing. In typically weakened muscles the deep neck flexors, lower shoulder blade fixators, deep back muscles and pelvifemoral muscles were statistically significantly strengthened; abdominal muscles were not strengthened (Graphs 5,6,7). We perceive the fact that abdominal muscles were not strengthened as a shortcoming of this exercise sequence since the abdominal muscles are an important opponent to back muscles maintaining the intra-abdominal pressure. Excessive overloading of the back muscles in the abdominal muscles insufficiency leads to back pain. All other typically weakened muscles were significantly strengthened.
An isolated training of handling the less mobile patients and the back school seem to be insufficient. Our proposed three-dimensional prevention program against back pain in nurses appears to be effective, assuming, however, that it will be accompanied by yoga exercises that compensate for the above mentioned shortcomings of lateroflesion, shortened muscles m. levator scapulae, m. scalenus, m. quadratus lumborum and the weakened abdominal muscles. Advantage of this workout program is a complete and comprehensive sequence of exercises presenting a simple alternative for nurses that does not take much time. It is very feasible and can be applied to a very wide group of nurses. Nurses perceived the exercises as harmonizing and revitalizing, which was appreciated all of them. For this psychosomatic dimension, most of them continue practicing at home. This study, in its final form, could very well serve all nurses and especially those working at inpatient wards, and all healthcare professionals whose spine is exposed to an increased load.
Recommendations for Practice
1. Our proposed three-dimensional compensatory program for nurses working at the patient´s bedside comprises of the back school, training of handling the less mobile patients and compensatory exercises. The workout program consists of relaxation, practicing proper breathing and the sequence of exercises Khatu Pranam from the System Yoga in Daily Life. This compensatory program has proven to be effective, but it should be complemented by yoga exercises improving lateroflexion, shortened muscles m. levator scapulae, m. scalenus, m. quadratus lumborum and weakened abdominal muscles.
2. Effectiveness of the compensatory program depends on the regularity, duration and frequency of practicing. A 20-minute program with a frequency of practicing 3 times a week seems to be sufficient to actively prevent back pain in nurses (7).
3. Using the back school and the principles of proper handling the less mobile patients should become a daily routine of each nurse. It is important that nurses get familiar with these principles already during their studies. An isolated use of these principles in practice does not seem to be effective enough.
4. An isolated training of manual handling of patients is not a sufficient prevention of back pain in nurses. Therefore, the issue of addressing the back pain in nurses requires a multidimensional approach (8).
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MUDr. Roman Bednár, PhD.
Trieda Hradca Králové č.9
Table 1 Distribution of nurses by wards / departments
Legend: nk: number, control group; nc: number
exercise group; n: total number
Figure 1 Starting position
Figure 2 Position No.1
Figure 3 Position No.2
Figure 4 Position No.3
Figure 5 Position No.4
Figure 6 Position No.5
Figure 7 Position No.6
Figure 8 Position No.7
Figure 9 Position No.9
Figure 10 Position No.10
Graph 1 Pain intensity in nurses
Graph 2 Changes in shortened muscles on the right
Graph 3 Changes in shortened muscles on the left
Graph 4 Changes in shortened head extensors and paravertebral muscles
Graph 5 Strengthening the weakened muscles
Graph 6 Strengthening the weakened muscles on the right
Graph 7 Strengthening the weakened muscles on the left