Introduction
In recent years, lower back pain (LBP) has emerged as a significant global health issue [1], affecting 619 million people worldwide. This alarming trend is projected to escalate, with estimates suggesting that by 2050, this number of affected individuals will rise to 843 million, largely due to population growth and aging demographics [2‐4]. Among the various contributing factors, occupational influences contribute significantly to the burden of LBP, accounting for 37% of cases globally [5]. The significance of chronic LBP cannot be understated, as it ranks among the top ten disorders, causing years lived with disability globally, thereby impacting workforce productivity, increasing work absenteeism, and degrading the overall quality of life. This considerable economic burden further highlights the pressing nature of LBP as a pressing public health concern requiring urgent attention [6‐8].
Among the recognized noncommunicable diseases, chronic lower back pain is one of the leading causes of disability, as identified in the Global Burden of Disease (GBD) study of injuries and risk factors. Chronic LBP is defined as lower back pain persisting for longer than 12 weeks despite medication or treatment [9]. Specifically, chronic or persistent pain is defined as “a symptom complex consisting of pain and muscle tension or stiffness in the lumbar region localized below the costal margin and above the inferior gluteal folds, with or without pain radiating into the legs” [10]. While many patients experience episodes of LBP that may be brief and resolve within a month, causing many to decide against seeking healthcare, recent studies indicate that LBP can last for a duration of six months or more and often recurs within a span of one year [12, 13].
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Moreover, epidemiological findings illustrate that 37% of LBP cases are attributable to occupational risk factors [14]; notably, work-related LBP was reported to cause 818,000 disability-adjusted life years lost (DALYs) each year [15]. In Egypt, the prevalence of chronic lower back pain (CLBP) is particularly concerning, affecting 53.2% of the population and severely impacting individuals’ quality of life (QoL) [16, 17 ].
The onset of CLBP is commonly associated with strain from physical activity or sedentary lifestyles, which can adversely affect everyday activities and physical performance. Various causes, including individual, physical, and psychosocial factors, are implicated in the development of CLBP. Symptoms of this condition can vary significantly, ranging from mild muscle aches to severe shooting or stabbing pain, often accompanied by limited flexibility, reduced range of motion, and difficulty standing upright [11, 18‐20].
Further complicating the epidemiology of CLBP, it is notably connected with several risk factors, including middle age, lower educational status, obesity, smoking, and prolonged computer use [21, 22]. Particularly concerning is the role of smoking, which exacerbates chronic lower back pain by introducing nicotine and other harmful chemicals that can lead to inflammation and tissue damage in the back, thereby increasing pain and hindering the healing process of injured tissues [23, 24].
Additionally, the development of this condition of CLBP often arises from a misalignment between the physical demands of a job and an individual’s physical capabilities. Factors such as repetitive motions, heavy lifting, forceful exertion, vibrating equipment, and awkward postures increase the risk of LBP due to repeated and prolonged exposure [25, 26]. Textile workers frequently fail to adhere to proper body mechanics and lack ergonomic practices during their daily tasks, exposing themselves to various body disorders, including CLBP and other orthopedic disorders [27, 28].
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Preventing LBP caused by muscle strain involves implementing lifestyle changes aimed at promoting better physical health. These include engaging in regular physical exercise, maintaining a healthy weight, abstaining from smoking, and learning correct techniques for lifting and moving heavy objects. Furthermore, simple measures such as placing a small, firm cushion behind the lower back during prolonged sitting, using a supportive pillow that maintains natural neck alignment during sleep, and utilizing a swivel desk chair offering appropriate postural support can alleviate LBP [27, 29, 30].
On a related note, the quality of work life encompasses the relationship between workers and their work environment [8]. A comprehensive approach to the quality of work life involves attending to various workplace needs, including health and safety, economic stability, family support, social interactions, esteem, personal growth, knowledge development, and environmental aesthetics [31, 32].
Furthermore, medications such as nonsteroidal anti-inflammatory medications (NSAIDs), analgesics, COX-2 inhibitors, muscle relaxants, some anticonvulsants and antidepressants, physical therapy, and surgery have been used to treat CLBP. However, these approaches frequently come with their own set of risks and limitations. Systematic evaluations show a moderate short-term benefit from most of these treatments for pain relief, though, as with nearly all medications, there are risks, prompting researchers to investigate alternative methods for managing this condition. Consequently, relaxation techniques emerge as one potential alternative [33, 34].
In this context, relaxation techniques encompass a range of methods and practices aimed at alleviating stress, muscle tension, and anxiety within the body. Specifically, these techniques prove beneficial in treating back pain by easing tense back muscles, alleviating muscle spasms, and shifting focus away from pain sensations. They operate by eliciting the relaxation response, which induces profound relaxation characterized by lowered heart rate, reduced respiration rate, decreased blood pressure, and enhanced overall breathing patterns. For example, key relaxation techniques include progressive relaxation, guided imagery, and deep breathing exercises, each contributing to promoting a state of calm and facilitating pain relief [21, 33, 35].
Building on the effectiveness of these techniques, occupational health nurses play a crucial role in their application. These nurses are uniquely qualified to employ relaxation techniques that assist in preventing secondary consequences and restoring workers’ physical and psychological well-being. Their involvement is critical to improving general well-being and cultivating a healthy work environment. By providing education on work hazards, health safety procedures, and lifestyle factors affecting health conditions [36].
