Upon conclusion of this course, students will be able to:
Describe how lifting, posture, and body position can give rise to chronic pain syndromes;
Define modifiable associated risk factors for back pain;
Identify specific mitigation and prevention strategies;
Understand the role of provider education and how departments can help.
The suggestion that the back is fragile or easily injured is not only false but provides a foundational belief that can negatively influence the pain experience.
Warnings about lifting mechanics and avoiding heavy loads are common in publications, public service announcements, and educational courses. For example, it has been suggested that lifting while bent over (stoop lifting), rather than with the back as vertical as possible (squat lifting), increases loading on the spine. Stated in different terms, lifting with a “neutral” spine to avoid flexion or extension is commonly recommended. More terms that augment the association of threat with lifting, such as “shearing the spine” and “microtears,” may be used in educational materials designed for the lay reader.1 There is evidence that suggests giving individuals negative information prior to exercise causes increased pain during activity.2
A study in 2016 evaluated loading of the spine in four patients who were implanted with lumbar vertebral body replacements with integrated force sensors. Spinal forces were measured during both stoop and squat lifting. The mean difference in loading between the two techniques was found to be only 4%.3 This raises questions about the significance of such a difference and whether it is a sufficient explanatory factor in injury risk. Biomechanical factors of spine posture (thoracic kyphosis and lumbar lordosis), pelvic tilt, and leg length discrepancies are also not clearly associated with the development of back pain.4–6
While correlative relationships with occupational lifting have been hypothesized, no causal link has been established. A 2010 review including 35 studies concluded, “It is unlikely that occupational lifting in general is independently causative of LBP [low-back pain] in the populations of workers studied.”7 A 2012 review found no clear dose-response relationship between occupational lifting and back pain.8 A 2011 review concluded, “Although occupational physical activities are suspected of causing LBP, findings from the eight [systematic review] reports did not support this hypothesis.”9
These systematic reviews do not suggest experiencing pain during lifting at work doesn’t happen—it most certainly does. However, while the pain is experienced during lifting, the experience of pain is likely to be multifactorial rather than a simple and direct consequence of lifting alone.
In contrast to common recommendations, lifting technique and supportive devices as isolated interventions may not be as effective as they seem. A 2008 meta-analysis of nearly 18,000 workers in 11 studies, eight of which investigated patient moving, assessed both education on lifting techniques and lifting equipment. The authors concluded: There is no evidence to support use of advice or training in working techniques with or without lifting equipment for preventing back pain or consequent disability. The findings challenge current widespread practice of advising workers on correct lifting technique.10
All of this is not to say one should pay no attention to the way they lift or avoid the use of available lifting devices. Power stretchers, for example, are associated with a reduction in the risk of musculoskeletal injury.11 Rather, these findings suggest lifting technique instruction and special equipment may be less successful as isolated interventions. Given that back pain is always a multifactorial experience, interventions targeting risk reduction must focus on additional contributing factors. EMS professionals should remain attentive to departmental policies on the use of lifting equipment and moving patients.
Numerous modifiable factors associated with experiencing back pain among EMS professionals have been defined.
Self-reported state of health is highly influential, with EMS professionals reporting “fair/poor” and “good” health being 5 and 2.5 times more likely to experience back pain, respectively, compared to those reporting “excellent” health.12 Compared to EMS professionals reporting a normal body mass index (under 25 m/kg2), those who had obesity (BMI over 30 m/kg2) were twice as likely to experience back pain.12 Similar observations have been noted among firefighters, where high body mass index is predictive of both musculoskeletal injury and job-related disability.13–15 Failing to meet the CDC Physical Activity Guidelines for Americans16 was associated with a 1.5 times higher odds of experiencing back pain.12 Obesity and inactivity as risk factors for back pain in EMS professionals correlate with known risk factors in the general population.17–19
The odds of experiencing back pain are also associated with several work-life characteristics, including dissatisfaction with the EMS profession and a particular job assignment and intention to leave the profession.12 This generates the hypothesis that back pain could be a factor in attrition from the EMS profession; however, this has not been directly investigated.
While not specifically investigated among EMS professionals, fatigue and poor sleep are associated with 2–3 times higher odds of experiencing back pain, respectively. Unfortunately, nearly half of EMS professionals report severe fatigue at work and suffer from significantly worse sleep quality compared to the general population.20
Several agency-related factors are associated with general injury risk, including higher call volumes and urban work environment.21 Age, race, marital status, certification level, and transport versus nontransport agency have not been associated with development of back pain among EMS professionals.22
Prevention, Risk Reduction
A 2016 meta-analysis of interventions to prevent low-back pain found that exercise alone, or in combination with education, was effective in reducing episodes in the short term and reducing sick leave due to low-back pain.23 Ergonomic interventions, shoe insoles, and back belts were not effective in the general workforce.23 General data on interventions for the prevention of low-back pain is not robust,24 so it is reasonable to emphasize programs to improve modifiable, known risk factors.
