PENGGUNAAN BACK SUPPORT UNTUK PENCEGAHAN LOW BACK PAIN PADA PEKERJA

i

UNIVERSITAS INDONESIA

PENGGUNAAN BACK SUPPORT UNTUK PENCEGAHAN LOW BACK PAIN PADA PEKERJA

TUGAS AKHIR Laporan Kasus Berbasis Bukti

RAYMOS PARLINDUNGAN HUTAPEA 1206236400

FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA PROGRAM STUDI PENDIDIKAN DOKTER SPESIALIS OKUPASI JAKARTA JUNI 2014

Universitas Indonesia

Penggunaan back ..., Raymos Parlindungan Hutapea, FK UI, 2014

ii

UNIVERSITAS INDONESIA

PENGGUNAAN BACK SUPPORT UNTUK PENCEGAHAN LOW BACK PAIN PADA PEKERJA

TUGAS AKHIR Diajukan sebagai salah satu syarat untuk memperoleh gelar Spesialis Okupasi

RAYMOS PARLINDUNGAN HUTAPEA 1206236400

FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA PROGRAM STUDI PENDIDIKAN DOKTER SPESIALIS OKUPASI JAKARTA JUNI 2014



ii

HALAMAN PERNYATAAN ORISINALITAS

Tugas akhir ini adalah hasil karya sendiri, dan semua baik yang dikutip maupun dirujuk telah saya nyatakan dengan benar

Nama

: Raymos Parlindungan Hutapea

NPM

: 1206236400

Tanda tangan

:

Tanggal

: 11 Juni 2014



iii

HALAMAN PENGESAHAN

Tugas akhir ini diajukan oleh : Nama

: dr. Raymos Parlindungan Hutapea, MKK

NPM

: 1206236400

Program Studi

: Program Pendidikan Dokter Spesialis Okupasi

Judul Laporan

: Penggunaan Back Support untuk Pencegahan Low Back Pain pada Pekerja (Laporan Kasus Berbasis Bukti)

Telah diajukan di hadapan Dosen Pembimbing dan diterima sebagai bagian persyaratan tugas akhir yang diperlukan untuk memperoleh gelar Spesialis Okupasi pada Program Studi Pendidikan Dokter Spesialis Okupasi, Fakultas Kedokteran, Universitas Indonesia.

Pembimbing

dr. Indah S Widyahening, MS,MSc-CMFM

(

)

Ketua Program Studi

Dr. dr. Astrid B Sulistomo, MPH, SpOk

(

)

Ditetapkan di

: Jakarta

Tanggal

: 11 Juni 2014



iv

KATA PENGANTAR

Puji syukur saya panjatkan kepada Tuhan Yang Maha Kasih, karena atas berkat dan karuniaNya, saya dapat menyelesaikan Laporan Kasus Berbasis Bukti. Penulisan tugas akhir ini dilakukan dalam rangka memenuhi salah satu syarat untuk melengkapi nilai akhir mata kuliah EBCR (Evidence Based Case Report) pada Program Pendidikan Dokter Spesialis Okupasi di Fakultas Kedokteran Universitas Indonesia.

Saya menyadari bahwa tanpa bimbingan dan

bantuan dari berbagai pihak, sangatlah sulit bagi saya untuk dapat menyelesaikan tugas akhir ini. Ucapan terima kasih saya berikan dengan tulus dan hormat kepada : 1. Dr. dr. Astrid B Sulistomo, MPH, SpOk sebagai Ketua Program Studi. 2. dr. Indah S Widyahening, MS, MSc-CMFM sebagai dosen pembimbing yang telah meluangkan waktu, tenaga dan pikiran untuk membimbing saya. 3. Orang tua, istri saya yang tercinta, dr. Christianti Asrida Panggabean, MKK, anak-anak saya : Raventian Maynar Asima Hutapea dan Rayvino Pieter Asian Hutapea, yang telah banyak memberikan dukungan doa, material dan semangat. Akhir kata, saya berharap Tuhan Yang Maha Kasih membalas segala kebaikan semua pihak yang telah banyak membantu. Semoga laporan akhir ini dapat memberikan manfaat bagi perkembangan ilmu pengetahuan.

Jakarta, 11 Juni 2014

Penulis



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HALAMAN PERNYATAAN PERSETUJUAN PUBLIKASI TUGAS AKHIR UNTUK KEPENTINGAN AKADEMIS

Sebagai sivitas akademik Universitas Indonesia, saya yang bertanda tangan di bawah ini : Nama

: dr. Raymos Parlindungan Hutapea, MKK

NPM

: 1206236400

Program Studi

: Program Pendidikan Dokter Spesialis Okupasi

Jenis Tugas Akhir

: Evidence-based Case Report

demi pengembangan ilmu pengetahuan, menyetujui untuk memberikan kepada Universitas Indonesia Hak Bebas Royalti Noneksklusif (Non-exclusive Royalty Free Right) atas tugas akhir saya yang berjudul : Penggunaan Back Support untuk Pencegahan Low Back Pain pada Pekerja beserta perangkat yang ada (jika diperlukan). Dengan Hak Bebas Royalti Noneksklusif ini Universitas Indonesia berhak menyimpan, mengalihmedia/formatkan, mengelola dalam bentuk pangkalan data (database), merawat, dan memublikasikan tugas akhir saya selama tetap mencantumkan nama saya sebagai penulis/pencipta dan sebagai pemilik Hak Cipta.

Demikian pernyataan ini saya buat dengan sebenarnya.