Significance of the study
The significance of this study lies in the long-lasting benefits of physical therapy, particularly relaxation techniques, as opposed to the temporary relief often provided by pain medications. While medications may alleviate discomfort in the short term, the skills and knowledge that workers gain from engaging in physical therapy exercises at home can persist for a lifetime. This is crucial because relaxation techniques not only promote immediate relief but also encourage beneficial lifestyle changes and self-management strategies. By equipping individuals with the tools necessary to maintain a healthier, pain-free life, these techniques contribute to long-term well-being [33, 37].
Moreover, despite the extensive research conducted on lower back pain (LBP) across various sectors in Egypt, including healthcare, education, and universities, there remains a significant gap in the literature regarding interventions aimed at industrial workers. Particularly, there is a lack of targeted strategies to address musculoskeletal disorders (MSDs), with a focus on LBP [15, 38, 39].
Purpose of the study
The study’s purpose was to evaluate the effect of relaxation technique on the quality of working life, pain and disability level with nurse-led interventions among occupational workers with CLBP.
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Hypotheses
H1
Workers who receive relaxation technique interventions are expected to have higher quality of working life scores post intervention than pre-intervention compared to control group.
H2
Workers who receive relaxation technique interventions will have lower pain intensity scores post intervention than pre intervention compared to control group.
H3
Workers who receive relaxation technique interventions will have lower disability scores post intervention than pre intervention compared to control group.
Subjects and method
Study design
A quasi-experimental research design with single blinding, utilizing both case-control and pre-post intervention approaches. Single blinding was achieved when the experimental group who received the intervention was working in the morning shift while the control group who received only the routine care was working in the afternoon shift (i.e., they did not meet each other during work hours).
Study setting
The study was conducted at a yarn and textile factory situated in Kafr El-Sheikh, the capital city of Kafr El-Sheikh Governorate, Egypt. This factory employs 500 male workers in the yarn and textile departments, which are the primary technical divisions of the facility. The textile department consists of five sections: namely, wrapping, sizing, starching, drawing in, and textile. The yarn department involves the following sections: bale opening, carding, combing and drawing, roving, spinning.
Sample size calculation
The researchers were used G power for sample size calculation in the current study. The researchers used the effect size equal 0.5 with power (1-β err prob) equal 0.85, and α err prob equal 0.15. Thus, the sample size was equal to 100 workers (50 persons for study group and 50 persons for control group).
Effect size d | 0.5 |
|---|---|
α err prob | 0.15 |
Power (1-β err prob) | 0.85 |
Output: Non centrality parameter δ | 2.5 |
Critical t | 1.45 |
Df | 98 |
Actual power | 0.8525387 |
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N.B The number of workers in the textile and yarn factory was 500. Workers suffering from chronic lower back pain were determined by examination. By using the statistical equation to determine the sample size, 135 workers were selected. 35 out of these 135 workers were excluded from the study (10 for pilot study, 19 refused to participate in the study and 6 were on sick leave), so the researchers recruited 100 of them to include in the study and complete the intervention.
Sampling technique
A purposive sample of 100 industrial workers with chronic LBP from yarn and textile factory in Kafr El-Sheikh city was selected after their diagnosis of chronic LBP and divided into two equal groups: Group I (experimental group), composed of 50 workers, received relaxation techniques intervention in addition to their medication regimen, while group II (control group), composed of 50 workers, did not receive the relaxation techniques but received their medication regimen only. The two groups were matched according to their education level and weight as follows:
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After determining the total sample, which was 100 workers suffering from chronic lower back pain, a list was made of the names of all participants in the sample and they were divided into two groups, so that each worker was matched with a worker in the other group who had the same characteristics in terms of weight and level of education.
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The number of workers under study was divided into the experimental and control groups. For example, if the weight of two workers was between 70 and 75 kg and they had an intermediate education, one of them would be assigned to the experimental group and the other to the control group.
The sample was selected according to the following inclusion and exclusion criteria:
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Workers with persistent LBP (lasting more than three months) were excluded if they were receiving any other form of physio-therapeutic treatment during their involvement in the trial, to ensure the clarity of the intervention’s effects.
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Their age was between18 and 60 years.
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Only male workers were included.
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Participants must be free from any orthopedic or neurological problems as diagnosed by a physician in the subject factory.
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If they had chronic diseases such as diabetes, control of the disease should be maintained at the time of study.
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Participants must have had no previous surgery on the spine or herniated disc.
Instruments of the study
I. A structured interview questionnaire
The researcher developed this after reviewing the literature. The questionnaire encompassed the following components:
Part 1
Basic socio-demographic information was gathered through structured questionnaires, covering essential details such as age, marital status, education level, place of residence (urban or rural), number of children, family income level, and participant weight. These factors were assessed to understand their potential influence on the study’s outcomes related to chronic lower back pain and relaxation techniques.
Part 2
Work characteristics encompassed variables such as duration of employment, daily hours worked, weekly working days, and job category. These factors were crucial in assessing their impact on chronic lower back pain and response to relaxation techniques in the study.
Part 3
Present and past medical history of the industrial workers under study.
Part 4: Personal health habits data: This included smoking habits and engagement in sports.
