Back School's In Session

Replacing hazardous materials with safer ones is an important strategy for protecting workers and the environment.

It is second only to the common cold as a cause of lost work days, it accounts for more than $10 billion in medical and workers' compensation costs annually and it afflicts more than 90 percent of all adults at least once in their lives. What is it?

The back injury.

Call it Nature's revenge for uppity quadrupeds walking erect: The unique floating-column structure of the spine and its critical triple role in protecting the spinal cord, supporting the body in an upright posture and absorbing shock are a formula for injury and pain. Weight gain, smoking (which decreases blood flow to spinal discs and to the vertebrae and surrounding soft tissues), disease, age, structural problems, physical trauma and poor body mechanics increase the likelihood of injury and slow recovery from it. The risk of injury is exacerbated by the pace of modern life.

Occupational therapist Viana Schmidl, occupational medicine coordinator for the HealthSouth clinic located in the Emory University Spine Center (Norcross, Ga.), observes, "In today's labor market, people are asked to do more and more. I see a lot of patients who work overtime as material handlers. Many of them are older, and when they work overtime, they tend not to take care of themselves. They become fatigued, and that's when injuries occur." Schmidl notes that deadline-related injuries aren't confined to material handlers: she frequently receives referrals for researchers and administrative staff who develop tendinitis from intensive computer work during crunch time.

Healthy backs depend upon achieving two objectives: minimizing the risk of injury and promoting back health. Health care providers, insurance carriers and employers have taken up the cause to do just that through what are variously known as back schools or healthy back programs.

These programs are either preventive or rehabilitative, but both involve, at a minimum, basic education about the physiology of the back and training in proper body mechanics. (The term "back schools" is less common today, reflecting a shift in focus from reactive to proactive care. Some providers prefer the term, however, because it reinforces the pivotal role of education in maintaining a healthy back.)

Many programs offer a menu of supporting services that can be tailored to the needs of the employee and the wishes of his employer. For example, Liberty Mutual's Rehabilitation Services Division (Somerville, Mass.)offers its corporate clients on-site workplace assessments. U.S. HealthWorks, headquartered in Alpharetta, Ga., offers patient evaluation and treatment, second opinions and expert testimony, as well as workplace evaluations. Some employers only want to distribute healthy back information at their "health week" event; others want programs that incorporate around-the-clock back health education.

As diverse as the services available are the sources of participants in these programs. Back rehabilitation programs receive patients referred by physicians and surgeons, workers' compensation and medical insurance case managers and attorneys. Employees referred to preventive programs commonly are sent by employers eager to head off workers' compensation claims and boost productivity. Ninety percent of U.S. HealthWorks' back school participants are patients with either acute or chronic occupational back injuries who are referred to the program not only by their physicians and surgeons, but by fellow patients and coworkers, as well. Liberty Mutual's Rehabilitation Services' back program is offered to local companies who are dealing with high rates of back injuries and associated claims, as well to its corporate clients.

Reasonable Expectations

Preventive back education programs are an investment that can minimize the number of people who need treatment for back injuries and can eliminate the associated medical and disability claims.

"A good program should include training in the anatomy of the spine, the problems that normally occur to the spine, basic preventive techniques in lifting, body awareness, and posture," HealthSouth's Schmidl says. "We have people practice activities and see how they feel. Then we have them compare that with another way of doing those activities and notice how that feels." The goal, she says, is to have participants better understand their own bodies and equip them with techniques to prevent injury.

Who needs preventive back health education? "Everyone needs it to a certain extent, but companies don't need to put money into it unless there are a lot of problems in a particular area," says physical therapist Virginia Hoffman, coordinator of rehabilitation services at Liberty Mutual's Medical Services Center. "Any company with a high rate of back injuries or a lot of people out on workers" compensation or people who experience repeated back injuries need seducation." She says companies that pay attention to good body mechanics may keep their workers' compensation costs low, because even individuals who have congenital back problems tend to do well in their jobs if they employ proper body mechanics.

According to Hoffman, an effective preventive program should include:

  • Employer and supervisor commitment to the program, including a willingness to adapt the workplace for individual employees, as needed.
  • Basic education in spinal anatomy.
  • Physiological problem-solving skills, including pacing techniques, that employees can try in class.
  • Basic exercises that can be used as needed throughout the workday.
  • Issues, such as smoking and diet, as they relate to maintaining a healthy back.

Rehabilitative Programs

Employers of participants in rehabilitation-based back health programs should have a completely different set of expectations from those enrolled in prevention programs. Studies indicate that back injuries that are treated medically but do not include a rehabilitation component require six to seven times more lost work days than those which include rehabilitation programs.

