Ottoand Wollesen
BMC Sports Science, Medicine and Rehabilitation (2022) 14:114
https://doi.org/10.1186/s13102-022-00508-z
RESEARCH
Multicomponent exercises toprevent
andreduce back pain inelderly care nurses:
arandomized controlled trial
Ann‑Kathrin Otto1,2* and Bettina Wollesen1
Abstract
Background: Sports science is making an important contribution to health services research and supports the
development of tailored interventions, e.g., in nursing settings. Working in elderly care is associated with a high
prevalence of low back pain (LBP). Due to the diverse requirements and high strains, multicomponent programs are
essential to address all relevant factors. This randomized controlled trial investigated the effects of a tailored ten‑week
ergonomics and twelve‑week strength training on lifting behavior, strength endurance, LBP, functional impairment
and adherence.
Methods: n = 42 nurses were randomly assigned to the intervention (IG; n = 20) or control group (CG; n = 22). They
were eligible for participation if they were active in residential care and if they provided written informed consent.
Other employees were excluded. The data were collected at baseline, at ten weeks (after ergonomics training), at
22 weeks (after strength training), and at 34 weeks (follow‑up). The analysis combined physical tests with ques‑
tionnaires (Progressive Isoinertial Lifting Evaluation, PILE‑Test; Biering‑Sørensen‑Test; Visual Analog Scale Pain, VAS;
Oswestry Disability Index, ODI; self‑developed questionnaire for adherence). Group differences were analyzed by
Chi2‑Tests, ANOVA, and Linear Mixed Models.
Results: The IG showed an improved lifting performance (PILE‑Test; 95% CI 1.378–7.810, p = .006) and a reduced
LBP compared to the CG (VAS; 95% CI − 1.987 to 0.034, p = .043) after ergonomics training (PILE‑Test, F(1,34) = 21.070,
p < .001; VAS, F(1,34) = 5.021, p = .032). The results showed no differences concerning the Biering‑Sørensen‑Test and the
ODI. Positive adherence rates were observed.
Conclusions: This approach and the positive results are essential to derive specific recommendations for effective
prevention. The study results can be completed in future research with additional strategies to reduce nurses’ burden
further.
Trial registration: The trial was registered at DRKS.de (DRKS00015249, registration date: 05/09/2018).
Keywords: Elderly care nurses, Multicomponent intervention, Low back pain, Prevention
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Introduction
Increasingly, sports science is making an essential con-
tribution to health services research, addressing occu-
pational health management and promotion in various
settings, such as nursing. An exercise science approach
that complements public health research supports the
development of tailored interventions and thus increases
Open Access
*Correspondence: ann‑kathrin.otto@uni‑hamburg.de
1 Department of Human Movement Science, University of Hamburg,
Turmweg 2, 20148 Hamburg, Germany
Full list of author information is available at the end of the article
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Ottoand Wollesen BMC Sports Science, Medicine and Rehabilitation (2022) 14:114
the likelihood of positive effects due to targeted physical
adoptions [1, 2].
Health promotion is of particular relevance in the care
of the elderly due to the increasing number of multimor-
bid people in need of care, resulting in a high physical
and psychological strain which is associated with a high
prevalence of LBP.
The high occurrence, incidence, and recurrence of
LBP are caused by multiple factors. Therefore, ergo-
nomic, social, biological, psychological and environmen-
tal factors such as e.g., lack of social prestige, work shift
organization, the number of staff members on duty, psy-
chological stress, and age play a crucial role [1–3]. How-
ever, physical workload, awkward work posture, frequent
resident handling activities such as manual lifting, and
low physical capacity of the nurses have been identified
as the most affecting factors for LBP [4–6]. The demand-
ing physical requirements in accumulated nursing work
shifts resulted in changes in physical function with a
decline of explosive and maximal strength [7, 8]. Con-
sequently, muscular fatigue could lead to work-related
musculoskeletal disorders, suggesting that there is a need
for strengthening training [8]. Furthermore, the already
existing shortage of skilled workers further aggravates the
situation, putting more workloads on the existing staff
[9]. Therefore, the relevance of workplace health promo-
tion programs for this target group is of utmost interest
to secure the work capacity in this field.
Although the number of health promotion programs
in the nursing sector is increasing [10–13], the evidence
of successful interventions affecting LBP in elderly care is
weak and heterogeneous [12, 14–17].
For example, multicomponent interventions inves-
tigated the effectiveness of participatory ergonomics,
physical training, and cognitive-behavioral training
[14–16] and found improved lifting performance [16] but
failed to show effects on perceived muscle strength [14],
LBP [14, 16] or working posture [16]. While Rasmussen
and colleagues [15] reduced LBP in nursing aides, there is
no evidence for any intervention affecting LBP in elderly
care.