II. Visual analogue scale (VAS)
The pain intensity scale used in this study was created by Refshauge et al., 2009 [40], and allowed participants to rate their pain levels on a numeric scale from 0 (no pain) to 10. This scale allowed for a more accurate assessment of pain severity by classifying pain into three categories: mild (1–3), moderate (4–6), and severe (7–10). By employing this scale, the study gained insights into how varying degrees of pain impacted participants’ daily activities and overall well-being. Such a detailed evaluation is critical for assessing the efficacy of interventions designed to manage chronic pain, providing researchers and healthcare professionals with valuable information to tailor treatment approaches effectively. This standardized approach ensures consistency in pain assessment across different studies, facilitating comparisons and advancements in pain management strategies.
III. Quality of Working Life Scale (QWL)
Edwards et al., 2007 [41] established a strategy for assessing the quality of working life among research participants. This instrument consisted of 23 items designed to assess six important domains: general health, work-life balance, career and job satisfaction, workplace management, working conditions, and stress levels. This comprehensive technique allowed for a thorough assessment of the multiple elements influencing participants’ work-related experiences and satisfaction levels.
The quality of working life was assessed for every patient. The total score of each patient was divided into four categories: “strongly disagree” if he received less than 40% of the total score, “disagree” if he received between 40% and 50% of the total score, “neutral” if he received more than 50% of the total score, “agree” if he received between 50% and 70% of the total score, and “strongly agree” if he obtained more than 70% of the total score on the quality of working life.
It included questions concerning the person’s opinion of QWL. No response was considered correct or incorrect. The following scoring system was used for the items: strongly disagree, disagree, agree, and strongly agree.
IV. Oswestry Disability Index
The index, initially designed by Wilhelm et al., 2010 [42], was meticulously translated into Arabic by the researcher, assuring its validity and reliability. This instrument was used to comprehensively assess the severity of LBP and its impact on daily activities (ADL) among research participants. It included ten items that assessed pain severity and its impact on essential functions such as personal care, mobility, lifting, sitting, standing, sleep quality, sexual activity, capacity to travel, and social engagements. This method gave a thorough insight into how chronic LBP affected the participants’ daily activities and overall quality of life.
Scoring system for Oswestry Disability Index:
Regarding assessment of the disability levels, the total score of each patient was categorized as “minimal disability” if he achieved 0–20%, “moderate disability” if he achieved 21–40%, “severe disability” if he achieved 41–60% and “crippling disability” if he achieved 61–80%.
Instruments’ validity
The study’s instruments were translated into Arabic and reviewed for content validity by a panel of five experts. This panel consisted of three community health nursing professionals and two community medicine experts. The panel validated the Arabic version of the instruments to confirm the accuracy of the translated contents (content validity). In accordance with the panel’s recommendations, changes were made to improve the clarity of the questions and the relevance of the contents.
Instruments Reliability
Reliability was estimated among 10 studied workers by using the test- retest method with two weeks between them. The correlation coefficient (Cronbach’s alpha) was calculated between the two scores for each instrument (analyzing and calculating the answers from the two tests). The Cronbach’s Alpha test reached 80% (r = 0.80) for the Visual Analogue scale (VAS), 83% for the Oswestry Disability Index, and 88% for the Quality of Working Life Scale (QWL).
Method
Two questions were directed to all the workers in the factory: Do you feel pain in the lower back? The answer was Yes or No. For each participant who answered Yes, we asked the second question: How long have you been feeling this pain? For how many days? If he answered Yes, and the pain had lasted for more than three months (chronic back pain), he was included in the group studied.
The factory’s physician diagnosed the diseased workers; and the factory nurse aided in the preparation of the patients and the surrounding environment.
Preparatory phase
The preparatory phase involved a comprehensive review of literature from books, articles, magazines, and online sources, focusing on various aspects of CLBP. This ensured a thorough understanding of the topic based on both historical and contemporary research findings.
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Administrative consent
The Dean of the Faculty of Nursing at Menoufia University issued a formal letter addressed to the director of Kafr El-Sheikh Yarn and Textile Factory, seeking permission for data collection. The letter outlined the study’s objectives to secure their cooperation. Additionally, each patient was briefed on the study’s aims prior to the start of data collection.
Pilot study
Ten yarn and textile workers participated in a pilot study [43] to assess the tool’s clarity, usefulness, and understandability. The time needed to finish the questionnaire was also determined by this pilot study. The results of the pilot study led to changes. These participants were subsequently excluded from the main study sample to prevent any influence on the study group due to increased familiarity with the questionnaire.
Ethical considerations
The Faculty of Nursing’s Ethical Committee in Menoufia University approved the conduct of the research with reference number: 890.
Formal approval was obtained from the director of the yarn and textile industry in Kafr El-Sheikh through formal communication. The Dean of Menoufia University’s Faculty of Nursing sent an official letter to the factory’s orthopaedical physician, requesting help in diagnosing workers with CLBP.
Prior to data collection, manufacturing workers provided oral agreement, allowing researchers to enter the factory clinic during break hours. Participants were informed that there were no hazards to their health, and that data would be kept confidential and anonymous. Ethical considerations included describing the study’s goal, assuring voluntary participation, and allowing participants to quit at any moment.
All data of the studied workers was maintained confidentially and used only for the purpose of the study. Measures were taken to promote transparency, respect for participant rights, and research integrity.
