Evidence base special report: Musculoskeletal disorders – adding value

The value of research evidence and how it affects everyday practice in occupational health nursing is becoming steadily more apparent. With increasing competition from other professionals it is crucial that OH nurses should be able to provide sound, evidence-based arguments and are then able to demonstrate “added value” to their employing organisations. This approach will ensure that our practice meets the requirements of the Nursing and Midwifery Code.3

Checklist for evidence-based approach

  • Relevant legislation
  • Existing guidelines (Health and Safety Executive, National Institute for Health and Clinical Excellence, Department of Health publications, professional bodies)
  • Statistical data and local studies compared with the national picture
  • Local policy
  • Literature review of relevant research studies
  • Discussion with colleagues and employees
  • Awareness of constraints that affect current provision
  • In using an evidence- based approach, I have found it useful to have a checklist to follow, that ensures my process of enquiry is systematic, so that accurate conclusions can be drawn (see box, right).

    When looking at the topic of rehabilitation and lower back pain, first consider the relevant legislation covering risk ­assessment, paying particular attention to the best practice for dealing with manual handling that has been incorporated into Manual Handling Operations Regulations 2004.4

    By far the most significant development in this discipline was the publication in 2001 of the Occupational Health Guidelines for the Management of Low Back Pain.5 No surprise then, that Hobson6 has recently found this work to be one of the most frequently cited or accessed on the subject. It is also interesting that the European guidelines that augmented the original work suggest that there is limited scope for the prevention of the incidence lower back pain but considerable scope for the prevention of its consequences, such as recurrence, disability and work-loss.

    In 2006 the Department of Health produced the Musculoskeletal Services Framework,7 which stresses the importance of the occupational health role in accident prevention, giving sound advice about the provision of healthy workplace initiatives.

    The latest guidance produced by the National Institute for Health and Clinical Excellence (NICE) in May 20098 highlights some recommendations for further research that can be followed up in the literature review, as they are particularly relevant for occupational health practice: for example, the delivery of effective educational information. The Health and Safety Executive (HSE) also has an immense amount of information and guidance on this subject, with easy access to assessment tools and evidence of best practice.

    In my own area of practice, a simple questionnaire is given to employees who have suffered from work-related musculoskeletal injuries, one of the major causes of absence from work in my workplace. This is a collaborative approach between the health and safety and OH departments.

    The principal object of this questionnaire is to look at numbers of employees injured at work, types of injuries, location, costs to the organisation in time and money, as well as the costs incurred by the individual in finding appropriate treatment. The time it takes to get appropriate treatment and the consequent impact on health and sickness absence are both significant factors for managing attendance in any organisation. Information gathered can be used when planning manual handling courses and providing statistics for quarterly reports, as well as when making a business case, for example, for the provision of physiotherapy services to aid rehabilitation.

    Because the subject area is so broad, my literature review focused on the three key areas of prevention, education and psychosocial factors linked to lower back pain. These correspond to my own experience of dealing with clients, which might have implications for practice.

    I started by searching, using the key words, for articles in electronic databases and professional journals for articles published from 2001, the time that the OH guidelines for lower back pain were published. The following are examples of some of the findings.


    I am employed by an occupational health provider and have worked in a public sector setting for a number of years. One of the many challenges in practice is to try to encourage organisations to adopt a proactive approach to rehabilitation that would enable workers to remain at work or return to work following minimal delay.

    By presenting the evidence on rehabilitation and work-related musculoskeletal disorders, in particular low back pain, I would hope to show my organisation the value to be gained from looking after the health of existing workers. It will also benefit the organisation in the longer term, both as a cost-benefit and in retaining the experience of their workforce.

    Salazar1 states that multiple benefits can result from using research in the OH setting. These include increasing the quality and effectiveness of services generally, generating new ideas for service delivery and increasing the professionalism of OH nurses. This view is endorsed by Whitaker2 who encourages us to consider that the future development of research in OH nursing holds many possibilities, although since chance may favour the prepared, we need to be aware of what we should do now in order to become a research-based profession.


    A Quick Exposure Check (QEC) tool has been developed to assess ­exposure to risk factors of work-­related musculoskeletal disorders.9 Results from trials indicated that the tool was easy to use for assessment in the workplace, although problems of scoring were ident­ified during the design stage. It is apparently straightforward to use and applicable in a wide range of settings, subsequent interventions can also be monitored using the same tool.

