Aveneu Park, Starling, Australia

ABSTRACT (SD) as mean pain level and 16.39±11.82 mean

ABSTRACT
Background: Low back pain is a major complaint among nursing professionals. LBP has been a major complaint for certain occupational groups and nursing professionals are one of the highest at risk, and exposed to variety of treatment options.
Aim: The study was to investigate low back pain prevalence and treatment preference among nurses in selected departments of a Teaching Hospital.
Methods: The study was a cross-sectional survey involving nurses working at Teaching Hospital for more than 12 months. Stratified random sampling technique was used to sample participants into four strata. A total of 161 subjects participated in this study. A structured questionnaire was administered by researchers to participants who gave their consent.  Descriptive statistics of frequency distribution was used to summarize data collected. A two-way between-groups analysis of variance was conducted to explore the impact of the service period and pain threshold on low back pain prevalence (?-level= 0.05).
Results: Male participants were 32 whilst females were 129 with ages ranging from 21 to 59 years. LBP prevalence was 88.8% among participants. The nurses reported 5.64±1.96 (SD) as mean pain level and 16.39±11.82 mean years of experience. Orthopaedic Department reported the highest LBP prevalence (93.9%). Most participants (37.3%) received self-medication and only 21.8% received physiotherapy.
Conclusion: Low back pain prevalence among nurses at the teaching hospital was high. Only few nurses resort to physiotherapy for the treatment of low back pain. Further research to develop methods to reduce the risks of LBP which are inherently part of the nursing profession is required.
Key words: Low back pain, prevalence, treatment, nurse.

Introduction
Low Back Pain (LBP) is a major public health problem in most industrialized nations and it is associated with major costs, in terms of health resource usage, worker disability and absenteeism (Maniadakis & Gray, 2000; Hoy et al. 2014). It is said to be one of the most common causes of sick leave in the Western world (Reiso et al. 2003).  It was estimated that in 1994–95, 116 million production days were lost in the United Kingdom due to LBP related work incapacity (Maniadakis & Gray, 2000). In Ireland, the Health and Safety Authority in 2003, recorded all work injury-related sickness absences of either less or equal to three days duration. Disability from LBP is a major loss to national productivity. Fabunmi and colleagues (2008) reported that LBP seems to be as common in Sub-Saharan Africa as in European countries, with a prevalence of 1 out of 3 rheumatology outpatients reporting LBP. In Ghana, 60% of adults report of LBP at one time of their lifetime (Osei, 2013)
Many studies have explored LBP in relation to specific occupational groups and have identified the health services sector as a workplace with a high risk for LBP (Maniadakis & Gray, 2000; Burton, 1997; Xu et al. 1996). This is reflected in the Health and Safety Authority annual report in Ireland, which indicated that back injuries accounted for 32% of all non-fatal work injuries within the health and social services sector, whereas the mean proportion for all work sectors was 26%. 
Many options are available for evaluation and management of LBP. However, there has been little consensus, either within or between specialties, on appropriate clinical evaluation and management of LBP (Cherkin et al. 1994; Cherkin et al. 1995).  Despite wide variations in treatment, patients seem to experience similar outcomes, though cost of care may differ substantially among and within specialties (Shekelle et al. 1995). Many patients have self-limited episodes of acute LBP and do not seek medical care (Carey et al. 1996). Among those who do seek medical care as a result of pain and disability, and return to work typically improve rapidly in the first month ( Pengel et al. 2003). A significant percentage of sufferers, estimated at over 50%, do not consult a healthcare professional for the problem (Waxman et al. 1998).
Research looking into the variables used for treatment selection and treatment preference among nurses in different specialties for low back pain has not been extensively studied. This observation spurred the researchers to extend the area of literature to cover the treatment preferred by nurses. The study therefore aimed to evaluate the levels of disabilities associated with low back pain and treatment preferences among nursing profession.
Method
Using a quantitative cross-sectional research design, data was gathered from nurses at a teaching hospital to estimate the prevalence of low back pain and treatment preference among them. The teaching hospital used in this study is the leading referral centre in Ghana. Nurses were recruited from Child Health, Orthopaedics and Medical departments of the hospital. A questionnaire containing the demographic characteristics of participants, prevalence of LBP, the treatment preference, the Oswestry Disability Index (ODI), and Visual Analogue Scale (VAS) which was originally developed by Magee (2002) and adopted by Hawker et al. (2011) was used to gather data from participants. The questionnaires were administered from January, 2014 to April, 2014. Participants were selected based on predefined inclusion and exclusion criteria. Nurses were included if they had 12 months and above of working experiences and had consented to participate in the study. Nurses were excluded if they were students, interns, less than 12 months of working experience or refused to consent. Ethical approval was obtained and written permission was obtained by the Management Board of each department. Similarly, informed consent was obtained from each participant.
Data Analysis
The data gathered was analysed using Statistical Package for Social Sciences (SPSS 16.0 software, Chicago, IL). Descriptive statistics of frequencies and percentages including means and standard deviations were calculated and presented in tables to illustrate the levels of low back pain and disabilities associated with the treatment preferences indicated by the participants.

