Home  |  Login  |  Inquiries | TOC Alerts  |  Sitemap |  

Advanced Search
J Exerc Rehabil > Volume 15(1);2019 > Article
Pakbaz, Hosseini, Aemmi, and Gholami: Effectiveness of the back school program on the low back pain and functional disability of Iranian nurse


Low back pain (LBP) as a recurrent and costly health problem and one of the leading causes of disability, is common in nurses. It can have adverse effects on the quality of life of nurses and quality of care of patients. The aim of the study was to evaluate the effectiveness of Back School program on the LBP and functional disability of Iranian nurses. A quasi-experimental methodological design was utilized for this study. Participants were nurses with back pain who participated in the Back School program workshop and completed a self-report visual analogue scales and Roland–Morris Disability questionnaire that measuring LBP and functional disability. Data were analyzed descriptively and comparisons in LBP and functional disability made between groups with t-test for pre-intervention and analysis of covariance for after intervention. Sixty-four participants (16 males, 48 females) completed this survey. The study participants’ mean age was 38.9 ± 8.1 years in intervention group and 38.1 ± 8.2 in control group. There were no significant differences in terms of pain (P = 0.575) and disability scores (P = 0.844) before intervention. Although, the intervention led to a decrease in the functional ability and LBP scores of the nurses (P<0.001) in the intervention group compared with that in the control group. Overall, Back School program as an educational strategy can reduce the LBP and functional disability in nurses. This program can be suitable for preventing of pain and functional disability among nurses working in hospital settings.


Low back pain (LBP) as most important musculoskeletal disorders and occupational health problem, has a high prevalence among healthcare workers especially nurses with a lifetime prevalence ranges from 35% to 80% that associated with enormous socio-economic and health costs to society (Azizpour et al., 2017; Járomi et al., 2018; Parreira et al., 2017; Soroush et al., 2018; Van Hoof et al., 2018). This occupational-related chronic nonspecific LBP as a major cause of functional disability lasts for more than 12 weeks and the inappropriate job condition, incorrect body positions, environmental factors, and high patient-care workload causes that millions of nurses around the world suffer from its (Noormohammadpour et al., 2018; Sahin et al., 2011).
Results of a systematic review and meta-analysis carried out by Azizpour et al. (2017) showed that the prevalence of LBP during the working life of Iranian nurses was 63%. Medical and social problems, impairment, chronic pain, activity and efficiency restriction, missed work, loss of optimal performance, diminish the quality of life, burnout, rising medical costs of treatment, care and occupational disability leading to a chronic condition that are some but not all negative impact of occupational LBP. These conditions cause an enormous medical and economic burden on individuals, families, employers, and the healthcare system (Azizpour et al., 2017; Mohseni-Bandpei et al., 2006; Van Hoof et al., 2018).
Nurses due to having a central and important role in providing care for patients, need to have educational interventions and awareness training for help them to prevent, manage and reduce the low back injuries and pain that they being able to provide better support for their patients (Ovayolu et al., 2014; Vieira and Brunt, 2016). There are some noninvasive interventions such as physical therapy modalities, exercise, and educational program to prevent and treatment of pain and functional disability of LBP (Sahin et al., 2011).
The comprehensive multidisciplinary programs Swedish Back School was introduced by Zachrisson Forsell in 1969 that aims to reduce the back pain and injury, teach people to care for their own backs and back pain in an active way to improve the functionality and quality of life. This program consisted of information on the structure and function of the spine, biomechanics, optimal posture, ergonomics, and performing special back exercises (Bartz et al., 2016; Forssell, 1981; Straube et al., 2016). It helps nurses on how to protect the spinal structures in daily activities and work (Brox et al., 2008).
The studies were conducted in Hungary showed that applying the Back School program for nurses reduced the chronic nonspecific LBP syndrome (Jaromi et al., 2012; Járomi et al., 2018), help nurses to the execution of proper patient lifting techniques (Járomi et al., 2018) and improve their body posture (Jaromi et al., 2012).
Here, this study provided the Back School workshop to nurses with back pain and examined the effectiveness of lumbar care education based on Back School program to decrease the LBP and functional disability among Iranian nurses.


