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Back Pain in the Workplace (1996)

Back Pain in the Workplace (1996)

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British Journal of Rheumatology
1997;
36:
260–264
OCCUPATIONAL MEDICINE & RHEUMATIC DISEASESSERIES EDITORS: H. AVERNS and M. WEBLEY
BACK PAIN IN THE WORKPLACE
N. RATTI and K. PILLING*
Institute of Occupational Health
,
University of Birmingham
,
Edgbaston
,
Birmingham B 
15 2 
TT and 
Rover Group Ltd 
,
Longbridge
,
Birmingham B 
31
TB 
K
 
: Back pain, Workplace, Management, Occupational disease.
L

back pain in the workplace takes up a highpercentage of the occupational physician’s time; it iswidespread across many occupations, from heavyindustrial through to light office work.There has been much research into the field of backpain looking at various aetiologies, the epidemiology,the effects of new and existing legislation, and thesuccess of different treatments. Despite this, if anemployee is absent from work for
q
6 months withback pain, there is only a 50% chance of him returningto work. This decreases to 25% if the absence is overa year [1]. In this paper, we review current literature,attempt to clarify some grey areas, and show how anoccupational health service can tackle this significantproblem. We also discuss the current management of low back pain as practised at the Rover Group.EPIDEMIOLOGYBack pain occurs in
0
80% of the population atsome stage during their working life. Of this 80%,fewer than 1% have a serious disease (primary bonecancer, paravertebral abscesses, arthritis, trauma orcauda equina lesion) and fewer than 5% have aprolapsed disc—the majority of which do not needsurgery. Most of what remains is encompassed underthe umbrella term mechanical back pain, althoughonly a proportion have a definite mechanicaldisturbance.This is not simply a new problem that has sprung outof the Western World in the last century due toincreasing industrialization. The first recorded case of occupational back pain was a patient of Imhotep, aconstruction worker on one of the pyramids in 2780

[2]. Back pain as a workplace injury in the UK was firstnotified in the nineteenth century and the cost sincethen has escalated. The cost of low back pain in the UKhas been estimated at £2000 million/year (1987–88) interms of lost output [3]. In the USA, it has beenestimated that the cost in terms of medical expenses of each back care patient is $18 000 and an additional$22 000 can be added in terms of interrupted incomeand loss of related benefits [4].Nurses appear to be the most common occupationalgroup studied epidemiologically. A French studypublished in 1994 followed up 469 nurses for a periodof 10 yr in six public sector hospitals. Usingquestionnaire analysis during that period, they foundthat 57.9% had suffered some back pain and 40.5%had chronic relapsing back pain. From longitudinalanalysis, the authors concluded that not only wasphysical workload a risk factor, but also other factorssuch as smoking, psychological stresses at work andeven the length of commuting [5]. A furtherinvestigation into back injuries among nurses showeda 3.7 times greater prevalence among nursing personnelwho performed stressful patient handling taskscompared to those who did not [6].RISK FACTORS
Previous back injury
A study looking at possible predictors in pre-em-ployment screening showed a history of previous backinjury as the most important risk factor for futureproblems. This was supported by a recent paper whichstated that a previous history of back trouble was amuch stronger predictor of future risk of back paincompared to any anthropometric data [7]. We believethat an applicant with a history of back pain within thelast year should be seen by an occupational physicianbefore being passed fit. Heap [6] showed that auxiliarynurses had a higher incidence of back injury comparedto trained staff, probably due to delegation of manualtasks. It is no surprise that all NHS trusts have madelifting and handling courses compulsory, and sometrusts are introducing a no-lifting policy.
Work
-
related risk factors
In industry, low back pain has been the subject of many studies looking at work-related risk factors. Riskfactors looked at include the following.
a
 ) 
Heavy physical 
/
manual work
. There have beencross-sectional studies looking at an associationbetween heavy physical work and radiographicallydetectable lumbar disc degeneration [8, 9]. Some of these have found an association, but other extrinsicfactors may have provided a bias in these studies.Indeed, the Clinical Standards Advisory Groupguidelines on low back pain [1] only recommend anX-ray if a clinical ‘red flag’ is breached. These includeage at onset
Q
20 or
q
55 yr, a past history of cancer,
Submitted 26 September 1996; accepted 29 September 1996.Correspondence to: K. Pilling, Rover Group Ltd, PO Box 41,Longbridge, Birmingham B31 2TB.
=
1997 British Society for Rheumatology260
 