Reasons for the weak evidence might be setting-spe-
cific factors like organizational barriers, time pressure,
shift work, and staff shortages, resulting in low attend-
ance and adherence [18, 19]. A key factor for the suc-
cessful implementation of interventions is proven to
be the involvement of employees in the planning and
implementation [20]. Thus, the differentiated documen-
tation of work-related risks, wishes, needs, and barriers
is relevant to ensure the initialization of sustainable and
long-term behavioral modifications and maintain these
employees’ motivation [20, 21]. Due to the expected work
of nurses, accompanied with burdens, multicomponent
interventions with ergonomics and strength training,
especially, are required to consider all relevant factors.
Based on these previous study results, the BASE concept,
a multimodal approach for health promotion developed
in Germany (BASE: B ‘Bedarfsbestimmung’ (require-
ments), A ‘Arbeitsplatzorganisation’ (organization of
work), S ‘Schulung des arbeitsbelastungsverträglichen
Alltagshandelns’ (coaching preventive behavior at work)
and E ‘Eigenverantwortung und Selbstwirksamkeit’ (self-
responsibility and self-efficacy)) might be efficient to
reduce LBP in the nursing setting [20]. BASE, includ-
ing ergonomic training, was successful, for example, in
a logistics department, reducing LBP and decreasing
dysfunctional lifting behavior. Furthermore, the concept
indicates an increased motivation for further strength
training [20].
Therefore, this randomized controlled trial aimed to
investigate whether an intervention program combining
ergonomics training with strength and resistance train-
ing tailored to the target group improves lifting behav-
ior, strength endurance, LBP, and functional impairment
caused by back pain.
The main research question was
• Which effects of the Multicomponent intervention
(combination of ergonomics and strength training)
related to LBP, functional impairment, lifting behav-
ior, and strength endurance of the lumbar extensors
of elderly care nurses can be demonstrated?
We hypothesized significant improvements in lifting
behavior, strength endurance and reductions in LBP, and
functional impairment in elderly care nurses for the com-
bination of the different parts of the program. We sup-
pose that the combination of both training contents is
more beneficial than only preventive ergonomics training
to gain positive results.
Moreover, we evaluated the adherence to the interven-
tion program to control if the intervention is feasible to
motivate the participation of the elderly care nurses.
Methods
The CONSORT statement (updated guidelines for
reporting parallel group randomized trials) [22] was used
as a guideline to report this randomized controlled trial.
Study design
This crossover single blind randomized controlled trial
(RCT) was conducted in two nursing homes (Germany,
September 2018 -September 2019). The study is part of
the project ‘PROCARE-Prevention and occupational
health in long-term care’ [23].
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Ottoand Wollesen BMC Sports Science, Medicine and Rehabilitation (2022) 14:114
The investigation was approved by the local ethics
committee (University of Hamburg, AZ:2018_168) and is
registered at DRKS.de (DRKS00015249, registration date:
05/09/2018). Participation in this study was voluntary.
The study followed the principles of the Declaration of
Helsinki.
Participants andrecruitment
A sample size calculation (G*Power; Version 3.1.9.2,
Heinrich Heine University of Duesseldorf) with an esti-
mated effect size of f = 0.25, α = 0.5, and 1 − β = 0.95 for
repeated-measures design revealed a number of N = 36
participants. Furthermore, we estimated a dropout rate
of 30% and therefore included a total number of N= 45
participants.
All nurses (N = 212) of two nursing home facilities were
asked to participate in comprehensive information events
by the study director and through flyers distributed by
the respective manager in the team meeting. Interested
participants signed up for a list with scheduled assess-
ment sessions.
A total of n = 68 nurses and nurse aides agreed to
participate. Nurses were included if they were active in
residential care and provided written informed consent.
Other employees like e.g., home management, and psy-
cho-social carers were excluded. We applied no other
inclusion or exclusion criteria.
Randomization andassignment totheintervention
The random allocation sequence to the IG or the wait-
list CG was done manually by lot to avoid selection bias.
The random assignment was conducted after the baseline
assessment by the study director, who was not involved in
intervention procedures. The data were assessed at base-
line (pre-test), at ten weeks (post-test 1; IG: after ergo-
nomics training, CG: after normal daily activities), at 22
weeks (post-test 2; IG: after strength training, CG: after
ergonomics training), and 34 weeks after starting the
program (follow-up; IG: after normal daily activities, CG:
after strength training) (Fig.1). Data collection was done
by blinded assessors in a strictly pseudonymized form to
guarantee a blinded analysis (e.g., NN08ER30). Following
the data collection, participants were informed regarding
the group allocation and the study flow. The IG and CG
performed the same Multicomponent intervention, start-
ing at different times. The groups were described to the
participants as the immediate starting group (means the
IG) and the delayed starting group (means the CG). As
the study was conducted as a cross-over design, alloca-
tion concealment was not necessary.
