Each year, American workers suffer more than 300,000 lost-time injuries involving musculoskeletal disorders of the back, with the costs running into the billions of dollars. According to Liberty Mutual researchers, 60 to 80 percent of the general population will experience low back pain. And most experts agree that, given the stew of work environments, lifestyle factors and genetics affecting back injuries, it is naïve to think that safety programs can eliminate them from the workplace. In the face of these daunting statistics, what can employers do?
As it turns out, plenty if they are willing to commit to comprehensive back injury prevention. What won't work, however, is a piecemeal, fad-of-the-month approach. Instead, experts stress the need for a multi-faceted, long-term program that seeks not only to reduce pain and injury, but also to improve workplace productivity.
Kent Wilson, CIE, director of ergonomics for Ergodyne Corp., said many companies see ergonomics strictly as an injury-reduction program and OSHA's forays into ergonomics rulemaking have only reinforced that viewpoint. But if employers look at the "big picture" of ergonomics as a way to enhance human performance, he said, they will get the biggest return on their investment. "You'll naturally reduce injuries because you can't have people being hurt and injured, and be productive and efficient at the same time," he said.
Making ergonomics a part of a company's management strategy is an excellent way to move ergonomics upstream and to garner the twin benefits of injury reduction and improved productivity, according to Wayne Maynard, CSP, CPE, director, Ergonomics & Tribology, Loss Prevention Department, Liberty Mutual Research Institute for Safety. Strategies such as lean manufacturing, Six Sigma and total quality management seek to reduce as much waste in an organization as possible, he noted. The bending, reaching and twisting associated with back and other injuries incurred on manual material handling tasks introduce unnecessary delays in cycle time and throughput.
"When jobs are designed ergonomically, fatigue is reduced, people perform at a higher level and throughput is increased. Cycle time efficiencies are introduced and those translate to cost savings and improvements at the bottom line," said Maynard.
Industrial-strength ergonomics programs, say most experts, consist of at least six elements: management commitment, employee involvement, risk identification, hazard control, training and education, and medical management.
"An ergonomics program is not sexy, but it works," said David Brodie, director of consulting for the Ergonomics Center of North Carolina. "You need a consistent, across-the-board approach. You have to hit it on multiple levels to really have a good impact."
Liberty Mutual's Maynard said that companies that want their safety director to singlehandedly prevent low back pain and reduce disability are "sadly mistaken." The safety director plays a key role in facilitating solutions, but it is "everyone's responsibility" to work to control this complex issue. "When we look at an ergonomics process, we identify gaps in the process and, if necessary, go right to senior management to have a heart-to-heart discussion," he said, asking them: "If you have back problems and disability problems, are you happy with that? Or do you want to improve? If you want to improve, here's what you've got to do."
Both management commitment and involvement are important, said Brodie. Commitment can be demonstrated through resources to purchase engineering solutions or to provide training to employees. He noted that training doesn't have to be expensive. "Get employees who are good at lifting and let them be your trainers," he suggested. That provides employees a chance to be actively involved, recognizes their expertise and shows management commitment.
Brodie also suggested having managers and supervisors serve on the ergonomics team or committee. In addition to improving their knowledge of ergonomics, he said, putting someone with power on the team speeds changes and shows the team is effective.
In its ergonomic guidelines for nursing homes, OSHA notes that workers must "buy into" the ergonomics program in order for it to achieve success. The OSHA document adds: "Employee participation is important to ensure that workers have input into the decisions regarding the equipment they will use. Employee input will certainly increase worker acceptance of the ergonomics process and specific control methods."
By including workers, said Chris Schulenberger, director of ergonomics for Clayton Group Services, companies gain valuable help in problem identification and solution. He noted that no one party has the "perfect" view of ergonomic issues. But in bringing employees into the mix, he cautioned, it is important that employers provide training so that there is common ground of communication about ergonomic issues. That way, everyone understands what a risk factor is, or what a non-neutral posture is.
Risk Identification and Hazard Control
In an article "Controlling Low Back Disability in the Workplace," written for LibertyDirections magazine, Maynard noted that risk factors for low back disability include:
- Excessive weights and forces
- Undesirable body motions (such as bending, reaching and twisting)
- Prolonged sitting
- Whole body vibration
Excessive weights and forces, he stated, are associated with "lifting, lowering, pulling, pushing and carrying tasks. They depend on a combination of:
- The weight of the object
- The hand distance from the body;
- The hand height at the start and end of the task;
- Pushing, pulling or carrying distances;
- Task frequency; and
- How long the task is performed during the working day or task duration."
Particular body motions increase the risk of low back pain, noted Maynard. They include bending over while lifting or lowering, twisting while lifting or carrying and reaching out at arms-length to pick up objects or to handle large, bulky or awkwardly shaped objects.
In manual material handling, said Brodie, the key factor will often be dimensions heights and reaches to the load. By organizing work so that workers can operate with good posture, he explained, much of the bending and reaching can be eliminated.
Our experts also noted the trap of looking at individual tasks rather than the cumulative exposure that workers encounter. A worker may lift boxes for a half hour a day, but what is going on the rest of the day? "Often, we don't look at cumulative fatigue," said Schulenberger. "What is okay for the first few hours may not be okay later."
That concept can even include previous jobs, said Brodie. For example, employees at a facility may start out in a department with a lot of lifting and then be promoted to another department, where back pain later manifests. The real stressors in the facility are in the first department, not where the employee is currently working.
