Rgc.docx

University of Santo Tomas Clinical Epidemiology Faculty of Medicine and Surgery

USE OF EXERCISE TO REDUCE THE SEVERITY OF BACK PAIN AMONG FILIPINO CALL CENTER AGENTS

Research Group D5 Rojas, Samantha Alda Romero, Florence Pauline

Rosita, Raphael Jommel

Rosita, Jasmine Rochelle

Ruiz, Louise Mari

Adviser: Dr. Regal

Abstract The most common occupational disorders are neck pain, shoulder pain and back pain. These are caused by prolonged sitting and faulty posture. Several interventions such as exercise,

medication and ergonomic modification have been used to reduce the risk and severity of pain. This study aims to determine the effect of exercise in reducing the severity of back pain among Filipino call center agents. A prospective cohort study will be conducted. A questionnaire will be given to the participants which includes the duration of back pain, length of stay in the company, medication and physical activity. Attached to this will be an additional Oswestry low back pain disability index. These will be the basis to determine which of the participants are exposed (exercise) and which receive the outcome (reduction in low back pain). The duration of the study will be 2 months and the questionnaires will be given weekly.

Keywords: Low back pain, Exercise, Call center agents

SECTION 1: RESEARCH QUESTION Will the use of exercise reduce the severity of back pain among Filipino call center agents?

SECTION 2: INTRODUCTION/BACKGROUND AND SIGNIFICANCE Back pain affects approximately two-thirds of the population at least once in their lifetime (Snook, 2005). It is a multifactorial problem with genetics, age, and workplace

conditions as some it of its causes. According to a survey conducted by the Philippine Statistics Authority in 2013, back pain, hypertension, and peptic ulcer were found to be the most common occupational diseases experienced by workers or employees in the Philippines. Out of the 125,000 surveyed, 32.8% were experiencing back pain, and it is the leading occupational disease among the three.

Because of its prevalence in the workplace, methods to reduce its recurrence and severity must be employed. Aside from comprising a large fraction of the workforce in the Philippines, the sedentary workplace environment of call center agents may be an important factor to consider in the study of work-related back pain.

The significance of this study is to determine whether the exercise regimen that will be provided will be effective in reducing the severity of back pain in call center agents who work at least 8 hours a day.

The results that will be generated from this research will hopefully provide relevant data to clinicians to improve treatment and management of back pain, and to help employers and companies design an ergonomic workplace for employees or implement new policies that will help the employees work more actively and physically in call center agencies. The researchers of this study also aim to learn different techniques in pain management and treatment through the use of exercise to aid them in future clinical practice.

SECTION 3: OBJECTIVES AND HYPOTHESIS General: -

To determine the difference in severity of back pain felt by call center agents depending on the presence of exercise during work

Specific: -

To assess the severity of back pain felt by call center agents using a back ache and disability questionnaire

-

To determine the effect of exercise to the back pain of call center agents

Alternative Hypothesis -

Exercise will reduce the severity of back pain among Filipino call center agents

Null Hypothesis

-

Exercise will not reduce the severity of back pain among Filipino call center agents

SECTION 4: CONCEPTUAL FRAMEWORK

Call Center

8 hours of sitting

Low back

Bad posture

Exercise

Frequency of physical

Improveme nt in lower

Intake of pain

This map illustrates the effect of exercise to back pain of call center agents based on the subjective pain scale. Before the intervention of an exercise is given, the back pain is assessed. This will then be compared to the reassessment of the pain after the continuous application of the exercise to determine the effect of the exercise to the severity of pain. Factors such as the taking in of pain medication and frequency of physical activity may be considered as confounding variables that may affect the assessment of the exercise given.

SECTION 5: LITERATURE REVIEW According to Brakenridge et al. (2018), neck and lower extremity pain is associated with sitting for long periods of time during work. Also, upper extremity pain may be associated with prolonged use of computers. Prolonged sitting combined with awkward postures are considered as aggravating factors for lower back pain. For deskbased workers, neck pain, shoulder pain, and back pain are considered as their most common musculoskeletal complaints.

According to the study of Shariat, Lam, Kargarfard, Tamrin, and Danaee (2017), individuals living a sedentary lifestyle are at risk of losing the strength and flexibility of their muscles which are necessary to maintain their physical fitness and natural postures. Those in office environments may experience these because of the long duration of sitting in office chairs, and these may cause or worsen existing pain problems. Incorrect sitting postures and poor ergonomics can contribute to an individual’s pain on their back,

shoulders, and neck. The introduction of an exercise training program for an office worker reduces the back, shoulder, and neck pains of the individuals.