Nurses were excluded from analysis when the partici-
pation rate in the intervention program was below 70%.
Of the 68 participants, there were 26 dropouts, which
corresponds to a dropout rate of 38%. In the IG, eleven
nurses dropped out due to illness (n= 3), injury (n= 2),
pregnancy (n= 1), night shifts (n= 1), or family reasons
(n= 1). Three individuals never participated in the inter-
vention. Of the 15 dropout individuals in the CG, four
were due to illness, another participant due to injury, one
due to personal reasons, three due to the termination of
the employment relationship, and two never participated
in the intervention. For the last four, the reasons were
unknown. Overall, 24% of the participants in IG and 37%
in CG dropped out during the intervention period.
In total, the analysis included 42 nurses with a mean
age of 42.5 (SD ±10.5, 92.9% female). Subject character-
istics of the participants and dropouts are presented in
Table1. The participants were analyzed in their original
assigned groups. There were no significant differences in
baseline characteristics between the IG and the CG. Fur-
thermore, participants lost to follow-up were not signifi-
cantly different from the considered.
Outcome measurements
The Progressive Isoinertial Lifting (PILE-Test), the endur-
ance of the trunk extensor muscles (Biering-Sorensen-
Test), and the LBP (VAS) were assessed as primary
outcomes.
PILE‑Test (Progressive Isoinertial Lifting Evaluation)
The PILE-Test recorded the nurses’ lifting performance,
including psychophysical fatigue of the trunk and extrem-
ities. The nurses repeatedly lifted a weight in a box from
the floor at the level of their trochanter major and placed
it on a nursing bed. The weight was increased by 2.5 kg
after an interval of four lifting attempts in 20s, starting
with a total weight of 4 kg for women and 6 kg for men.
The test stopped when the nurse exceeded the 20-sec-
ond interval, decided to quit due to muscular fatigue or
pain, reached 85% of the maximal heart rate (220 - age),
or when the maximum weight that can safely be lifted
has been reached (50% of body weight). Following the
suggestion by Wollesen and colleagues [24], additional
criteria were added for recording dysfunctional posture:
Thoracic spine hyperkyphosis or lumbar spine kyphosis
and activation of additional musculature. The weight that
the participants could lift in the given time without a ter-
mination criterion was recorded. The relative test-retest
reliability was high (ICC= 0.91) [25].
Biering‑Sørensen‑Test
The Biering-Sørensen-Test measured the strength endur-
ance of the lumbar extensors. The nurses lay prone on a
padded massage table. The body’s trunk extended off the
edge of the table at the anterior superior iliac spine level.
The buttocks and ankle joints were fixed to the table with
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straps. At the start of the test, the subject raised his upper
body to a horizontal position, crossing their arms in front
of their chest, holding their head in a neutral position,
and looking down to the floor. Then, the participants
were introduced to hold the position until the maximum
duration time of 240s ends or if they leave the test situ-
ation due to fatigue. Another termination criterion was
the deviation of the horizontal line by more than 5%,
Fig. 1 Flow diagram
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Ottoand Wollesen BMC Sports Science, Medicine and Rehabilitation (2022) 14:114
measured with a stadiometer [26]. The time that the par-
ticipants remained in the position without occurring a
termination criterion was recorded. The reliability shows
ICC values of 0.77–0.83 [27].
Visual analog scale (VAS)
The Visual Analog Scale measured the subjective per-
ception of LBP intensity. The scale is a horizontal line
anchored by smileys at each end. The smileys ranged
from no pain (0) to very severe pain (10). The partici-
pants marked the point that they feel represents their
perception of their current state. The test-retest reliability
is ICC= 0.95 [28].
The Disability Index due to LBP (Oswestry Disabil-
ity Index) and adherence were assessed as secondary
outcomes.
Oswestry disability index
The Oswestry Disability Index measured functional
impairment caused by back pain during nine different
daily activities: personal care, lifting, walking, sitting,
standing, sleeping, sex life, social life, and traveling. The
scale ranged from 0 to 5, with higher values representing
more significant disability. The functional impairment
caused by back pain is then calculated using the score
obtained divided by the maximum possible score x 100.
The minimum value is 0% (no disability) and the maxi-
mum value is 100% (bedridden). The correlation coeffi-
cient for test-retest reliability is ICC= 0.96 [29].
Adherence
The adherence was measured by a list where the attend-
ance of the participants and reasons for dropout were
documented and by a self-developed questionnaire [20].