Implementation phase
Once the permissions were granted to conduct the study and the study instruments were prepared, the researcher started to collect the data at the factory clinic. The experimental group received the intervention, including relaxation techniques in addition to their medication regimen, while the control group (Group II) did not receive the relaxation techniques but received medication regimen only.
The data collection process started from November 2023 and continued to the end of June 2024. A base-line assessment was conducted which included the following activities:
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Information was gathered by conducting independent interviews with each patient in each group to evaluate the socio-demographic and medical information of the workers using Instrument I (Parts 1 and2).
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The severity of pain for each pain patient’s CLBP was evaluated across all groups. (Instrument II: A numeric rating scale (NRS).
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The researcher collected data about Instrument III: Quality of Working Life Scale to assess its six domains.
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Instrument IV, Oswestry LBP disability Scale: was used to evaluate how each subject’s daily activities are affected by persistent complaints.
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All studied workers were matched according to their weight and education category into two groups (experimental group GI and control group GII) as explained in the sampling section.
Experimental group
The experimental group was interviewed in groups (each group composed of 5 patients) in the clinic of the factory during Saturday and Sunday (morning shift) for four sessions, each lasting 40–50 min, to instruct them about relaxation techniques as follows:
During the 1st session
instructions and guidelines clarified the nature of the disease (CLBP) and its definition, the anatomy and function of the vertebral column, causes, prevalence, risk factor, ergonomic mechanisms, prevention and its management. At the end of the session, all patients received a colored booklet with illustrated pictures that contained the contents of the intervention.
During the 2nd session
at the beginning of the second session, the researcher asked questions related to the previous session. Instructions about the relaxation techniques components and its instructional guidelines nursing strategy (body mechanics in the work setting) were provided as follows.
I-Deep breathing (breathing exercises):
Quick relaxation technique focusing on breathing: deep inhalation and holding the breath for a few second before exhalation, i.e., breathing as people breathe when asleep or deeply relaxed. The belly pushes outward during inspiration, pulling air deep into the lungs, then the belly is released, allowing air to leave the lungs effortlessly. The shoulders and chest move very little. This is also a basic mindfulness exercise, meaning focusing without judgment on one pleasant experience, such as the motion of the belly during relaxed breathing [35, 44].
II-Guided imagery
Imagery-based relaxation involves replacing negative or stressful feelings with pleasant mental images to induce relaxation. It is a mindfulness technique offering powerful distraction from pain, stress, and worry. It works by bringing to bear all the senses at once, in the participants’ imagination. Guided imagery involves going to a happy place, then thinking about all of that place’s sights, sounds, smells, textures, air temperature, etc. This floods the brain with distracting and pleasant sensations, leaving little room for other thoughts or sensations. To ensure that exercises are working, the researcher at the end of the week, after practicing each day, sees if the participant has noticed overall changes in his mood, pain, and stress levels [21, 30].
III-Progressive relaxation
Progressive relaxation entails systematically tensing and then relaxing each major muscle group, generally starting with the lower legs by pulling the feet upward toward the body, holding that tension for five seconds, then relaxing for ten seconds before moving on to the next muscle group. It is frequently combined with guided imagery and controlled breathing exercises, which improves relaxation efficacy and stress reduction. This method allows individuals to focus on muscle tension release, fostering a heightened sense of calmness and overall well-being. Regular practice of progressive relaxation has been shown to alleviate muscular tension and promote psychological relaxation, making it a valuable component in stress management and enhancing mental resilience [21, 44].
IV: Nursing strategies for maintaining body mechanics in the work setting.
The following guidance illustrates how to perform a basic lift safely, using both hands, lifting a load in front of and close to the body, without twisting.
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Think before handling/lifting.
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Remove obstructions such as discarded wrapping materials.
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Use suitable handling equipment for long lifts.
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Keep the load close to your waist.
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Ensure a good hold on the load and adopt a stable position.
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Slightly bend the back, hips, and knees.
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Don’t flex the back any further while lifting.
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Avoid twisting the back or leaning sideways, especially while your back is bent.
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Keep the head up when handling.
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Move smoothly; keep control to decrease the risk of injury.
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Don’t lift or handle more than you can easily manage.
During the 3rd session
The steps of the three types of relaxation techniques were demonstrated, i.e., guided imagery, progressive, and deep breathing or breathing exercises.
NB
The relaxation techniques among the workers were carried out under the supervision of psychiatric researchers who also had trained the community health researchers.
During the 4th session
Re-demonstration of the relaxation techniques by each patient.
Teaching strategy
The researcher used lectures, group discussion techniques, role playing, and demonstration as teaching methods through educational videos, and YouTube as a teaching aid to fulfill the study objectives.
Control group
The control group were interviewed in groups in the factory clinic on Monday and Thursday in the afternoon shift and given an illustrated booklet containing instructions for medication for treatment of CLBP.
Follow-up activities during intervention sessions
At the beginning, the 1st session was concerned with collecting data about basic and pre-intervention period, it stayed 2 weeks in time. During completing the sessions, the researchers taught the patients under study the steps of relaxation techniques during 2nd and 3rd sessions, (stayed 6 weeks in time). They supervised the workers by gave instructions and modifications to follow right body mechanics and work associated ergonomics in work setting. Communication and contact were carried out at their homes by telephone and WhatsApp through sending the educational videos that illustrated application of different types of relaxation techniques in a simple way. In the 4th session (stayed 4 weeks) the researchers demonstrated and continued to encourage the patients to implement the accurate steps of relaxation techniques by giving snacks and simple gifts.
