Mechanisms for reducing low back pain: a mediation analysis of a multifaceted intervention in workers in elderly care

Stevens, Matthew L.; Boyle, Eleanor; Hartvigsen, Jan; Mansell, Gemma; Søgaard, Karen; Jørgensen, Marie B.; Holtermann, Andreas; Rasmussen, Charlotte D. N.

doi:10.1007/s00420-018-1350-3

Original Article
Published: 01 September 2018

Mechanisms for reducing low back pain: a mediation analysis of a multifaceted intervention in workers in elderly care

Matthew L. Stevens ORCID: orcid.org/0000-0002-2621-4811¹,
Eleanor Boyle²,
Jan Hartvigsen^2,3,
Gemma Mansell⁴,
Karen Søgaard²,
Marie B. Jørgensen⁵,
Andreas Holtermann^2,5 &
Charlotte D. N. Rasmussen⁵

International Archives of Occupational and Environmental Health volume 92, pages 49–58 (2019)Cite this article

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Abstract

Purpose

A multifaceted workplace intervention consisting of participatory ergonomics, physical training, and cognitive–behavioural training (CBT) has shown effectiveness for reducing low back pain (LBP). However, the mechanisms of action underlying these intervention components are not well understood.

Methods

This was a mediation analysis of a cluster-randomised controlled trial of a multifaceted intervention in 420 workers in elderly care. Mediation analysis was carried out via structural equation modelling. Potential mediators investigated were: fear-avoidance beliefs, perceived muscle strength, use of assistive devices at work and perceived physical exertion at work. LBP outcomes assessed were: days with LBP, LBP intensity and days with bothersome LBP.

Results

There were no significant indirect effects of the intervention on LBP outcomes. There were significant effects of the intervention on both fear-avoidance measures [β = − 0.63, 95% CI (1.23, 0.03); β = − 1.03, 95% CI (− 1.70, − 0.34)] and the use of assistive devices [β = − 0.55, 95% CI (− 1.04, − 0.05)], but not on perceived muscle strength [β = − 0.18, 95% CI (− 0.50, 0.13)] or physical exertion [β = − 0.05, 95% CI (− 0.40, 0.31)]. The only potential mediator with a significant effect on LBP outcomes was physical exertion, which had a significant effect on LBP intensity [β = 0.14, 95% CI (0.04, 0.23)].

Conclusions

A multifaceted intervention consisting of participatory ergonomics, physical training, and CBT was able to decrease fear-avoidance beliefs and increase use of assistive devices in the workplace. However, these changes did not explain the effect of any of the intervention components on days with LBP, LBP intensity and days with bothersome LBP.