Dibuat di

: Jakarta

Pada tanggal : 11 Juni 2014 Yang menyatakan

(dr. Raymos Parlindungan Hutapea, MKK)



vi

ABSTRAK

Nama Program Studi Judul

: Raymos Parlindungan Hutapea : Pendidikan Dokter Spesialis Okupasi : PENGGUNAAN BACK SUPPORT UNTUK PENCEGAHAN LOW BACK PAIN PADA PEKERJA (Laporan Kasus Berbasis Bukti)

Latar belakang : Penggunaan back support untuk pencegahan low back pain pada pekerja manual handling banyak dianjurkan, walaupun belum dapat dibuktikan efektivitasnya. Tujuan : Memperoleh bukti apakah back support dapat digunakan untuk pencegahan low back pain pada pekerja. Metode : Pencarian artikel dengan mempergunakan PubMed dan Google scholar serta kriteria inklusi dan eksklusi yang telah ditentukan sebelumnya. Artikel yang ditemukan kemudian dilakukan telaah dengan mempergunakan kriteria penilaian validitas, besarnya manfaat dan kemampu-terapan. Hasil : Hasil pencarian didapatkan sebanyak 16 artikel dari PubMed dan 10 artikel dari Google scholar. Hanya 1 artikel “systematic review” yang memenuhi kriteria inklusi dan eksklusi. Artikel ini selanjutnya dilakukan telaah artikel berdasarkan tinjauan sistematis dengan hasil baik dan dapat dipercaya. Kesimpulan : Belum diketemukannya bukti yang cukup tentang efektivitas penggunaan back support dalam pencegahan low back pain pada pekerja. Kata kunci : back support, pekerja, low back pain



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ABSTRACT

Name Study Program Title

: Raymos Parlindungan Hutapea : Occupational Medicine Recidency : Back Support for Prevention Low Back Pain in Workers (Evidence Based Case Report)

Background : The use of back support for prevention low back pain in workers manually handling much recommended, although its effectiveness has not been proven yet. Objective : To prove whether a back support can be used for prevention low back pain in workers. Methods : Searching the article by using PubMed and Google scholar as well as inclusion and exclusion criteria predetermined, articles were then performed using the assessment criteria of validity, the benefits and ability applied. Results : Results were 16 articles from PubMed and 10 articles from Google scholar. Only 1 article was found in accordance with the inclusion and exclusion criteria. The article was then performed a systematic review of articles and the result was valid. Conclusion : There was insufficient evidence about effectiveness of using a back support in prevention low back pain in workers. Keywords : back support, worker, low back pain



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DAFTAR ISI

HALAMAN JUDUL........................................................................................................................i HALAMAN PERNYATAAN ORISINALITAS............................................................................ii HALAMAN PENGESAHAN........................................................................................................iii KATA PENGANTAR ...................................................................................................................iv HALAMAN PERNYATAAN PERSETUJUAN PUBLIKASI TUGAS AKHIR .........................v ABSTRAK .....................................................................................................................................vi ABSTRACT ...................................................................................................................................vii DAFTAR ISI ...............................................................................................................................viii DAFTAR SINGKATAN ...............................................................................................................ix DAFTAR TABEL ...........................................................................................................................x DAFTAR GAMBAR ....................................................................................................................xi DAFTAR LAMPIRAN.................................................................................................................xii 1. Ilustrasi Kasus .....................................................................................................................1 2. Latar Belakang.....................................................................................................................1 3. Pertanyaan Klinis ................................................................................................................2 4. Metode ................................................................................................................................2 5. Telaah Artikel berdasarkan Tinjauan Sistematis ................................................................4 6. Hasil ....................................................................................................................................5 7. Diskusi.................................................................................................................................5 8. Kesimpulan..........................................................................................................................8 DAFTAR PUSTAKA ....................................................................................................................9



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DAFTAR SINGKATAN

LBP

: Low Back Pain

COPORD

: Community Oriented Program for Controle of Rheumatic Disease

RCT

: Randomised Controlled Trial



x

DAFTAR TABEL

Tabel 1. Pencarian Artikel dengan menggunakan PubMed dan Google scholar .....3 Tabel 2. Hasil telaah kritis artikel ............................................................................4 Tabel 3. Perbedaan hasil studi yang terdapat dalam artikel yang didapatkan .........6



xi

DAFTAR GAMBAR

Gambar 1. Bagan Alur Strategi Pencarian .............................................................3



xii

DAFTAR LAMPIRAN

Lampiran 1. Back Belt Use for Prevention of Occupational Low Back Pain : A Systematic Review



1

1.

Ilustrasi Kasus Tn. A, 35 tahun, datang ke klinik dengan keluhan rasa tidak nyaman dan nyeri

padapunggung bawah sejak 1 bulan yang lalu. Nyeri kadang disertai rasa kesemutan dan baal pada kedua tungkai. Nyeri dirasakan setempat dan tidak menjalar sampai ke perut depan. Tidak ada riwayat trauma sebelumnya. Pasien mengaku tidak mempunyai riwayat trauma sebelumnya. Pada pemeriksaan fisik didapatkan status hemodinamik yang stabil dan tes laseque positif. Berdasarkan anamnesis okupasi, diketahui bahwa pasien bekerja di PT”X” bagian batching (mengangkat karung susu secara manual handling). Data body discomfort map menunjukkan adanya keluhan pegal di daerah punggung bawah, sedangkan dari analisis brief survey, pasien memiliki risiko tinggi pada tangan kanan dan kiri, leher, punggung dan kedua tungkai. Diagnosis pasien ini adalah low back pain. Beberapa program pencegahan low back pain dilakukan di PT”X” diantaranya pelatihan ergonomi, penggunaan vacuum untuk pengangkatan agar tidak melakukan manual handling, dan penggunaan back support terutama di bagian batching. Penggunaan back support untuk pencegahan low back pain tetap dipergunakan walaupun beberapa dari pihak manajemen perusahaan masih ada perdebatan sehingga perlu diketahui apakah penggunaan back support dapat mencegah low back pain. 2.

Latar Belakang Nyeri punggung bagian bawah (low back pain) adalah nyeri yang berhubungan dengan masalah

tulang lumbal, tulang rawan intervertebralis, ligamen di sekitar tulang, medula spinalis dan

persarafannya , otot-otot punggung, organ panggul dan perut, atau kulit yang menutupi daerah lumbal. Nyeri punggung bawah ini dapat bersifat akut maupun kronis dan menjadi salah satu penyebab terjadinya kecacatan.1,2 Prevalensi nyeri punggung bawah orang dewasa pada Negara USA dan negara berkembang adalah 70%-80%. Sedangkan prevalensi di Indonesia berdasarkan penelitian Community Oriented Program for Controle of Rheumatic Disease (COPORD) menunjukan bahwa prevalensi nyeri punggung 18,2 % pada laki-laki dan 13,6 % pada wanita. Penelitian yang dilakukan di Nigeria (2005) menunjukkan bahwa 59,7% pekerja industri mengalami keluhan nyeri punggung bawah.3,4 Back support telah digunakan sebagai profilaksis dan penatalaksanaan untuk mencegah cedera pada tulang belakang lumbosakral dan membantu dalam mengurangi proses patologi yang Universitas Indonesia


2

ada.

