What pain-related factors are associated with lost work days in nurses?

Low back pain (LBP) is a leading cause of disability [5] including lost work days (LWDs) and early retirement [3; 4]. Among the work-related disability domains, LWDs are particularly important because they increase the economic burden of pain for the individual, family and society.  A number of factors such as overall work demands, working on a nightshift, perceived lack of support and/or encouragement from supervisors, and lack of rest time have been previously found to be associated with LWDs among nurses [4].  Although a variety of factors are known to be associated with LWDs, not a lot is known about the role that modifiable pain-related factors play in LWDs. Exploring the role that these factors might play is important because it could  inform the development of treatments designed to reduce the impact of chronic pain on LWDs.

In a recent study [6], we examined these issues in a sample of nurses from a Tertiary Hospital in Nepal. Nurses have a high prevalence of LBP which affects their work productivity and can potentially jeopardize patient care [3]. We asked 111 nurses if they had LBP, and further asked those who had LBP (N = 72, 65%) to tell us: (1) their total number of LWDs in the past year; (2) the average and worst pain intensities of their LBP on 11-point numerical rating scales; (3) whether or not pain was constant or intermittent; (4) aggravating factors such as bending, lifting, walking and standing, and (5) relieving factors such as rest, medications, and exercise.  We hypothesized that more LWDs would be reported by those who (1) reported higher pain intensities and (2) endorsed passive management strategies such as rest and use of medications to alleviate pain. We further hypothesized that those who reported use of active management strategies such as exercise would report fewer LWDs.

The findings indicated that LWDs were not associated with maximum pain intensity over the last week or average pain intensity in most days in a week. Of the other associations evaluated, only two pain-related factors emerged to be significantly associated with LWDs; reporting constant pain and reporting rest as an alleviating factor for pain. Thus, more LWDs were reported by (1) those who endorsed having constant pain than those who did not endorse having constant pain and (2) those who reported using rest to relieve pain than who did not report using rest to relieve pain. Further, the role of rest as a predictor of LWDs remained despite controlling for pain intensity.

Inconsistent with the study hypotheses, pain intensity (both worst and average pain) were not associated with the LWDs, nor were many of the activities that nurses generally do at work (e.g., bending, lifting, walking and standing).

The findings suggest the possibility that factors other than pain intensity may be more important in the number of LWDs due to LBP [3].  Likewise, they support the notion that rest as a management strategy for LBP may not be maladaptive – at least with respect to its positive association with LWDs in nurses.  Research is needed to examine the potential causal association of rest as a management strategy and LWDs in nurses with LBP.  If found to play a causal role, then the findings suggest that it may be more effective to teach nurses active pain management strategies than to focus treatment on pain intensity reduction.

About Saurab Sharma

saurab-sharmaSaurab Sharma is a physiotherapist and a pain researcher from Nepal interested in assessment and treatment of chronic pain. Working for over 8 years in a country so different to the west from where bulk of research originates, Saurab identified numerous differences and difficulties of managing people living with chronic pain in Nepal.  Thus, he is currently testing a number of hypotheses on cross-cultural, psychosocial factors in chronic pain as a part of “Developing Country Collaborative Research Grant” with Professor Mark Jensen.  Saurab has developed other important collaborations across the globe to study chronic pain.  His current research projects include development, translation and validation ofpain-related outcome measures in Nepali.  Saurab also runs a website, www.linkphysio.com where he invites students to write blog posts and encourage their scientific writing skills and at the same time bring the evidences to clinicians and patients with chronic pain in Nepal.

Saurab teaches at the only physiotherapy school in Nepal in Kathmandu University which he is passionate about.  Apart from teaching, Saurab loves to travel and explore the world.  Saurab plans to start a ‘Pain Research Group’ within the university after his PhD so as todevelop novel pain management programs specific for Nepalese population which could then be adapted to other similar developing nations.

About Mark Jensen

Mark P JensenMark P. Jensen, is a Professor and Vice Chair for Research in the Department of Rehabilitation Medicine, University of Washington School of Medicine. Dr. Jensen’s research program focuses on the development and evaluation of psychosocial interventions for pain management.  He has been awarded a number of grants from the National Institutes of Health and other funding sources for this work, and is the author or co-author of over 400 articles and chapters.  He has received a number of awards from the American Psychological Association (2003 APA Division 30 Award for Best Clinical Paper and 2012 Award for Distinguished Contributions to Scientific Hypnosis), the Society for Clinical and Experimental Hypnosis (Roy M. Dorcus Award for Best Clinical Paper, 2004), and the American Society of Clinical Hypnosis (Clark Hull Award for Scientific Excellence in Writing on Experimental Hypnosis, 2009) for his scientific contributions.  He is the author of Hypnosis for chronic pain management, which won the 2011 Society for Clinical and Experimental Hypnosis Arthur Shapiro Award for Best Book on Hypnosis.  He is also the current Editor-in-Chief of the Journal of Pain.


[1] Ballantyne JC, Sullivan MD. Intensity of Chronic Pain–The Wrong Metric? N Engl J Med 2015;373(22):2098-2099.

[2] Delitto A, George SZ, Van Dillen LR, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ. Low back pain. J Orthop Sports Phys Ther 2012;42(4):A1-57.

[3] George SZ, Fritz JM, Childs JD. Investigation of elevated fear-avoidance beliefs for patients with low back pain: a secondary analysis involving patients enrolled in physical therapy clinical trials. J Orthop Sports Phys Ther 2008;38(2):50-58.

[4] Henderson M, Glozier N, Holland Elliott K. Long term sickness absence. BMJ 2005;330(7495):802-803.

[5] Hoogendoorn WE, Bongers PM, de Vet HC, Ariens GA, van Mechelen W, Bouter LM. High physical work load and low job satisfaction increase the risk of sickness absence due to low back pain: results of a prospective cohort study. Occup Environ Med 2002;59(5):323-328.

[6] Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G, Smith E, Vos T, Barendregt J, Murray C, Burstein R, Buchbinder R. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014;73(6):968-974.

[7] Sharma S, Shrestha N, Jensen MP. Pain-related factors associated with lost work days in nurses with low back pain: A cross-sectional study. Scandinavian Journal of Pain 2016;11:36-41.

[8] Sullivan MD, Ballantyne JC. Must we reduce pain intensity to treat chronic pain? Pain 2016;157(1):65-69.

Commissioning Editors:  Neil O’Connell and Carolyn Berryman


  1. May I suggest that in a population of young women, a major factor is their menstrual period, as many young women have severe low back pain at this time.
    While many young women ascribe their low back pain publically to work related issues or motor vehicle accidents – this is because they do not wish to discuss menstrual related issues, due to shyness, embarrassment or cultural concerns. LBP due to work is far more respectable as a reason to have a day off work, than pelvic pain.