A quasi-experimental methodological design was utilized for this study. This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (register number: IR.USWR.REC.1394.151) and the protocol was registered by the Iranian Registry of Clinical Trials (No. 20150-93024277N1).

Participants and recruitment

The inclusion criteria for this study was nurses who to be bachelor’s degree in nursing (BSN), employment in one of the medical departments, having back pain and an interest for participating in the Back School workshop in Shohada Tajrish Hospital affiliated to the Shahid Beheshti University of Medical Sciences, Tehran-Iran from May to August 2015. Participants were recruited across purposeful sampling and then randomly assigned to the intervention and control group equally (32 nurses in each group). Nurses were not eligible for inclusion in the study if they have a history of back surgery in the past 2 years, congenital anomaly and inflammatory diseases of the spine, pregnancy, severe osteoporosis. The research objectives and process were explained to all the nurses and written informed consent was obtained. All the nurses were informed that participation was voluntary and they had the right to withdraw at any time.


The LBP of nurses evaluated by the visual analogue scales (VAS) as a popular and self-reported tool for the measurement of pain. This scale consists of a straight line that ranging from “no pain” on the left end (0 cm) of the scale and the “worst pain” on the right end of the scale (10 cm) (Delgado et al., 2018). The nurses select the point on the line that best represents his/her perception of LBP level. A higher score indicates greater pain intensity.
The Roland–Morris Disability Questionnaire (RMDQ) (Roland and Morris, 1983) as one of the most recommended back-pain specific questionnaires to assess disability was utilized for measures of disability in nurses. This self-completed questionnaire was designed in 1983 for use in research, clinical practice and different settings to assess physical disability due to LBP and consist of 24 items (yes/no) that assess the execution of daily physical activities and life functions that may be affected by LBP, such as housework, sleeping, mobility, dressing, getting help, appetite, irritability, and pain severity. The scores range from 0 (no disability) to 24 (maximum disability). This instrument is short, simple to complete and readily understood and as a standardized measure widely used by back pain researchers (Roland and Fairbank, 2000; Smeets et al., 2011; Yamato et al., 2017). The questionnaire has undergone validity and reliability testing in several studies (Asghari, 2011; Mousavi et al., 2006). The correlation coefficient was 0.80 in the present study.


After sampling, nurses in the intervention group were included in the Back School workshop to prevent the LBP. The program was administered by a physiotherapist and the duration of the workshop was 3 hr. This workshop consisted of information on the structure and function of the spine, biomechanics, optimal posture, ergonomics, and performing special back exercises in accordance with Back School program (Table 1). The 15 min of the workshop’s end was dedicated to questions and answers and at the end, a LBP booklet that included a summary of workshop discussions was given to the participating nurses. Participants in both groups completed the VAS and RMDQ questionnaire before and two months after the workshop. Although the workshop was not held for the control group, after the end of the study in order to observe ethical issues, a LBP booklet was given to these nurses.

Statistical analysis

The sample size was estimated based on a similar study conducted by Sahin et al. (2011) who investigated the effectiveness of Back School for treatment of pain and functional disability in patients with chronic LBP (Sahin et al., 2011) and considering β = 0.20, α = 0.05, estimate of variance = 1.643 and d = 0.9, a total of 32 study participants were estimated to be required in each group.
Descriptive statistics were used to report nurses’ demographic and clinical characteristics. Statistical analyses were performed at a confidence level of 0.05 using IBM SPSS Statistics ver. 21.0 (IBM Co., Armonk, NY, USA). The mean and standard deviation were used to describe the quantitative variables, whereas the frequency and percentages were used to describe the qualitative variables. The normality of the data distribution was examined using the Kolmogorov–Smirnov test. We used the nonparametric tests for the data, which were not normally distributed. To compare the mean difference in functional disability and LBP, the independent t-test was used in pre-intervention and analysis of covariance was used among the two groups after intervention.


