Correspondence
An Educational Program to Prevent Disabling Low Back Pain
N Engl J Med 1997; 337:1923-1925December 25, 1997
- Article
To the Editor:
In their study of occupational back injuries, Daltroy et al. (July 31 issue)1 show that gains in knowledge can fail to result in improvement in practice or outcome. This is certainly familiar to clinicians who attempt to encourage weight reduction and smoking cessation. In his accompanying editorial, Hadler,2 who has written extensively on back pain in the workplace, misrepresents this finding to belittle the role of ergonomic factors in causing low back pain. While laudably calling for more attention to job satisfaction, “styles of management, job security, and group dynamics,” he ignores a large body of epidemiologic literature on low back pain that clearly delineates a constellation of risk factors that include job tasks (such as heavy physical work, lifting, twisting, prolonged sitting and standing, and accidents), personal risk characteristics (such as age, anthropometry, and structural abnormalities), and factors that reflect the organization of work.3,4 It is not a mystery to those who fully appreciate the meaning and nuances of incapacitating pain that workers who have intermittent back pain should find pain does not diminish their job satisfaction whereas workers with incapacitating back pain have a contrary view. It is self-evident that back pain can be rendered intolerable by the physical demands of a job, which cannot logically be equated with voluntary activities that range from “prolonged slouching, lifting groceries . . . [and] body building to golf.”
By minimizing the relation between work practices and disabling back pain, Hadler challenges the need for compensation for the more than 600,000 cases of disabling back pain that occur each year among American workers. A more pragmatic remedy would include effective prevention based on studies of such work practices and ergonomic interventions as task rotation, simple mechanical adjustments, proper illumination, and the rate of repetitive motion. Efforts to undermine the practice of compensating injured workers only makes a serious problem worse.
4 ReferencesEugene Schwartz, M.D., M.P.H.
Ralph E. Yodaiken, M.D., M.P.H.
Rosemary Sokas, M.D., M.O.H.
Occupational Safety and Health Administration, Washington, DC 202101
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
Full Text | Web of Science | Medline2
Hadler NM . Workers with disabling back pain. N Engl J Med 1997;337:341-343
Full Text | Web of Science | Medline3
Bernard BP. Musculoskeletal disorders and workplace factors. Washington, D.C.: Department of Health and Human Services, 1997. (DHHS (NIOSH) publication no. 97-141.)
4
Hagberg M . Exposure variables in ergonomic epidemiology. Am J Ind Med 1992;21:91-100
CrossRef | Web of Science | Medline
To the Editor:
The findings of Dr. Daltroy et al. show the failure of educational programs to prevent low back injuries. This should come as no surprise to anyone who has attempted to improve his golf swing or tennis game. The distinction between imparting information and changing behavior is fundamental to the practice of medicine. Training in the absence of a high level of motivation and without vigorous one-on-one reinforcement may make the trainers feel good but is almost certain to fail in bringing about behavioral change.
If imparting information alone worked, then getting cigarette smokers to quit and our obese patients to lose weight would be simple matters (and I would be competing in the PGA). Dr. Daltroy and colleagues have confirmed my suspicion that back-school educational programs are ineffectual when they are offered without some commitment to behavioral change.
Now we can get on with the real work of being certain our employees lift properly — or, better yet, engineering hazardous lifting out of the work site entirely to minimize lower back disabilities, Dr. Hadler's editorial notwithstanding.
Jerry H. Berke, M.D., M.P.H.
W.R. Grace, Cambridge, MA 02140Author/Editor Response
The authors reply:
To the Editor: Dr. Berke writes, “The distinction between imparting information and changing behavior is fundamental to the practice of medicine,” and implies that our program to prevent low back injuries in postal employees was designed primarily to impart information, in the hope that behavioral change would follow. We differ with this assessment.
Our program was designed explicitly to produce voluntary changes in behavior1,2 that were consistent with good health-education practice, using an intervention planning model3 that addresses the predisposing, enabling, and reinforcing factors affecting behavior. The program provided much more reinforcement for behavioral change than the typical industrial back-school program. Its failure to achieve long-term behavioral change reflects difficulties in changing a multitude of personal, social, and environmental factors that affect the performance of sitting, standing, and handling of loads. We look forward to seeing what methods Dr. Berke will propose to make “certain our employees lift properly.” Even though various postures and physical maneuvers have been shown in the laboratory to reduce lower-back loads, there is no proof that these would be effective in reducing injury in daily practice, even in the best-designed program.