Penggunaan bracing lumbar belum menunjukkan keberhasilan sebagai sarana untuk

mencegah low back pain di tempat kerja.5,6 Penelitian tentang penggunaan back support dalam pencegahan terjadinya nyeri punggung bawah masih sangat sedikit. Laporan ini dibuat untuk mengetahui apakah penggunaan back support dapat mencegah angka kejadian nyeri punggung bawah pada pekerja. 3.

Pertanyaan klinis Pencarian artikel dimulai dengan menetapkan pertanyaan klinis dari ilustrasi kasus yang

ada. Back support telah digunakan untuk pencegahan LBP di PT “X”. Penggunaan back support untuk pencegahan LBP masih dalam perdebatan, sehingga perlunya dilakukan pencarian artikel untuk mengetahui apakah penggunaan back support dapat mencegah angka kejadian low back pain pada pekerja. Pertanyaan klinisnya adalah “Apakah penggunaan back support dapat mencegah angka kejadian low back pain pada pekerja ? “ Dari pertanyaan klinis kemudian ditentukan dengan mempergunakan “The PICO Model” : P (patient, population, (clinical) problem)

: Pekerja

I (intervention / indicator / index test)

: Menggunakan back support

C (comparison)

: Tidak menggunakan back support

O (outcome)

: Low Back Pain

4.

Metode Pencarian artikel dilakukan pada PubMed dan Google Scholar pada tanggal 24 September

2013 dengan mempergunakan kata kunci “low back pain”, “back support” , “corset”, “back belt” dan “worker” bersama dengan sinonim dan istilah terkait. Kemudian dilakukan skrining dengan mempergunakan kriteria inklusi dan eksklusi, berupa artikel yang mempergunakan bahasa Inggris, metode penelitian RCT (randomised controlled trial) atau systematic review dari RCT. Hasil pencarian dapat dilihat pada table 1.



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Tabel 1. Pencarian Artikel dengan menggunakan PubMed dan Google scholar (dilakukan pada tanggal 24 September 2013) Database

Istilah

Hasil Artikel yang dipilih

PubMed (24 September 2013)

Low back pain AND (back support OR corset OR back belt) AND worker

16

0

Google Scholar (24 September 2013)

“low back pain”,“back support”, “corset”, “back belt”, “worker”

10

1

Penggunaan Kriteria Inklusi dan eksklusi (artikel yang berbahasa Inggris dan menggunakan metode penelitian RCT / systematic review dari RCT) didapatkan 1 artikel dari Google Scholar. Strategi pencarian dan hasil dapat dilihat pada gambar 1. Low back pain AND (back support OR corset OR back belt) AND worker

PubMed

Google scholar

16

10

Kriteria inklusi dan eksklusi : Bahasa Inggris, RCT / Systematic review

0

1 Waktu pencarian 24 September 2013

Gambar 1. Bagan Alur Strategi Pencarian Hasil seleksi dan penyaringan terdapat 1 artikel. Universitas Indonesia


4

5.

Telaah Artikel berdasarkan tinjauan sistematis. Artikel yang ditemukan kemudian di telaah berdasarkan beberapa pertanyaan untuk

tinjauan sistematis. Pertanyaan untuk tinjauan sistematis pada artikel ini dapat dilihat pada tabel 2. Tabel 2. Hasil telaah kritis artikel Apakah artikel menggambarkan pertanyaan (PICO) ?

fokus Ya, P : Pekerja I : Penggunaan “back belt” C : Tidak menggunakan “back belt” O : Nyeri punggung bawah (LBP) Ya. Kriteria inklusi yang dipergunakan adalah ... dan dipergunakan untuk pencarian artikel serta berdasarkan kriteria inklusi ? metode penelitian RCT (randomised controlled trial) Apakah pencarian penelitian dalam artikel Tidak. Pencarian penelitian hanya berasal dari tersebut berasal dari bukti ilmiah yang saling data dasar MEDLINE, CINAHL, EMBASE, berhubungan? HEALTHSTAR. Hal-hal yang tidak dilakukan dalam pencarian penelitian adalah : mencari artikel dari daftar pustaka penelitian yang ada serta science citation index, tidak menghubungi penulis/narasumber yang terdapat pada daftar pusaka penelitian, terutama untuk penelitian yang belum dipublikasikan. Apakah artikel yang ditemukan telah di nilai Ya. Artikel telah dinilai dengan secara kritis ? mempergunakan The Canadian Task Force methodology (penilaian validitas internal) ...dan apakah isi artikel tersebut telah ditelaah Ya. Isi artikel telah dilakukan penilaian ganda secara benar ? (baik dalam hal desain penelitian dan penilaian validitas internal) oleh 2 orang secara independen. Apakah hasil penelitian dalam artikel telah Ya. Ada tabel ringkasan. Karena hasil disajikan dalam bentuk tabel ringkasan ? penelitian dalam artikel tersebut berbeda-beda, maka tidak dilakukan meta-analisis. ...dan apakah hasilnya sama diantara penelitian Tidak. Hasil penelitian berbeda-beda. yang ada dalam artikel tersebut ? Hasil Baik, dapat dipercaya



5

6.

Hasil Hasil pencarian artikel di dapatkan sebanyak 16 artikel dari PubMed dan 10 artikel dari

Google Scholar. Berdasarkan kriteria inklusi, maka didapatkan satu artikel yang relevan dengan pertanyaan klinis. Studi yang dilakukan oleh Carlo Ammendolia,dkk merupakan sebuah studi “systematic review” terhadap randomised controlled trial (RCT). Artikel ini meliputi 10 penelitian tentang penggunaan back support, walaupun tidak semua studi menggunakan desain RCT. Pencarian studi yang dilakukan berdasarkan database yang sesuai (MEDLINE, CINAHL, EMBASE, HEALTHSTAR), walaupun tidak mempergunakan pencarian daftar pustaka yang berhubungan dengan masing-masing studi yang ada, science citation index, dan menghubungi penulis atau narasumbernya. Penulis mempergunakan “The Canadian Task Force methodology” serta dilakukan oleh 2 orang penilai dalam melakukan penilaian studi. Hasil dari berbagai penelitian berbeda sehingga tidak dilakukan meta-analisis dan disajikan dalam satu tabel. Efek intervensi dari masing-masing penelitian dapat dilihat pada tabel 3. 7.