Evaluation phase
Statistical comparisons were conducted between the two groups to analyze the influence of relaxation techniques on the quality of working life, pain intensity and disability levels. The intervention spanned a 12-week period, measuring outcomes in both the experimental and control group before and after the intervention to capture any changes over time. This time frame allowed for a comprehensive assessment of the sustained effects of relaxation techniques on improving participants’ functional abilities and overall well-being in an occupational setting.
Statistical analysis
The collected data were organized, tabulated and statistically analyzed using SPSS software (Statistical Package for the Social Sciences) version 23, SPSS. For quantitative data, the mean and standard deviation were calculated. For qualitative data, which describe a categorical set of data by frequency and percentage of each category, comparison between two groups for qualitative data was done using Pearson Chi-square test and Fisher exact test. For comparison between means of two groups of parametric data of independent samples, an independent sample t-test was used. The level of significance was set according to P value ≤ 0. 05.
Results
Table 1
Socio-demographic characteristics of studied textile and yarn workers (N = 100)
Socio-demographic Characteristics | Groups (n = 100) | Test of Significance | p-value | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
Study group (n = 50) | Control (n = 50) | |||||||||
No. | % | No. | % | |||||||
Age (SD ± Mean) Years | 8.7 ± 41.4 | 7.8 ± 40.5 | t = 0.47 | 0.63 NS | ||||||
Residence | Rural | 40 | 80.0 | 39 | 78.0 | X2 = 0.06 | p = 0.81 NS | |||
Urban | 10 | 20.0 | 11 | 22.0 | ||||||
Education Level | Illiterate | 5 | 10.0 | 4 | 8.0 | X2 = 1.9 | p = 0.17 NS | |||
Elementary education | 10 | 20.0 | 22 | 44.0 | ||||||
Secondary-level education | 35 | 70.0 | 24 | 48.0 | ||||||
Type of machine | Yarn machine | 35 | 70.0 | 38 | 76.0 | X2 = 0.45 | p = 0.49 NS | |||
Textile machine | 15 | 30.0 | 12 | 24.0 | ||||||
Marital state | Single | 4 | 8.0 | 8 | 16.0 | X2 = 0.84 | p = 0.35 NS | |||
Married | 42 | 84.0 | 14 | 28.0 | ||||||
Divorced/Widowed | 4 | 8.0 | 3 | 6.0 | ||||||
No. of children | <=2 children | 13 | 26.0 | 20 | 40. 0 | X2 = 2.2 | p = 0.13 NS | |||
3–5 children | 37 | 74.0 | 30 | 60.0 | ||||||
Transportation | Train | 23 | 46.0 | 30 | 60.0 | X2 = 1.9 | p = 0.2 NS | |||
Car | 27 | 54.0 | 20 | 40.0 | ||||||
Time to reach work place | 20 > minutes | 28 | 56.0 | 29 | 58.0 | X2 = 0.04 | p = 0.84 NS | |||
20 < minutes | 22 | 44.0 | 21 | 42.0 | ||||||
Income | Enough | 1 | 2.0 | 5 | 10.0 | Fisher exact test | p = 0.20 NS | |||
Not enough | 49 | 98.0 | 45 | 90.0 | ||||||
Total | 50 | 100.0 | 50 | 100.0 | ||||||
Table 1 illustrates the socio-demographic characteristics of the studied sample of textile and yarn workers with CLBP. It shows that the mean age among the study group was 41.48.7 ± compared to 40.5 ± 7.8 among the control group. It also shows that the majority of the studied workers were living in rural areas, had moderate education, worked on yarn machines and were married. The differences between the study group and control group were insignificant.
The table also shows that the differences between the study and control groups were insignificant.
(p > 0.05) regarding transportation method, number of children and income level.
Table 2
Special habits and worker’s medical history among yarn and textile workers with chronic lower back pain pre- intervention (N = 100)
Special habits and worker’s medical history | Groups (n = 100) | Total | Test of Significance | p-value | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
Study group (n = 50) | Control (n = 50) | ||||||||||
No. | % | No. | % | No. | % | ||||||
Smoking | Smoking | 18 | 36.0 | 15 | 30.0 | 33 | 33.0 | X2 = 0.40 | p = 0.52 NS | ||
Not smoking | 32 | 64.0 | 35 | 70.0 | 67 | 67.0 | |||||
Practice sports | Yes | 2 | 4.0 | 1 | 2.0 | 3 | 3.0 | Fisher Exact Test | p = 0.5 NS | ||
No | 48 | 96.0 | 49 | 98.0 | 97 | 97.0 | |||||
Worker’s present and past medical history | Diabetes | 13 | 26.0 | 11 | 22.0 | 24 | 24.0 | X2 = 4.9 | p = 0.17 NS | ||
Hypertension | 11 | 22.0 | 4 | 8.0 | 15 | 15.0 | |||||
No history | 22 | 44.0 | 30 | 60.0 | 52 | 52.0 | |||||
Liver | 4 | 8.0 | 5 | 10.0 | 9 | 9.0 | |||||
Total | 50 | 100.0 | 50 | 100.0 | 100 | 100.0 | |||||
Table 2 illustrates special habits and medical history among the studied workers with CLBP pre-intervention. It shows that the majority were not smoking, did not practice any sports and did not have diabetes. There was no discernible difference between study and control groups, (p > 0.05).