The likelihood of “engineering hazardous lifting out of the work site entirely to minimize lower back disabilities” is slight, given that many ergonomic fixes result in unforeseen negative consequences (workers who sit for long periods at machines designed to do their lifting for them may also be at high risk). Long-term solutions will probably come from some combination of ergonomic engineering, voluntary changes in behavior, and job reorganization that reduces prolonged exposure to repetitive tasks and postures. Our point in the article1 was that educational programs designed to prevent back injuries by themselves are not effective.
3 ReferencesLawren H. Daltroy, Dr.P.H., M.P.H.
Maura D. Iversen, S.D., M.P.H., B.S.P.T.
Matthew H. Liang, M.D., M.P.H.
Brigham and Women's Hospital, Boston, MA 021151
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
Full Text | Web of Science | Medline2
Daltroy LH ,Iversen MD ,Larson MG , et al. Teaching and social support: effects on knowledge, attitudes, and behaviors to prevent low back injuries in industry. Health Educ Q 1993;20:43-62
CrossRef | Medline3
Green LW, Kreuter MW. Health promotion planning: an educational and environmental approach. 2nd ed. Mountain View, Calif.: Mayfield Publishing, 1991.
Author/Editor Response
The Grail of the “correct lift” has been both the object of a quest by occupational medicine and a tenet of our culture for much of this century. I would not have had the temerity to assault such an idée fixe without having compelling science on my side.1 Many people need to rethink their assumptions.
Back pain is not at issue. Rather, the issue is the regional back “injury”; meaning disabling back pain that has no violent or even unusual precipitant but that proves so insurmountable it leads to a workers' compensation claim. It has long been assumed that the compromise in performance at work defines what caused such an injury in the first place. This assumption persists even though no consistent relations have emerged from thousands of studies seeking correlations between job titles and the incidence of such injuries. Even state-of-the-art ergonometrics2 can tease but meager influences of task demands out of the enormous variability; lifting frequency, load moment, lateral or twisting velocity, and trunk sagittal angle — each can compensate for the others. Leading European ergonomists recognize the futility of restructuring task demand solely on the basis of such data.3 Amelioration of the risk of regional back “injuries” will prove as elusive as have all the other empiricisms of the past decades.
Fortunately, the worker with disabling back pain need not wait forever. The relevant science is not monolithic 1; other studies have probed for influences on the incidence of regional back injuries beyond task demand. Several influences have emerged that relate to the psychosocial context in which back pain is suffered. This is not to belittle the pain or impugn the worker. Rather, it calls for empathy. Realization by management and labor,4 medicine,5 and society at large 6 is long overdue that coping with regional back pain can be confounded by such job attributes as styles of management, job security, and group dynamics. If there is any primary role for ergonomics, it is to render the workplace more comfortable when we are well.
6 ReferencesNortin M. Hadler, M.D.
University of North Carolina School of Medicine, Chapel Hill, NC 27599-72801
Hadler NM . Back pain in the workplace: what you lift or how you lift matters far less than whether you lift or when. Spine 1997;22:935-940
CrossRef | Web of Science | Medline2
Marras WS ,Lavender SA ,Leurgans SE , et al. Biomechanical risk factors for occupationally related low back disorders. Ergonomics 1995;38:377-410
CrossRef | Web of Science | Medline3
Buckle PW ,Stubbs DA ,Randle IPM ,Nicholson AS . Limitations in the application of materials handling guidelines. Ergonomics 1992;35:955-964
CrossRef | Web of Science4
Hadler NM ,Carey TS ,Garrett J . The influence of indemnification by workers' compensation insurance on recovery from acute backache. Spine 1995;20:2710-2715
CrossRef | Web of Science | Medline5
Hadler NM . The injured worker and the internist. Ann Intern Med 1994;120:163-164
Web of Science | Medline6
Hadler NM . Regional back pain: predicament at home, nemesis at work. J Occup Environ Med 1996;38:973-978
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Linda M. Goldenhar, Anthony D. LaMontagne, Theodore Katz, Catherine Heaney, Paul Landsbergis. (2001) The Intervention Research Process in Occupational Safety and Health: An Overview From the National Occupational Research Agenda Intervention Effectiveness Research Team. Journal of Occupational and Environmental Medicine 43:7, 616-622
CrossRef
