"THE HEART OF THE MATTER"
a special program of the National Emergency Medicine Association (NEMA)


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Week: 587.7 

Guest: Dr. Lawren Daltroy, Brigham & Women’s Hospital, Boston 

Topic: The "back school" doesn’t really help 

Host/Producer: Steve Girard  

NEMA: Makes sense....if lower back injury and pain is a reality in your job...wouldn’t it be good to get some instruction on how to avoid it? That’s what many companies around the world thought...and set up special programs to teach people how to perform a variety of work and everyday activities without hurting the lower back. With us today is the associate director of the arthritis center at the Brigham and Women’s Hospital in Boston, Dr. Lawren Daltroy...who’s done a study on whether so called "back schools" make a difference, healthwise or economically....  

DALTROY: Last week, the Archives of Internal Medicine came out with an article that pegged the cost of low back injuries on thejob at 42 point 9 billion dollars a year to the United States in 1992. You compare that with AIDS...30 billion...and you can see what kind of problem it is. Most people tend to have lower back injuries...they’re what we call soft tissue injuries...they’re mainly muscle strain or ligament strain....and they do tend...most of them tend to heal up by themselves within a few weeks.  

NEMA: Tell me about the development of ‘back schools’...even though they’ve been around a while, many people may not know how many companies have tried to prevent these back injuries...and the huge costs they create.  

DALTROY: Sure...well, back schools were invented originally in Sweden in 1969, and exported very quickly tothe United STates. And they were developed by physical therapists who were trying to do something that would help chronic back pain patients just get on with their lives. And they’re basically a set of classes that you can have with a small number of people, and people are taught proper posture, pain management, how to lift things, how to sit, how to sleep at night, how to lift a baby, how to carry the groceries...y’know, anything you could think of that we might use our backs for. And there is some evidence that these things can be useful for people with chronic back pain, but it’s not overwhelming that this is a cure-all. And despite this, industries kind of jumped on this in the 1970’s and 1980’s as a way to help them contain costs for all of these back injuries, which I just mentioned cost 42 billion dollars in ‘92, but the trouble is that nobody had ever really tested this out in an industrial setting to see if it really did make a difference. There was just an assumption that, "If it’s good for patients, it must....if we train everybody, then maybe we could prevent injuries".  

NEMA: And your study has just been published in the July 31st edition of the New England Journal of Medicine. Tell us about what happened and what you found...  

DALTROY: So, what we decided to do, starting in the early 80’s, was to give one of these programs a rigorous test...in what’s known as a ‘randomized controlled trial’, where you assign some people at random to get the training, and other people to not get the training...and then you follow them up and compare. So, we...what we did was we surveyed the back schools in ...around the country - there were over a hundred at that time in the early 1980’s - and we kind of tried to take the best of what was out there, and then build on it, and develop what we consider to be kind of a ‘Cadillac’ back school....which had everything that you could think of going for it. And we tested this out in the United States Postal service general mail facility here in Boston, which has about 4 thousand workers. And we trained half the workers, and the other half we had serve as controls, and we gave them reinforcement regularly...and tried to work with supervisors, tried to change things like chairs and shelf heights and make the environment better. And we found after following people for 5 and a half years that there were no differences between controls and experimentals in the rate of injuries, the length of time off per injury, the cost per injury, or the liklihood that you would have a re-injury when you came back. Even if we gave them refresher training when they came back. So, our conclusion was that the policy of training everbody at a company is not an effective way to reduce back injuries. And I have to be careful to say that this doesn’t mean that I think back schools don’t work...what I think it means is that back schools should be limited to people who have a current back problem and who are motivated...and other research shows that it really needs to be tied in with a good exercise program. But just to train everybody across the board really doesn’t appear to be a good way to spend out money.  

NEMA: So, how do we better spend our efforts toward preventing back injury...or dealing with it in the workplace after someone is injured?  

DALTROY: Well, I think there’s a couple of things that can happen...one is that there’s kind of a psychology of being engaged in the workplace, and if people stay off of work too long, then they kind of stop thinking of themselves as workers. And so, from what I’ve seen, companies that reach out and try to get people back as soon as possible, even if it’s having a light work job...where they come back and do something else for a while until their back is 100%...those types of programs seem to be fairly helpful, just keeping people engaged in work, making them feel like this is part of their lives. I think that you need to be able to do something specifically around the activity that was bothering you, unfortunately there’s a lot of things that can bother your back. So, for instance, lifting and twisting regularly can bother your back...and that becomes a risk factor for injuries. On the other hand, if you design a machine that does the work, and then you sit in a chair and run the machine...then sitting in the chair all day is also a risk factor for your back. So the conclusion that I draw from that is that we’re not meant to do the same thing all day, everyday. So, one of the things that I think is very important, but also very difficult to do today in modern industry, is to have some flexibility on the job. If your back is bothering you, you do something else for a while. You have a variety of tasks that you perform throughout the day. Unfortunately, this is not the way most of our jobs are designed.  

NEMA: What are some of the techniques that industry uses to lessen the risk of injury on the job...?

DALTROY: There’s a lot of stuff that’s common sense from the biomechanical point of view. When you lift things, you need to hold them closer to you. The farther out... just think of a see saw...the farther out someone is on the see saw, the more force they exert on the other end? Well, the farther out you hold something from you, the more force it exerts along the length of your arm...which is taken up by the lower back. So, holding things close to you...not twisting, but rather turning on your feet can make a big difference. Having your knee, when you sit, having your knee elevated so its at least the height of your hip, can be very useful. If you notice, when you go into a bar...there’s that railing where people stand, and you can put one foot up? Well, that does the same thing...it lifts the knee a bit, which tends to flatten out the curve in the lower back, and reduce the strain. So, having that type of footrest...if you’re standing someplace, like on an assembly line, can make a difference for your lower back. Having shelves at a height where you don’t have to stoop or reach up too high. All of those types of things can make a difference, and it can help to have ergonomics engineers go through a place and kind of redesign it along that basis.  

NEMA: Were you surprised by the results of the study?  

DALTROY: Well, knowing the literature, I wasn’t really surprised but I was disappointed...because I would have liked to design something that worked, and saved people a lot of money. But very often, when you put things up to a very rigorous scrutiny that kind have a lot initial enthusiasm by their proponents, they don’t turn out to do as well as you might like.  

NEMA: How did what seemed like such a good idea turn into a dead end?  

DALTROY: Essentially...only two workers per hundred in any given year will have a back injury...and for most people, there really isn’t enough motivation to make all these little behavioral changes and modifications unless they’re in pain. And I think that has a lot to do with the lack of success of this kind of program for the general working population, and why it can be useful for motivated people who are in pain.  

NEMA: Dr. Lawren Daltroy...the associate director of the arthritis center at the Brigham & Women’s Hospital in Boston. 30 to 40 percent of workers’ compensation costs in the U.S. and Canada are attributed to low back injuries and conditions. People in both countries hobble to doctors 30 million times a year for diagnosis and treatment of back pain. But it seems that making the situation cost and hurt less has more to do with variety in the workplace than in learning to lift safely. Again, the study on back schools appears in the July 31st edition of the New England Journal of Medicine.  

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NEMA: Thanks for joining us for today’s program. If you have any comments or suggestions, contact this station. Or visit our home page at: www.nemahealth.org/ ...for a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I’m Steve Girard at The Heart of the Matter.