Fig. 1
Pain intensity among studied groups with chronic lower back pain pre- and post-intervention (N = 100)
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Figure 1 represents the intensity of lower back pain in the studied group pre- and post- intervention. At first, there was no discernible difference between the study and control groups’ pain levels. However, the average level of pain in the studied group decreased significantly after the intervention; only 3 workers (6%) reported moderate pain post-intervention, compared to 35 workers (70%) pre-intervention. Moreover no worker (0%) reported severe pain post-intervention compared to 15 workers (30%) pre-intervention. The intervention completely eased significant pain (X2 = 89.6, p = 0.000).
Table 3
Effect of relaxation techniques intervention on Oswestry Disability Index pre- and post-intervention among studied workers with chronic lower back pain (N = 100)
Oswestry Disability Index | Pre-intervention | Post-intervention | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
Study group (n = 50) | Control (n = 50) | p1 | Study group (n = 50) | Control (n = 50) | p2 | |||||
No. | % | No. | % | No. | % | No. | % | |||
Minimal disability | 4 | 8.0 | 2 | 4.0 | Xˉ =2.4 p = 0.49 NS | 43 | 86.0 | 0 | 0.0 | Xˉ=129.5 p = 0.0000 HS |
Moderate disability | 23 | 46.0 | 18 | 36.0 | 6 | 12.0 | 0 | 0.0 | ||
Severe disability | 19 | 38.0 | 26 | 52.0 | 1 | 2.0 | 35 | 70.0 | ||
Crippling | 4 | 8.0 | 4 | 8.0 | 0 | 0.0 | 15 | 30.0 | ||
Total | 50 | 100.0 | 50 | 100.0 | 50 | 100.0 | 50 | 100.0 | ||
Table 3 shows that scores on the Oswestry Disability Index statistically improved post-intervention compared to pre-intervention. Before the intervention, 38% of the study group had severe disability, which decreased to 2% post-intervention. Additionally, 8% of the group had crippling disability pre-intervention, and this was completely eliminated post-intervention.”
Table 4
Effect of relaxation techniques intervention on mean score on quality of Working Life scale and overall quality score among studied groups (N = 100)
Quality of Working Life Scale | Pre- intervention | Post-intervention | ||||
|---|---|---|---|---|---|---|
Study group (n = 50) SD ± Mean | Control group (n = 50) SD ± Mean | p1- value | Study group (n = 50) SD ± Mean | Control group (n = 50) SD ± Mean | p2- value | |
General Well-Being (GWB) | 26.4 ± 2.5 | 19.9 ± 3.4 | 0.92 NS | 19.9 ± 3.1 | 19.8 ± 6.3 | 0.000 HS |
Home-Work Interface (HWI) | 21.4 ± 1.9 | 18.6 ± 3.2 | 0.15 NS | 9.4 ± 2.3 | 8.8 ± 2.1 | 0.000 HS |
Job & Career Satisfaction (JSC) | 12.7 ± 1.6 | 8.9 ± 2.2 | 0.83 NS | 20.2 ± 4.1 | 20 ± 3.5 | 0.000 HS |
Control at Work (CAW) | 12.6 ± 1.6 | 9.5 ± 2.5 | 0.28 NS | 9.2 ± 2.8 | 9.7 ± 2.2 | 0.000 HS |
Working Conditions (WCS | 13.2 ± 1.8 | 8.6 ± 2.3 | 0.76 NS | 9.5 ± 3.2 | 9.7 ± 2.1 | 0.000 HS |
Stress at Work (SAW) | 7.0 ± 1.9 | 3.2 ± 1.6 | 0.01 Sig. | 4.6 ± 1.2 | 3.1 ± 1.6 | 0.000 HS |
Overall Quality of Working Life | 93.3 ± 6.8 | 68.8 ± 8.7 | 0.47 NS | 72.8 ± 12.8 | 71.1 ± 10.1 | 0.000 HS |
Table 4 clarifies the effect of the Relaxation Techniques intervention on the mean score on the Quality of Working Life scale and overall quality score among the studied groups. It shows that the application of relaxation techniques had a highly statistically significant impact on the average score of each individual component of the working life quality scale as well as the overall quality score for the groups under study (P = 0.000).
Table 5
Effect of pain intensity on disability levels post intervention among studied workers (N = 50)
Pain intensity post-intervention | Post-intervention total disability level | Total | P-value | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
Minimal disability | Moderate disability | Severe disability | ||||||||
No. | % | No. | % | No. | % | No. | % | |||
Pain intensity | No pain | 26 | 96.3 | 1 | 3.7 | 0 | 0.0 | 27 | 100.0 | X2 = 6.3P = 0.17 NS |
Mild | 15 | 75.0 | 4 | 20.0 | 1 | 5.0 | 20 | 100.0 | ||
Moderate | 2 | 66.7 | 1 | 33.3 | 0 | 0.0 | 3 | 100.0 | ||
Total | 43 | 86.0 | 6 | 12.0 | 1 | 2.0 | 50 | 100.0 | ||
Table 5 highlights that, after intervention, an increase in pain intensity was associated with higher percentages of degree of disability. Among the studied workers who complained of moderate pain intensity, only one worker (33.3%) had moderate disability. Also, among the 20 workers who had mild pain intensity post intervention, 75% had minimal disability, 20% and 5% had moderate and severe disability, respectively. In addition, the majority of textile and yarn workers who had no pain had minimal disability (96.3%) post-intervention. The non-significant difference may be due to the small sample size of studied workers (N = 50).