RATTI AND PILLING: BACK PAIN IN THE WORKPLACE
261
F

. 1.—Repetitive bending is a feature of most car assembly jobs—workers need to be fit.
weight loss, constitutional symptoms, and widespreadneurological signs. X-rays and magnetic resonancescanning in mechanical back pain can be veryambiguous and, despite the apparent reassurance of normal radiological investigations, this can prove to becounterproductive in the management of individuals.Such individuals can quite easily cross over to chronicillness behaviour and long-term absence withoutproper care [10, 11].
b
 ) 
Manual handling
. Manual handling carries asignificant risk of back injury resulting from overload-ing of tissues if the technique of lifting is incorrect. Thishas led to regulations making the employer responsiblefor the teaching of correct lifting methods to theemployee, which are discussed below. A study carriedout on men aged 18–55 yr who lifted at least 20 kgmore than twice a day showed that they were atincreased risk of low back pain [12]. A study of three-dimensional dynamic trunk movements, coveringover 400 industrial lifting jobs in 48 industries, showedthat an increase in dynamic factors such as loadmovement, lifting frequency and trunk twistingvelocity in association with a high-risk job magnifiedthe risk of low back pain by 11 times [13].
c
 ) 
Twisting and bending
. Twisting and bending withloads is a significant risk factor. Video analysis of workers in various industries has shown that the moresevere the trunk flexion whilst carrying a load, thegreater the likelihood that a back injury will occur. Atvarious industries, including Rover Group, ergonomicshas grown in importance. At Rover, associates(employees) are taught the importance of ergonomicsand improvements in certain work processes aresuggested, thereby decreasing the incidence of musculo-skeletal problems.
 ) 
Whole
-
body vibration
. Whole-body vibration inmotor vehicle driving has been found to be a risk factorfor low back pain. Vibration in motor vehicles oftencoincides with the natural frequency of the lumbarspine, thus rendering tissues vulnerable to injury fromresonance. Combined with drivers taking loads to andfrom destinations, this can lead to increased incidenceof low back pain [14–17].
e
 ) 
Trauma
. Trauma to the back may result inlong-term mechanical and psychological effects evenwhen the acute injury has healed. Some cross-sectionalstudies have shown back accidents as a causal factorfor back problems. A general population surveysuggested that 16.5% of sciatica and 13.7% of mechanical back pain was due to trauma [18].
 ) 
Psychosocial factors
. Low job esteem, highworkload, low control and pressures from managers allplay an important role in the psychological aspects of back pain. Cross-sectional studies have shownmonotonous work and working under pressure to beparticularly associated with back pain [4]. Indeed, ourexperience within motor manufacturing has shown thatindividuals with low job esteem are the most difficultto rehabilitate.INDIVIDUAL RISK FACTORSHeight, weight and age have been studied as riskfactors, and have not shown any significant associ-ation. Smoking is a habit which crosses variousoccupational groups. Some studies have shown anassociation with low back pain even though some of the evidence is contradictory [19]. Animal studies haveshown that exposure to smoking impairs nutrition of the disc, causing metabolic changes to the disc whichcan last up to 3 h. This can lead to increased changesand hence injury.SOCIAL CLASSThe incidence of back pain is linked to a lack of educational level. Those in social class 4 and 5 havea higher frequency of low back pain, which can beattributed in part to heavy manual jobs. However, alack of understanding of back pain and its natural
 