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Results
A total of 200 nurses were recruited for the studies with 161 nurses successfully completing the questionnaires and returned them for the analysis, yielding a response rate of 80.1% at the teaching hospital participated in the study. Out of this number, 143 (88.8%) reported having LBP as shown in Table 1. 
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Participants’ treatment preferences 
Out of the 143 that complained of low back pain, only one of the participants had no treatment for his/her syndrome. Fifty-three of the participants (37.1%) went for self-medication, 24 (16.8%) went for advice/education from a General Practitioner (GP), 18 (12.6%) went for advice from Physiotherapist, 31(21.7%) received Physiotherapy, 5 (3.5%) had chiropractic, 1(0.7%) received osteopathic treatment and 10 (7.0%) had surgery for their low back pain as shown in Table 2.
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Relationship between number of years in service and the pain level within the departments
Figure 1 show the period in years of service of the participants. The respondents had an average duration of 16.4 years of service with a maximum period of 39 years of service and minimum of 1 year. Majority of participants (41%) had between 1-10 years of experience whilst a lesser percentage (13.7%) of the participants had between 31-40 years experience. 
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A two-way between-groups analysis of variance was conducted to explore the impact of the period of service and the level of pain on the prevalence of low back pain among participants of the various departments. The prevalence of LBP with the periods of service does not differ in terms of the departments suggesting that LBP is more related to duration of service. The level of pain experienced was not affected by the number of years spent in nursing service within department. The main effect of the level of pain was also not significant at p=0.05 and neither was the interaction effect as presented in Table 3.
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Participants’ treatment choice and duration of treatment 
Table 4 presents mean duration of treatment in days received by participants. The physiotherapy treatment recorded the highest mean of days for treatment. Participants also had longer durations for self-medication, especially participants from the medical department (37.75±26.52).

