Major study casts doubt on value, effectiveness of back education
Training workers may not prevent injuries
Recent medical studies may shake up how you try to prevent and diagnose work-related back injuries, casting doubt on some of the most fundamental parts of typical occupational health programs.
In this study, researchers strongly suggest there is almost no value in educating workers in the proper way to lift and avoid back injuries. They stop short of declaring back schools worthless, but they do say occupational health providers have put too much confidence in the ability of education to actually reduce workplace injuries. Workers come away with a firm understanding of the proper way to lift and avoid injuries, the study says, but they rarely apply that knowledge. Another study has called into question the commonly accepted practice of using radiographs to diagnose back problems. (See related story, p. 104.)
The education program study was a large-scale, randomized, controlled trial to assess how an education program affects workplace injuries.1 The authors say it is the largest and best-controlled study ever of back education programs. The researchers included back pain specialists, physical therapists, occupational medicine physicians, and others from Brigham and Women’s Hospital in Boston; Harvard Medical School in Cambridge, MA; Boston University; and other institutions. (For a summary of the study findings, see p. 102.)
Serious lack of long-term benefits
There are "no long-term benefits associated with training" workers in the prevention of back injuries, says Lawren H. Daltroy, DrPh, lead author of the study and associate director of the Robert Breck Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center at Brigham and Women’s Hospital. Daltroy says OH providers have taken a basically good idea educating workers and relied on it to work miracles in the workplace.
"These back schools started out as a method designed by physical therapists for chronic back pain patients. Even with those people, the back school makes very little difference for the patient’s well-being and has only short-term benefits," Daltroy tells Occupational Health Management. "People then made the leap that if these things are biomechanically sound, we can start training everybody and prevent back injuries in the first place."
Part of the problem is that workers are educated on how to avoid back injuries and then find that they cannot apply those lessons in the real world, explains James Ryan, MD, MPH, FACOEM, an OH physician and co-author of the study. He is a visiting lecturer in occupational health at the Harvard School of Public Health. The workers in the study clearly retained a significant portion of the safety information provided in the back school, but Ryan says that was not enough to overcome some hurdles on the job.
"Under pressures of the workplace, people just don’t do it no matter what you tell them," Ryan says. "The function of any company is to get the work done. If you have to get the mail delivered by tomorrow morning, and the sacks are coming down the chute and they look too heavy, people aren’t going to necessarily do what you told them to do. Workplace pressures are very real to these people, and it’s not realistic to expect them to stop and call their supervisor to ask for a second person to help lift this bag."
Daltroy agrees, saying the study shows it is much more important to change the physical work situation than to train workers how to lift properly.
"The issues are much deeper than training," Daltroy says. "Partly they’re ergonomic, and partly they concern the organization of your work. Those things aren’t new to occupational health, but it’s time to emphasize those things much more than back schools."
A key failure in the back school concept is that workers often do not have enough confidence and authority in their jobs to make it work. No matter how well they understand that a box is too heavy to lift alone, and even if the official company policy is that it’s OK to ask for help, workers may be discouraged by what they know is the real reaction to pausing to ask for help.
"You have to change the work situation so that you don’t leave it to the worker to say that the box is too heavy or rely on this overworked guy to go through all the less convenient ways of lifting a load when he has pressure from his supervisor to get the plane or truck loaded," Ryan explains. "It just doesn’t work to put all the responsibility on him." (For more on how to act on the study’s conclusions, see related story, p. 102.)
Still some value in providing back education
In addition to lifting the burden off the worker’s back, reconfiguring the workplace and work system can improve overall job satisfaction. Daltroy and Ryan stress that job satisfaction can itself be a major factor in reducing workers’ compensation costs related to low back injuries.
"It’s clear that everyone has back pain to some degree and at some point in their work career. But your level of job satisfaction makes a big difference in whether you consider it normal or treat it as a workers’ comp injury," Daltroy says. "Our system of labeling back pain a compensable injury can lower the threshold for reporting back pain, and that’s another side effect of back schools."
Daltroy says he saw that effect in his own study, although not to a degree that was statistically significant. The subjects who had undergone extensive education in back injury prevention actually reported slightly more injuries than the control subjects with no training. The researchers conclude that the education of the workers and their supervisors heightened awareness and created a more sympathetic environment for reporting injuries.
There is no need to eliminate back schools altogether, the researchers say, but they should be only part of a multidimensional approach to reducing injuries and a smaller part than currently represented in some programs.
"The bottom line is we’re not knocking back schools. But training everyone whether they’ve ever had an injury or not in hopes of preventing injuries is probably a false hope," Daltroy says. "Money should be focused elsewhere."
Reference
1. Daltroy LH, Iversen MD, Larson MG, et al. A controlled trial of an educational program to prevent low back injuries. N Engl J Med 1997; 337:322-328.
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