Prevention of Chronic Lower Back Pain in Female Nurses

The effectiveness and cost-effectiveness of muscle strength exercises and counselling on the intensity and recurrence of non-specific back pain, lumbar control problems and avoidance behaviour among female nurses.


In Finland, the average age of a nurse applying for the disability pension is 56. Musculoskeletal disorders are the most common reason for early retirement and non-specific back pain is the most common reason for sickness absence. The prevalence and disadvantages of musculoskeletal disorders and the related disability pensions are expected to increase because the population is aging and obesity, limited amount of exercise and poor physical fitness are becoming more common. Good musculoskeletal functioning is important for nursing staff and maintaining it requires a diverse range of exercises.

Heavy physical loading increases the physical symptoms and mental fatigue of nurses. Working in a hunched position as well as lifting and transferring patients is particularly straining on the back.

At the acute stage, the main factors that predict the recurrence and prolongation of back pain are related to movement control problems caused by back ligament injuries as well as the fear of pain and avoidance behaviour. A lack of reliable indicators makes it difficult to predict these factors, identify risk factors and investigate the effectiveness of rehabilitation methods.

The factors that promote returning to work after acute non-specific back pain usually include positive assumptions about recovery as well as a reduced feeling of fear, worry and reservation. Multi-site pain predicts the occurrence of disability.

Physical training and counselling have a favourable effect on the above-mentioned aspects, but there is a lack of consensus regarding the amount and type.


The study investigated the effectiveness of muscle strength exercises and counselling on lower back pain, movement control and avoidance behaviour. The aim was to reduce pain, the recurrence or prolongation thereof and the related functional problems and sickness absences among working female nurses who suffered from non-specific back pain.

In addition, the study developed methods for assessing the physical loads carried by nursing personnel as well as their performance and work ability. Finally, the study developed methods for predicting the recurrence and prolongation of back pain.

The aim of the muscle strength exercises was to reduce lumbar control problems that are believed to be caused by injury to ligaments of the back, fascia and other stretch-sensitive connective tissues during harmful loading.

The main aim of the exercises was to resolve pain-induced movement control problems by improving the control of the lumbar spine in different positions and during different movements. In addition, the aim was to improve balance, coordination, muscle endurance and lower limb strength. The hypothesis was that training helps one avoid strain on their lower back. In addition, muscle strength training done while breathing calmly affects the autonomic nervous system and promotes recovery.

Counselling was based on a cognitive behavioural method. The aim was to change negative beliefs related to pain and reduce the avoidance and fear behaviour related to physical activity. Counselling advised the participants to load their back safely in different positions and during different moves both at work and in their free time and encouraged them to be physically active.

The method used was problem-based learning and the aim was that the nurses would be able to identify back strain factors related to their work and free time and they could find solutions to reduce these factors. The hypothesis was that increased pain management reduces the body's stress, increases the body’s adaptability to external strains and promotes recovery.


The study was a randomized controlled intervention. The participants were voluntary 30 to 54-year-old female nurses (n=240) who work in inpatient wards and who suffer from non-specific back pain. They were randomly assigned to four groups: training, counselling, combination of those two and control group.

The measurements were carried out using a blind method (at the beginning and 6, 12 and 24 months later). The results were analysed according to the intention-to-treat principle and work-related aspects etc. were taken into consideration.

The study's inclusion criteria were:

  1. back pain at least 20 mm measured on a linear pain intensity scale (scale 0–100) during the last two months
  2. at least two findings in six back movement control impairment tests.

The primary outcome measures were the changes in the intensity of back pain, movement control impairment tests and avoidance and fear behaviour which were measured subjectively through a questionnaire and objectively using an exercise monitor (accelerometer).

The cost-effectiveness of the interventions was investigated using the Potential model which has been developed for analysing the measures focused on occupational health. The model evaluates costs and benefits on an annual level.

As part of the development of the preliminary study methods, different indicators were analysed in terms of their repeatability (two initial measurements), criterion validity (parallel measurements) and sensitivity to changes after 6 months of intervention.


The study was carried out in two phases. The preliminary study began in November 2011 (n=60) and the more extensive follow-up study took place during the same time of year in 2012 (n=180). The study design was the same for both studies, but some of the initial measurements were conducted twice as part of the preliminary study (assessment of repeatability) and they included physiological parallel measurements (criterion validity assessment).

The measurements were conducted at the participants' workplace and at the UKK Institute. The intervention (6 months) group sessions were arranged in small groups of 10–15 people near the workplaces when shifts changed. The intervention groups were supervised by trained professionals.

The functional progressive muscle strength training (60 min) progressed from skill and technique training to increasing muscle endurance and strength. During the first eight weeks, the participants exercised twice a week under supervision and the remaining 16 weeks once a week under supervision and once a week at home using a DVD/instruction manual.

The counselling groups (45 min) first met four times once a week, then four times every two weeks and then twice during the last 16 weeks. In addition to the above-mentioned, there were two supervised training and/or counselling sessions between the first and second follow-up measurements (6–12 months).


  • UKK Institute
  • Tampere University Hospital (TAYS)
  • Finnish Institute of Occupational Health (FIOH)
  • University of Zürich

People from the workplaces also took part in planning and implementing the study.


New training and counselling models were developed for the study and they provided new information on methods that can reduce female nurses’ back pain and the recurrence and prolongation thereof. The study was multidisciplinary and it utilised the latest biomechanical and behavioural data regarding early rehabilitation of back pain (biopsychosocial model).

The cost-effectiveness analyses produced information about the usability of the methods. The results can also be applied to the early rehabilitation of non-specific back pain in other patients with back problems, especially women who have a physically straining job.







Jaana Suni, Head of Health-Enhancing Physical Activity Unit



For publications (international and Finnish) of this research see the Finnish description.
To find the list of publications (Julkaisuja), scroll the page down.

Last Modified: 27.11.2014


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