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The distribution of mean level of disability and preferred treatment by participants 
The mean level of disability among participants who received chiropractic was the highest (52.40±21.61) while those participants who received physiotherapy as a treatment choice reported a mean disability level of 36.90±14.95 (Table 5). The overall mean total disability level of participants was recorded to be 28.13±18.67.
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Discussion
The findings of the study provide excellent understanding about low back pain among nurses at the teaching hospital where the study was carried out. As identified, more than half of the nurses interviewed reported experiencing LBP. This finding is consistent with the outcomes of Lagerstrom and colleagues (1996) report. A similar outcome was identified among Nigerian nurses (Fabunmi et al. 2008) with a prevalence rate of 78%. Though nurses’ jobs are associated with lifting, transfers of patients, prolonged sitting or standing sometimes, it is not clear from these studies if they are responsible for the high prevalence reported by this study.
The nursing profession is at great risk for low back pain. LBP prevalence as a result of the number of years in service does not differ within departments and so nurses no matter the department of work have equal chances of experiencing low back pain. Further studies may be required to understudy the involvement of nurses taking into consideration, their expertise and the various departments from which they work. This will better help expand the findings and the understanding of the higher conditions reported among participants. From the study, nurses at the orthopaedic ward spent greater number of years on the job, suggesting that, the development of LBP is also associated with work load and increasing years of working experience.  With increasing age, there is gradual weakening of the cartilage, the soft elastic material that covers the surface of the vertebral joints and the other joints in the body as well as the degeneration process of the articular cartilages (WHO, 2001; Hilde et al. 2002). 
In this study, there was no significant relationship between average duration in service and the pain intensity of participants. In contrary, Arrighi and Hertz-Piccotto (1994) reported that, as the average duration in service increased the pain intensity of participants gradually increased. From occupational studies, healthy survivor effect describes a continuing selection process such that those who remain in an employment tend to be healthier over time (Evanoff, 1999). This was not significantly reflected in this study. It is believed in a cross-sectional study carried out by the National Research Council in 1999 that, survivor effects will typically decrease the observed associations between symptomatic disorders (pain) and physically demanding jobs.
According to Carey and colleagues (1996), many patients have self-limited episodes of acute low back pain and do not seek medical care.  In a study conducted by Tinubu and colleagues (2010), only 30.3% of the participants suffering low back pain sought for treatment. From the study, 99.3% of the nurses who reported experiencing low back pain sought treatment for their low back pain. The highest percentage of nurses received self-medications to resolve their complaints with few seeking advice from the general practitioner. This could be due to the fact that, nurses due to their background in pharmacology tend to identify various medication which could subside their complaints. It was realized that only 21.7% went for physiotherapy whilst 12.6% sought advice from physiotherapists. The few who sought physiotherapy as treatment could be due to inadequate awareness on the appropriate types of physiotherapy to undertake to alleviate their low back pain symptoms. 
Disability is one of the most important determinative factors that cause costly treatment / rehabilitation and subsequently lower quality of life among nurses (Kingwell et al., 2012). The current result reported quite higher pain intensity related to the cause of increasing disability levels recorded among nurses. The result also underpinned the theory that disability is no respecter of the group understudy revealing the need for planning strategies geared towards prevention especially from the working class. Laleh et al. (2016) also established the existence of significant differences between disability intensity among nurses suffering from chronic pain and they added that, the presence of disability has much effect on the social, psychological and physical factors likely to affect the work output of nurses. It is therefore prudent that, issues relating to disability are given a second look among nurses and priority is given to the designing of effective interventions to improve the health status of this target group in future.
This result revealed that participants who received physiotherapy recorded the highest mean disability level second to those who had chiropractic. This could be explained by the findings of Hayden and peers (Hayden et al. 2005). Physiotherapy is considered to be moderately effective non-pharmacologic therapy. Also, in their meta-regression analyses, interventions which incorporate individual tailoring, supervision, stretching, and strengthening were associated with the best outcomes. The high disability levels recorded by those who received chiropractic could be due to the fact that, the benefits of such intervention were dependent on the presence or absence of radiating pain (Assendelft et al. 2003).  With increasing prevalence of low back pain among the nursing profession and for that matter, the levels of disability recorded, it is prudent that interventional policies are put in place to assist the profession. Again, proper posture techniques are required to assist nurses and other health professions develop very good ergonomics skills to enhance their levels of performance as well as developing plans to better improve their working abilities. It will also be prudent to mention that, the multidisciplinary team approach by health professional is required and that, physiotherapy interventions should be made available to this caliber of individuals. The use of only a hospital and the sample population may be a limitation to this study and so the researchers suggest that further work is required inculcating large population samples and other hospitals to aid in generalization of the findings and to help comparison within various departments of hospitals. This will add bunch to the knowledge base on low back pain and its associated outcomes among nurses in Ghana. It is worth to mention also that, considering the reduced number of the sample population, researchers were not able to carry out a statistical test of association hence, a methodological bias which is a limitation of this current study. However, the two-way analysis of variance was insignificant.
Conclusion
The study identified that low back pain is common among nursing profession and a higher number of nurses reporting low back pain tends to prefer self-medication to physiotherapy. The study also realized some levels of disabilities associated with the development of low back pain among the nursing profession. Though this study could not report on the implications of these disabilities on the work output, it is appropriate to mention that further research is carried out to investigate interventional plans for nurses to enable them curb the increasing levels of disabilities. Again, since the main levels of disabilities reported by participants in this study are mechanical and activity related, it is worth mentioning that, proper mechanisms are put in place like regular medical check-ups for health personnel at least twice per year are instituted and made compulsory. This will help alleviate most of the disability related complaints which may be reported. Health directors and personnel must include discussing issues relating to disability and mainly possible causes require top notch attention since the outcomes are rather devastating (Torgbenu et al. 2017), so as to safeguard the working health force for the country in general. Implications of the outcomes of this study for policy makers and physiotherapists are that, the public needs a well-structured awareness programme on low back pain, appropriate treatment modalities, and proper lifting techniques aiming to enhance a better practice among the nursing professionals to curb the increasing levels of disabilities recorded and its effects on the economy. If the war against disability could be won then education of the general on physiotherapy and other rehabilitation procedures must be intensified among the general populace.

Acknowledgement
The authors acknowledge the assistance of staff of Korle Bu Teaching Hospital, Accra during the data gathering.

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Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

TABLE 1 Percentage Distribution of Characteristics of Participants Experiencing Low Back Pain
 

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