At the time of this writing, no published studies of fitness interventions for injury-risk reduction in EMS professionals could be found. Fitness interventions in firefighters may provide a useful basis for future EMS interventions.
In 2007 252 firefighters with the Howard County (Md.) Fire Department were enrolled in a physician-organized wellness regimen with the goal of improving compliance with the National Fire Protection Agency’s 1582 Standard on Comprehensive Occupational Medical Program for Fire Departments.25 After the NFPA test each firefighter met with a physician who utilized motivational interviewing to help the firefighter develop a wellness plan. Each firefighter developed a plan to perform at least 120 minutes of weekly cardiovascular exercise, received baseline laboratory testing, and was counseled on smoking. Exercise equipment was available at each station, and participants were offered personal training, nutrition counseling, and exercise time during the workday. Injuries were reduced by 40% in the first nine months and by 60% by 24 months after implementation. Estimated cost savings from reduced injuries was $322,080 the second year after implementation, with a return on investment of nearly $5 for every $1 invested.
For the individual, evidence-based education about low-back pain is the first step. Several additional individual risks factors should be a focus of attention.
Obesity is a significant risk factor for musculoskeletal injury and back pain in EMS professionals and firefighters.12–15,26 More than half of EMS professionals experience obesity, a rate higher than the national average.27–29 Physical activity is protective against both obesity and on-duty injury; however, fewer than half of EMS professionals meet even the aerobic component of the Physical Activity Guidelines for Americans, with even fewer meeting the strength component.
EMS professionals should strive to meet the Physical Activity Guidelines for Americans. These consist of three main tenets:
Move more than sit, as some activity is better than none;
Perform moderate or vigorous muscle-strengthening exercise at least twice a week;
Perform at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity aerobic exercise per week.
With any injury at work, follow departmental protocols for occupational health evaluation, treatment, and return-to-work procedures. Remember, the vast majority of cases result in recovery within a few weeks. Fears, beliefs, and behaviors affect the pain experience, the risk for developing persistent pain, and the speed of recovery.
Education is key. There are two first-line treatments with the best evidence for recovering from an episode of back pain: 1) Remain active and 2) understand the nature of low-back pain.24
Understand most low-back pain does not have a specific tissue-level cause. Pain may be experienced while staying active, but this is not an indication of ongoing tissue damage or harm.30 Understand that most back pain resolves within a few weeks without need for prescription medications, injections, or surgeries.24
Acknowledge and work to reframe catastrophizing thoughts (believing something is worse than it actually is) and kinesiophobia (fear of movement). Understand that behavioral responses to an acute pain episode can improve its outcome (self-efficacy). Manage risk factors—inactivity, obesity, fatigue, depression, and anxiety. Stay active.
Increased physical activity is both protective against experiencing back pain and plays a role in managing obesity and decreasing the experience of pain.31
How Departments Can Help
Culture change is necessary to reduce the burden of back pain and injury. Evidence-based education on the experience of pain, implications of injuries, and a focus on modifiable risk factors may be helpful.
Departments should encourage EMS professionals to engage in regular physical activity. For maximum benefit, the goal should be meeting or exceeding the Physical Activity Guidelines for Americans. However, if this is not feasible for an individual, there is no minimum threshold of exercise required for benefit. Any amount is better than none.
While specific types of exercise may confer different benefits, the best type of exercise is one that will be performed regularly. Department physical fitness standards may be helpful in encouraging an active culture, but new standards should be implemented in a positive, nonpunitive manner. The goal is to encourage more activity rather than punish those less fit.32
Creating social contracts with peers or using a buddy system to be held accountable for achieving fitness goals is strongly associated with increased physical activity and aerobic capacity.33 Fitness and weight-loss challenges may be helpful.
Departments should consider interventions to mitigate fatigue, improve job satisfaction, and provide resources for depression and anxiety.34
Back pain is common worldwide and the most common work-related injury experienced by EMS professionals. Pain is a complex experience related to the perception of threat. It is influenced by a number of factors beyond tissue-level changes: fears, beliefs, behaviors, other biological factors, and past experiences, among others. Understanding those factors that affect the pain experience, including catastrophizing, fear avoidance, and self-efficacy, can play an important role in modifying behavioral responses to pain and ultimately improving outcomes.
A number of individual risk factors affect the experience and outcome of back pain, including physical inactivity, obesity, and fatigue. Lifting techniques and equipment may not be helpful as isolated interventions, and attention to pain education and personal risk factors is needed. Further research may help identify beneficial interventions for EMS professionals.
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Michael W. Supples, MD, NRP, is an academic emergency medicine physician and EMS fellow at the Indiana University School of Medicine and a deputy medical director in Indiana. He is a nationally registered paramedic and was formerly an AEMT with a fire-based EMS service.
Austin N. Baraki, MD, is an academic internist and assistant professor of medicine at Brooke Army Medical Center in San Antonio, Tex.