|No one really knows what causes back pain, agrees Stover Snook, certified professional ergonomist (CPE) and lecturer on ergonomics at the Harvard School of Public Health. There is no known cause for up to 85 percent of low back pain. We dont even know where the pain comes frommuscles, discs, ligamentswe simply dont know.
There are, of course, many opinions about the cause of back pain, but there is little supportive scientific data, Snook says. Every practitioner will be glad to tell you exactly whats causing it. The physician will tell you its a muscle strain. The surgeon will tell you its a disc. The chiropractor will tell you its misalignment. The physical therapist will tell you its muscle weakness. The psychiatrist will tell you its in your head. Everyone has a different story, but no one has the data to prove it.
Just as the causes of back problems are enigmatic, so are the solutions. Treatment varies from bed rest to exercise to manipulation, from medication to heat to cold, from traction to acupuncture to injections to surgery, Snook says. You name it, its been tried. Which is better? It doesnt make much difference who you go to or what kind of treatment you get, he says. The outcomes are about the same: 75 percent of people recover from acute low back pain within two weeks, and 90 percent recover within six weekswith or without treatment, and regardless of the type of treatment.
The fact that back pain tends to come and go on its ownas if brought on by gremlins within the bodymakes it almost impossible to ascertain whether a particular action sped up recovery. Snook quotes Voltaire from almost 200 years ago: The art of medicine consists of amusing the patient while nature cures the disease.
Given that there is no clear best manner for treating back problems, employers are probably best served by steering employees to the least expensive alternatives possibleespecially since medical outlays alone will total 40 percent of all workers comp costs this year, according to the Workers Compensation Project for the National Academy of Social Insurance.
The chiropractor and the orthopedic surgeon tend to be the highest cost per case, says Snook. The chiropractor sees them once a week for an extended period; the surgeon only once, but at a very high fee. Least expensive is the general practitioner, who prescribes some pills and perhaps exercises. Who picks up the tab? The employer; either through workers comp or health care premiums.
In a small percentage of casesperhaps 5 percent or lessemployees will require more serious treatment or examinations. If its impeding their ability to work, they need to see someone to make sure its not a rare diagnosislike a compression fracture or cancer that has metastasized to the spine, says Tom Hales, occupational physician, Centers for Disease Control in Cincinnati, Ohio.
Start with Audits
With the tremendous costs of back problems and the apparent lack of effective solutions, prevention is the name of the game for employers.
Many prevention efforts focus first on the work and how it is performed. This is where employers will reap their quickest rewards, experts say. But they shouldnt stop there, suggest the experiences of employers that have successfully reduced lost time and other expenses associated with back injuries.
Employers should be leery of quick fixes, such as the once highly touted back belts. You get manufacturers who are promoting back belts and companies buying them as quick fixes, says Marjorie Werrell, president of ERGOWORKS Consulting in Gaithersburg, Md. Ergo gizmos give ergonomics a bad name. Just because it has the label doesnt mean its ergonomics. Ergonomics is the interaction of the individual with the workplace, with the equipment and the design of the equipment. You have to consider the totality. So handing out a back belt and brushing it off as your ergonomics program is not adequate.
Attempting the wrong solutions can be costly as well as ineffective, adds Brent Clark, a partner at the law firm of Seyfarth, Shaw, Fairweather & Geraldson in Chicago. I would start with an analysis of the job, look at the injury history and figure where I am getting my injuries. Then I would prioritize.
Carriers such as Liberty Mutual, and consulting and engineering firms offer workplace audits and follow-up as a first step in workplace safety. An audit can run from one day to two weeks, and usually generates suggestions for safety improvements or job re-design.
Although precise data is not readily available, participants claim such audits cut workers comp costs when they turn the spotlight on workplace safety. The cost of an audit depends on the number of jobs and functions examined.
Some employers avoid audits because they fear recommendations for costly changes. Over 50 percent of our clients will readily admit it was their big fear that we would give them a huge laundry list of what theyd have to do and purchase, says Werrell. A large portion are surprised that they can have a functional ergonomics program without breaking the bank.
Werrell recalls a worksite where employees suffered strains from pushing and pulling carts. When we measured the force of people pushing and pulling them, the force was twice that of well-maintained carts, she says. They set up a wheel-maintenance program at minimal costs, and injuries dropped off.
Finding simple techniques for cutting workplace injuries is crucial because workers comp is one of the single biggest costs associated with back problems. Sixteen percent of all workers comp claims involve the back, adding up to 30 percent of the total costs of all workers comp claims, says Karl Jacobson, senior vice president, the Loss Prevention Department at Liberty Mutual in Boston.
And most of that money will go to a small percentage of workers comp recipients.
Liberty Mutual, the leading workers comp insurer in the United States, writes 10 percent of the business. According to Barbara Webster, researcher at the Liberty Mutual Center for Disability Research in Hopkinton, Mass., 15 percent of workers comp recipients accounted for 89 percent of Liberty Mutuals total workers comp costs. This same group missed a month or more of work; 5 percent of those on workers comp missed more than a year. By contrast, 75 percent of the individuals collecting workers comp from Liberty Mutual missed one week of work or less.