A total of 64 nurses provided informed consent and 100% completed the survey (n = 64). The study participants’ mean age was 38.9 ± 8.1 years in intervention group and 38.1 ± 8.2 in control group—75% of them were female (n = 48). Almost more than half (n = 34, 53.1%) had an overweight status in body mass index. No significant differences were observed between the two groups in terms of the demographic data (Table 2). The results showed that the two groups were not significantly different in terms of LBP (P = 0.575) and functional disability scores (P = 0.844) before intervention. Table 3 indicating that the intervention led to a decrease in the functional ability and LBP scores of the nurses (P<0.001).


The findings of this study revealed that the LBP and functional disability significantly reduced in the nurses participated in the Back School program. The results of systematic review indicated that due to the low- to very low quality of the evidence for all treatment comparisons, outcomes, and follow-up periods of Back School program for chronic nonspecific LBP, it is recommended that additional and future research be done to determine the different effects of this program (Parreira et al., 2017). According to other studies report, the educational intervention and preventive program such as Back School program can be significantly effective in pain relief (Glomsrød et al., 2001; Járomi et al., 2018; Van Hoof et al., 2018), increased the number of properly techniques in patient lifting (Járomi et al., 2018) in nurses and decreased pain intensity (Bartz et al., 2016) and disability (Sahin et al., 2011), improved functionality, and the recovery of activities of daily living in people with chronic musculoskeletal pain (Bartz et al., 2016).
The work condition such as high patient-care workload, longer work hours, and long-standing and walking per day are as risk factors for LBP in hospital nurses that occupational safety and regular education programs such as Back School program should be initiated to control these risk factors (Ovayolu et al., 2014; Shieh et al., 2016). Nurses due to the nature of work, need to protect and improve their health in order to be able to provide effective care and be more beneficial for the patients. The LBP and functional disability caused by it, is a challenge to provide the best care and it can have adverse effects on quality of life for nurses and the quality of care of patients; although it can be completely preventable if the necessary precautions and educations are taken (Shieh et al., 2016; Patil et al., 2018).
Our study has some limitations. In this study, we assessed the pain and disability using the self-administered questionnaires that there is potential for the severity of LBP and disability conditions to be overestimated. Thus, the use of objective measurements is recommended in future studies. Also, the work condition such as standards of nurse-to-patient ratios is accordance with Iran condition that it be considered in the generalization of the results. It is recommended to conduct further studies with a larger group of nurses including staff of hospitals of different regions and sizes, which would be useful for confirming the results of this study.
This study provided evidence that the Back School program can reduce the LBP and functional disability among nurse. Thus, our data indicate that this program can be suitable for preventing and improving pain and functional disability among nurses working in hospital settings.



No potential conflict of interest relevant to this article was reported.


The present research was based on a master’s thesis and was supported by University of Social Welfare and Rehabilitation Sciences grant (921696013). The authors thank all nurses who cooperated with them in this research.


Asghari A. Psychometric properties of a modified version of the Roland-Morris disability questionnaire (M-RMDQ). Arch Iran Med. 2011;14:327–331.

Azizpour Y, Delpisheh A, Montazeri Z, Sayehmiri K. Prevalence of low back pain in Iranian nurses: a systematic review and meta-analysis. BMC Nurs. 2017;16:50
crossref pmid pmc pdf

Bartz PT, Vieira A, Noll M, Candotti CT. Effectiveness of the back school program for the performance of activities of daily living in users of a basic health unit in Porto Alegre, Brazil. J Phys Ther Sci. 2016;28:2581–2586.
crossref pmid pmc

Brox JI, Storheim K, Grotle M, Tveito TH, Indahl A, Eriksen HR. Systematic review of back schools, brief education, and fear-avoidance training for chronic low back pain. Spine J. 2008;8:948–958.
crossref pmid

