Injury Prevention at Work: More Than Meets the Eye
Alwyn Cosgrove, a popular strength coach and gym owner, has been quoted as saying that we overreact in the short term and underreact in the long term to many things in health and fitness. A more recent example of this is with ergonomics education, particularly pertaining to load handling and sitting arrangements. For many decades it was (and still is) pushed as an injury prevention panacea, particularly for back and neck pain. Now the pendulum has swung and many, in wake of research showing no preventative effect of lifting education on back pain, question if ergonomics is even worthwhile (1).
In this blog, I discuss:
- The common pitfalls of ergonomic education
- How ergonomic education can be improved
- Where it fits within a biopsychosocial model of musculoskeletal pain rehab and injury prevention
Injury prevention in the workplace isn’t as sexy a topic as injury prevention in sport. However, if you work in a general orthopedic setting or with people with persistent pain, returning to work may be a goal of your client. Many clients whom I’ve treated for work injuries express a goal of injury prevention. If injury prevention in sport is something you’d like to learn more about, check out the Masterclass by Travis Pollen on Injury prevention: theory into practice.
Common pitfalls of ergonomic education
1) The premise of ergonomics and absence of the biopsychosocial model
The biggest pitfall of ergonomic education is the premise that by itself, it will prevent back and neck pain. This implies that back and neck pain are purely mechanical problems and we know from decades of study that many biological, psychological, and social factors can influence pain and that it isn’t as simple as tissue load. It is also important to note that most people experience back pain during their lives and that both back and neck pain have high recurrence rates (2).
2) Lack of postural and movement variability
One of the most common pitfalls of ergonomic education (and our approach to pain rehabilitation and management in general), is the assumption that there is a single optimal posture. While a decent amount of research has shown a correlation between prolonged postures and pain (3-4), the idea that there is one optimal posture to avoid pain has been widely refuted based on hard evidence (5-12). Plus, there is a lot of postural variability between individuals.
With this in mind – sitting education can be improved by encouraging posture changes, movement, stretching, and activity breaks rather than reinforcing the static “90/90 posture” all day. Another pitfall is the idea that there is one right way to lift objects. This is short sighted and fails to take into account the following:
- Differences in individual anatomy: Someone like me who’s 6’5” with long legs, (relatively) shorter arms and retroverted hips is going to lift differently than a 4’9” chap with peg legs. Many articles are written on why people need to squat differently and the same principles apply to lifting. Individualization applies to:
- Hip shape and squatting/lifting stance
- Arm length and grip width
- Other variables (e.g. comorbidities, strength etc)
- Differences in load lifted: A milk crate with handles that fits nicely between most people’s feet will require a much different technique than a stone or a skid which will likely require some further degree of spinal flexion to lift. See the video below for the Body Mechanics series I recorded where I demonstrate strategies for lifting different shaped loads (and movement variation in the workplace).
3) The ergonomic narrative and the nocebo effect
I’ve written extensively before on the magnitude of the nocebo effect in previous articles. Nocebo is the opposite of placebo and is relevant here given that pain can result from the expectation of pain (13). This is quite apparent with lifting education.
Some people I work with are so guarded and fearful of doing the wrong thing that their pain is more a result of fear heightening nervous system sensitivity than any actual tissue damage. Don’t get me wrong, the semi-retired powerlifter and the part of me influenced by Stu McGill, is pretty particular about lifting technique, but there’s a right way and a wrong way to coach it.
Some examples of things not to say are:
- “Don’t do that, you’ll blow your back out.”
- “You’re going to hurt your back lifting that way.”
- “My uncle lifted that way and he got a slipped disc. He’s never been the same.”
Better ways to coach involve focusing on performance. Many of my clients not only find this more comfortable than what they were doing before but also find it easier to move the same level of weight. By modeling lifting techniques on performance and efficiency rather than on structural preservation, I get much better bang for buck.
4) Other limitations
A) Use of brief, single session education methods (i.e. watching a video or reading a pamphlet only).
Given that patient’s struggle to retain information – is showing someone a quick video demonstration really cutting the mustard? When I introduce body mechanics with my clients, I discuss it across multiple sessions depending on the following:
- If the client is having difficulty learning the desired technique
- Client confidence is an issue
- Based on a specific symptom presentation that might make symptoms a lot better or a lot worse quickly
There is some recent evidence showing that didactic, kinesthetic and verbal feedback; along with the use of different cues than the traditional “lift with your knees, not with your back”; can reduce spine motion and load even more so than traditional methods (14-15). Whether these methods translate to reduced back pain is yet to be established.