Diskusi Artikel ini menggambarkan fokus pertanyaan “PICO” yang sesuai.

Dari artikel yang

didapatkan, populasi menunjukkan pekerja dengan materials handlers, intervensi yang dilakukan adalah penggunaan back support dalam pencegahan low back pain di tempat kerja. Artikel ini merupakan kumpulan penelitian yang membandingkan kelompok yang mempergunakan back support dengan yang tidak mempergunakan back support. Sedangkan hasil yang diharapkan adalah adanya perbedaan keluhan low back pain pada kelompok yang diberikan back support dengan kelompok kontrol. Pencarian artikel mempergunakan kriteria inklusi yaitu artikel yang mempergunakan bahasa Inggris dan metode penelitian RCT. Hasil yang didapakan berupa penelitian “systematic review” dari 10 penelitian yang dilakukan. Pencarian penelitian berasal dari data MEDLINE, CINAHL, EMBASE, dan HEALHSTAR yang dipublikasikan sampai dengan Juli 2003. Hal-hal yang tidak dilakukan dalam pencarian penelitian adalah : mencari artikel dari daftar pustaka penelitian yang ada serta science citation index, tidak menghubungi penulis/narasumber yang terdapat pada daftar pusaka penelitian, terutama untuk penelitian yang belum dipublikasikan. Dari 10 penelitian tersebut, masing-masing artikel dilakukan penilaian dengan mempergunakan The Canadian Task Force methodology (penilaian validitas internal) oleh 2 orang secara Universitas Indonesia


6

independen. Kualitas validitas internal mempunyai 3 kriteria berdasarkan The Canadian Task Force methodology, yaitu : baik (good) (apabila desain penelitian memenuhi semua kriteria yang sesuai), cukup (fair) (apabila desain penelitian tidak memenuhi semua kriteria yang sesuai, tetapi tidak fatal), dan jelek (poor) (apabila desain penelitian memiliki satu kesalahan fatal, atau penelitian dianggap tidak mampu menginformasikan kesimpulan). Hasil penilaian menunjukkan bahwa dari 10 penelitian yang diketemukan : 1 penelitian mempunyai kualitas yang baik (good), 4 penelitian mempunyai kualitas yang cukup (fair) dan 5 penelitian mempunyai kualitas yang jelek (poor). Perbedaan dari 10 penelitian dalam artikel ini dijelaskan dalam bentuk narasi sehingga untuk memudahkannya, maka penulis membuatnya dalam bentuk tabel (Tabel 3).

Hasilnya menunjukkan bahwa dari 5 studi dengan metode RCT, hanya 2 studi yang mendukung penggunaan back support, yaitu penelitian yang dilakukan oleh Walsh-Schwartz dan Kraus JF et al. Penelitian non RCT, yang dilakukan oleh Anderson et al dan Thompson et al hanya menunjukkan penurunan keluhan nyeri punggung pada pekerja yang mempergunakan back support yang secara statistik tidak bermakna.

Penelitian dengan metode kohort yang

dilakukan oleh Kraus et al dan Wessel et al mempunyai hasil yang saling bertolak belakang dan memiliki kelemahan masing-masing. Berdasarkan ulasan diatas, belum diketemukannya bukti yang cukup tentang efektivitas penggunaan back support dalam pencegahan low back pain pada pekerja. Masih sedikitnya penelitian yang dilakukan baik secara kuantitas maupun kualitasnya.



7

Tabel 3. Perbedaan hasil studi yang terdapat dalam artikel yang didapatkan. Metode Penelitian

Hasil Penelitian

1

No

The influence of prophylactic orthoses on abdominal strength and low back injury in the workplace

Walsh and Schwartz

RCT

2

An evaluation of a weightlifting belt and back injury prevention training class for airline baggage handlers

Reddell et al

RCT

3

The effectiveness of back belts on occupational back injuries and worker perception

Alexander et al

RCT

4

Lumbar supports and education for the prevention of low back pain in industry

Van Poppel et al

RCT

5

A field trial of back belts to reduce the incidence of acute low back injuries in New York city home attendants

Kraus JF et al

RCT

90 orang pekerja gudang, dibagi 3 kelompok : kelompok tanpa intervensi, kelompok yg diberi 1 jam pelatihan lifting, kelompok yg diberi 1 jam pelatihan lifting dan menggunakan back belt dalam bekerja. Hasil : ada penurunan yg bermakna hilangnya hari kerja (2,5 hari) pada kelompok yg diberi 1 jam pelatihan lifting dan menggunakan back belt dalam bekerja (p=0,03) 642 orang “airline baggage handlers”, dibagi 4 kelompok : kelompok yg menggunakan back belt saja, kelompok yg diberi pelatihan 1 jam lifting, kelompok yg diberi pelatihan lifting dengan penggunaan back belt, dan kelompok tanpa intervensi. Hasil : tidak ada perbedaan diantara kelompok (dalam hal hilangnya hari kerja, kasus nyeri LBP) 60 pekerja kesehatan (3 bulan) dibagi 2 kelompok : yang menggunakan back belt dan yang tidak menggunakan. Hasilnya ada 3 kasus LBP ( 1 orang dari kelompok yang menggunakan back belt dan 2 orang dari kelompok kontrol). Secara statistik tidak bermakna (p=0,53) 315 orang “airline cargo worker”, (6 bulan) dibagi 4 kelompok : kelompok yang dilatih+lumbar support, kelompok pelatihan lifting saja, Kelompok penggunaan kelompok lumbar support saja, dan kelompok tanpa intervensi. Hasil : tidak ada perbedaan yg bermakna antara kelompok terkait insiden LBP (risk difference 1%; 95 CI, -10 – 13) atau absen akibat LBP (risk difference 4%; 95% CI, -3 – 11) 12.772 “home attendants” dibagi 3 kelompok : kelompok yg menggunaan back belt, kelompok yg hanya dilatih lifting dan kelompok tanpa intervensi. (selama 28 bulan). Hasil : ada perbedaaan yang bermakna antara kelompok yg menggunaan back belt dengan kelompok kontrol (rate ratio 1,36; 95%CI, 1.021.82)

6

The effectiveness of using lumbar support belt Attitudes and back belts in the workplace