The participants rated twelve questions, for example: ’I
liked the exercises’, ’I was able to execute the exercises,
or ’The exercises were related to my everyday work’. The
response options were presented on a 3-point scale,
ranging from 1 (Yes, I agree) to 3 (No, I disagree). The
responses were presented as frequencies of agreement.
Additionally, demographic characteristics were col-
lected, such as gender, age, body height, and body weight.
Intervention
The intervention program consisted of standardized
ergonomics training and standardized strength train-
ing [20, 30]. The program followed the validated BASE
concept and workplace observations in each facility. The
intervention started with observing daily nursing rou-
tines in each facility to identify specific primary ergo-
nomic conditions (e.g., existing lifting aids). Work-related
tasks were observed to determine areas where nurses
have to assume awkward postures or are exposed to par-
ticularly high physical workload (e.g., during residents
positioning). In addition, nurses’ health risks, wishes,
needs, and barriers were surveyed before as part of the
PROCARE project and considered for planning and
implementing them in training.
The ergonomics training took place over a period of ten
weeks (once a week for 20–30min) with six to eight par-
ticipants per group. In order to deal with physical stress
at the workplace and compensate for it, the training
included learning different techniques and compensatory
exercises (Table2). Each unit prioritized different work-
related tasks and topics (e.g., work organization, work-
ing on care bed, transfer situations). The units included
the results of the workplace observation (e.g., handling of
existing lifting aids).
The sections of the training were structured as fol-
lows:
1. Explanation of related problem/topic from the nurs-
ing work life and the goal of the session.
2. Exercises for movement and body perception in the
work process (e.g., standing on Airex cushion while
a partner tries to get one off-balance, moving partner
Table 1 Baseline characteristics of participants and dropouts
VAS Visual Analog Scale, ODI Oswestry Disability Index
Intervention (n = 22) Control (n = 20) Stat. analysis Dropout (n = 26) Stat. analysis
F(1,40) p ɳ2p F(1,66) p ɳ2p
Age, Mean (SD) (years) 41.1 (10.5) 44.0 (10.7) .820 .371 .020 44.7 (11.8) 1.156 .286 .017
Female, n (%) 22 (100) 17 (85.0) – – – 23 (88.5) – – –
Height, Mean (SD) (cm) 165.8 (7.7) 165.9 (7.5) .001 . .980 .000 165.0 (7.5) .175 .677 .003
Weight, Mean (SD) (kg) 73.2 (12.8) 81.4 (18.6) 2.813 .101 .066 73.6 (21.0) .552 .460 .008
VAS (score) 1.2 (1.6) 2.1 (2.2) 2.195 .146 .052 2.2 (3.1) .654 .422 .010
ODI (%) 7.8 (6.2) 12.8 (9.9) 3.623 .064 .083 13.6 (13.5) 1.962 .166 .029
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Ottoand Wollesen BMC Sports Science, Medicine and Rehabilitation (2022) 14:114
from lying to a sitting position with several variations
of body positions).
3. Reflections of movement experiences and movement
optimizations (trainer asks specific questions, e.g.,
the changing body position, and encourages different
movement patterns).
4. Instructions for independent compensation exer-
cises (e.g., side planks, lunges, rowing with resistance
band) [20, 30, 31].
The movement experience consisted of three com-
ponents: body awareness, recognizing dysfunctional
movements, and understanding positive and negative
work behavior. All three components were reflected and
adapted to the working conditions. The repeated imple-
mentation and testing in the work situation should lead
to positive attitudes, intentions, and behaviors. After-
ward, participants should be able to independently recog-
nize and influence health-related resources and potential
dangers.