Musculoskeletal disorders are common occupational disorders. Factors such as awkward posture may lead to a person’s work-related musculoskeletal disorder (Mehrparvar et al., 2013). Interventions such as training, ergonomic modifications, rest breaks, and workplace exercises are possible interventions to overcome these disorders.

A study conducted by Anema et al. (2004) shows how ergonomic modifications in the workplace expedited the return-to-work of employees with lower back pain who were sicklisted. Workplace adaptations, and, on the long term, adaptation of job tasks and working hours seem to be effective to improve return-to-work for workers sicklisted for three to four months due to lower back pain. Another research by Snook (2005) states that, “…workplaces must be designed for people with low back pain as well as for people without low back pain. Good workplace design will permit employees with low back pain to remain on the job, or to return to the job sooner.”

Hides, Jull, and Richardson (2001) studied the long-term effects of specific stabilizing exercises on recurring lower back pain. Patients with back pain were medically managed and randomly assigned to a control or an exercise group. The intervention involved exercises targeting to rehabilitate multifidus in cocontraction with the transverse abdominis muscle, telephone questionnaires were conducted with the patients after one year and three months. The results showed that patients in the exercise group had fewer recurrences of lower back pain than patients from the control group. One year after treatment, specific exercise group recurrence was 30%, and control group recurrence was 84%. Two to three years after treatment, specific exercise group recurrence was 35%, and control group recurrence was 75%. From this, they were able to glean that specific exercise therapy in addition to medical management and resumption of normal activity may be more effective in reducing recurrences of lower back pain than medical management and normal activity alone.

In the randomized, controlled trial conducted by Shariat, A., et al (2017), 180 work officers, between the ages of 20-50, all office workers with at least 2 years experience of shifts from 8:00am- 5:00pm (rest hour from 1:00pm-2:00pm, entire work sessions spent sitting) were randomly assigned to various groups, with a control group (no exercise; no ergonomic modification), exercise training

group, ergonomic

modification group, and a group with a combination of both interventions. The participants were asked to cite at least one musculoskeletal disorder they were

experiencing, and exercise mainly consisted of stretching, which was constant, controlled, and slow, applying tension to the particular muscle/muscle group, at the end of the joint’s range of movement, done once a day, 3 times a week. Outcomes for all groups were measured using the the Cornell Musculoskeletal Disorders Questionnaire at intervals of 2, 4, and 6 months. By the end of the period, the only group with consistent significant improvement in pain scores (by the 4th to the 6th month) were the exercisestretching group, and is attributed to pressure reduction on the nerves innervating the various muscles, and in the case of the hip extensors and flexors, along with the pyriformis, would result in a decrease in pain of the multifidus muscles. Ergonomic modifications in contrast, were considered short term, and should be kept consistent (desk placement, seat height, position of keyboard, CPU, mouse, etc.), which may have to depend on the commitment of companies involved.

According to Garcia, et. al. (2014), the McKenzie method is an active intervention which aims to minimize pain, disability and improve spinal mobility. The McKenzie exercise is composed of different parts. The researchers will be using the sitting McKenzie exercise and the standing McKenzie exercise. The participants will be asked to do a sitting extension exercise and hold it for 10 seconds that should be done 3 times. The next exercise is the standing extension

SECTION 6: STUDY DESIGN

Prospective Cohort Study

The call center agents are the subjects for this study. The study will be conducted for 2 months and will be monitored weekly. For the first week, the baseline information will be collected from all subjects by using the Oswestry Low Back Pain Questionnaire as well as questions regarding the frequency of their act of exercise during work hours. For the follow up, the subjects will be given the same questionnaires and these will be compared to their baseline from the first week in order to determine the relationship between the exposure (exercise) and outcome (reduction in low back pain)

Follow up of the subjects will be done on a weekly basis. After two months of data collection and obtaining the baseline values, the subjects can be classified according to the frequency of their exposure to the exercise. They will be followed up on a weekly basis to determine the effect of the exposure (exercise) to the severity of their back pain. This is done to determine whether the exposure has an effect on their back pain. The

weekly follow-up is done for one month before the final assessment of their outcomes. The study will last for 2 months.

SECTION 7: OPERATIONAL DEFINITIONS Ergonomics - an applied science concerned with designing and arranging things people use so that people and things interact more safely and efficiently; defined as the study of people’s efficiency in their workplace.

