It s broke, so let s fix it: Anatomy of an Injury, Fallacy of Body Mechanics

1. It�s broke, so let�s fix it: Anatomy of an Injury, Fallacy of Body Mechanics Valerie Beecher, MS, AEP Ergonomics � Employee Health Danielle Wheeler-Vickery, PT Acute Rehabilitation SUNY Upstate Medical University

2. History of Patient Handling

3. History of Patient Handling Quotes from nursing texts: �Occasionally the complaint is made that a nurse has injured her back or strained herself in some way in moving a patient. This will generally be because she has failed to do the lifting properly.� (Hampton, 1898, p.102) �It is very good for strength To know that someone needs you to be strong� (Committee of the Connecticut Training-School for Nurses, 1906, preface verso). �Lifting does not always require strength. It takes skill which the nurse can readily develop once she has made good body mechanics a habit� (Gill, 1958, p.299). Taken from: Safe Patient Handling and Movement: A Practical Guide for Health Care Professionals, Nelson, A. Ed. (2006).

4. Awkward Handling �Compared to objects manually lifted or moved in industrial settings, the body is heavier, more delicate and awkward to handle� Source: A Back Injury Prevention Guide for Healthcare Workers; Cal/OSHA �The adult human form is an awkward burden to lift or carry. Weighing up to 100 kg or more, it has no handles, it is not rigid, and it is liable to severe damage if mishandled or dropped. In bed a patient is placed inconveniently for lifting, and the placing of a load in such a situation would be tolerated by few industrial workers� (�The Nurse�s Load�, 1965, p.422). Taken from: Safe Patient Handling and Movement: A Practical Guide for Health Care Professionals, Nelson, A. Ed. (2006).

5. National Problem of Ergonomic Injury in Healthcare Services Top Ten Occupations for MSDs Truck drivers, light and delivery Janitors and cleaners Stock clerks and order fillers Construction laborers Maintenance and repair workers

6. National Problem of Ergonomic Injury in Healthcare Services In 2006, nursing aides, orderlies and attendants had:

7. National Problem of Ergonomic Injury in Healthcare Services In 2000, ANA reported that compared to the general workforce, nurses used 30% more sick leave annually due to back pain.

8. National Problem of Ergonomic Injury in Healthcare Services

9. Cost Factors In 1990, the annual cost of back injury ranged from $50 to $100 billion in the US One low back injury: $40,000 Indirect costs outweigh direct costs 5:1 $20 billion per year is spent annually on workers compensation costs associated with musculoskeletal disorders (MSDs) $100 billion per year is spent on indirect costs Source: US Department of Labor, Occupational Safety and Health Administration National Problem of Ergonomic Injury in Healthcare Services

10. National Problem of Ergonomic Injury in Healthcare Services Reporting In 2006 there were over 350,000 musculoskeletal disorders (MSDs) reported that required days away from work. Many experts believe this figure represents significant under-reporting of cases. MSDs account for 30% of all lost-workday injuries and illnesses. Source: US Department of Labor, Occupational Safety and Health Administration

11. Low Back Pain Prevalence Back injury is the #2 work-related injury in the US Back pain is the most common reason for filing workers comp claims Low back pain (LBP) is the #2 reason why patients are seen by an MD. 80% of adults will experience LBP. Most of the time injury to the low back happens at work.

12. What is Low Back Pain? Pain that originates from the spine, muscles, nerves or other structures in the back that can radiate into the lower extremities, such as tingling, burning sensation, dull or sharp ache. Causes weakness/imbalance in strength and flexibility in the lower back and abdominal areas.

13. Low Back Pain Statistics 15-20% of US adult population experience back pain every year. Out of that number, another 15-20% require medical care for a minimum of 3 years. 90% LBP resolve in 6 weeks 5% LBP resolve in 12 weeks <1% LBP serious spinal disease <5% LBP true nerve root pain

14. Anatomy of Lumbar Spine Intervertebral disc Facet joints Vertebral body Ligaments Spinous process Transverse process Muscles Spinal cord

15. Causes of Low Back Pain Lifting of heavy objects Prolonged sitting Injury/accident Quick movements Other Causes: Muscle spasms Decreasing alignment Herniated Disc (HNP) Small fractures Degenerative Disc Disease (DDD)

16. Low Back Pain Disorders

17. Herniated Disc (HNP) Nucleus pulposus (center of disc which is a fibrogelatinous pulp) acts as a shock absorber. Disc protrudes outside of the center (annulus fibrosis), i.e. jelly donut when squeezed. 95% occur at L4L5 or L5S1 (center of gravity) 75% recover within 6 months Sudden onset of LBP and radicular symptoms in leg(s).

18. Facet Joints Occur in 40%; mainly extension and rotation Symptoms increase with lumbar extension �compression� Symptoms decrease with lumbar flexion �separates� Sudden attacks No radicular symptoms to buttocks or below knee.