BRITISH JOURNAL OF RHEUMATOLOGY VOL. 36 NO. 2
262course, and back care education, are also important.Therefore, we have developed Backwatchers classes atthe Longbridge Rover plant, which introduce allaspects of back pain and its management to thelayman.REGULATIONSThere are three sets of regulations which deal withback pain in the workplace, which have come intoeffect since the Health and Safety at Work Act 1974[20, 21]. These are: (a) The Management of Healthand Safety at Work Regulations 1992 (MHSW);(b) The Manual Handling Operations Regulations1992 (MHO); (c) The Provision and Use of WorkEquipment Regulations 1992 (PUWE).The MHSW Regulations require the employer tomake a suitable assessment of the health and safetyrisks to which the employee is exposed, includingmanual handling tasks. This risk assessment acts as ameans of identifying any action required to control therisks.The MHO Regulations are one of the ‘six pack’of UK regulations which came into effect in January1992. The regulations state that employers shouldensure that manual handling operations are avoidedwherever possible; the employer should assess andrecord any hazardous operations which cannot beavoided, and remove or reduce risk of injury througha risk assessment. The responsibility is placed on theemployer to designate someone who is responsible forthe implementation of these regulations.The PUWE Regulations place a duty on theemployer to ensure that work equipment is designed tobe suitable for the task in hand. Any equipment thatan employer intends to install must be within theconstraints of the working environment and notconstitute a health hazard to the employee.A viewpoint article in 1994 looked at the regulationsand the incidence of back disorders [22]. It concludedthat although the regulations are based on soundscientific principles, the implementation of theseregulations has been disappointing in terms of theresults. This is borne out by the continuing rise inincidence and cost of back pain.A cursory glance at the recent Olympics, and inparticular the weight-lifting competition, would revealhow important lifting techniques are. Nobody issuggesting that employees should be lifting loads overthree times their body weight, but poor lifting methodsobviously increase the risk of injury. Advice on how tolift correctly is to be found in the MHO Regulations.Employers should also ensure that there are plenty of visual aids around on this topic in areas where suchtasks are performed.ERGONOMICSErgonomics is the study of human movement andthe co-existence of humans and machines in theworkplace. It has a role in the rehabilitation of peoplewith back pain, but its prime role is in relation to theprevention of back pain. This is done in three distinctphases: medical screening, training (covered above) andergonomic job design.Medical screening looks at the individual andattempts to direct that person away from potentiallyhazardous jobs, e.g. a 5 ft 6 inch person doing a job needing constant stretching over a particularheight which a 6 ft person would have no problemswith.Ergonomic job design is directed at looking at the job concerned and changing it in an attempt to reducethe hazard at source. There are two principles involved:change the work organization to decrease thefrequency of exposure to problem tasks or producechanges to the workplace to reduce the severity of thetask. The latter is the most obvious area whereergonomic job design can contribute.Various studies have looked at ergonomic interven-tion. Gravelling
et al 
. [23] looked at physical andphysiological stress in coal face operations, andconcluded that postural muscle loading was asignificant factor in modern mining. Machine designwas found to be a particularly important causativefactor in postural muscle loading and stress, sochanges to machine design were recommended.Various ergonomic studies have led to industryrealizing the importance of teaching such principlesto employees. It is now commonplace to haveergonomic external consultants visiting industrialsettings to pass on ergonomic principles.
The Rover Group experience
We have introduced a system at the Rover GroupLongbridge plant with the help of our Germancounterparts at BMW. This is an ergonomic riskassessment called ABA (Associate Job Analysis) andtakes into account various activities at the workplace.There are 26 criteria measured, including requiredheight, mobility of arms, overhead work, lifting andcarrying, noise, climate, lighting, shift work and riskanalysis. Values for illumination, noise and weightscarried are recorded.A scoring system has been devised, allowing atrained assessor to tick particular boxes on a formaccording to the criteria being measured. By ticking abox with one of three abbreviations, decisions can bemade to adjust a particular workplace activity toreduce the chances of injury. The abbreviations are asfollows: g=design objective met; a=action required;r=high-priority action required. All criteria of a jobcarrying an r rating are immediately acted upon,whereas an a rating, if in isolation, would be addressedless urgently unless this was an environmental factorsuch as noise or lighting. This allows the assessor toidentify particular problem areas and recommendaction.This system has only recently been devised, but weare hopeful that it will prove successful in identifyingpotential problems.We have a working population of 17 500. Theoccupational health service includes two occupationalphysicians, two sessional GPs, three physiotherapists,

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