Protecting Against Back Injuries

By Bryan Fass

It has been a busy shift, and you’re at the halfway point of your tour. You managed to get in a quick nap, but you are feeling the fatigue from running all day. Finally, at 2300 hours, it slows down and all is quiet in the station. Right in the middle of a dream, the lights cut on and tones drop for a fall with injury; begrugingly, you drag yourself out of bed and climb into the truck.

On scene, you find the patient down in a bathtub with an obvious injury to a lower extremity. Emergency medical services (EMS) checks in en route with an estimated arrival time of 10 minutes. You and your crew set to work extricating the patient from the tub, which turns out to be no easy task. Instead of going back to the truck for a lifting tarp, you decide to just grab and lift the patient onto a spine board for extrication from the house. Calling the lift, you feel a pop in your back and experience immediate pain. You finish the call in pain.

Back Injury Economic Toll

Injury, disability, and even death are risks every first responder accepts when entering the profession. Back injuries account for more than 20 percent of all workplace injuries in the United States. They are a particular problem for fireEMS providers, where, at any given time, nearly 10 percent of the workforce is out of work because of an injury.¹ The Centers for Disease Control and Prevention monitors first responder injuries. In its most recent data set, more than 27,000 fireEMS workers experienced on-the-job injuries and illnesses; more than 21 percent of the injuries were to the lower back.² International Association of Fire Fighters’ data show that more than 50 percent of line-of-duty claims and 50 percent of early retirements result from lower-back injuries. Departments incur significant costs from these injuries, which also challenge staffing.

(1) Chair lifts. (Photos by author.)

Back pain is difficult for injured firefighters to cope with; it affects every aspect of their lives. They are in pain at home or while on light duty; and, in many cases, they are bringing home only two-thirds of their normal paycheck, creating financial hardship. On the employer side, there are workers’ compensation payments and open positions that must be backfilled, possibly with forced overtime. Overtime shifts are not only expensive, but they also lead to higher levels of provider fatigue, increasing patient care errors and risk of injury to healthy members.

Main Causes of Back Injuries at Work

More than half (62 percent) of all prehospital provider back injuries happen when lifting patients.³ Injuries result from three major factors: significant lifting forces (patient weight), repetitive movements, and awkward positions. Prehospital back injury statistics have changed little during the past decade despite the introduction of many safe lifting devices such as automatic-lift stretchers, slide boards, slide sheets, and bariatric equipment. Candidly, fireEMS has some of the best patient-handling technology available, yet provider injuries continue to increase.

Three Forces

In the prehospital environment and on the fireground, responders must deal with three forces that affect the spine and can lead to injury: compression, shear, and torque.

• Compression forces push down on or squeeze the spine parallel to the spinal axis. Intervertebral discs help us withstand compression forces.
• Forces that impact the spine perpendicular to the axis are called shear forces. Examples of shear forces are leaning over to the side by dropping one shoulder lower than the other and picking up a heavy pack. Shear force also occurs when you bend at the waist to pick up an object. The rounder your back is when bending, the higher the shear force.
• Rotational forces are referred to as torque. Torque is calculated by multiplying force times distance where distance is the space between the spine and the weighted object in motion. Significant torque can cause ligament and disc injuries as compression is distributed unevenly; they can also occur when you lift heavy objects with one arm.

“Safe” Lifting Limits

To help protect workers, the National Institute for Occupational Safety and Health (NIOSH) established safe lifting limits for health care providers. The load limit for a single-person lifting is 51 pounds; the maximum spine compression force is 764 pounds.⁴ Unfortunately for prehospital providers, many routine lifts far exceed this recommended compression limit. For example, pulling a 105-pound patient between two beds with a bed sheet applies between 832 and 1,708 pounds of compressive force. With increased obesity, the occupational load also rises. Carrying the same patient down a set of stairs compresses the spine with 1,012 to 1,281 pounds. (4) The combined compression, shear, and torque make fireEMS one of the few professions with a required job task of picking up catastrophically heavy loads on a routine basis.

(2) Chair lifts. (Photos by author.)

Consider deadlifting 300 pounds strapped to a spine board that is flat on the floor. The load shifts as you lift it, and it must then be maneuvered down a hallway, down a set of stairs, and outside onto a stretcher. No other profession requires such injurious loads to be picked up from such low positions. The wet patient in the bathtub described earlier exponentially increased shear, torque, and compressive forces on the spines of the firefighters.

Injuries Caused During Sleep

A fluid shift that occurs while you sleep causes spinal discs to swell to help to nourish and heal injured spinal discs. It is estimated that 15 minutes of standing is needed to dissipate this additional fluid. During this time frame (immediately after awakening), disc injury is much more likely. One thing I constantly remind crews of is the risk of severe back injury after sleeping. A call for a fall or a lift assist, the call you just want to run and get back to sleep, poses the greatest risk for injury. In these cases, slow down and use a tool to help reduce the load and trunk angle and increase mechanical advantage.