    An observational tool to assess risk was the object of research ­carried out by Beaton and Kennedy.10 This study investigated workers’ perceptions of their limitations at work and could be used as a measure of “at work” disability due to lower back pain. This tool might be useful during a phased ­return to work to assess improvement.

    Using tools for screening to target treatments is one of the areas mentioned in the NICE guidelines8 that require further study.

    Buckle11 stated that target-setting linked to absence from work in the UK may direct effort away from primary prevention, towards rehabilitation and return-to-work. This review also suggested that understanding the causes of musculoskeletal disorders, especially those that are work-related, remains key to primary prevention.


    One OH doctor working for a large employer12 ran a back-care school and showed a reduction in sickness absence of 43%, with a cost-benefit per employee to the business of £1,660 over two years. The cost-benefits aimed to show both individual and economic ones for the company. Workshops were aimed at being educational as well as practical.

    Education is important, to help employees overcome fear and to promote the responsibility for their own care. Effective rehabilitation programmes tend to include a progressive active exercise and physical activity element, but further studies are also needed because it is still unclear which type of interventions are most successful.

    Further study is recommended relating to the NICE guidelines “Delivery of patient education – How can education be delivered effectively for people with persistent non-­specific low back pain?”8 Could OH nurses be instrumental in collaborating on further research about education programmes in the workplace?

    Psychosocial factors

    The prerequisite for establishing good practice in workplace health management is the conscious and creative support as well as the fullest participation of senior management, employees and their trade union representatives. This enables OH to provide a proactive service through health promotion and by developing risk-reduction strategies, rather than a reactive service, dealing with problems after they happen. Interventions aimed at tackling risk factors that are common to musculoskeletal disorders and stress, as well as persuading organisations to change their behaviour and/or culture, might be effective.13

    It has also been shown in the literature that providing health and well-being programmes can have a positive impact in encouraging employees to remain at work and avoid obstacles to recovery.

    Having gathered the available evidence, it is now possible to discuss the findings with colleagues and for the organisation to begin action-planning and identifying what the constraints might be.

    Developing skills to be able to change clinical practice on the basis of the published literature is a skill itself, and in the OH field this becomes magnified, as a wide range of clinical knowledge can be required along with the huge raft of legislation and guidelines for practice.

    Back pain is one of the most common health problems experienced by workers and, as confirmed by Black,14 early intervention is critical to achieving speedy and sustained recovery.

    Diane Rogers is an OH adviser at Connaught Compliance, currently providing OH services to Harrow Council.

    Elizabeth Griffiths is a lecturer in OH at Brunel University.


    1. Salazar M (2002) Applying Research to Practice. AAOHN Journal 50 (11), 520 – 525
    2. Whitaker S, Maw J (2003) Research and occupational health nursing in Oakley K (ed). Occupational Health Nursing. 2nd edition, London: Whurr Publishers
    3. Nursing and Midwifery Council (2008) The Code Standards of conduct, performance and ethics for nurses and midwives. London
    4. Health and Safety Executive (2004) Manual Handling. Manual Handling. Operations Regulations 1992 (as amended). Guidance on Regulations. London, The Stationary Office
    5. Waddell G, Burton A.K. (2001) Occupational health guidelines for the management of low back pain at work: evidence review Journal of Occupational Medicine 51 (2) 124-135
    6. Hobson J (2009) Occupational Medicine Jan 2009, 59 (1)
    7. Department of Health (2006) The Musculoskeletal Services Framework – A Joint Responsibility: doing it differently. www.dh.gov.uk/publications
    8. National Institute for Health and Clinical Excellence (2009) Low back pain Early management of persistent non-specific low back pain www.nice.gov.uk
    9. David G, Woods V, Li G, Buckle P (2007) The development of the Quick Exposure Check (QEC) for assessing exposure to risk factors for work-related musculoskeletal disorders Applied Ergonomics 39: 57-69
    10. Beaton D, Kennedy C (2005) Beyond return to work: Testing a measure of at-work disability in workers with musculoskeletal pain. Quality of Life Research 14: 1869 -1879
    11. Buckle P (2005) Ergonomics and musculoskeletal disorders: overview, Journal of Occupational Medicine 55: 164-167
    12. Hoban, J (2007) Back to the Future Occupational Health 59 (5) 18-20
    13. Whysall Z (2008) Stress and MSDs: Moving Towards Common Ground? Occupational Health February 60 (02) 27-29
    14. Black C. (2008) Working for a healthier tomorrow; Review of the health of Britain’s working age population. London


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