Anderson et al

Non RCT

Penurunan angka nyeri punggung

Thompson et al

Non RCT

8

Reduction of acute low back injuries by use of back supports

Kraus et al

kohort

9

A prospective study of back belts for prevention of back pain and injury

Wessel et al

kohort

10

Effectiveness and cost-effectiveness of employer-issued back belts in areas of high risk for back injury

Mitchell et al

survey

Penurunan keluhan nyeri punggung diantara para pekerja yg menggunakan back support dibandingkan pekerja yg tidak. Penelitian pada 36000 pekerja ritel, hasilnya menunjukkan 34% keluhan nyeri punggung dapat dicegah setelah penggunaan back support (incidence density ratio of 1.52; 95% CI, 1.36-1.69). Perbandingan antar kelompok yang diuji tidak sesuai. Peneltian terhadap 13.873 pekerja manual handling, hasil menunjukkan bahwa tidak ada perbedaan klaim untuk keluhan nyeri punggung (OR 1.22; 95% CI, 0.87-1.70) atau timbulnya episode nyeri punggung (OR 0.97; 95% CI, 0.831.13). Partisipasi pekerja yang ikut sangat rendah (non-participation rate 32%) dan 33% pekerja tidak menyelesaikan wawancara lanjutan. Survei pada pekerja di sebuah pangkalan angkatan udara, adanya efek perlindungan yang bermakna pada pekerja yang menggunakan back support

7

Judul Penelitian

Penulis



8

8.

Kesimpulan Penggunaan back support untuk pencegahan low Back Pain pada pekerja, terutama pekerja

dengan manual handling, masih belum bisa dibuktikan efektivitasnya, sehingga diperlukan penelitian lebih lanjut. Pada kasus ini, rekomendasi terhadap perusahaan adalah perlu ditinjau kembali kebijakan dalam penggunaan back support untuk pencegahan low back pain pada pekerja.



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2.

Levy, B. Occupational and Environmental Health. 6th ed. 2011.p.351-54

3.

Hoy,D. et al. A Systematic Review of the Global Prevalence of Low Back Pain. Arthritis &

Rheumatism.Vol.64,

No.6,

June

2012.

p.2028-37.

Available

from

:

http://onlinelibrary.wiley.com/doi/10.1002/art.34347/pdf 4.

Chopra,A. Abdel-Nasser,A. Epidemiology of rheumatic musculoskeletal disorder in the developing worl. Best Practice & Research Clinical Rheumatology. Vol.22, No.4, 2008. p.583-604. Available from : http://bjdindia.org/epidemiology%20of%20MSK.pdf

5.

Chen,JC. Chang,WR. Chang,W. Christiani,D. Occupational factors associated with low back pain in urban taxi drivers. Occupational Medicine Journal, 2005(55).p.535-40. Available from : http://occmed.oxfordjournals.org/content/55/7/535.full.pdf+html

6.

Poppel, MN. Hooftman, WE. Koes, BW. An update of a systematic review of controlled clinical trials on the primary prevention of back pain at the workplace. Occupational Medicine, 2004(54).p.345-52. Available from : http://www.ncbi.nlm.nih.gov/pubmed/15289592



10

Lampiran 1. Back Belt Use for Prevention of Occupational Low Back Pain : A Systematic Review



REVIEW OF LITERATURE BACK BELT USE FOR PREVENTION OF OCCUPATIONAL LOW BACK PAIN: A SYSTEMATIC REVIEW Carlo Ammendolia, DC,a Michael S. Kerr, PhD,b and Claire Bombardier, MDc

ABSTRACT Background: Back pain continues to be the leading overall cause of morbidity and lost productivity in the workplace.

Recently, there has been a renewed interest in the use of back belts by industry to reduce occupational low back pain (LBP). Objectives: To examine the literature and evaluate the effectiveness of back belt use for the primary prevention of

occupational LBP. Methods: MEDLINE, CINAHL, EMBASE, and HEALTHSTAR were searched for relevant articles published up to July

2003. Studies were included if participants were material handlers, and outcomes included the incidence and/or duration of lost time of reported LBP among workers who wore back belts compared with those who did not. The quality of the evidence was scored independently by 2 reviewers using a double rating method, first according to research design followed by an internal validity rating. Final synthesis of the evidence was performed in which the evidence was classified as good, fair, conflicting, or insufficient. Results: Ten epidemiologic studies meeting inclusion criteria were identified. Of 5 randomized controlled trials, 3 showed no positive results with back belt use; 2 cohort studies had conflicting results; and 2 nonrandomized controlled studies and 1 survey showed positive results. Conclusions: Currently, because of conflicting evidence and the absence of high-quality trials, there is no conclusive evidence to support back belt use to prevent or reduce lost time from occupational LBP. (J Manipulative Physiol Ther 2005;28:128 - 134) Key Indexing Terms: Low Back Pain; Prevention; Effectiveness; Back Belts; Review Literature

a Research Associate, Institute for Work and Health, Toronto, Canada; Research Associate, Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Canada; PhD Candidate, Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Canada. b Assistant Professor, School of Nursing, Unversity of Western Ontario, London, Ontario, Canada; Scientist, Institute for Work and Health, Toronto, Canada. c Professor of Medicine and Rheumatology Division Director, University of Toronto, Toronto, Canada; Senior Scientist, Institute for Work and Health, Toronto, Canada; Director, Clinical DecisionMaking and Health Care Division, University Health Network, Toronto, Canada; Rheumatologist, Mount Sinai Hospital, Toronto, Canada; Reasearch Chair. Submit requests for reprints to: Carlo Ammendolia, DC, Institute for Work and Health, 481 University Ave, Suite 800, Toronto, Ontario, Canada M5G 2E9 (e-mail: [email protected]). Paper submitted September 25, 2003; in revised form December 12, 2003. 0161-4754/$30.00 Copyright D 2005 by National University of Health Sciences. doi:10.1016/j.jmpt.2005.01.009

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ack pain continues to be the leading overall cause of morbidity and lost productivity in the workplace. Recently, there has been a renewed interest in the use of back belts by industry to reduce the incidence of occupational low back pain (LBP).1-3 This paper is a systematic review of the literature, conducted to identify and critically appraise published epidemiologic studies evaluating back belt use. Although there have been previous reviews on this topic, this review differs in that it evaluates both clinical trials and observational studies and includes the largest and most recent randomized controlled trial (RCT)4 evaluating back belts. The inclusion of observational studies was deemed important because of the limited number of published high-quality trials, the difficulty in conducting such trials in the workplace, and the existence of influential cohort studies on the topic that were not included in other recent reviews on the topic.3,5 In Canada, like other industrialized countries, back injuries account for 20% to 30% of all lost time claims, the largest single claims category in most workers’ compensation jurisdictions.6,7 Disability resulting from LBP is the most common chronic health problem in adults