Experts agree that reducing the number of these long-term cases is the best way to cut workers comp costs. The conundrum for HR is to learn why some people in pain dont complain at all; why others complain, are treated and get better quickly; and why others linger on, soaking up resources.
Only 10 percent of workers with work-related back pain seek compensation, says Hales of the Centers for Disease Control. Since everyone gets it and everyone gets better, the question is what cases cause people to have disability?
Causation: Conflicting Theories
Eliminating injuries is a no-brainer, say ergonomists such as Purdues Jim McGlothlin. Go after the problem at the root, he advises. Engineering is the ticket, the long-range solution. And remember the 80/20 rule: Eighty percent of the costs are from 20 percent of the workforce. So start where the injury occurs; take care of the highest risk jobs first and work your way down.
Neglect engineering and job design at your peril, McGlothlin says. If your job is lifting 100-pound bags of seed off the ground and putting them into a cart, youre lifting 49 pounds more than the NIOSH lifting standards suggest. When you blow out your back, they send you to HR where they try to manage the problemput you on work restriction for a few weeks, send you to a physical therapist.
But thats only a short-term solution, he says. Then you go back to the job and hurt yourself again. Only difference is this time you never come back. Ninety percent of those who hurt themselves a second time never return to work. HR winds up with a liability problemcash settlements, workers comp. Its a huge headache, and youve failed to treat the problem at the source.
But not everyone shares McGlothlins view.
The link between a job and reported injuries is tenuous, says Nortin M. Hadler, professor of medicine and microbiology/immunology at the University of North Carolina. He is the leading critic of what he calls medicalizing back problemscategorizing back pain acquired at work as an injury and paying for medical treatment only if the pain can be positively linked to the job.
Hadler says psychosocial factors, not the job itself, are accurate predictors of who will claim an injury. Contented workers in stable, caring settings are less likely to claim injuries.
If theres any hazard to your back at work, it pales in comparison to the social issues that influence your health, he says. Facilities with low complaint rates are more likely to be staffed with supervisors who empathize and nurture, managers who show genuine concern for workers, who understand how multivariate the challenges of going to work are.
To support his theory, Hadler cites a recent ergonomics study focused on workers sorting parcels at a number of different UPS hubs. Jobs at some hubs were targeted for ergonomic interventions, others were not. There is not even a hint of an association between physical task demands and the likelihood of recorded disabling back pain, Hadler observes.
Then why do most ergonomics programs report savings? Hadler attributes it to the Hawthorne Effect, the theory that any change will improve workplace performanceat least for a while. Cornell Universitys Hedge counters: Companies that implement an ergonomics program will see decreases in injuries. Every study shows injuries go down and costs go down over a period of time. To the extent that we minimize the risk, we will make things better.
Hadlers psychosocial factors are absolute nonsense, Hedge says. Psychosocial factors is a garbage term that suggests its all in peoples head.
Even conceding some merit to psychological factors, Hedge says, its folly to start with them in mind.
Always look for the simplest explanation first, he says. Psychosocial explanations are not the simplest. I look at the work situation first. Change the physical causes and youll get results.
But Hadler is not easily dismissed, health and safety experts concede.
You cant explain Hadler away, says Ted Courtney, associate director of Liberty Mutuals Research Center for Safety and Health. Hes an important voice, a balancer. He keeps the situation from being that ergonomics is always the answer.
Either potential solutionanalyzing the physical functions of a job or ensuring that employee relations, morale and management are handled correctlyfalls squarely on HRs shoulders.
Ergonomics and the Bottom Line
McGlothlin says most large employers are committed to ergonomics programs, but middle-size and small organizations have been slower to climb on board. Often, smaller firms fear the cost of making their workplaces ergonomically sound. But the financial case for investing in safety is compelling.
Over 80 percent of the injuries we see in the workplace can be eliminated and we can get return on investment, McGlothlin says. For every dollar you invest in ergonomics, youll get a three dollar return.
Stephen Gutmann, senior ergonomics specialist at 3M headquarters in St. Paul, Minn., says theres no question that ergonomics programs pay off. He cites the following formula as proof: Total your medical and indemnification costs for a back injury with your indirect costs. Divide by your profit margin. That will give you the sales your company needs to generate to cover the cost of the injury. If you have a $5,000 injury and a 10 percent profit margin, youll need $50,000 in additional sales to cover the injury cost.
It may not be quite that simple, adds attorney Brent Clark, although he does believe there are plenty of savings to be realized. Nobody knows how much we can reduce the costs, he says. It could be 50 percent or 10 percent, but theres enough low-hanging fruit still out there that we know if we address them well get reductions.
Diminishing marginal returns is the real issue, Clark continues. Many companies begin by spending wisely, then start to chase down rabbit holes. If the intervention gets down to an individual who just happens to get injured, re-engineering may not be cost effective.
Looking Long Term, Part I In the short term, employers have an incentive to minimize the number of accidents and injuries they report to OSHA because state workers compensation premiums are based on experience ratings. Basically, the more accidents and injuries you report, the more likely it is that your rates will increase.