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References

Alsaadi SM, McAuley JH, Hush JM et al (2014) Poor sleep quality is strongly associated with subsequent pain intensity in patients with acute low back pain. Arthritis Rheumatol (Hoboken) 66:1388–1394. https://doi.org/10.1002/art.38329
Article Google Scholar
Basler H-D, Luckmann J, Wolf U, Quint S (2008) Fear-avoidance beliefs, physical activity, and disability in elderly individuals with chronic low back pain and healthy controls. Clin J Pain 24:604–610
Article Google Scholar
Borg GAV (1962) Physical Performance and perceived exertion. Gleerup, Lund, pp 1–32
Google Scholar
Borg E, Kaijser L (2006) A comparison between three rating scales for perceived exertion and two different work tests. Scand J Med Sci Sport 16:57–69. https://doi.org/10.1111/j.1600-0838.2005.00448.x
Article CAS Google Scholar
d’Errico A, Viotti S, Baratti A et al (2013) Low back pain and associated presenteeism among hospital nursing staff. J Occup Health 55:276–283. https://doi.org/10.1539/joh.12-0261-OA
Article Google Scholar
Dionne CE, Dunn KM, Croft PR et al (2008) A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine (Phila Pa 1976) 33:95–103. https://doi.org/10.1097/BRS.0b013e31815e7f94
Article Google Scholar
Driessen MT, Proper KI, van Tulder MW et al (2010) The effectiveness of physical and organisational ergonomic interventions on low back pain and neck pain: a systematic review. Occup Environ Med 67:277–285. https://doi.org/10.1136/oem.2009.047548
Article Google Scholar
Fenner P (2013) Returning to work after an injury. Aust Fam Physician 42:182–185
Google Scholar
Fordham B, Ji C, Hansen Z et al (2017) Explaining how cognitive behavioural approaches work for low back pain. Spine (Phila Pa 1976). https://doi.org/10.1097/BRS.0000000000002066
Article Google Scholar
Hall AM, Kamper SJ, Emsley R, Maher CG (2016) Does pain-catastrophising mediate the effect of tai chi on treatment outcomes for people with low back pain? Complement Ther Med 25:61–66. https://doi.org/10.1016/j.ctim.2015.12.013
Article Google Scholar
Heneweer H, Staes F, Aufdemkampe G et al (2011) Physical activity and low back pain: a systematic review of recent literature. Eur Spine J 20:826–845. https://doi.org/10.1007/s00586-010-1680-7
Article Google Scholar
Hoy D, Bain C, Williams G et al (2012) A systematic review of the global prevalence of low back pain. Arthritis Rheum 64:2028–2037. https://doi.org/10.1002/art.34347
Article Google Scholar
Jørgensen MB, Ektor-Andersen J, Sjøgaard G et al (2011) A randomised controlled trial among cleaners—effects on strength, balance and kinesiophobia. BMC Public Health 11:1–10. https://doi.org/10.1186/1471-2458-11-776
Article Google Scholar
Kamper SJ, Apeldoorn AT, Chiarotto A et al (2015) Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ 350:h444. https://doi.org/10.1136/bmj.h444
Article Google Scholar
Kelly GA, Blake C, Power CK et al (2011) The association between chronic low back pain and sleep: a systematic review. Clin J Pain 27:169–181. https://doi.org/10.1097/AJP.0b013e3181f3bdd5
Article Google Scholar
Laisné F, Lecomte C, Corbière M (2012) Biopsychosocial predictors of prognosis in musculoskeletal disorders: a systematic review of the literature (corrected and republished). Disabil Rehabil 34:1912–1941. https://doi.org/10.3109/09638288.2012.729362
Article Google Scholar
Lee H, Hübscher M, Moseley GL et al (2015) How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain. Pain 156:988–997. https://doi.org/10.1097/j.pain.0000000000000146
Article Google Scholar
Lee H, McAuley JH, Hübscher M et al (2016) Does changing pain-related knowledge reduce pain and improve function through changes in catastrophizing? Pain 157:1. https://doi.org/10.1097/j.pain.0000000000000472
Article Google Scholar
Lee H, Mansell G, McAuley JH et al (2017) Causal mechanisms in the clinical course and treatment of back pain. Best Pract Res Clin Rheumatol. https://doi.org/10.1016/j.berh.2017.04.001
Article Google Scholar
Leeuw M, Goossens MEJB, Linton SJ et al (2007) The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 30:77–94. https://doi.org/10.1007/s10865-006-9085-0
Article Google Scholar
Linton SJ, Boersma K, Jansson M et al (2005) The effects of cognitive-behavioral and physical therapy preventive interventions on pain-related sick leave: a randomized controlled trial. Clin J Pain 21:109–119. https://doi.org/10.1097/00002508-200503000-00001
Article Google Scholar
Linton SJ, Nicholas M, Macdonald S (2010) Development of a short form of the Örebro musculoskeletal pain screening questionnaire. Spine (Phila Pa 1976) 36:1891–1895. https://doi.org/10.1097/BRS.0b013e3181f8f775
Article Google Scholar
Mannion AF, Horisberger B, Eisenring C et al (2009) The association between beliefs about low back pain and work presenteeism. J Occup Environ Med. https://doi.org/10.1097/JOM.0b013e3181beac69
Article Google Scholar
