Operation back care

A
study of low back pain among hospital doctors revealed surgeons to be the
greatest sufferers.  By Matthew G
Tytherleigh and Roderick LR Dunn

Many
healthcare workers – in particular nurses, physiotherapists and occupational
physicians – recognise low back pain (LBP) as an occupational hazard.9, 10
Despite this, few measures have been taken to prevent its occurrence in this
group.6

We
decided to investigate the incidence of LBP among hospital doctors and compare
it with that of the general population. We also wanted to see if there was any
difference in the incidence of LBP between surgeons and physicians.

Method

A
detailed survey was sent to the 406 doctors employed by the Plymouth Hospitals
NHS Trust. The questionnaire was designed to gain a picture of:


The doctors’ physical characteristics and their status at the hospital


The frequency of LBP occurring for more than 24 hours and its effect on the
doctors’ lives


The presence of neurological signs, symptoms and the duration of symptoms


Aggravating factors and the treatment and prevention of LBP

To
ensure confidentiality, the hospital audit department sent out the
questionnaires and subjects were identified by number. The differences between
the groups were analysed by the Department of Mathematics and Statistics at
Plymouth University, using the comparison of two proportions using standard
normal deviates.

Results

Of
the 406 doctors working for the Plymouth Hospitals NHS Trust at the time of the
study, 298 (73 per cent) returned their questionnaires.

There
were two study groups: surgeons (108) and physicians (190), and the response
rate for both groups was almost the same (73.5 per cent of surgeons and 73.4
per cent of physicians).

Figure
1 shows the characteristics of these doctors.

Figure
2 shows the prevalence of LBP. From the 298 respondents, 146 (49 per cent)
suffered LBP. It also shows the rates of LBP among surgeons and physicians,
comparing consultants with their junior counterpart (omitting the
pre-registration house officers). The gender and body mass index (BMI) of the
doctors is also shown. Ophthalmologists (75 per cent) and plastic surgeons (88
per cent) were the specialists with the highest rates of LBP.

Figure
3 shows the frequency and the severity of the LBP.

Major
factors shown to improve LBP which occurred while surgeons were operating
included sitting and correct operating height. Seventy two per cent of the
surgeons found their symptoms were improved while sitting to operate and 85 per
cent had symptomatic improvement with the correct operating table height.
Physicians undertaking invasive procedures (radiologists and cardiologists) who
had LBP also found similar benefits, with four out of five (80 per cent)
improving after table adjustment and 7 out of 10 (70 per cent) with sitting.

Thirty-six
from 62 (58 per cent) of surgeons noted a reduction in LBP during holiday
periods compared with only 36 out of 91 (40 per cent) of physicians, (p=0.012).
In both groups there was an equal incidence of a past history of low back trauma
(20 per cent), which included road traffic accidents and lumbar vertebral crush
fractures.

Surgeons
generally used diclofenac and aspirin for analgesia, whereas physicians
preferred paracetamol and ibuprofen. Other analgesics such as alcohol were popular
for both groups.

Only
two doctors, one from each group, had undergone surgery for LBP. Other forms of
treatment used were physiotherapy, osteopathy, chiropractice and aromatherapy.
The physicians generally used the more "alternative" treatments.

Methods
used to avoid LBP included stretching exercises, swimming, weight loss and
avoidance of heavy lifting.

Discussion

LBP
is a common, debilitating condition. The prevalence of LBP is difficult to
elucidate, but a life time prevalence between 7.6-59 per cent in different
general populations has been reported.1-8

The
figures in the literature vary widely due to many different reasons. A firm
diagnosis is rarely made and this limits comparability between studies.1

Compensation
claims and accident reports from hospital workers are also thought to
underestimate the problem because of the perceived frequency and less severe
nature of the LBP and also the possibility of informal consultation and
self-treatment.3

The
prevalence in a number of occupations has been investigated in the past (given
the above inherent problems). Nurses have been found to have a prevalence
somewhere between 20.4 per cent and 47 per cent2, 3 physical therapists 49.2
per cent1 and teachers 12.6 per cent10.

