By Whitney Lowe
This article was initially published in the September/October 2012 issue of Massage Bodywork.
With more than 5 million nurses working today, nursing ranks as the largest of the health-care professions.1 Given the type of work nurses do and the stresses they endure, it is not surprising that nursing has such a high rate of musculoskeletal injuries tied to it. Physical demand is a primary reason nurses choose to downgrade their work hours, request administrative nursing roles, or even leave the profession.2
Today, many facilities find they have serious staff shortages due to the dearth of qualified nursing professionals, resulting in increased pressure and demands on existing workers. While there is movement toward creating ergonomic solutions to the physical demands of nursing (such as using equipment to move patients), the fact is, nursing is a physically demanding occupation with long hours.
An ominous problem is brewing as the baby boomer population reaches an age of increased need, while the nationwide shortage of nurses is expected to increase. Keeping nurses healthy and bringing them back to health should be key goals. Massage therapy can be a strong player in meeting these goals, particularly because of the skill and focus the profession has on musculoskeletal soft-tissue challenges.
Prevalence of Musculoskeletal Injuries
Of the various musculoskeletal disorders that affect nurses, low-back injury is far and away the most common complaint. A recent study found that 60 percent of musculoskeletal injuries among nursing students involved low-back pain.3 Following low-back pain, disorders of the ankle, foot, knee, neck, shoulder, and upper extremities are reported.
Musculoskeletal injuries can cause serious disabilities for nurses and excessive costs for their employers. Unfortunately, these workers are sometimes redirected into lower-paying, non-nursing work because of their injuries.4 Without proper treatment and attention to contributing factors, the tasks demanded in the work environment may simply be too much for the worker to continue to bear. Sadly, this means the nation loses more quality nurses.
Prevention has not been a focus for facilities, government oversight agencies, or individuals. Occupational injury is accepted as a given for those going into the profession, and there isn't a proactive approach toward prevention or addressing these disorders when they occur.5 This does not need to be the case. There are both preventive and maintenance strategies that workers can take to reduce the risk of injury. Massage therapy can play an important role in the prevention and rehabilitation of the types of injuries experienced by those in the nursing profession.
There are a number of key factors that contribute to the occupational injury of nurses. Patient-care activities often require moving heavy loads, performing repetitive movements, standing for long periods of time, working in awkward positions, and working in the same position for long periods of time. These biomechanical challenges are a recipe for musculoskeletal disorder.
Nurses often work 12-hour shifts and experience significant physical demands during their workday. Muscular fatigue can set in after many hours, leading to poor body mechanics and overwhelming the soft tissues from excessive demand. Fatigue is a key factor in the cause of many muscular and soft-tissue injuries. Not only are the soft tissues weakened from fatigue, but biomechanical force relationships around the joints change as muscles no longer work in balance with each other. Consequently, reduction of muscular fatigue during these long work shifts should be a key goal.
In many cases, the physical demands of nursing activities exceed safety recommendations from the National Institute for Occupational Safety and Health (NIOSH). For instance, NIOSH recommends a safe lifting limit of 51 pounds for men and 46 pounds for women.6 There are no easy solutions for safe methods of lifting patients. However, new strategies, such as the use of lifting devices and lifting teams, are being employed, which decrease impact on a single individual. Lack of training in ergonomics and proper body positioning during work activities is also cited as a frequent cause of injuries. Intervention programs such as "back school" are valuable in teaching good mechanics and can greatly reduce injuries.
Seldom mentioned is the detrimental effect of increased obesity on the physical demands placed on workers who must physically assist larger people. For nurses, a preponderance of heavy patients adds significant physical stress to a job that is already demanding. In addition, we have an aging population, along with an aging workforce. These factors all add up to produce intense physical demands that can lead to injury.
Nurses often report increased psychological stress as a primary factor contributing to their musculoskeletal injuries. There are clear correlations between workplace stress and the aggravation and perpetuation of musculoskeletal injuries. Once they become injured, nurses often have fear or concern about their ability to stay in the profession. These additional psychological stressors can lead nurses to go beyond their physical limit or ignore the signs of developing problems to protect their jobs.
Lumbar Region Injury
As mentioned, low-back injury is the most common musculoskeletal complaint affecting nurses. A brief review of relevant anatomy and lifting mechanics sheds light on the reason for this problem. The primary lumbar extensor muscles, such as the quadratus lumborum, erector spinae, and multifidus, carry the vast majority of load during heavy lifting activities (Image 1). However, these muscles are not ideally designed for heavy lifting.
The most effective way for a muscle to generate power as it moves a joint is for it to be located farther away from the joint's axis of rotation. Because the lumbar muscles lie very close and run parallel to the spine, they have a very poor mechanical position. As a result, it is easy for them to be overwhelmed. Muscular overuse, such as strains or acute spasm, and myofascial trigger point irritation are common occurrences from overload associated with patient-lifting activities.
Lifting patients manually is not only dangerous for nurses, it is inefficient and dangerous for patients. Improper lifting can lead to bruising, dislocations, fractures, skin tears, or tube dislodgment if a patient is accidentally mishandled or dropped during lifting. As a result, several countries have initiated "no lifting" policies for nursing staffs, instead using manual lift-assisting devices to move patients.7
Lifting heavy loads also puts high compressive forces on the intervertebral discs (Image 2, page 107), which can lead to disc degeneration and herniation. The eventual result of disc herniation can be nerve root compression and severe sciatic nerve pain.