Journal of Manipulative and Physiological Therapeutics Volume 28, Number 2

Table 1. Levels of evidence and quality ratings of individual

Ammendolia et al Back Belts for Low Back Pain Prevention

Table 2. Main methodologic quality criteria

studiesT Internal validity criteria Levels of evidence A. Research design rating I Evidence from at least 1 RCT II-1 Evidence from controlled trial(s) without randomization II-2 Evidence from cohort or case-control analytic studies, preferably from more than one center or research group II-3 Evidence from comparisons between times or places with or without the intervention; dramatic results from uncontrolled studies could be included here III Opinions of respected authorities, based on clinical experience; descriptive studies or reports of expert committees B. Quality (internal validity) ratingy Good A study that meets all design-specific criteria well Fair A study that does not meet (or it is not clear that it meets) at least one design-specific criterion but has no known bfatal flawQ Poor A study that has at least one design-specific fatal flaw, or an accumulation of lesser flaws to the extent that the results of the study are not deemed able to inform conclusions T The Canadian Task Force methodology is described in Woolf et al29 or available from the Canadian Task Force Web site (http:/www.ctfphc.org), under History and Methods. y General design-specific criteria by study type are outlined in Harris et al.30

younger than 45 years and second only to arthritis in those aged 45 to 65 years.8 In terms of costs, LBP is estimated to be the most costly ailment of working age adults.9,10 There are 3 main categories of potential risk factors for occupational LBP: individual, biomechanical, and psychosocial. For a given individual, the strongest risk factor is a previous history of LBP, along with the severity of the previous episode.9 The most consistent associations among biomechanical risk factors have been exposure to lifting or carrying heavy loads; whole body vibration; and frequent bending and twisting.1,9,11-14 Although the literature on psychosocial risk factors for LBP is less consistent,1,14-17 there is growing empirical evidence linking psychosocial stressors, such as perceived high workload, time pressure, lack of intellectual discretion, and job dissatisfaction, with an increased risk of occupational LBP.9,11,15,18-20 There are 2 primary prevention strategies for occupational LBP: those directed at the individual worker and those directed at the workplace. Workplace strategies involve modification of the work site to suit the worker, such as ergonomic job redesign. Programs directed at the worker are by far the most common preventive strategy in industry.21 Such programs include education (eg, improving knowledge regarding lifting techniques and injury awareness), exercise (eg, improving strength and overall fitness), preemployment screening efforts to detect risk factors such as smoking, obesity, previous LBP, and psychosocial factors, and the use of mechanical back supports (eg, belts or corsets).13,17,21,22

1. Was there appropriate assembly and maintenance of comparable groups? 2. Was there adequate follow-up? 3. Were interventions clearly defined? 4. Were equal, reliable and valid outcome measures used? 5. Were the analyses/sample size appropriate and was intention-totreat analysis used?

There are no standards for back belts with respect to materials or design. For example, many are modeled on weight-lifting belts and can be made of plastic or elastic. All are designed to support the lumbar spine and abdomen. There are a number of mechanisms of action postulated; the belts may prevent back pain by providing: 1. An increase in abdominal pressure, which provides an extensor moment, thus decreasing the force required by the back muscles and relieving the compressive forces on lumbar intervertebral disks.23,24 2. An increase in spinal rigidity by limiting end range movement, which protects the spine from extreme ranges of movement, thereby minimizing shearing forces.25,26 3. An increased proprioceptive awareness (such as a reminder for using proper safety measures) and an increased sense of security.25,27,28 Despite the recent increase in their popularity as a preventive measure, the effectiveness of mechanical back supports such as back belts remains uncertain. The main objectives of this review are to evaluate the evidence on the effectiveness of back belt use for primary prevention or reduction of lost time from occupational LBP and to develop clinical practice recommendations for primary health care providers for their use.

METHODS The published English literature up to July 2003 was identified with a computerized search of MEDLINE, CINAHL, EMBASE, and HEALTHSTAR databases using the following keywords: back, lumbar, spine, belts, supports, braces, orthotic devices, prevention, and occupational. Pertinent references from articles obtained from the above search were reviewed. Studies were included if the study participants were material handlers (eg, exposed to lifting), and outcome measures included the incidence and/or duration of lost time of reported LBP among workers who wore back belts compared with those who did not. Although the primary population of interest is asymptomatic workers, studies that included workers with a previous history of LBP were not excluded. No restriction was made on the style of back belt used.


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Journal of Manipulative and Physiological Therapeutics February 2005

Table 3. Methodologic quality of studies on the effectiveness of back belts Internal validity criterion Study

1

2

3

4

5

Study design

Overall rating

Walsh and Schwartz33 Reddell et al31 Alexander et al34 Van Poppel et al32 Kraus et al4 Anderson, 199335 Thompson et al36 Wassel et al38 Kraus et al37 Mitchell et al39

+ + ? ? ?

+ + + + + + + +

? + + + ? + + + + +

+ ? ? ? + ? ?

? ? + + ? ? + ? ?

I I I I I I-2 I-2 II-2 II-3 III

Fair Poor Fair Fair Fair Poor Poor Good Poor Poor

+, criterion met; , criterion not met; ?, not reported.

The evidence was reviewed systematically using the methodology of the Canadian Task Force on Preventive Health Care (Table 1).29 The quality of the evidence was scored using a double rating method first according to research design, RCTs were given the highest rating (level 1 evidence), followed by an internal validity rating (good, fair, or poor) using design-specific criteria developed with the US Preventive Services Task Force.30 The internal validity of each study was assessed independently by 2 authors (CA, MK). The main internal validity items are summarized in Table 2. Consensus was used to resolve disagreements in scoring.

RESULTS Ten epidemiologic studies meeting inclusion criteria were identified. These include 5 RCTs,4,31-34 2 nonRCTs,35,36 2 cohort studies,37,38 and 1 survey.39 A summary of the study quality evaluations is shown in Table 3.