The strength training took place once a week for
45–60 min, over twelve weeks (Table3). The sessions
were divided into four parts:
1. 5–10min warm-up and mobilization (e.g., slow aer-
obic and range of motion exercises for upper ankle
Table 2 Exercise examples of training sessions for the ergonomics and posture training
Training components Session Content and example exercises
General All At the beginning of each session, participants will be welcomed. The session and its related problem/topic from
the nursing work life will be explained and the goal for the respective session. After the introduction, exercises
and leading questions will be dealt with
Work organization 1 Change the workplace to minimize bodily strain
Compensation exercise: relaxation of shoulder and neck area (pull up shoulders, hold, release them), 10–15
repetitions
Standing & positioning 2–3 Standing on an Airex cushion with different stances while a partner tries to get one off balance,
Lift weight while standing with varying stances on an Airex cushion
Compensation exercise: side plank, 2 × until fatigue; standing scale, 3 × for 10 s on each side
Working on the care bed 4–5 Getting off the floor with and without a partner,
Lift weight in different angles from the body
Compensation exercise: lunges, 3 × 10 per leg; overhead press, 3 × 10 per arm
Transfer situations 6–8 Move partner from a lying to a sitting position with several variations of own or partner’s body position,
Lift partner from one to another chair with several variations of body posture, chair positions, etc.,
Lifting weights with rotation
Compensation exercise: rowing with a resistance band, 3 × 10–15 repetitions; deadlift with a resistance band,
3 × 10–15 repetitions; “picking apples”, 3 × for 15 s
Nursing aids and summary 9–10 Lifting weights with aid (e.g., rope)
Compensation exercise: wall slides, 3 × 10–15 repetitions
Table 3 Exercise examples of training sessions for strength and resistance training
Training components Exercise examples
Mobilization and Warm‑up Exercises for the mobilization of upper ankle joint, hip joint, thoracic spine, shoulder joint, and wrist joint
Coordination Imparting theoretical knowledge about conscious movement execution and targeting of muscles
Exercises for:
Feet (e.g., rotation of the tibia around the foot first in sitting, then in standing position),
Hip (e.g., cat‑cow),
Spine (e.g., round and straighten up the back vertebra by vertebra),
Shoulder blades (e.g., breathing into the shoulder blades),
Head (e.g., push the head back and forth)
Level 1
Week 1–4 Level 2
Week 5–8 Level 3
Week 9–12
Circuit strength training Deadlift, 2 × 5 repetitions
Hip thrust, hold 2 × for 60 s
Sit Ups, 2 × for 60 s
Lunges, 2 × for 30 s on each side
Deadlift, 2 × 5 repetitions
One‑legged hip thrust, hold 2 × for
30 s on each side
Sitting rotation, 2 × for 60 s
Step Up, 2 × for 30 s on each side
Deadlift with a partner, 2 × 5 repetitions
Standing scale, hold 2 × for 30 s on each
side
Lying leg rotation, 2 × for 60 s
Split Squad, 2 × for 30 s on each side
Relaxation Static stretching, self‑massage (myofascial release) with, e.g., a tennis ball, breathing exercises, progressive muscle relaxa‑
tion
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joint, hip joint, thoracic spine, shoulder joint, and
wrist joint).
2. 10–15min coordination with theoretical knowledge
about conscious movement execution and targeting
of muscles and exercises. The goal is to enable par-
ticipants to reflect and improve their posture and
movement patterns (e.g., rotating the tibia around
the foot, first in sitting, then in standing).
3. 30–40 min strength exercises (e.g., progressive
upper- and lower body exercises, partly with addi-
tional resistance band).
4. 5–10min relaxation (e.g., breathing exercises, self-
massage, static stretching).
Strength training was divided into three phases (four
weeks per phase) with a progression achieved by adjust-
ing the exercises’ difficulty, and intensity/range of
motion. The intensity of the exercises was planned to be
moderate (5–6 on Borg CR10 Scale [32]).
The program was conducted by certified exercise sci-
entists or physiotherapists trained to work according to
a standardized manual. Based on participants’ perceived
exhaustion, they could take individual breaks or perform
a lighter exercise, simplified by trainers. The interven-
tions took place at the nursing home facilities during
working hours in the transition period from early to late
shift.
Statistical methods
All analyses were performed with SPSS Version 27 (IBM
SPSS Statistics for Windows, Armonk, NY, USA), with
the alpha level set to .05. Descriptive statistics was used
to determine the frequency, mean, and standard devia-
tion of each variable. In addition, a one-way Analysis of
Variance tested the differences in baseline characteristics.
Linear Mixed Models, fitted with an unstructured
covariance matrix, were used to investigate interven-
tion efficacy. The outcomes were assessed for the impact
of time. All analyses were performed using fixed effects
for group and random intercept per subject. Afterward,
a one-way Analysis of Variance was calculated to analyze
time point comparisons. Frequency analysis of termina-
tion criteria was done by Chi2- Tests.
At the end of the trial, we conducted an intention-to-
treat analysis with the whole group (including the 26
dropouts) using Linear Mixed Models to avoid the risk of
unbalanced groups.
Main analyses oftheoutcomes
Table4 reports the descriptive values and statistics of the
measurement points (Pre, Post 1, Post 2, Follow-up). The
interactions and main effects for the PILE-Test and Bier-
ing-Sørensen-Test are illustrated in Fig.2.