This underlines Schulenberger's contention that employers need to keep asking "why" until they get to the root causes of back injuries. To illustrate, he hypothesizes a situation in which an employee has to take parts from two pallets on the floor and feed them into a machine. The job is leading to back problems for operators. The employer investigates and has a solution to his back injury problem raise the pallets and tip them. But Schulenberger said a more thorough examination might find that the root of the problem is poor inventory control and process layout, leading to the parts being "handled three or four times when they didn't need to be."
Many times, engineering controls such as conveyor systems and lift assists that reduce manual handling can be cost-justified, Brodie said, if engineers factor in the resulting productivity and quality improvements.
One benefit of simple changes to processes is that it can increase the labor pool available for a job. For example, said Schulenberger, the incremental cost between using 50 and 100 pound bags of flour or cement is not much, but "look what it does for opening up the number of people who could actively perform the job."
While training has an important role in effective ergonomics programs, experts say programs too often stop with trying to get employees to use better lifting techniques. "If you're having workers lift 200 pound sacks of concrete or whatever, you can't have then bend their knees deep enough or keep their backs straight enough to make it effective," said Ergodyne's Wilson. "They're still going to get hurt."
In its nursing home guidelines, OSHA states that ergonomics training should "enable employees at all levels of the organization...to further the ergonomics program." It recommends that employees be able to "(1) recognize the signs and symptoms of MSDs so that they can report them early and respond to them appropriately; (2) identify those jobs or tasks that have ergonomic stressors capable of causing MSDs; and (3) know how to control ergnomic stressors." OSHA said training should be provided to all employees "who are at risk of incurring MSD injuries, as well as all employees who have responsibility for implementing ergonomics policies and procedures."
In his two-day training classes, David Brodie said his goal is to get people who have been focused on production, quality and other issues to "open their eyes" and look for ergonomic risk factors. He covers ergonomic basics on the first day. The next day, he takes them out on the shop floor, armed with a simple checklist, to examine their jobs and see why they may be presenting problems. "By the end of the day, we have a list of potential solutions to start thinking about," he said.
Brodie said employers should avoid doing the same ergonomic training year after year. He suggested developing a list of topics to address, bringing in guest speakers, and involving employees through occasional contests or games. He also said revitalizing ergonomic teams not only raises the level of education and awareness for more people, but brings in fresh ideas and promotes ownership of ergonomic steps being taken.
"Every company should have a return-to-work program," said Liberty Mutual's Maynard. Employers need to reduce risk factors for back injuries as much as possible, but the job of managing disability and returning employees to productive work is equally important and can have a huge impact on the bottom line. That's why experts stress the need to return employees with back pain to the job as soon as possible.
Maynard said employers should develop detailed descriptions of jobs and their physical demands. This helps physicians make an informed assessment of what jobs the employee can do, what restriction might be placed on them and what job accommodations might be needed.
The longer employees are out with a back injury, the less likelihood they will return to work and the higher the disability costs will climb. If an employee is injured, said Maynard, "the supervisor should call or visit the employee within the first day or two, not to intimidate the employee, but to let him/her know that the company is supportive."
Maynard noted that psychosocial factors "drive pain and disability." Studies indicate that employees who are happy in their jobs are more likely to return to their jobs and actually experience less pain than those with high job dissatisfaction. So it is important, he said, to create a supportive atmosphere for employees with low back pain and avoid an adversarial situation.
Sidebar: The Smoking/Back Pain Link
Ask Dr. Rey Bosita, a spine surgeon at Texas Back Institute (www.texasback.com), what people can do to keep their backs fit, and his answer is immediate. "Stop smoking." How is smoking and back pain connected? "When a person smokes, two things happen," he explained. "First, the nicotine causes small blood vessels that feed your back and the rest of your body to constrict so less blood flow gets through. Second, smoking reduces the amount of oxygen that is in your bloodstream and also puts a few poisons in there, so it slows the healing process. Those two factors combined reduce your body's ability to withstand the microtrauma that your back goes through every day."
Bosita also stresses the importance of stretching. Stretches should include not only the spine, but also the lower extremities, as tight hamstrings and weak quadriceps can have a negative impact on the back. Aerobic conditioning also helps to fight fatigue, which can lead to poor biomechanics and then injury.
While aging plays a role in back injury, Bosita emphasized that individuals can do a lot to maintain a healthy back. He compared the process to taking care of a car or other fine working machine. "The more preventive maintenance you do, the longer it lasts," he said, "so staying in shape, maintaining flexibility, not being obese and not smoking can help a person work longer and more efficiently."
Bosita said there is a role for back belts in combination with proper lifting technique during heavy lifting. However, he advised against wearing the belts constantly. "You actually decondition the muscles around the lumbar spine because a lot of stresses get placed through the belt."
Bosita said there are good physiological reasons for returning employees with back problems to the workplace as soon as possible. "Muscles in your back will atrophy when you lie in bed for extended periods of time," he said, adding that that is a special concern for laborers who perform strenuous physical work. As a result, the goal of therapy and medication, he said, is to help patients increase their pain-free range of motion and the loads they can safely lift with good biomechanics.
Bosita said the only about 11 percent of the patients seen by Texas Back Institute physicians end up in surgery. Where possible, they prefer to treat patients with anti-inflammatory medications and exercise-based physical therapy. Bosita said enlisting employers in workplace modifications frequently is also part of the treatment program to make sure the problem doesn't recur. "Workers' comp cases have been going along pretty smoothly because there is a heightened awareness of prevention," he noted. "Employers realize a few dollars spent on prevention can save thousands of dollars in treatment later on."