The
management of LBP is undergoing a revolution from the old-style routine imaging
and strict bed rest to limited imaging and early return to normal activity.12,
13

Our
response rate to the questionnaire was good (73 per cent) and lies at the upper
end of other rates from similar studies (59, 65.3, 67.3, 76).6, 7, 9, 14
Reasons for a failed response from busy, doctors is obvious. Hillman (1996),
however, showed that after three attempts to obtain answered questionnaires,
the overall prevalence estimates of LBP remained constant across the three
response waves.14 Papageorgiou (1995) found that first-time respondents had
only a small but non-significant increase in the prevalence of LBP compared to
those who responded to the second or third mailing.7

Operating
conditions

Our
study shows that the prevalence of LBP among doctors at Derriford Hospital,
which represents a typical hospital doctor population, lies at the upper end of
the range for the general population (49 per cent compared to 7.6-59).

It
was found, however, that the prevalence of LBP among surgeons was higher
compared with the physicians, although this difference was seen only in the
junior training grades. The pre-registration house officers were omitted from
this comparison as we were specifically concerned with the effect of the actual
practice of surgery on LBP and it is now unusual to have house officers in the
operating theatre for any length of time.

We
suggest that this difference may be due to conditions experienced in the
operating theatre, namely prolonged standing, incorrect table height, and the
awkward posture often required to assist another surgeon, particularly when
leaning across the operating table to hold a retractor.

Consultant
surgeons operate at an advantage – they have the table at the correct height
for them and have the experience and expertise to perform a procedure in a more
comfortable position. It is a common fault of inexperienced surgical trainees
to operate while adopting an uncomfortable posture. It is reassuring that the
high rate of LBP in junior surgeons does not seem to persist, as the incidence
of LBP is the same for both consultant physicians and surgeons.

The
increased incidence of LBP among ophthalmologists has been noted and is thought
to be due to prolonged stooping over the patient.6 This reiterates the
importance of posture while operating.

The
frequency of LBP was similar for surgeons and physicians except for the LBP
occurring more than 12 times per year (24 per cent vs 31). This coincides with
a higher mean duration of symptoms (six days and 10 days) and a concomitant
increase in the number of occasions when the physicians (10 per cent vs 23)
required a period of time off work. These differences may be partly explained
by two of the physicians who have chronic relapsing LBP who have subsequently
skewed these figures.

Many
previous reports have demonstrated that increased height, weight, and therefore
BMI, are associated with an increased rate of LBP.15 We could not confirm this,
suggesting that factors other than those experienced by the general population
may be causing the LBP in our study group.

Neurological
signs and symptoms were infrequently reported and only two doctors had required
back operations, leading to the speculation that little of the LBP was due to a
surgically remedial cause such as an acute disc prolapse and more likely due to
non-specific mechanical low back pain.

Treatment

LBP
treatment regimes followed standard guidelines although the difference in the
preferred analgesics used by surgeons and physicians is difficult to explain.
Perhaps the now routine management of patients with upper gastrointestinal
bleeds by the physicians may have made them more wary of non-steroidal
anti-inflammatory drugs.

The
total number of days off work during each doctor’s working life was very low
when compared with the general population. This reflects the low incidence of
illness-related absence from work among the medical profession.2, 16  

Holidays
were found to be particularly good for the reduction in the frequency of LBP in
surgeons as compared to the physicians, suggesting again that conditions at
work aggravate these surgeons’ LBP. There was no difference in the use of
preventative measures other than lumbar supports, which were used more
frequently by the surgeons.

In
conclusion, hospital doctors have a prevalence of LBP at the higher end of the
range for the general population. Surgical trainees are more likely to have LBP
than trainee physicians. A comfortable posture while operating reduces the
frequency of LBP and this can be facilitated by correct adjustment of the
operating table height or sitting to operate.