Controlled Trials Walsh and Schwartz33 randomly assigned 90 warehouse workers into 3 equal groups to receive either, no intervention, a 1-hour training session in lifting techniques and back pain prevention, or 1 hour of training and a back belt for use during working hours. No group was assigned the back belt only. The results revealed a significant decrease in lost time (2.5 days) in the group receiving training plus back belts ( P = .03). In the subgroup analysis, the authors suggest the reduction in lost time seen in the group receiving training plus back belts was limited to workers with previous LBP ( P = .02). The main weaknesses of this study include the lack of adjustment for the apparent baseline differences in days lost among the groups and the failure to assess group similarity with respect to history of LBP at baseline. Reddell et al31 studied 642 out of an initial 896 selected airline baggage handlers who were randomly assigned to

4 groups: back belt only; 1-hour training class (on proper lifting) only; back belt and 1-hour training class; and no intervention. There were no significant differences in injury rates, lost workdays, or Workers’ Compensation Board costs among the groups. However, the results are inconclusive because patients were analyzed according to use of back belts, and not on group assignment; there was high noncompliance (58% discontinued back belt use) and high nonparticipation rate (28%). Alexander et al34 randomly assigned 60 health care workers to wear a belt or to be in a control group and then followed them for 3 months. There were only 3 self-reported low back injuries at follow-up, 1 in the belted group and 2 in the control. The difference was not statistically significant ( P = .53). The small number of injuries in this study suggests the sample size may have been too small or the follow-up period was too short to detect any significant difference in injury rates between the 2 groups. In another RCT, van Poppel et al32 randomly assigned a total of 315 airline cargo workers (within preexisting work groups) to 1 of 4 groups: education and lumbar support; education only; lumbar support only; or no intervention. After 6 months there was no significant difference in selfreport LBP incidence (risk difference 1%; 95% CI, 10 to 13) or sick leave for LBP (risk difference 4%; 95% CI, 3 to 11) among workers in the groups assigned to wear lumbar supports compared with those who were not. In a small subgroup of workers with LBP at baseline (15%), the group with lumbar supports had fewer days with LBP per month than did the group without (mean of 3.1 vs 8.4 days, P = .03). A limitation of the study was the randomization process, where assignment was made by workgroups instead of the individual worker, which may have potentially introduced confounding if there were undetected systematic differences between the work groups. In addition, there was potential recall bias and selection bias due to high noncompliance. In the most recent RCT, Kraus et al4 randomized 9 agencies, employing 12,772 home attendants, into



3 groups: back belts only, lifting advice only, and control. Over a 28-month period the authors reported a marginally significant lower back injury rate among the back belt group when compared with the control group (rate ratio 1.36; 95% CI, 1.02-1.82). There was no significant difference when the back belt group was compared with the advice-only group (rate ratio 1.22; 95% CI, 0.70-2.11). The limitation to this study was the inability to adjust for cluster randomization and known risk factors when comparing the back belt and control groups because the control group data were based on crude (unadjusted) injury data only because of a lack of baseline data. Therefore, it is not certain if the difference observed was due to confounding. Other weaknesses include no comparison of preintervention injury rates and no data on previous LBP. In 2 nonrandomized trials, Anderson et al35 found a reduction in back injury rates and Thompson et al36 found a decrease in back injuries and back pain, respectively, among workers who wore a back support compared with those who did not. The positive results found in these 2 nonrandomized trials raise questions because the groups being compared were not assessed for factors associated with increased risk of LBP. Known and unknown confounding factors within work sites may have influenced the results.

Observational Studies In a retrospective survey among workers at an air force base, Mitchell et al39 reported a marginally significant protective effect with back belt use (OR 0.60; 95% CI, 0.36-1.00) for the first low back injury. The limitations in this study include the lack of randomization, back belt users and nonusers were not matched in time, and the use of selfreport data on back belt use and injuries. In a historical cohort study, Kraus et al compared the low back injury rates of 36,000 retail workers before and after mandatory back support use policy periods implemented over a 6-year period.37 The results indicated an incidence density ratio (or ratio of the number of low back injury claims per million working hours before and after back support policy implementation) of 1.52 (95% CI, 1.36-1.69). The authors reported that 34% of injuries could have been prevented if all subjects had worn a back support. The conclusions of the Kraus study must be interpreted with caution. Because the comparison groups were not matched in time, it was not possible to control for unknown confounders such as a change in hiring practices, job duties, claims handling, safety regulations, and workers’ compensation claims policies. In addition, the gradual increase in the use of forklifts and pallets during the 6-year study could have been an important co-intervention contributing to the significant decrease in the incidence density ratio. The largest prospective study on back belt use was conducted by Wassel et al38 who compared the incidence of low back injuries and self-report LBP among a sample


of 13,873 material handlers employed at either 1 of 89 retail stores who had a mandatory back belt policy or 1 of 71 stores that had a voluntary policy. When controlling for potential confounding factors the authors found no difference in back injury claims (OR 1.22; 95% CI, 0.87-1.70) or self-report episodes of LBP (OR 0.97; 95% CI, 0.83-1.13) among the stores with mandatory or voluntary back belt use policy. The limitations of this study included the high nonparticipation rate (32%) and the high number of workers who did not complete follow-up interviews (33%). Lack of randomization with the inability to control for unknown confounders and recall bias from self-report interviews may have been other potential sources of bias.

Potential Harms Potential negative effects of back belt use were discussed in most studies that were reviewed. In 1 trial, 20% of workers felt that the belt rubbed, pinched, or bruised their ribs; 15% stated the belt caused problems during sitting or driving; and 20% said that it was too hot or caused excessive sweating.31 Reduced movement, uncomfortable sitting, and excessive heat were complaints expressed by workers in another study.32 The negative comments may have contributed to the high noncompliance rate for back belt use in these 2 studies.31,32 Post hoc analysis of noncompliant back belt users in 1 study31 indicated a significantly higher number of lost workdays ( P b .0181) when compared with compliant back belt or control groups. However, a similar finding was not observed in the compliance subgroup analysis from another study.32 Two studies evaluating abdominal strength change found no significant loss of abdominal strength among back belt users.32,33

