Exploring Causative and Preventative Forces

Even caseworkers mistakenly believe back injuries are the result of a single-injury incident, but it is estimated only 4 percent of back injuries actually are.

• By Judy L. Fitch, Ph.D., Barry E. Fitch, MBA, DPT, IOC
• Jun 01, 2004

BACK injuries represent a problem of epidemic proportions in the United States and are among the most common and costly musculoskeletal disorders experienced. According to the Bureau of Labor Statistics, 400,000 people have back injuries on the job each year (www.bls.gov, 2000).

Back injuries represent 40 percent of all recorded absences from work (McReynolds, 1992). They are second only to the common cold for lost work days and account for a disproportionate share of worker's compensation costs (Fernberg, 1999; Gates, 1988). According to the American Society of Orthopedic Surgeons, back injuries are the most costly medical condition in America. It is only recently, with the steady rise in health care costs, that more of the worker's compensation settlements go to paying medical costs than go toward the lost wages of the injured employee (Dresang, 2003).

Causes of Back Injuries
Currently, there exists an almost universal misconception regarding the causes of back injury. Some occupations, of course, traditionally have a higher incidence of back injury, such as construction workers, miners, transportation workers, garbage collectors, warehouse workers, auto mechanics, and nurse's aides. However, clerical and other office (desk) workers are not exempt from injury (National Safety Council). With the increased use of computer terminals and associated prolonged poor sitting posture has come an increase in the number of work-associated back injuries among such computer-operating occupations (Bencivenga, 1996; Glick, 1991).

In addition, many workers, managers, and even caseworkers mistakenly believe back injuries are the result of a single-injury incident. In fact, it is estimated that only 4 percent of back injuries are the result of a single-incident injury (e.g. a sprain , strain, or fracture) (Donajkowski, 1993; Muir, 1994). Rather, back injuries generally are repetitive trauma injuries caused by poor posture, poor body mechanics, physical limitations, unsafe work site/work habits, poorly designed workstations, or forceful repetitive movements requiring bending, twisting, pushing, pulling, reaching, or any combination thereof (Bencivenga, 1996; Byrns et al., 2002; Donajkowski, 1993; Glick, 1991; Hooper, 2002; Marras, 2000; Muir, 1994).

Over time, the supporting ligaments of the spine are gradually stretched and weakened, causing a "cascade" (Paris, 1997) of associated problems, which may include inefficient muscular balance and therefore increased muscle strain, bony changes, disc degeneration, and nerve irritation (Marras, 2000). This makes "back injuries the most preventable of all workplace injuries." (Leonard, 1994, p. 4).

More injuries result in more days away from work and thus lower net productivity for injured workers. In most organizations, managing the forces would come under the authority of the human resource manager and/or the safety manager, but various other people might have such accountability.

Existing Research in Back Injury Prevention Programs
Because of the costs of these back injuries, as well as the number of individuals affected, organizations have been forced to look for solutions to decrease back injuries. A key area of focus for industry is back injury prevention through education and training programs, which often are called "back schools."

A back school may be designed to facilitate the rehabilitation of an existing back injury or attempt to minimize the risk of back injury (Fernberg, 1999; Glick, 1991; Hooper, 2002). The scope and content of back schools vary greatly. Whether preventative or rehabilitative, both involve, at a minimum, basic education about the physiology of the back and training in proper body mechanics. Others may represent a more comprehensive rehabilitation and/or prevention program. The terms "back school" and "back injury prevention program" (BIPP) often are used interchangeably in the literature.

While it is difficult to quantify the effect of these programs relative to other factors, industry efforts have garnered positive results, most often measured in decreased lost time injuries. In one year, the total direct and indirect costs of work injuries easily exceeds $150 billion (Dresang, 2003). This may be due in part to insufficient enforcement of back injury prevention programs. New, safe work habits are not easily learned and must be consistently enforced and periodically re-enforced. If not, the injury prevention program will begin to break down and its effectiveness diminished (Donajkowski, 1993; Melnik, 1992; Smerz, 1996).

Numerous studies have concluded certain back schools are cost effective, while others have concluded back schools are ineffective and may even be harmful (see Hooper, 2002 for a review). From the perspective of an industrial safety officer looking to buy a program, it is wise to determine whether the efficacy of the program is supported by research. A brief review of the literature on back injury prevention programs can aid in determining the scope of preventative initiatives necessary for success.