Discussion
The data collection of the current study lasted twelve weeks regarding application of relaxation technique with three procedures. After this period of intervention the post intervention data reveal an improvement in pain intensity level and alleviate the Oswestry disability index so the finding showed an development in the daily living such as walking, sitting, lifting, sleeping and standing. An implication was clear of the intervention that appeared also with quality of working life index that improved in the subscale items to include managing stress, promoting physical functioning and the maintaining career satisfaction.
The current study was conducted at a textile and yarn factory in Kafer El Sheikh city, focusing on industrial workers diagnosed with CLBP. Many studies have confirmed that workers in this sector face significant occupational hazards. Ahmed et al., (2011) [45] highlighted that lifting heavy objects increases strain on the lower back muscles, exacerbating LBP among industrial workers.
In terms of age demographics, in the current study among textile workers experiencing chronic LBP the mean age of the study group was 41.4 ± 8.7 years, while the control group averaged 40.5 ± 7.8 years. This aligns with the observations of Roman et al., (2020) [46] who reported a mean age of 45.6 ± 11.67 years for subjects with LBP. Similarly, other studies [47‐49] have identified the highest prevalence of LBP among individuals aged 40–50 years. This trend may be attributed to age-related changes such as intervertebral disc degeneration and loss of moisture content after the age of thirty [50]. However, Lamadah et al., (2021) [51] highlighted that LBP can affect individuals across various age groups, suggesting genetic factors as a possible cause. This variance underscores the complex nature of LBP and the need for tailored interventions based on individual circumstances.
Concerning smoking, the present study found that, the higher percentage of studied workers (64%) were non smoke. This was consistent with, Alemam et al., (2023) [15] who found that smoking was not a significant risk factor for low back pain. Likewise, this finding was aligned with the study conducted by Yang et al., (2023) [52] who similarly found no significant correlation between smoking and back pain among nurses in their study. On the other side, the meta-analysis suggests that current and former smokers have a higher prevalence of lower back pain compared to non-smokers, and smoking cessation may reduce these effects. Similarly, Zheng et al., (2023) [53] stated that smoking contributes to increased levels of back discomfort. Likewise, Rezaei et al., (2021) [54] discovered a substantial link between smoking and the prevalence of LBP in their investigation of risk variables and costs related to LBP, emphasizing smoking’s negative impact on spinal health.
In terms of family history and its relationship to lower back pain, the current study discovered that patients under study suffered from diabetes. This study lends support that diabetic patients frequently have low bone density, weak muscles, and reduced flexibility and coordination, all of which can exacerbate back pain. Heikkala et al. (2022) [55]and Alfalogy et al. (2023) [56] observed, however, that a history of musculoskeletal disorders did not significantly increase the risk of LBP. This finding implies that diabetes may be more significant under certain circumstances.
Pertaining to the effect of Relaxation Techniques on the mean score of the Quality of Working Life scale and overall quality score. The current study findings showed that there was a highly statistically significant impact on the mean score of each patient component of the Quality of Working Life scale, as well as the overall quality score for the study group compared to the control group (P = 0.000). These findings support the study findings that conducted in Egypt by Sharaf et al., (2020) [57] Shariat et al., (2019) [21]; in Saudi Arabia by Alshehre et al., (2023) [58] who showed that QoL significantly increased after the intervention among study group compared to control group. Also, there was statistical improvement in QoL after the intervention (P < 0.001).
These findings of the current study highlight the comprehensive benefits of relaxation techniques in improving the overall quality of life, including general wellbeing, home-work interface, job and career satisfaction, control at work, working conditions, stress at work and overall quality of working life. The difference was significant between study and controls post-intervention. This finding was in line with Saleem et al., (2023) [59], who discovered significant variations in work-related quality of life between the study and control groups, particularly in areas such as overall well-being, work-home balance, job satisfaction, work control, working conditions, and workplace stress. This finding was also consistent with Grace et al.‘s (2023) [60] “Examination of the impact of progressive muscular relaxation training on industrial workers’ quality of life”. The improvements found in several categories of work-related quality of life demonstrated the ability of relaxation techniques to improve employees’ physical well-being and job satisfaction. Likewise, these findings were consistent with those by Sagar et al., (2022) [61], who found minor but significant improvements in social contacts, sexual activities, and the ability to travel substantial distances among their study participants.
Pertaining to the effect of the Relaxation Techniques Intervention on Oswestry Disability Index among studied workers with chronic lower back pain showed that the disability index was significantly improved after intervention, with greater improvement among the study group compared to the control group (p = 0.000). This finding was supported by the study finding conducted in Saudi Arabia by Alshehre et al., (2023) [58] who showed that there were statistical improvements in disability intensity among the study group compared to control group after the intervention (p = 0.001).
Also, the current study finding was in agreement with the findings of a study conducted in Croatia by Kuvačić et al., (2018) [62]; and Phattharasupharerk et al., (2019) in Thailand [63], who illustrated that there was statistical improvement in disability index level among the study group compared to the control group after the intervention (p < 0.001).