The analysis showed significant differences between
the IG and the CG in the lifted weight during the PILE-
Test. Moreover, the nurse’s perception of LBP inten-
sity on the VAS was reduced in the IG (Table4). Group
comparisons revealed significant differences at the sec-
ond measurement time point (Post 1) of the PILE-Test
(F(1,34) = 21.070, p < 0.001) and the VAS (F(1,34) = 5.021,
p = 0.032). At the same time, the termination criteria
for the PILE-Test changed (Table 5). The IG recorded
Table 4 Descriptive values and linear mixed models statistics
PILE Test Progressive Isoinertial Lifting Evaluation, VAS Visual Analog Scale, ODI Oswestry Disability Index, IG intervention group, CG control group
*p < 0.05
Pre Post 1 Post 2 Follow-up Estimates (SD) Statistics p
Mean (SD) 95% CI’s
PILE‑test (kg)
Lower upper
IG 6.9 (6.5) 9.4 (5.1) 9.9 (5.8) 10.1 (5.2) 4.594 (1.587) 1.378 7.810 .006*
CG 3.7 (5.0) 2.0 (4.2) 10.4 (7.4) 5.1 (5.6)
Biering-Sørensen-
Test (time)
IG 62.3 (30.0) 73.8 (50.3) 96.9 (64.5) 87.7 (38.6) 7.949 (9.866) − 12.281 28.179 .427
CG 54.2 (35.0) 63.3 (53.4) 55.6 (47.6) 68.3 (43.3)
VAS (score)
IG 1.2 (1.6) 1.0 (1.7) 1.1 (1.7) 0.9 (1.6) − 1.011 (0.482) − 1.987 − 0.034 .043*
CG 2.1 (2.2) 2.7 (2.9) 2.2 (2.2) 1.1 (1.9)
ODI (%)
IG 7.8 (6.2) 6.6 (9.0) 5.0 (5.2) 6.5 (6.9) − 4.577 (2.524) − 9.688 0.533 .078
CG 12.8 (9.9) 10.5 (8.8) 11.5 (11.7) 11.8 (10.4)
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Ottoand Wollesen BMC Sports Science, Medicine and Rehabilitation (2022) 14:114
fewer terminations due to thoracic spine hyperkyphosis
(Chi2 = 9.531, p = 0.002) and more terminations due to
muscular fatigue (Chi2 = 10.413, p = 0.001) than the CG
after participation in ergonomics training. There were no
differences concerning the test time regarding the Bier-
ing-Sørensen-Test and the functional impairment caused
by back pain (ODI).
Fig. 2 Interactions and main‑effects PILE‑Test and Biering‑Sørensen‑Test visualized in cloud plot, rain plot, box plot and line plot
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Ottoand Wollesen BMC Sports Science, Medicine and Rehabilitation (2022) 14:114
The intention-to-treat analysis showed no signifi-
cant differences between the IG and the CG concern-
ing the LBP intensity on the VAS (95% CI − 0.49 to 1.66,
p = 0.281).
Overall, the participants were optimistic about the
program. The participants enjoyed the content, liked the
exercises, had fun, and wanted to learn more about per-
sonal health promotion (Table6).
Discussion
This RCT aimed to investigate the effectiveness of a tai-
lored multicomponent intervention (combination of
ergonomics and strength training) to improve lifting
behavior, strength endurance of the lumbar extensors,
LBP, and functional impairment caused by back pain for
elderly care nurses. Additionally, participants’ adherence
to the intervention was assessed.
The results showed positive effects on IG nurses’ lift-
ing performance, illustrated by higher lifted weight
with concomitant changes in termination criteria. Fur-
thermore, the analysis revealed significant differences
between both groups in back pain (after IGs’ participa-
tion in ergonomics training). The differences were found
at the second measurement time point. However, the
effect on LBP did not remain within the intention-to-
treat analysis.
The further evaluation revealed no significant differ-
ences at any measurement time point concerning the
strength endurance of the lumbar extensors and the
functional impairment caused by LBP. As expected, par-
ticipants’ adherence showed positive ratings.