B) Addressing lifting technique under load
If you watch the old EliteFTS “So You Think You Can Squat” and “So You Think You Can Deadlift” playlists (16) you’ll notice that in both sets of videos the technique of the lifter changes as the load gets heavier. It’s one thing to coach people how to lift an empty box. It’s another thing to coach people how to lift a heavy object or a heavy barbell.
What I like to do in these situations is:
- Ensure people can perform the lift properly
- Then (if appropriate for their goals or situation) get them up to a challenging weight.
- If form changes under load, coaching them on the correct technique both in between and during reps, and seeing if that changes things.
If the client can display great technique both unloaded and loaded – great! If the client can display great technique unloaded but poor technique with load, then the following should be considered.
C) Lack of emphasis on proper physical conditioning and management of psychosocial and lifestyle factors
From a powerlifting or strongman standpoint this is considered “weak point training.” But really, all lifting programs, be it for strength training or in the workplace, should promote both:
- Cardiovascular and resistance training exercise
- Healthy eating and sleeping behaviours
- Maintaining a healthy body weight
- Maintaining good psychosocial health
Whether these work through improved fitness, better technique, neuro-hormonal effects, better overall health, and/or other mechanisms, encouraging overall good physical health is an underrated aspect of both injury rehab and risk reduction. This area is more thoroughly researched in the sporting world. However, there is some early research on the effectiveness of these kinds of interventions in the workplace (17).
Where does ergonomics fit within the biopsychosocial model?
Ergonomics must fit within a biopsychosocial framework. Things I consider with each individual client include:
- How much emphasis I put on load/biomechanics/tissue compared to other factors (i.e. beliefs, psychosocial & lifestyle factors)
- Whether we avoid painful movements or expose into pain (within reason).
Other considerations include:
1) What is the pain presentation?
As Kieran O’Sullivan says – if it behaves like a tissue there is likely a tissue component. In this case, at least in the acute-subacute stage, I’m more apt to recommend more “joint sparing” movement strategies.
If it’s one of these cases (i.e. fibromyalgia) where everything hurts, I’m less likely to be nit picky about movement technique and I’m more concerned about just getting people moving, especially if they are deconditioned.
2) Are there psychosocial factors or avoidance behaviours?
With clients who are super avoidant and fearful of activity, particularly if it’s gone on for a while, I try to drop the nit picking and encourage more general movement. By contrast if it’s one of these clients who consistently and unknowingly “pokes the bear” (to quote Greg Lehman) or “picks the scab” (to quote Stu McGill), then we may need to address why they are working into pain so much.
3) What is the client’s injury/medical history?
Some may criticize me here but there are three populations where I use the “minimize spinal flexion at all times” approach:
- People with osteoporosis and moderate/high fracture risk: In this case the vertebrae have decreased load tolerance and very small & slow adaptation capabilities (19-20).
- People with LBP induced by recurrent flexion: While I’m never a fan of any exercise or movement being off limits, sometimes certain movements are problematic for some individuals.
- Powerlifters and olympic lifters who need spinal stiffness for their sport and are also pushing their spinal capacity to the absolute limit during their sport.
While ergonomic education shouldn’t be thought of as a panacea, the baby shouldn’t be thrown out with the bathwater. A different approach to ergonomic education, and where it fits with the biopsychosocial model of pain, needs to be applied. If prevention of injuries is something you’d like to learn more about, check out the masterclass by Dr. Travis Pollen Injury Prevention: Theory Into Practice.
As always – thanks for reading!
Want to master injury prevention?
Dr Travis Pollen has done a Masterclass lecture series for us on:
“Injury prevention: theory into practice”
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Eric, interesting blog. As a Certified Professional Ergonomist & Occupational Therapist, I appreciate your perspective of treating the patient / injured worker. Its great to see Physiotherapists hopping on the biopsychosocial model train, a model founded in the Ergonomic and Occupational Therapy professions in the 1950s. I hope you don’t mind me pointing out that ‘ergonomics’ is by definition a profession based on this model and has led research in the psychosocial field for decades. Perhaps your point is, that Physiotherapists teaching ergonomic principles have a limited understanding of the topic and profession. The Human Factor & Ergonomics Society would be more than happy to provide education if you would like and share our research on the effectiveness of preventing injury through good work design – after all, you can try to condition the worker to the work demands all you like, but it will not reduce their exposure to the hazard. Injury prevention is a risk management approach which needs to be targeted at changing the work demands to include movement, reduce tissue loading, reduce cognitive demands and provide positive social interaction. Our profession does not state there is ‘one optimal posture’ for sitting, lifting, standing – we promote variation. I agree with all of your treatment focuses, but would appreciate a more considered view of the Ergonomic and OT professions ……
Thanks – someone who is married to a Physio with a Physio Network account!