On the other hand, study also revealed that the intervention program significantly improved workers’ ability to execute activities such as personal care, sleeping, walking, lifting, and standing. This result was consistent with Manolaki et al., (2021) [64], who found significant improvements in these areas among CLBP patients who practiced relaxation techniques. Similarly, Grace et al., (2023) [60] found statistically significant differences between groups in post-test assessments of personal care and sleeping among workers, suggesting that pain treatment therapies can improve these daily tasks. Sengar et al. (2023) [65] likewise found no significant associations between pain scores and gender or body mass index in their study, but in contrast, Lucha-López et al. (2023) [66] found substantial relationships between pain scores and age and body mass index in their study, indicating that these characteristics influence pain perception differently among groups.
As regards to the effect of pain intensity on disability level post intervention among studied group. the present study revealed that, an increase in pain intensity was associated with higher percentages of degree of disability (positive relation) with a non-significant difference this result was consistent with While, this result was consistent with Peters et al., (2005) [67], who found that pain intensity was correlated with disability and was one of the independent variables which significantly influenced the disability in CLBP patients, with significant correlations between CLBP intensity and disability also reported.
This result was in line with Jia et al., 2022 [68] who reported that statistically significant differences were found in the Brief Pain Inventory score and multidimensional locus of control among occupational groups in key industries in China after intervention with relaxation techniques. The study found that relaxation techniques provide positive results in pain reduction and cortisol decrease and should therefore be incorporated into rehabilitation protocols.
Moreover, the current study findings revealed that there were statistical improvements in pain intensity among the studied groups after the intervention (p-value = 0.000). These findings were supported by the findings of a study conducted in Egypt by Sharaf et al., (2020) [57]; Shariat et al., (2019) [21] in Iran, and Alshehre et al., (2023) in Saudi Arabia [58], who showed that there was statistical improvement in pain intensity among the study group compared to the control group after the intervention (p < 0.001).
On the other side, Turner et al., (2005) [69] reported that the relationship between pain intensity and disability level was linear in the carpal tunnel syndrome (CTS) but nonlinear in the low back pain injuries group. Likewise, Harahap et al., (2021) [70] who reported that” significant positive relationship between pain intensity and disability, i.e., the greater the pain intensity, the higher the disability and the lower the ability to perform daily activities.
A non-significant difference was appeared in the present study and other studies may be due to small sample size, low in duration intervention time and cultural differences in body mechanic related movements among workers from country to another.
The most important study finding was that the change in VAS and Oswestry Index scoring reached statistical significance, showing great improvement regarding pain reduction and disability level, as well as the quality of working life. This outcome reinforces the concept that relaxation techniques should be incorporated into rehabilitation programs for chronic LBP. Also, nursing strategies for appropriate body mechanics for patients with CLBP were shown to aid in eliminating impairments in back flexibility, improve the quality of working life, decrease stress at work, reduce pain intensity and lower disability levels.
In conclusion, relaxation techniques are an easy and cost-effective method for chronic pain treatment. Pain reduction using non-pharmacological methods may contribute dramatically to reducing the economic and social costs of CLBP, especially for patients in the textile and yarn setting, who may not be able to overcome the side effects of medication. Diaphragmatic breathing, PMR, autogenic relaxation, guided imagery, and other techniques that were not examined in this study may also be valuable solutions for pain and stress management.
Limitations of the study
The current study had some limitations. First: it did not implement the follow-up phase in-between pre and post intervention. While the researchers satisfied to utilize pre and post design only because time and effort were spent to coordinate the groups in every session of the intervention additionally, 12 weeks was considered a long period from the industrial worker perspective. So, the researcher in the current study recommended the future research to make stress to follow up phase to maintain validated data and valuable outcomes. In addition, A subsequent study with a larger sample is required to determine standardized, validated measurements for data collection.
Conclusion
After 3 months of application of relaxation techniques, including deep breathing, guided imagery and progressive relaxation, these techniques were shown to be cost-effective, easy and safe in CLBP management. It showed a highly statistically significant impact on the mean score of each patient component of the Quality of Working Life scale, as well as the overall quality score for the groups under study. Furthermore, the intervention resulted in a significant decrease in pain intensity among patients.
In addition, the mean score on the Oswestry Disability Index improved significantly after intervention, indicating improved performance in everyday activities such as personal care, lifting, walking, sitting, standing, sleeping, social contacts, and travel. Acting on all these implications can lead to reduced economic burden and improved overall quality of working life, promoting physical well-being, maintaining career satisfaction and managing stress.
Recommendations
Based on the findings of this study, the following suggestions are proposed:
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Health education and awareness programs about how to improve the quality of working life for industrial workers through application of relaxation techniques.
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Integrate relaxation techniques as an essential part of a rehabilitation program for industrial workers in textile and yarn factories.
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Enhance the occupational health nurse’s role in early detection and referral of lower back pain among workers in different industrial settings.
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Encourage the workers to practice sports, taking breaks during work hours.
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Further studies are recommended on wider sample size and different industrial workers and different workplaces.
Acknowledgements
NA.
Declarations
Ethics approval and consent to participate
In accordance with the Declaration of Helsinki and principles of ethical research, this study was approved by the Faculty of Nursing’s Ethical Committee in Menoufia University (Ethics code: 890). Participants were assured of the confidentiality of their data. They were also informed of their right to withdraw from the study at any time. Informed consent was obtained from all individual participants included in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Clinical trial number
Not applicable.
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