Regarding the lifting performance and behavior as one
common risk factor for increasing LBP, the analysis of the
PILE-Test revealed significant improvements in the IG
after participation in ergonomics training. This effect in
the IG remained similarly positive after participating in
strength training. Additionally, the CG showed compa-
rable improvements after their ergonomics intervention,
Table 5 Termination criteria for the PILE‑Test
IG intervention group, CG control group
*p < 0.05
Termination criteria %
Pre Post 1 Post 2 Follow-up
IG CG IG CG IG CG IG CG
85% of HR max 18.2 25.0 23.8 13.3 28.6 16.7 9.1 25.0
50% body weight 0 0 0 0 0 0 0 0
20‑s interval 0 5.0 9.5 0 0 25.0 36.4 12.5
Muscular fatigue 18.2 5.0 42.9* 0 35.7 25.0 36.4 12.5
Thoracic spine hyperkyphosis 54.5 65.0 19.1* 86.7 28.6 25.0 18.2 50.0
Pain 9.1 0 4.8 0 7.1 8.3 0 0
Table 6 Evaluation of the ergonomics and posture training (n = 32) and strength training (n = 31)
Questions Yes, I agree (%) No, I disagree (%) No response (%)
ep st ep st ep st
I enjoyed the training content 95.5 93.6 0 6.5 4.5 0
I liked the exercises 93.2 93.6 4.5 6.5 2.3 0
I think the exercises are useful 95.5 96.8 2.3 0 2.3 3.2
I learned something new 88.7 83.9 11.4 12.9 0 3.2
I remembered previous teaching 70.5 67.7 25.0 25.8 4.5 6.5
I had fun during the exercises 90.9 96.8 6.8 0 2.3 3.2
The exercises were related to my everyday life 86.3 77.4 6.8 19.4 6.8 3.2
I was able to execute the exercises 86.4 96.7 11.4 0 2.3 3.2
The trainers expressed themselves in an understandable way 86.4 93.5 11.4 3.2 2.3 3.2
The training was too short 75.0 71.0 20.5 29.0 4.5 0
The amount of time of the training was appropriate 79.5 90.3 13.6 6.5 6.8 3.2
I would like to learn more about personal health promotion 90.9 80.6 9.1 12.9 0 6.5
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Ottoand Wollesen BMC Sports Science, Medicine and Rehabilitation (2022) 14:114
including the same training contents. In line with Ewert
and colleagues [16], our data support that ergonomics
training successfully increases lifting performance for
both groups.
Notably, the groups also differed in their quality of
movement execution. The IG demonstrated a simulta-
neous increase in terminations due to muscular fatigue
in addition to reduced terminations due to thoracic
spine hyperkyphosis. We assume a reason might be the
increased lifted weight during the test and individuals’
low physical capacity [6]. However, the differences were
only present at the second measurement point, indicating
that both groups benefited equally from the training. In
line with Wollesen and colleagues [20], ergonomic train-
ing reduced dysfunctional lifting behavior successfully.
Therefore, we suggest that the program is suitable to
reduce a major risk factor of LBP. Moreover, we can sum-
marize that the training content was successfully adapted
to the nursing field and promises to be useful for further
implementation in other care settings.
In addition, the IG increased their Biering-Sørensen-
Test time by approximately 23s after participating in the
strength training, while test time of the CG decreased.
However, these observations failed to be significant. We
assume that the results are caused by interindividual dif-
ferences between the nurses’ strength endurance, which
are reflected in the standard deviations (cf. Table 2).
Our results align with Stevens and colleagues [14], even
though they measured subjectively perceived strength.
The lack of significant group differences can probably
be attributed to methodological problems we observed,
such as motivation, tolerance of the discomfort of fatigu-
ing muscles or pain, or fear of pain [29]. This observation
suggests that another test is needed to obtain valid data
(e.g., electromyography).
Moreover, the duration of the strength training might
have been insufficient to increase strength. The nurses
in our study were analyzed when they reached at least a
70% participation rate, which corresponds to participa-
tion in at least nine units over nine weeks. A recent meta-
analysis recommends training over 12 to 16 weeks to
gain significant improvements in strength. Furthermore,
according to the specific training stimulus [33], crite-
ria of load control, stimulus scope, and stimulus density
must be considered to generate adaptation effects. In our
study, despite dividing the strength training into three
phases with progression, the degree of difficulty had to
be increasingly adapted individually to the participants.
Therefore, the overly high level of difficulty resulted in
simplifying the exercises, leading to inadequate pro-
gression control. Overall, future strength interventions
should be performed for extended periods with a higher
stimulus density and include exercises with a lower
intensity and slower progression. This highlights the need
to address nurses’ time constraints and offer alternate
dates for training sessions that could not attend.
The analysis of the LBP within the VAS revealed sig-
nificant differences between both groups. Participation in
the ergonomics training resulted in the same Level of LBP
in the IG, whereas pain slightly increased in the CG. As a
clinically significant change does not occur until a value
of 20 mm, the results should be interpreted with caution
[34]. Nevertheless, the further aggravation of the staff
shortage may have affected results in the CG [9]. Unfor-
tunately, this effect did not remain in the intention-to-
treat analysis. One might assume that the reason, again,
was the heterogeneity of the recorded data, exposed by
high standard deviation. However, the participants failed
to follow-up were not significantly different from the
considered participants concerning baseline characteris-
tics and primary and secondary outcomes studied.
Future studies should verify the pain situation over at
least 17–20-weeks, consistent with the literature [33].
Nevertheless, we suppose that our tailoring, the individ-
ual adaptation of the training content to the conditions
of the nursing home facility, and the movement experi-
ences, including body awareness, recognition of dys-
functional movements, and understanding positive and
negative work behavior, might affect back pain positively.
This highlights the need for interventions, considering
the bottom-up approach, taking work-related burdens,
wishes, barriers, and the facility’s condition into account
[1].