Delgado DA, Lambert BS, Boutris N, McCulloch PC, Robbins AB, Moreno MR, Harris JD. Validation of Digital Visual Analog Scale Pain Scoring with a traditional paper-based Visual Analog Scale in adults. J Am Acad Orthop Surg Glob Res Rev. 2018;2:e088
crossref pmid pmc

Forssell MZ. The back school. Spine (Phila Pa 1976). 1981;6:104–106.
crossref pmid

Glomsrød B, Lønn JH, Soukup MG, Bø K, Larsen S. “Active back school”, prophylactic management for low back pain: three-year follow-up of a randomized, controlled trial. J Rehabil Med. 2001;33:26–30.
crossref pmid

Járomi M, Kukla A, Szilágyi B, Simon-Ugron Á, Bobály VK, Makai A, Linek P, Ács P, Leidecker E. Back School programme for nurses has reduced low back pain levels: a randomised controlled trial. J Clin Nurs. 2018;27:e895–902.
crossref pmid

Jaromi M, Nemeth A, Kranicz J, Laczko T, Betlehem J. Treatment and ergonomics training of work-related lower back pain and body posture problems for nurses. J Clin Nurs. 2012;21:1776–1784.
crossref pmid

Mohseni-Bandpei MA, Fakhri M, Bagheri-Nesami M, Ahmad-Shirvani M, Khalilian AR, Shayesteh-Azar M. Occupational back pain in Iranian nurses: an epidemiological study. Br J Nurs. 2006;15:914–917.
crossref pmid

Mousavi SJ, Parnianpour M, Mehdian H, Montazeri A, Mobini B. The Oswestry Disability Index, the Roland-Morris Disability Questionnaire, and the Quebec Back Pain Disability Scale: translation and validation studies of the Iranian versions. Spine (Phila Pa 1976). 2006;31:E454–459.
crossref pmid

Noormohammadpour P, Kordi M, Mansournia MA, Akbari-Fakhrabadi M, Kordi R. The role of a multi-step core stability exercise program in the treatment of nurses with chronic low back pain: a single-blinded randomized controlled trial. Asian Spine J. 2018;12:490–502.
crossref pmid pmc pdf

Ovayolu O, Ovayolu N, Genc M, Col-Araz N. Frequency and severity of low back pain in nurses working in intensive care units and influential factors. Pak J Med Sci. 2014;30:70–76.
crossref pmid pmc

Parreira P, Heymans MW, van Tulder MW, Esmail R, Koes BW, Poquet N, Lin CC, Maher CG. Back Schools for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;8:CD011674
crossref pmid

Patil NJ, Nagaratna R, Tekur P, Manohar PV, Bhargav H, Patil D. A randomized trial comparing effect of Yoga and exercises on quality of life in among nursing population with chronic low back pain. Int J Yoga. 2018;11:208–214.
crossref pmid pmc

Roland M, Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine (Phila Pa 1976). 2000;25:3115–3124.
crossref pmid

Roland M, Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine (Phila Pa 1976). 1983;8:141–144.
crossref pmid

Sahin N, Albayrak I, Durmus B, Ugurlu H. Effectiveness of back school for treatment of pain and functional disability in patients with chronic low back pain: a randomized controlled trial. J Rehabil Med. 2011;43:224–229.
crossref pmid

Shieh SH, Sung FC, Su CH, Tsai Y, Hsieh VC. Increased low back pain risk in nurses with high workload for patient care: a questionnaire survey. Taiwan J Obstet Gynecol. 2016;55:525–529.
crossref pmid

Smeets R, Köke A, Lin CW, Ferreira M, Demoulin C. Measures of function in low back pain/disorders: Low Back Pain Rating Scale (LBPRS), Oswestry Disability Index (ODI), Progressive Isoinertial Lifting Evaluation (PILE), Quebec Back Pain Disability Scale (QBPDS), and Roland-Morris Disability Questionnaire (RDQ). Arthritis Care Res (Hoboken). 2011;63:Suppl 11. S158–173.
crossref pmid