Many of the back injury prevention programs reviewed that were not effective addressed only a minimal amount of training or education and little else. There is very little evidence that such "piecemeal" approaches work (Minter, 2003). Although education and training should be part of any prevention program, inappropriate education and training may, in fact, be harmful to the success of the program (Byrns et al., 2002). In a study conducted by Paul E. Terry, Ph.D and Alfred Pheley, Ph.D, (Terry & Pheley, 1993), there was an increase in patients' symptoms and utilization of health care by patients suffering from back pain after receiving an educational brochure only.

Inappropriate education and other misguided and poorly designed or researched preventative forces actually can add to the number of injuries reported, further reducing productivity.

Other studies utilizing back education only (Cherkin, 1995) or education and few other interventions (van Poppel & Koes, 1998) also found no decreases in back injuries. These studies appear to demonstrate that, although education and training are necessary, the causative forces for back injuries are numerous and must be fought on several fronts in order to be effective. That is, a set of preventative forces must be in place to reduce the effects of the causative forces.

Examples of Effective Programs
The studies that build a strong case for the efficacy of back injury prevention programs in decreasing the number of work-related injuries or reinjuries of the back have tended to be more comprehensive than the ones mentioned above (Minter, 2003). Of course, comprehensive programs will cost more and their success should be measured in real dollars saved by the company.

The potential expense of back injuries for employers is enormous and is not limited to direct costs (medical and lost-time costs). Other, indirect, costs include replacing injured workers, overtime pay, and lost productivity (Dresang, 2003). Some HR managers estimate indirect costs to be as high as 10 times direct costs (Leonard, 1994). For this reason, tracking and reporting of all prevention factors is important.

Lieyu (1993) reviewed the results of a study of the cost benefit analysis of an educational program, targeting the prevention of back injury in one California county. The program utilized an integrated combination of education, training, physical fitness activities, and ergonomic improvement. The results of the back program were decreased incidence in back-related injuries in the intervention group and cost savings for the county. Total savings, including direct medical costs and sick time costs, were $251,108. Total costs of the program, including consultation fees, ergonomic improvement, and materials, were $90,000, for a net savings of $161,108. This represents a 179 percent return on investment.

Another successful comprehensive program implemented at a hospital in Texas included four aspects:

1. All employees were required to take a pre-employment physical examination that was upgraded to include a spinal exam and a lift capacity test for those jobs where lifting more than 50 pounds was necessary.
2. New hire orientation was expanded from a half-day program to a full-day program. The orientation included information about safety and proper body mechanics when lifting.
3. Each department underwent a work site analysis for classification of physical work intensity.
4. A team was established to review all work-related injuries and an "early return to work" program was established. The program was successful in reducing the number of back injuries by 28 percent in a two-year period, for a savings of $41,529 (McReynolds, 1992).

Glisan (1993) cited an example of another back injury prevention program implemented in response to a 750 percent increase in job-related injury costs at a hospital in California. The back school included a musculoskeletal screening, training for work postures and body mechanics, and a light-duty return to work program. The incidence of back injuries fell from 33 per 1,000 to 15 per 1000 annually. Overall costs fell to $72,296 from $200,000, for annual savings of $127,704 (Glisan, 1993).

Finally, in a remarkable reduction of costs, a Florida municipality implemented a back injury prevention program that reduced the costs per back injury claim from $50,000 average from 1983 through 1986 to $800 average from 1987 through 1990 (Votel, 1993). The program consisted of extensive physical examinations, initial training, and mandatory use of back belts. Worker's compensation payments went from $160,000 in 1985 to $400 in 1987.

Summary and Discussion
Controversy has surrounded aspects of the effectiveness of back schools or back injury prevention programs for years (Hooper, 2002). BIPPs, like all health care programs, should be evidence-based. In industry, an effective BIPP should be cost effective. That is, the amount of money saved in medical costs and lost time days is greater than the cost of the program.