The final backbreaker is called a “moment.” We have all experienced moments picking up a spine board or scoop stretcher when we are pulled slightly forward, forcing us to take a step and lean forward; that is a flexion moment. We see similar effects with rotation and extension of the spine. What happens is that all the compressive and shear forces hit your spine so quickly that soft tissue structures have no time to buffer or dissipate the load (the muscle cannot fire fast enough to protect you). Your spine takes the full force of the movement in a “moment.” You must avoid these injurious forces.5

Soft-Tissue Traumas

These traumas occur in the public sector from three major causes:

• Overexertion. This type of injury occurs when an external force produces torque and compressive loads the tissues are unable to handle. When the soft tissue failure tolerance is met, the tissue can fail outright (injury) or sustain microtrauma that weakens the tissue, causing it to eventually fail. This might occur when a responder has to lift a patient from a bathtub and carry him into a hallway where medical treatment can begin. The poor working environment and the weight of the patient cause the tissue to sustain forces it cannot dissipate, and the tissue fails as a result.
• Repetitive motion disorder. Repetitive movements ultimately lead to tissue failure from countless repetitions of faulty and dangerous movements. A common pattern is seen in how responders enter and exit their vehicles. Years of rapidly entering and exiting, often weighted down with gear, self-contained breathing apparatus, or vests, can fatigue the tissue to the point of failure.⁶ The same effect can result from faulty lifting. In EMS, repetitive rotator cuff strain can occur from repeatedly lifting the 40-pound monitor/defibrillator from the floor of the cot in a swinging motion. Repetitive traumas of the job add up over time.
• Prolonged static positioning. As children, we went to school and sat at little tables, hunched forward. As adults, we essentially do the same thing, except that we’re hunched over a computer, phone, or steering wheel. These repetitive static postures (like sitting, standing, or desk work) will “program” the body over time to believe the faulty postures are normal. Yet, it is not normal to have a forward head posture and a rounded upper back.

FireEMS personnel often display tightness in the calf, foot, and ankle. These are the results of standing on concrete floors, spending hours in duty boots, training and working in fire-specific boots/gear, and hours on ladders and pitched roofs. How firefighters and EMS providers enter and exit their apparatus affects the foot and ankle as well. When the ankle joint is tight or restricted, the ability to squat and climb steps is altered. (3) Additionally, many first responders neglect to foam roll and stretch the gastric-soleus-peroneals-posterior tibialis. This complex of muscles, when tight, will affect the joints above and below the restricted area-in this case, the knee and/or the foot, which can contribute to shin splints and knee tendonitis.

This illustration shows the reasons many responders have difficulty lifting with their legs: What should be mobile has become tight and weak, and what should be stable is forced to become mobile. This phenomenon is at the root of all poor biomechanics and many injuries. (Illustration by author.)

Solutions

First and foremost, we have to stop thinking of the firefighter as the ultimate multitool. Eventually, the loads, positions, extreme trunk angles, and chronic fatigue will break down tissue and cause injury. When we do root cause analyses (RCAs) on many field injuries, we often find that they occurred while performing a seemingly routine task. Our experience and the data show that most responders have similar patterns that often can be tied back to the job task. Additionally, many responders have behavioral patterns that are repetitive and static or chronic. Some of the changes we can make to prevent these injuries include the following:

• Training. Lift training to simulate job performance with Olympic bars or perhaps a kettle bell (the handle of which places the initial hip hinge lift position at roughly mid-shin height) poses two problems. First, if we constantly train on heavy lifts from the floor, we quickly expose responders to dangerous and injury-producing spinal torques. Exercise should never cause injury. Second, the vast majority of responders I have trained have heavily engrained biomechanical patterns that inhibit deep, safe lifting. Fewer than 10 percent of the first responders in the hundreds of classes I have taught every year are able to work safely from the floor. The easy answer to this problem would be not to lift from the floor. Although there are techniques that can alter lift height and make lifting from the floor safer, some patients must be lifted and, ultimately, no technique or tool will help in all situations.
• Change the lift height. Instilled in every first responder is a duty to act, to serve, and to help. The consequence of this thinking is that we often use ourselves as the tool to get the job done. We end up picking up a patient or a piece of equipment from an awkward position or from a height below the knees. Instead, use a commercially made device to change the lift height and allow multiple responders to get their hands on the patient. It allows lifting from knee height (rather than from the floor) and reduces friction and trunk angle when transferring a patient to the hospital stretcher.
• Reduce friction. Friction can be a big deal, especially when you are tasked with transferring large patients from a bed to a stretcher. Common techniques include moving the patient on a bed sheet or blanket; both add resistance because of the coefficient of friction. Couple this increased resistance with the extreme trunk flexion angle needed to lean over the bed and grasp the sheet, and you have the trifecta for spinal disaster: shear, compression, and torque. Using a soft stretcher, as mentioned above, will reduce and trunk the flexion angle. These devices have built-in handles; since they are made of high-strength materials, they also reduce friction. Additionally, the lift height is more like that of a dead lift with greater hip involvement and less lumbar spine load.
• Master the hip hinge. As a paramedic and as a certified strength and conditioning specialist, I have observed that very few responders use a good hip hinge to spare the spine and reduce compressive and shear forces. This likely appears to be related to poor hip mobility and a lack of coaching on the importance of the hip hinge. A very common pattern prevalent in first responders is very short and tight hip flexors. As hip flexors become tight, they cause an anterior pelvic rotation that inhibits (shuts off) the abdominal wall (the “guts and butts” posture). As the abdominal wall weakens, the spine bears a greater load. As Janda7 predicted, the glutes become tight and weak, and the hamstrings tighten in an attempt to pull the pelvis back into place (agonist-antagonist relationship with the hip flexors). As this pattern becomes more severe (lower crossed syndrome), the responder loses the ability to lift properly. The most common manifestation of this is evident when lifting a cot into the ambulance. The majority of EMS providers lifting a cot (empty weight of 95 pounds for a manual cot or 115 to 130 pounds for a powered cot) will use the lumbar spine as a hinge (extension moment). Most use profound spinal extension, a hinge mechanic, instead of their hips to lift the cot. Active stretching of the hip flexors followed by a long duration low-load stretch of the hip flexor group will almost immediately reduce the tightness many responders experience daily. Tying that into some simple gluteal integration exercises like single-leg bridges, lateral step-ups, and fire hydrants can have an immediate and positive effect. We often see responders with active back pain become pain free after less than 10 minutes of resetting and reactivating the glutes. During conditioning and training, a best practice is to tie the hip hinge into everything our responders do. Beginning the shift with stretches and mobility work builds and, more importantly, reinforces the hip hinge. We build in exercises that teach the hip hinge from multiple angles including standing and kneeling exercises (unilateral/bilateral), to name a few. We particularly like tall kneeling push, pull, and chop patterns to groove this pattern deeper into their neuromotor system. This is important, especially when the call is very dynamic or the patient is critical and the responders’ focus is on patient care, not biomechanics.
• Embrace the squat. Squatting is a critical job ability. Possessing the physical ability and strength to squat and lift from the floor can often make the difference between sustaining an injury and remaining uninjured. As we know, the squat requires a synergy of mobility and flexibility in the calf-ankle complex and the hips (rotation) and thoracic mobility (particularly extension and good overall kinesthetic balance). However, after 10 years of training responders to lift safely, I have noticed the dominant pattern in the field is their inability to squat well, especially when they have a load in their hands. There are two ways to win this battle. As discussed above, the first step is to change the lift height by using a tool so that the lift height is raised and squat (dead lift) is not as deep. Step two involves education and exercise. Crews need education on the importance of mobility tied into their job: You have to move well so that you can move patients well. Exercises should teach the squat just as we groove the pattern for the hip hinge with almost all of our exercise choices, especially kneeling.

The bottom line is simple: As a profession, we must learn to move well. This includes fitness, patient handling, fireground activities, and all aspects of training. If we learn to move well in a controlled environment, we can greatly reduce the risk of poor movement in the field. We must reeducate ourselves and learn not to be the tool. Stack the deck in your favor on every call by using a device that raises lift height and reduces friction and by constantly focusing on reducing the occupational load on your body. Finally, you must learn that pain is not normal; it is a symptom and a warning sign.

(3) Stop lifting from the floor. Use a commercially available device to change your lift height.

References

1. Studnek, JR, Ferketich A, Crawford JM. “On-the-job illness and injury resulting in lost work time among a national cohort of emergency medical services professionals.” Am J Ind Med; 2007 Dec; 50(12): 921-31.

2. Centers for Disease Control and Prevention. Emergency Medical Services Workers Injury and Illness Data, www.cdc.gov/niosh/topics/ems/data2011.html.

3. Hogya PT, Ellis L. “Evaluation of the injury profile of personnel in a busy urban EMS system.” Am J Emerg Med;1990 Jul; 8(4): 308-11.

4. Oregon OSHA. Firefighter and Emergency Medical Services Ergonomics Curriculum, www.cbs.state.or.us/osha/grants/ff_ergo/index.html.

5. McGill, S. “Low Back Disorders.” Human Kinetics; 2007, 218-222.

6. Frost, David. TSAC presentation “Protecting our Public Protectors,” Norfolk, Va., 2012.

7. http://www.jandaapproach.com/the-janda-approach/jandas-syndromes/.

BRYAN FASS, ATC, LAT, CSCS, EMT-P (ret.), has dedicated the past 10 years to changing the culture of fireEMS from one of pain, injury, and disease to one of ergonomic excellence and provider wellness. He has leveraged his 15-year career in sports medicine, athletic training, spine rehabilitation, and strength and conditioning and as a paramedic to become an expert on prehospital patient handling/equipment handling and fireEMS fitness. His company, Fit Responder, works nationally with departments to reduce injuries and improve fitness for first responders.