Acute herniation of intervertebral discs that are not already damaged is not very common.8 Most disc herniations occur from long periods of compressive load that have led to gradual disc degeneration. In many cases, chronic muscle tightness and muscular dysfunction of the low-back muscles increase compressive forces on discs.
Lumbar Region Treatment
Massage therapy is highly valuable in reducing the chronic, compressive loads that lead to disc injury. Techniques such as myofascial release, deep longitudinal stripping, and trigger point therapy are particularly helpful for addressing the chronic muscular overload experienced by nurses.
Injuries in Other Regions
In addition to low-back problems, numerous other musculoskeletal injuries also occur and can be serious problems. There is a clear and obvious myofascial continuity of muscles from the lumbar region through the thoracic and cervical regions. Chronic tension that develops in the lumbar musculature from overuse is frequently transferred to the thoracic and cervical regions. Postural disorders in the cervical region, such as forward head posture, put increased tension on these myofascial tissues.
Nurses are frequently bent over with excessive forward head posture as they treat patients who are lying in a bed. Neck pain may result from this postural strain, but this stress can also be a significant component of pain in other areas, such as the low back.
Musculoskeletal disorders of the neck are the second most common complaint for those in the nursing profession and also include myofascial trigger point development, nerve entrapment, and headache pain that develop from chronic muscle tension. Consequently, comprehensive treatment of any musculoskeletal condition in the torso region should include not only treatment of the thigh, gluteal, and lumbar regions mentioned earlier, but also significant attention to all the myofascial tissues throughout the thoracic and cervical regions as well.
While lower-extremity injuries do not occur as often as lumbar and cervical complaints, there are some important biomechanical considerations that make this type of injury common for nurses. Long shifts mean nurses are on their feet for long periods of time, producing compressive loads that are compounded at the knees, as well as at the foot and ankle complex. In many facilities, these shifts are done on cement floors, intensifying these problems.
Long durations of compressive loads on the knee joints can cause early development of arthritis. Disorders of the knee are exacerbated by the presence of other postural or alignment problems such as genu valgum (knock-knees). Extensive compressive loads are particularly challenging for force distribution in the foot. As a result, plantar fasciitis and chronic overuse disorders affecting the tibialis posterior muscle are potential problems as well.
Massage therapy approaches cannot reverse the compressive loads on these joint regions. However, massage is a valuable approach for reducing the cumulative stresses absorbed by the soft tissues. Deep, longitudinal stripping techniques and active engagement methods applied to the tibialis posterior and other posterior calf muscles are very effective in addressing the chronic cumulative stresses in the distal lower extremities. Similar deep stripping techniques applied to the plantar fascia help reduce chronic tension loads in these soft tissues that support the longitudinal arch of the foot.
While health-care workers are highly compassionate for those in their care, it is often at the expense of their own health, especially when it comes to musculoskeletal overuse. Massage therapists can do much to tend to these workers who play an often undervalued but critical role in our communities. However, those in the profession must also be willing to let someone else nurse them once in awhile--letting go of the caregiver role and learning to enjoy being cared for.
Whitney Lowe is the author of Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2009). He teaches advanced clinical massage in seminars, online courses, books, and DVDs. Contact him at www.omeri.com.
1. Bureau of Labor Statistics, "Occupational Employment and Wages, May 2011," accessed August 2012, www.bls.gov/oes/current/oes291111.htm.
2. A.M. Trinkoff et al., "Perceived Physical Demands and Reported Musculoskeletal Problems in Registered Nurses," American Journal of Preventive Medicine 24, no. 3 (2003): 270-5.
3. D.R. Smith and P.A. Leggat, "Musculoskeletal Disorders Among Rural Australian Nursing Students," The Australian Journal of Rural Health 12, no. 6 (2004): 241-5.
4. R.F. Edlich, "A Tribute to a Gifted Scholar, Anne Hudson, Who Has Made Revolutionary Advances in Healthcare and Patient Safety in our Nation," Journal of Long-Term Effects of Medical Implants 16, no. 3 (2006): 207-22.
5. T.M. Gropelli and K. Corle, "Nurses' and Therapists' Experiences with Occupational Musculoskeletal Injuries," American Association of Occupational Health Nurses Journal 58, no. 4 (2010): 159-66.
6. R.F. Edlich et al., "Prevention of Disabling Back Injuries in Nurses by the use of Mechanical Patient Lift Systems," Journal of Long-Term Effects of Medical Implants 14, no. 6 (2004): 521-33.
7. Edlich, "A Tribute to a Gifted Scholar, Anne Hudson, Who Has Made Revolutionary Advances in Healthcare and Patient Safety in our Nation."
8. M. Adams et al., The Biomechanics of Back Pain (Edinburgh: Churchill Livingstone, 2002).
9. D.R. Smith et al., "Musculoskeletal Disorders among Professional Nurses in Mainland China," Journal of Professional Nursing?20, no. 6 (2004): 390-5.