Koes, et al. (1994) reviewed randomized controlled trials investigating the effectiveness of back schools and found most to be of poor quality except those that were "intensive," multidisciplinary, and specialized for a specific occupational group. Several studies, such as the Cherkin (1995) study, have cast serious doubt on the benefits of purely educational or traditional "poster and off-the-shelf" video programs in treating or preventing back injuries (Cherkin, 1995; Faas, et al. 1993; Terry & Pheley, 1993). These programs are generally limited in both scope and focus. They are not job-specific and provide insufficient preventative forces (e.g., exercise training or education) necessary to overpower the causative forces of back pain.

Several studies have concluded more comprehensive back schools are effective in decreasing back injuries and re-injuries (see DiFabio, 1995 for a meta-analysis). These programs brought sufficient preventative forces to bear in order to overpower causative forces and decrease injuries in the workplace. Implementation of an appropriate program can result in real and measurable cost savings to a company.

From the literature, a template for an evidence-based back injury prevention program is proposed and the critical preventative forces are identified.

Template for a Back Injury Prevention Program
1. Pre-employment screening. A physical abilities test is recommended. At a minimum, pre-employment physicals should be expanded to include a spine exam with a postural assessment and a lift test.

2. Job-specific education. Both general and job-specific information should be included and should be presented by a qualified health professional, such as a physical therapist with industrial experience. A tour of the site is essential to prepare. Programs should be developed based on on-site job analysis and should address job-specific injuries. Generally, "one size fits all" programs are not supported in the literature.

Management should receive education, as well as workers. Content should include information about:

• Anatomy of the spine and its supporting structures
• Common causes of back injury (generally a repetitive trauma injury, site-specific causes)
• Posture (proper and improper)
• Body mechanics
• Proper lifting techniques
• Safety, the core of any injury prevention program. Prevention of injuries is the purpose of safety policies. Employees should be educated to develop safe work habits. In addition to general safety policies, information such as clearing aisles of obstructions and preparing for lifts can prevent many injuries. Safety guidelines must be consistently enforced and periodically re-enforced.
• Ergonomics. Workers and management should be oriented to the concept of making the workstation fit the worker.
• Personal responsibility. Workers must understand they have a responsibility in the prevention of injuries.

3. Job-specific training. This should be presented by a qualified health professional and should include mock workstations for:

• Body mechanics: Supervised practical application and practice
• Proper lifting techniques: Supervised practical application and practice.
• Strengthening and flexibility exercises: Benefits and demonstration; strengthening and flexibility exercises for the trunk are an important component for preventing back injuries or reinjuries.
• Proper handling techniques: Supervised practical application and practice
• Supervisor training: Supervisors must understand the causes of back injuries. It is important they respond positively with early reporting and empathy for the worker. They must understand company policies regarding safety and back school. An effective back injury prevention program must have full administrative support and sponsorship.

4. Ergonomics: Job site analysis and modification to address problems with forceful repetitive motion should be performed by a qualified health professional. Many inexpensive workstation changes and devices can reduce worker handling, pushing/pulling, and lifting stresses (Fragala, 1994).

5. Tracking and reporting: Results of the prevention program must be tracked and periodically reported. Injury rates, causes of injuries, number of lost time injuries, and number of lost time days should be tracked. Proper tracking and reporting can be useful feedback to modify programs for more positive outcomes. Early reporting of injuries may prevent the development of more serious injuries (Fragala, 1994).

Conclusions
A review of the literature and analysis of specific studies indicate back injury prevention programs can be cost effective in industry. Analysis of the research seems to indicate more comprehensive programs are more effective than less comprehensive programs. When viewed as opposing forces, it appears less comprehensive programs simply may bring insufficient preventative forces to bear on causative forces.

There appears to be a certain "critical mass" necessary to effect a positive change. The critical preventative forces identified and the subsequent template for a back injury prevention program represent a targeted safety program.

Other injury causative and preventative forces may exist beyond those identified here. Safety programs should be dynamic, comprehensive, and proactive, constantly searching for causative forces and efficiently applying opposing preventative forces. In addition, the causative and preventative forces identified may not have equal strength of force. That is, some forces either causative or preventative may be stronger than others. Future empirical research is necessary to: 1) identify additional causative and preventative forces of injury, 2) quantify strength of forces, and 3) adjust the critical mass of preventative forces necessary to overcome causative forces.

For now, however, HR managers may review the present template for a back injury prevention program when designing their company's safety program and assess their own organizational causative forces to modify as necessary.

This article originally appeared in the June 2004 issue of Occupational Health & Safety.