20. Spondylolysis Stress fracture of pars interarticularis Repetitive flexion/extension LBP with occasional radicular symptoms past buttocks and thighs, no neurologic deficits

21. Spondylolisthesis �Slipping of vertebrae� 75% have LBP Restrictive ROM

23. DDD/Spinal Stenosis Neurogenic claudications Pain/symptoms increase with standing/walking (buttock and lower extremity symptoms) Pain decreases with flexion

24. LBP Risk Factors Heavy manual lifting Repetitive movement: lifting/twisting Constant vibration Poor posture Continuous work Poor physical fitness Low pain threshold Weak trunk musculature Smoking Stressed/depressed Pregnancy Arthritis

25. Biomechanics How does it work together?

26. �It�s broke�� Past Approaches to Reducing Injury in Healthcare Training in body mechanics and appropriate lifting techniques, i.e. �bend your knees, not your back�. Lectures addressing human anatomy and function of the musculoskeletal system. Promotion of healthcare worker physical fitness. Promotion of healthcare worker proper nutrition. Modified from: Ergonomics, How to Contain On-The-Job Injuries in Health Care by Guy Fragala, PhD. Reprinted with permission from Joint Commission on Accreditation of Healthcare Organizations.

27. Dispelling the Myth Education on lifting techniques and training in body mechanics are not effective in reducing injuries. Research over past 35 years reveals that these efforts by themselves have failed to reduce injury. Most common factor contributing to ergonomic injury in healthcare is the caregiver�s tendency to exceed one�s own safe lifting capacity when handling patients, putting excess force on the spine. Sources: Patient Safety Center of Inquiry of the Veterans Administration Medical Center (www.visn8.med.va.gov/patientsafetycenter/) and Back Injury Prevention (www.premierinc.com)

28. Facts Early studies on body mechanics focused on men and nursing still consists primarily of women. Early body mechanics studies were performed in controlled settings with boxes with handles (patients are bulky and don�t have handles!) Patients can be combative, experience muscle spasms, or lose their balance. A patient�s ability to assist varies. The environment is complex.

29. Facts When the lifting capacity is exceeded, there is no way to �lift properly� or use �proper body mechanics�. Forces exerted on the musculoskeletal system when caregivers perform patient-handling tasks are beyond reasonable limits and capabilities, regardless of technique to perform the task manually. Training programs fail to consider that lifting, turning, and repositioning patients are frequently performed on a horizontal plane, such as a bed or stretcher, requiring the nurse to use the weaker muscles of the arms and shoulders, rather than the stronger muscles of the legs.

30. Patient Handling Risk Factors Personnel Factors: Staff shortage Healthcare worker general health factors Poor patient handling techniques Repetitive tasks End-of-shift fatigue Lack of equipment training Lack of time Resistance to change Patient Related Factors: Decreased consciousness Decreased strength and ability to cooperate Mental status and combativeness Patient size and weight No handles Progression for patient Patient/family resistance to equipment use

31. Patient Handling Risk Factors Environmental Factors: Confined space of patient room and bathroom Wet and slippery floors Multiple monitors, IV poles, equipment, etc. in rooms Equipment Factors: Lack of proper equipment (lateral transfer equipment, bariatric equipment) Broken and poorly maintained equipment Low height of patient chairs, toilets, or high height of patient bed Modified from Ergonomics, How to Contain On-The-Job Injuries in Health Care by Guy Fragala, PhD. Reprinted with permission from Joint Commission on Accreditation of Healthcare Organizations.

32. NIOSH Lifting Equation Can be used to calculate a weight limit for a lifting task under ideal conditions. Based on biomechanics, psychophysics, physiology, and epidemiology. Recommended weight limit is 35 pounds for most patient-lifting tasks, but less when conditions are not ideal. Reasonable to use this maximum limit to assess patient handling when equation isn�t feasible.

33. NIOSH Lifting Equation Not originally used for assessing the lifting of patients due to limitations: Patient unpredictability and combativeness Patient movements while lifting can create additional loads Can be used under ideal conditions as a guide Patient can follow directions, non-combative Weight a caregiver handles can be estimated Lifting is smooth and slow �Geometry� of the lift doesn�t change

34. What does this mean? Many patient-handling tasks that caregivers perform are unacceptable based on a 35-pound limit. Few patients weigh less than 35 pounds (except in pediatrics). Recommended weight limit (RWL) can assist with identifying tasks/situations for which the use of equipment is necessary.

35. Patient Handling Scenarios 2 nurses helping patient to stand from chair Patient weighs 180lbs Can assist partially (about � his weight) 2 nurses need to lift 90lbs 45lbs > 35lb RWL

36. Patient Handling Scenarios 1 nurse needs to raise a patient�s leg off the bed for wound care Patient weighs 300lbs (leg is ~16% of total body weight) 47lbs > 35lb RWL

37. Patient Handling Scenarios 4 nurses about to move a fully dependent patient from bed to chair Patient weighs 250lbs 4 nurses need to lift 250lbs 62.5lbs > 35lb RWL

38. Patient Handling Scenarios 1 nurse about to move a fully dependent patient from bed to chair Patient weighs 100lbs 1 nurse needs to lift 100lbs 100lbs > 35lb RWL

39. ��So, let�s fix it� Change in philosophy: Modify the job to fit the worker rather than changing the worker to fit the job. Lifting techniques are still important but no longer the only key elements. Elimination or modification of lifting activities is more effective. Use task analysis and patient assessment. Use engineering solutions (such as patient lifts, friction-reducing devices, or transfer belts to reduce risk of injury). Standardized processes for equipment, sling and staff selection.

40. Questions?