Kevin Trangle, M.D., medical director of U.S. HealthWorks in Euclid, Ohio, and a fellow in the American College of Occupational and Environmental Medicine (ACOEM), points out that most back injuries improve with conservative treatment, and that the old treatment algorithm of complete bed rest has been overturned by studies demonstrating that keeping patients mobile minimizes morbidity. Thus, keeping workers at home during recovery may exacerbate their back problems; however, Trangle warns that those who experience chronic pain, who have had multiple back surgeries, and who have had multiple courses of therapy may not be appropriate candidates.

He advises employers who have employees in rehabilitation programs to expect feedback from the provider. "You should know what the goals are, how long it will take, the types of modalities to be used and how often, and you should get regular progress reports," he says. "The provider should be able to tell you what you can expect and what the parameters are for you to have the employees back at work so you can either accommodate them or make [other] decisions." To facilitate a return to work for these employees, Trangle recommends that employers create detailed written job descriptions that outline whether there is repetitive lifting involved with the job, to what level objects are to be lifted, how heavy the objects are, and the like.

Employers also should expect the physician to speak with the patient about his expectations of the program, give him a realistic appraisal of what the program can do for him, what is involved and what the goals are.

An effective back health rehabilitation program has at its foundation a basic education in the physiology and mechanics of the back, paired with practical application of this information. Karen Bitzer, an occupational therapist in Rehabilitation Services at University Hospitals of Cleveland, observes that, by learning new ways to perform physical activities and comparing them with how they normally are done, patients gain insight into what is going on in their bodies and get ideas about how to manage their current pain level and strategies for preventing reinjury.

University Hospitals offers a two-hour back school each week for patients referred by their physician or workers' compensation case manager. Most have a history of back problems. Along with education in spinal anatomy, physiology and lifting techniques, patients spend time in the Activities for Daily Living (ADL) module. The module simulates a home environment and includes half of an automobile to enable patients to practice back-saving techniques of performing everyday tasks, such as driving, loading the dryer, or carrying packages. Patients are encouraged to raise questions and discuss problems they have encountered since their return to work. Bitzer adds that many participants in the program also are enrolled in the hospital's pain management, aquatic or OT programs.

Schmidl estimates that 80 percent of those with back injuries recover on their own, without further assistance. The other 20 percent of back injury victims wind up in a rehabilitation program, and their expectations must be handled with care. "Whether a person in rehab can be 100 percent again depends primarily on how bad the injury was," she says. "Therapists have to be very frank with patients, particularly those who do a lot of repetitive work, and evaluate the risk for further injury and how they are responding to therapy."

Schmidl cautions employers not to think their problems will end when they send an employee to back school. "[Recovery is] still about individual responsibility," she says. HealthSouth's commitment to the concept of the patient assuming responsibility for his recovery includes asking patients to identify their need for social services (such as psychotherapy) to cope with their back injury, since recovery can be hampered by secondary gains (i.e., a reason for holding on to that injury, such as more attention at home and work or hatred of a supervisor). Patients for whom no organic cause or consistent pattern of pain can be identified may require psychological counseling as part of their rehabilitation.

Rehabilitation programs should include strengthening and conditioning the patient so he can return to work in a healthier state, Trangle recommends, as well as applicable medical specialties, including mental health, physical and occupational therapy and biofeedback.

Signs of Hope

What should employers expect from a back school? "A realistic expectation of this kind of program is that the total number of back injuries [in your company] will go down. An unrealistic expectation is that nobody will be injured on the job," says Hoffman. She advises safety and health managers perform a cost-benefit analysis that takes into account workers' compensation rates, the number of workers' compensation claims for back injuries, and their effect on the corporate bottom line. Establishing the connection between employee health and profitability is effective in gaining the support of top management for healthy back programs.

When selecting a back health program, particularly from those with a rehabilitation component, Trangle warns that patients often enroll in programs where physician contact ends after the referral. The employer has no point of contact, no information source for current information about the patient, his prognosis, or his progress in rehabilitating from his injury. "The patient practically disappears," he says. "You need a contact, a person in whom you can have faith, and a provider within the institution to whom you can talk, one-to-one, and know what is going on and what you can reasonably expect."


For a Healthy Back

Use your head:

  • Keep your back erect in whatever you do. Move your feet; don't twist your back.
  • Use arm and leg muscles, not back muscles, when moving objects.
  • Carry objects close to your body.
  • Prejudge your positioning and the amount of force you will need to accomplish a task, in order to prepare your body.
  • Get help if a load is too heavy or awkward to handle alone.

Get healthy, stay healthy:

  • Start an aerobic activity and stick with it.
  • Do stretching exercises for
  • tight muscles.
  • Do strengthening exercises for abdominal, back and thigh muscles.
  • Reduce stress.
  • Stop smoking and avoid excesses in food and alcohol consumption.

Source: Virginia Hoffman, Rehabilitation Services Div., Liberty Mutual Group

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