Soroush A, Shamsi M, Izadi N, Heydarpour B, Samadzadeh S, Shahmohammadi A. Musculoskeletal disorders as common problems among iranian nurses: a systematic review and meta-analysis study. Int J Prev Med. 2018;9:27
crossref pmid pmc

Straube S, Harden M, Schröder H, Arendacka B, Fan X, Moore RA, Friede T. Back schools for the treatment of chronic low back pain: possibility of benefit but no convincing evidence after 47 years of research-systematic review and meta-analysis. Pain. 2016;157:2160–2172.
crossref pmid pmc

Van Hoof W, O’Sullivan K, O’Keeffe M, Verschueren S, O’Sullivan P, Dankaerts W. The efficacy of interventions for low back pain in nurses: A systematic review. Int J Nurs Stud. 2018;77:222–231.
crossref pmid

Vieira ER, Brunt D. Does wearing unstable shoes reduce low back pain and disability in nurses? A randomized controlled pilot study. Clin Rehabil. 2016;30:167–173.
crossref pmid

Yamato TP, Maher CG, Saragiotto BT, Catley MJ, McAuley JH. The Roland-Morris Disability Questionnaire: one or more dimensions? Eur Spine J. 2017;26:301–308.
crossref pmid pdf

Table 1
Content of educational intervention
Part Content
First part Epidemiology of skeletal and muscular disorders, costs of these disorders, individual factors associated with skeletal and muscular disorders, the relationship between job with skeletal and muscular disorders and high-risk occupations in this regard, the impact of lifestyle in musculoskeletal disorders, the importance and necessity of self-care in preventing and reducing these disorders
Second part Physiology and anatomy of the spine, types and common causes of low back pain and symptoms of its, factors causing of low back pain, the results of inaccurate anatomical status
Third part Lumbar protection techniques and how to prevent back pain, proper body conditions in some cases as sleeping, sitting, driving, standing and walking, proper techniques for picking up objects and patients, relocation, transporting
Forth part Sports exercises and related and useful therapeutic movements for back pain
Table 2
Demographic characteristics of nurses
Characteristic Intervention group (n = 32) Control group (n = 32) P-value
Gender 0.586a)
 Male 7 (21.9) 9 (28.1)
 Female 25 (78.1) 23 (71.9)

Age range (yr) 0.737b)
 <30 8 (25) 10 (31.25)
 31–44 12 (37.5) 12 (37.5)
 >45 12 (37.5) 10 (31.25)

Relationship status 0.055a)
 Married 21 (65.5) 13 (40.6)
 Single 11 (34.5) 19 (59.4)

Second job 1.000a)
 Yes 8 (25) 8 (25)
 No 24 (75) 24 (75)

Employment background (yr) 0.312b)
 <10 12 (37.5) 12 (37.5)
 11–20 10 (32.25) 11 (34.4)
 >21 10 (32.25) 9 (28.1)

Body mass index (kg/m2) 0.148b)
 Underweight (16–18.5) 0 (0) 1 (3.1)
 Healthy weight (18.5–25) 12 (37.5) 13 (40.6)
 Overweight (25–30) 16 (50) 18 (56.3)
 Obese (>30) 4 (12.5) 0 (0)

Values are presented as number (%).

a) Chi-square.

b) t-test.

Table 3
Comparison of the mean and standard deviation of nurses’ low back pain and functional disability scores in the intervention and control groups
Variable Group Type and test results

Intervention Control
Functional disability
 Before 11.06 ± 5.105 10.81 ± 35.65 P = 0.844
t = 0.198 (t-test)
 After 9.66 ± 6.553 11.09 ± 5.195 P<0.001
F = 30.001 (ANCOVA)

Low back pain
 Before 5.44 ± 2.552 5.09 ± 2.319 P = 0.575
t = 0.564 (t-test)
 After 4.03 ± 1.975 5.22 ± 2.310 P<0.001
F = 196.875 (ANCOVA)

ANCOVA, analysis of covariance.

Editorial Office
E-mail: journal@kser.co.kr
Copyright © Korean Society of Exercise Rehabilitation.            Developed in M2PI