Matthew
G Tytherleigh FRCS and Roderick LR Dunn DMCC FRCS* are senior house officers,
at the Department of General Surgery, Derriford Hospital, Plymouth

References

1
Frank A, Low Back Pain. BMJ 1993; 306: 901-909.

2
The Back Pain Epidemic. Editorial. Acta Orthop Scand 1989; 60: 633-4.

3
Agnew J. Back Pain in Hospital Workers. Occup. Med 1987; 2 (3): 609-615

4
Carey TS. Occupational Back Pain: Issues in Prevention and Treatment. Ballieres
Clin Rheumatol 1989; 3: 143-56.

5
Kaplan RM, Deyo RA. Back Pain in Health Care Workers. Occup Med 1988; 3 (1):
61-73.

6
Chatterjee A, Ryan WG, Rosen ES. Back Pain in Ophthalmologists. Eye 1994; 8:
473-4.

7
Papageorgiou AC, Coft PR, Ferry S, Jayson MI, Silman AJ. Estimating the
Prevalence of Low Back Pain in the General Population. Evidence form the South
Manchester Back Pain Survey. Spine 1995; 20(17): 1889-94

8
Borenstein DG. Epidemiology, Etiology, Diagnostic Evaluation and Treatment of
Low Back Pain. Curr Opin Rheumatol 1997; 9(2): 144-50

9
Mierzejewski M, Kumar S. Prevalence of Low Back Pain Among Physical Therapists
in Edmonton, Canada. Disabil Rehabil 1997; 19(8): 309-317

10.
Cust G, Pearson J, Mair A. The Prevalence of Low Back Pain in Nurses. Int Nurs
Rev 1972; 19: 169-79

11.
Dehlin O, Hedenrud B, Horal J. Back symptoms in nursing aides in a geriatric
hospital. Scand J Rehabil Med 1976; 8: 47-53

12.
Deyo RA. Acute low back pain: a new paradigm for management. BMJ 1996; 313:
1343-1344

13.
Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Low back pain evidence
review. London: Royal College of General Practitioners, 1996.

14.
Hillman M, Wright A, Rajaratnam G, Tennant A, Chamberlain MA. Prevalence of low
back pain in the community: implications for service provision in Bradford, UK.
J Epidemiol Community Health 1996; 50(3): 347-52

15.
Kuh DJL, Coggan D, Mann S, Cooper C, Yusef E. Height, occupation and back pain
in a national prospective study. Br J Rheum 1993; 32: 911-916

16.
Department of Health. The Health of the Nation: strategy for health in England.
London; HMSO, 1992. (Cm 1986)

Acknowledgments

Thanks
to Linda Bennett of the Clinical Audit Department, Derriford Hospital, for her
help in data collection, and Hilary Sanders, of Plymouth University, for her
help with the statistical calculations.

Figure
1: Characteristics of doctors

                                                                                    Surgeons                     Physicians

Total
number of forms sent (406)                                  147
(36%)       259 (64%)
Forms returned (298)                                                   108
(36%)       190 (64%)
Number of consultants (141)                                         43
(40%)         98 (52%)
Number of juniors (157)                                               65
(60%)         92 (48%)
Mean age (years)                                                          39                    39
Age range (years)                                                         23-61               24-62
Male                                                                            88
(82%)         130 (68%)

Figure
2: Prevalence of low back pain

                                                                                    Surgeons                     Physicians

At
least 1 episode per year                                           59 (60%)                     87
(48%)  (p=0.057)
Consultants with LBP                                                   23
(53%)                     51 (52%)
Juniors with LBP                                                          36
(67%)                     36 (43%)  (p=0.003)
Males with LBP                                                            51
(58%)                     66 (51%)
Females with LBP                                                        11
(55%)                     25 (42%)
Mean BMI with LBP                                                    24.1                             23.8
Mean BMI without LBP                                               24.4                             23.0

Figure
3: Frequency and severity of the low back pain

                                                                                    Surgeons                     Physicians

LBP
1-4 times per year                                                28 (47%)                     37
(44%)
LBP 5-11 times per year                                              17 (29%)                     23
(27%)
LBP >12 times per year                                                14 (24%)                     27
(31%)
Mean duration of symptoms (days)                               6                                  10
LBP needing time off work                                           6 (10%)                       20
(23%)
Mean days off                                                              0.45                             5.6
Range (days)                                                                0-7                               0-280
LBP & neuro signs/symptoms                                       16%                             21%
LBP in theatre                                                              49 (45%)                     N/A
LBP during ward rounds                                               N/A                             41
(22%)

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