Surprisingly, the intensity of LBP in the IG and CG was
relatively low, compared to the high prevalence of LBP
(around 50%) in this target group which is, additionally,
repeatedly demonstrated in the literature [6, 35]. The
discrepancy might indicate a lack of ability of the nurses
to discriminate between the presence of pain and assess-
ing the pain intensity which is associated with a possible
underestimation of the severity of LBP. As a result, nurses
reported low functional impairment caused by back pain.
The evaluation of the ODI and the classification of the
percentages showed a minimal disability in both groups
and no significant differences in the study [29]. However,
the intervention period may not have been long enough
to reduce functional impairment and should be consid-
ered more closely in future investigations. Overall, the
low intensity in LBP and the low functional impairment
of all included nurses may also indicate that only those
who already live health-consciously and suffer less from
pain and functional impairment were motivated to par-
ticipate in the intervention. For this reason, we recom-
mend conveying education about the importance, the
mode of action, and the effects of health-promoting
Page 11 of 12
Ottoand Wollesen BMC Sports Science, Medicine and Rehabilitation (2022) 14:114
interventions in future research to motivate the non-par-
ticipating nurses.
Regarding the participation, it is newsworthy to report
that the intervention program achieved a positive adher-
ence. The participants of the CG determined the high
dropout rate. Within the participants that joined the
program regularly, the dropout quote was only 24%.
According to our results, the nurses equally accepted and
tolerated the intervention. Nurses regularly participated
in the intervention despite the barriers, such as time
pressure. This highlights the need for the participatory
approach in the process and the tailored structure of the
training with the individually adapted intensity of the
exercises [20].
Limitations
Next to the study’s strengths, some limitations need to be
addressed. The participants took part in the study dur-
ing working hours. Therefore, time pressure, lack of time,
or motivation could have influenced the data assess-
ment. Moreover, the LBP and functional impairment
were assessed with self-administered questionnaires and
scale. This may have led to a possible underestimation of
the severity of LBP and disability due to a lack of ability
for discrimination between the presence of pain and the
assessment of the pain intensity.
The results were not controlled for the duration of
employment, the type of employment (e.g., full time,
part-time), or the activities during leisure time which
might be a relevant factor for burdens and strains. More-
over, the high level of difficulty in back fitness and the
resulting simplification of the exercises could have led to
the progression not being sufficiently controlled. Finally,
the dropout rate of 37% was high. However, considering
the difficulties in implementing a randomized controlled
study in elderly care, the number of participants achieved
can be considered a success and fulfilled the prior calcu-
lated power.
Conclusion
The intervention reported in this study showed positive
effects on lifting performance, ergonomic behavior, and
LBP. Moreover, the multidimensional approach of the
BASE concept led to a positive adherence as it includes
the specific integration of the expected work of the tar-
get group. Thus, we conclude that a multicomponent
intervention tailored to the target group, taking aspects
such as movement experiences and strength training into
account, can positively affect nurses. The results of this
study are essential to derive more specific recommenda-
tions for effective prevention in nursing home facilities.
As the number of longitudinal studies with multicom-
ponent interventions tailored for elderly care nurses is
rare, the positive results can be completed in future stud-
ies with additional strategies for pain reduction, ratio
prevention, and work situations to reduce burden of the
nurses further.
Author contributions
A‑KO and BW conceived and designed the study, A‑KO collected data in the
field and analyzed the data, A‑KO drafted the manuscript, BW reviewed the
manuscript. Both authors read and approved the final manuscript.
Funding
Open Access funding enabled and organized by Projekt DEAL. This study
was funded by the health insurance Techniker Krankenkasse to the scientific
concept. The study is part of the project "Prevention and occupational health
in long‑term care" (PROCARE). Trial data were analyzed independently of the
trial sponsors. This funder did not play any role in the design of the study, data
analysis, reporting of results, or the decision to present the manuscript for
publication. The study has not been reviewed by the funding body.
Availability of data and materials
The datasets generated and analyzed during the study are available from the
corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This research was conducted in accordance with the Declaration of Helsinki.
The study was approved by the local ethics committee (University of Ham‑
burg, AZ:2018_168) and is registered at DRKS.de (DRKS00015249, registration
date: 05/09/2018). Participation in this study was voluntary. All participants
gave informed consent before taken part in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no conflict of interest.
Author details
1 Department of Human Movement Science, University of Hamburg, Turmweg
2, 20148 Hamburg, Germany. 2 Department of Biopsychology and Neuroergo‑
nomics, Technical University of Berlin, Fasanenstraße 1, 10623 Berlin, Germany.
Received: 5 April 2022 Accepted: 15 June 2022
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