Mansell G, Kamper SJ, Kent P (2013) Why and how back pain interventions work: what can we do to find out? Best Pract Res Clin Rheumatol 27:685–697. https://doi.org/10.1016/j.berh.2013.10.001
Article Google Scholar
Mansell G, Hill JC, Main C et al (2016) Exploring what factors mediate treatment effect: example of the STarT back study high-risk intervention. J Pain 17:1237–1245. https://doi.org/10.1016/j.jpain.2016.08.005
Article Google Scholar
Mansell G, Hill JC, Main C et al (2017) Mediators of treatment effect in the back in action trial: using latent growth modelling to take change over time into account. Clin J Pain 33(9):811–819
Article Google Scholar
Murray CJL, Lopez AD (2013) Measuring the global burden of disease. N Engl J Med 369:448–457. https://doi.org/10.1056/NEJMra1201534
Article CAS Google Scholar
Nguyen TH, Randolph DC (2007) Nonspecific low back pain and return to work. Am Fam Physician 76(10):1497–502
Google Scholar
Rabe-Hesketh S, Skrondal A, Pickles A (2005) Maximum likelihood estimation of limited and discrete dependent variable models with nested random effects. J Econ 128:301–323. https://doi.org/10.1016/j.jeconom.2004.08.017
Article Google Scholar
Rasmussen CDN, Holtermann A, Mortensen OS et al (2013) Prevention of low back pain and its consequences among nurses’ aides in elderly care: a stepped-wedge multi-faceted cluster-randomized controlled trial. BMC Public Health 13:1088. https://doi.org/10.1186/1471-2458-13-1088
Article Google Scholar
Rasmussen CDN, Holtermann A, Bay H et al (2015) A multi-faceted workplace intervention for low back pain in nurses’ aides: a pragmatic stepped wedge cluster randomised controlled trial. Pain 156:1786–1794. https://doi.org/10.1097/j.pain.0000000000000234
Article Google Scholar
Rasmussen CDN, Lindberg NK, Ravn MH et al (2017) Processes, barriers and facilitators to implementation of a participatory ergonomics program among eldercare workers. Appl Ergon 58:491–499. https://doi.org/10.1016/j.apergo.2016.08.009
Article Google Scholar
Rivilis I, Van Eerd D, Cullen K et al (2008) Effectiveness of participatory ergonomic interventions on health outcomes: a systematic review. Appl Ergon 39:342–358. https://doi.org/10.1016/j.apergo.2007.08.006
Article Google Scholar
Schofield DJ, Shrestha RN, Passey ME et al (2008) Chronic disease and labour force participation among older Australians. Med J Aust 189:447–450
Google Scholar
Schofield DJ, Shrestha RN, Percival R et al (2011) Early retirement and the financial assets of individuals with back problems. Eur Spine J 20:731–736. https://doi.org/10.1007/s00586-010-1647-8
Article Google Scholar
Schofield DJ, Callander EJ, Shrestha RN et al (2015) Back problems, comorbidities, and their association with wealth. Spine J 15:34–41. https://doi.org/10.1016/j.spinee.2014.06.018
Article Google Scholar
Sjøgaard G, Justesen JB, Murray M et al (2014) A conceptual model for worksite intelligent physical exercise training-IPET-intervention for decreasing life style health risk indicators among employees: a randomized controlled trial. BMC Public Health 14:652. https://doi.org/10.1186/1471-2458-14-652
Article Google Scholar
Smeets RJEM, Vlaeyen JWS, Kester ADM, Knottnerus JA (2006) Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J Pain 7:261–271. https://doi.org/10.1016/j.jpain.2005.10.011
Article Google Scholar
Spinhoven P, Ter Kuile M, Kole-Snijders AMJ et al (2004) Catastrophizing and internal pain control as mediators of outcome in the multidisciplinary treatment of chronic low back pain. Eur J Pain 8:211–219. https://doi.org/10.1016/j.ejpain.2003.08.003
Article Google Scholar
Strøyer J, Jensen LD, Avlund K et al (2007) Validity and reliability of self-assessed physical fitness using visual analogue scales. Percept Mot Ski 104:519–533. https://doi.org/10.2466/PMS.104.2.519-533
Article Google Scholar
Taylor JB, Goode AP, George SZ, Cook CE (2014) Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis. Spine J 14:2299–2319. https://doi.org/10.1016/j.spinee.2014.01.026
Article Google Scholar
Tveito TH, Hysing M, Eriksen HR (2004) Low back pain interventions at the workplace: a systematic literature review. Occup Med 54:3–13. https://doi.org/10.1093/occmed/kqg109
Article Google Scholar
van Tulder MW, Ostelo R, Vlaeyen JW et al (2001) Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group. Spine (Phila Pa 1976) 26:270–281. https://doi.org/10.1097/00007632-200102010-00012
Article Google Scholar
Vos T, Flaxman AD, Naghavi M et al (2012) Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380:2163–2196. https://doi.org/10.1016/S0140-6736(12)61729-2
Article Google Scholar
Whittle R, Mansell G, Jellema P, van der Windt D (2017) Applying causal mediation methods to clinical trial data: what can we learn about why our interventions (don’t) work?. Eur J Pain 21:614–622. https://doi.org/10.1002/ejp.964
Article CAS Google Scholar
Wieser S, Horisberger B, Schmidhauser S et al (2011) Cost of low back pain in Switzerland in 2005. Eur J Heal Econ 12:455–467. https://doi.org/10.1007/s10198-010-0258-y
Article Google Scholar