Physical Activity - any bodily movement produced by skeletal muscles that require energy expenditure. A clear definition of exercise allows health care providers to speak to patients about improving their physical activity, particularly given that physical inactivity is a leading but very modifiable risk factor for a wide range of diseases

Non-specific low back pain - low back pain that is not associated to a recognizable or known pathology, such as an infection, spinal, nervous, or inflammatory disorder; usually categorized into acute, sub-acute, and chronic back pain ● Acute - low back pain for less than 4 weeks ● Sub-acute - low back pain between 4 to 12 weeks ● Chronic - low back pain for 12 weeks or more

SECTION 8: STUDY POPULATION AND STUDY SETTING The study will compose of 20-40 call center agents from the company of TeleTech located in Muntinlupa. Participants must be working at least 8 hours a day. Inclusion Criteria -

Ages 18-30

-

Employees experiencing constant low back pain within 6 months prior to the interview

Exclusion Criteria -

Workers with prior diagnosis of low back pain (before employment)

-

Pain experienced is due to physical activity

Participants will be given a questionnaire to determine their exposure to exercise and it’s association with the outcome of reduction in low back pain.

The confounding variables of this study are as follows: ● Intake of pain relievers ● Regular participation in physical activity

SECTION 8: SAMPLING DESIGN AND SAMPLE SIZE CALCULATION The study will make use of stratified sampling. The researchers will gather participants from the Teletech company who have experienced low back pain during the past 6 months. The researchers will group the participants by the chronicity of the pain experienced; <4 weeks, 4-12 weeks and >12 weeks. Stratified sampling would be best for this study since the researchers will be observing the effect of the exercise on the different low back pain durations.

Sample Size Estimation of the sample size was based on the work of Plaskiewicz et al. (2018) entitled, “The efficacy analysis of the McKenzie method in the treatment of lumbosacral spine ailments .” 50 patients from a local health center in Solec Kujawski were recruited, and divided into a treatment group (15 women, 10 men, subjected to McKenzie method for three weeks) and the control

group (15 women and 10 men, underwent traditional kinesiotherapy and physical therapy). Before and after performing their respective interventions, each patient’s level of pain experienced was assessed using the VAS Scale, evaluating pain levels in a scale of 1 to 10. 32% of patients assessed their pain as 6/10, 32% as 8/10, 4% as 9/10, 4% as 5/10. In the control group 36% of patients assessed the pain as 8/10, 28% as 6/10, 20% as 7/10, 12% as 9/10 and 4% as 5/10. Using the SPSS program, subsequent calculations and figures were made. Cohort/RCT was used to determine the sample size estimate. The following data were entered based on the aforementioned study. Values for the outcome were based on the subjective pain felt by the participants on the study, which were manifested in scores of less than or equal to one.

SECTION 9: METHODOLOGY 9.1 Operational Definitions Workers are introduced to an exposure of exercise targeted for lower back pain. These exercises are derived from McKenzie exercises. The Mckenzie method targets pain in the lower back. By doing this intervention, there should be an extension of the spine in order to alleviate pain and provide relief for the workers. The exercises done would be a standing backward bend and a stretch exercise done while sitting. The duration of the exercise regimen ranges from 1 to 2 minutes which will be done 2-3 times in one day. The workers will do this exposure everyday. The outcome of this study would be the reduced lower back pain felt by the workers. 9.2 Study Procedure

Workers aged 18-30 years old with lower back pain within the last 6 months will be recruited for the study. A survey will be introduced to the participants, which will factor in the duration of the back pain, the length of stay in the company, any intake of medication, and any physical activity performed. Together with the survey, the Oswestry low back pain disability index will be administered to determine the severity of the back pain experienced by the participant. The participants will then be classified according to the duration of their exposure to exercise. The participants of the study will then perform the set of exercises daily, for two to three times a day for two months. Each week, the researchers will monitor the progress of the workers by administering the survey which will track the frequency, consistency, and progress of their set of exercises. By the end of the two months, they will then be asked to answer once more the Oswestry low back pain disability index to check for any changes in the severity of back pain.

9.3 Outcome to be Measured The researchers’ outcome is to determine whether the given exercise reduced the severity of the low back pain. The participants will be asked to answer the Oswestry questionnaire before the start of the program and after. The pain will be measured by the rating scale in the Oswestry questionnaire.

SECTION 10: STATISTICAL ANALYSIS 10.1 Inferential Statistics The statistical test that will be utilized to compare the effect of the intervention to the back pain of office workers is the paired t-test wherein two paired samples would be compared. In the study, the dependent variable is the low back pain assessment based on the Oswestry Low Back Pain questionnaire while the independent variable is time (before and after intervention).

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Brakenridge, C.L., Chong, Y.Y., WInkler, E.A.H., Hadgraft, N.T., Fjeldsoe, B.S., Johnston, V., … Clark, B.K. (2018). Evaluating short-term musculoskeletal pain changes in desk-based workers receiving a workplace sitting-reduction intervention. International Journal of

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