Synthesis of Key Evidence Of 5 RCTs reviewed, 3 failed to show positive results with back belt use.31,32,34 One RCT showed decreased time loss in workers who received both training and used a back belt.33 A review of their subgroup analysis suggests this effect is seen only among workers with a previous history of LBP. Another RCT reported a marginally significant decrease in low back injury rates among employees receiving a back belt compared with the control group.4 This analysis however was based on unadjusted data not controlling potential confounders. All RCTs reviewed had methodological flaws, some of which, such as lack of blinding, are inherent to workplace studies and the type of intervention used, whereas others, such as inappropriate randomization, lack of intention-to-treat analysis, and inadequate follow-up times, are related more to the study designs. A priori sample size calculation for lost time was conducted in only one RCT.32 Based on this calculation, only 2 RCTs appeared to have had a sufficient sample size.31,32 Only one RCT performed a sample size calculation for the


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incidence of low back injuries.4 This RCT had an 80% power to detect a 30% or more decline in the low back injury rate. No sample size calculations were performed for assessing change in the incidence of LBP in any of the reviewed RCTs. Sample size estimates for this outcome, based on mean incidence values found in 1 trial,32 suggests only 2 trials31,32 had sufficient sample size to detect a reduction in the incidence rate of less than 70% (using a power of 80%). None of the RCTs reviewed were considered to be of bgoodQ quality. Four were considered of bfairQ quality4,32-34 and 131 was considered bpoor.Q The only study with a good-quality rating was the recent large cohort.38 This study failed to show any benefit to back belt use for the main outcomes or in the subgroup analysis. Lost time in this study was not assessed. The remaining studies found positive results with back belt use.35-37,39 These studies, however, were found to have significant weaknesses in both methods and analysis, as reflected in their poor-quality scores. When considering only good- and fair-quality studies the evidence remains conflicting. There were 2 level I studies evaluating lost time from LBP with back belt use, both rated fair quality. One showed a negative result,32 the other positive.33 However, for the prevention of LBP the evidence appears weighted against the use of back belts with 4 negative studies (3 level I studies of fair quality32-34 and 1 level II-2 study of good quality)38 and only 1 positive study (a level I study of fair quality). In the subgroup analysis of 2 fair-quality trials, workers with a previous history of LBP33 or LBP at baseline32 had significantly reduced time off if randomized to wear a back belt.

DISCUSSION Based on this review, the evidence for the effectiveness of back belt use in preventing the incidence or reducing lost time for occupational LBP among material handlers is conflicting and limited in both quantity and quality. In contrast, in 2 recent literature reviews of back belt clinical trials, 1 concluded there was moderate evidence3 and the other strong and consistent evidence5 that lumbar supports are not effective for primary prevention. Another recent review of back belts, which included both clinical trials and cohort studies published since 1995, found the evidence for primary prevention to be inconclusive.40 None of these reviews included the most recent positive RCT.4 Moreover, in one of these reviews,3 2 of the 7 trials included32,33 were considered to be of high quality, which was not concordant with our quality designations. Both these trials were downgraded to fair quality, 132 because of inappropriate randomization (ie, work-group level only) and high noncompliance and the other33 because of the lack of comparability of the groups at baseline.


Earlier reviews on the topic concluded there was insufficient evidence to make recommendation for or against the use of back belts for the prevention of occupational low back injuries.22,27,41,42 National Institute for Occupational Safety and Health (NIOSH), following the results of their most recent back belt study, concluded there was no evidence to support the use of back belts as a preventive measure.38 This further supports their previous review and recommendations on back belt use.43 The publication of the Canadian Centre for Occupational Health and Safety regarding back belt use44 refers to the NIOSH review43 and recommends that back belts should not be used as a primary workplace prevention approach. In contrast, the recent ergonomics regulation of the Occupational Safety and Health Administration classified lumbar supports as personal protective equipment and suggests they may prevent back injuries in certain industrial settings.45 Controversy over back belt use also extends into the area of treatment, where results from RCTs are also conflicting.3,46 However, the positive results demonstrated in 2 RCTs47,48 and in the subgroup analysis in 2 trials reviewed here32,33 suggest that patients with a history of LBP may benefit from back belt use. The lack of consistent conclusions from the studies included for this review is not surprising given the conflicting laboratory evidence on how back belts are thought to prevent LBP.22-25,27,43,49 Conclusions from studies reporting adverse effects were limited in both quantity and by the methods used. NIOSH has suggested that a false sense of security may accompany back belt use, which may lead to increased risk taking behaviors (such as excessive lifting).50 Other potential risks include cardiovascular strain,51,52 back muscle weakening,53 and abdominal hernia.23 However, these possible risks have been extrapolated from studies evaluating various physiological parameters such as intra-abdominal pressure, electromyogram, heart rate, and blood pressure, and we were unable to find any epidemiologic evidence to support these possible adverse effects of back belt use.

CONCLUSION Implications for Clinical Practice In general, the majority of the evidence presented in this review, and the evidence presented in earlier reviews of the topic, indicates that individual workers presenting with no prior history of LBP are unlikely to benefit from the use of a back belt. Those with a previous history of LBP may experience some potential benefit from back belt use. However, before back belt prescription, individuals should be screened for cardiovascular risk and receive training on lifting mechanics.28,52 Although there is some laboratory evidence suggesting possible concern for the adverse effects



of long-term use,28 these possible risks have not been proven. However, given the combination of questionable benefits and potential for negative effects, if back belts are to be prescribed, it should only be for short-term use.28

Research Agenda The overall level and quality of this evidence on the topic remains limited and conflicting. Well-conducted RCTs into the efficacy of back belts are still needed. Although it is recognized that rigorous workplace effectiveness trials are logistically very difficult to conduct, it is recommended that future studies should include a large bat-riskQ population; individual worker randomization; appropriate control groups; long follow-up; high compliance rate; and the use of validated outcome measures, including a special focus on those with a prior LBP history.

ACKNOWLEDGMENTS We acknowledge Dr Timothy Carey, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill; Dr Harry Shannon, Program in Occupational Health and Environmental Medicine, McMaster University, Hamilton, Ontario; and Dr Howard Vernon from the Canadian Memorial Chiropractic College, Toronto, Ontario, for reviewing a draft form of this report and Dr Elaine Wang and Nadine Wathen for their guidance and encouragement.

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40. 41. 42. 43.

44. 45. 46. 47. 48.

49. 50.

51. 52.

53.

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PENGGUNAAN BACK SUPPORT UNTUK PENCEGAHAN LOW BACK PAIN PADA PEKERJA

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