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Acknowledgements

This study was funded by The Danish Working Environment Research Fund (Journal Number 201100813) and the National Prevention Fund (Journal Number 11-2-1a-113). MS is supported by a scholarship provided by the Chiropractic and Osteopathic College of Australasia (COCA) Research Limited. GM is supported by a National Institute for Health Research (NIHR) School for Primary Care Research Seedcorn funding.

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Authors and Affiliations

Musculoskeletal Health Sydney, School of Public Health, The University of Sydney, PO Box M179, Missenden Rd, Sydney, NSW, 2050, Australia
Matthew L. Stevens
Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
Eleanor Boyle, Jan Hartvigsen, Karen Søgaard & Andreas Holtermann
Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
Jan Hartvigsen
Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
Gemma Mansell
The National Research Centre for the Working Environment, Copenhagen, Denmark
Marie B. Jørgensen, Andreas Holtermann & Charlotte D. N. Rasmussen

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Matthew L. Stevens
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Eleanor Boyle
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Jan Hartvigsen
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Gemma Mansell
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Karen Søgaard
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Marie B. Jørgensen
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Andreas Holtermann
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Charlotte D. N. Rasmussen
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Correspondence to Matthew L. Stevens.

Ethics declarations

The trial on which this analysis is based was approved by the Danish Data Protection Agency and the Ethics Committee for the regional capital of Denmark (Journal Number H-4-2012-115) and was conducted in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

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The authors declare they have no conflicts of interest.

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Informed consent was obtained from all individual participants included in the trial.

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Stevens, M.L., Boyle, E., Hartvigsen, J. et al. Mechanisms for reducing low back pain: a mediation analysis of a multifaceted intervention in workers in elderly care. Int Arch Occup Environ Health 92, 49–58 (2019). https://doi.org/10.1007/s00420-018-1350-3

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Received: 13 February 2018
Accepted: 28 August 2018
Published: 01 September 2018
Issue Date: 03 January 2019
DOI: https://doi.org/10.1007/s00420-018-1350-3

Keywords

Workplace interventions
Cognitive behavioural training
Physical training
Participatory ergonomics
Musculoskeletal disorders
Nurses’ aides