Planning to Prevent Sprains and Strains and Slips and Falls

Robert Pater, SSA/MoveSMART Director
Industrial Safety & Hygiene News (June 1999)

The Problem

Movement related injuries--sprains and strains to the back, cumulative trauma disorders and slips, trips and falls) have been expensive, persistent, and frustrating across a wide range of industries, in field and office locations, with even the best employees throughout the world. And addressing each of these problems individually can be time consuming and costly.

Wherever workers move their bodies, they are at risk of a range of injuries--slips, trips and falls, strains and sprains (due to cumulative trauma or acute causes), repetitive motion disorders, hand injuries, knee problems and others. In essence, many workers trade their movement for pay--whether they are lifting, palletizing, assembling, cleaning, repairing, manufacturing, feeding a machine, delivering, distributing, installing or more.

Data from the US Bureau of Labor Statistics (BLS) data on lost work day injuries (Table R73: nonfatal occupational injuries and illnesses involving days away from work in 1996) supports the prevalence of movement-related injuries:

• "Falls" accounted for 17.6 % of lost-time work injuries
• "Bodily reaction injuries and exertion" comprised 43.8% of lost-time work injuries.
• "Struck against stationary object" accounted for 4.2% of lost-time work injuries

Added together, these movement-related injuries accounted for almost two-thirds (65.6%) of all lost-time injuries. And the same table shows that sprains and strains accounted for 43.6 % of all lost-time injuries. Some organizations with which we have worked have experienced a more severe rate of movement injuries.

According to the BLS record keeping system, "bodily reaction" injuries can result from: lifting, climbing, crawling, reaching, twisting, running, sitting, slip/trip/loss of balance without fall, standing, walking without other incident, pulling, pushing, holding, carrying, turning, wielding objects, repetitive use of tools, repetitive placing, grasping or moving objects, and more. In addition, other specific activities that can result in movement-related injuries are:

• Being in one position for long periods of time.
• Handling equipment at arm's length.
• Going down steps and stairs, especially while carrying.
• Working below knee level.
• Crossing slick, uneven or cluttered decks.
• Torquing lever and wrenches or turning pieces of equipment.
• Carrying heavy or awkward loads.
• Stepping backward, particularly while carrying.
• Jumping, including swing rope transfers.
• Working more than a few meters off the ground.
• Lifting, particularly out of containers or overhead.
• Stepping, handling and lifting tasks done as a team.

And these activities can result in strains and sprains, dislocations, fractures, abrasions, cuts, even fatalities (these predominantly from slips and falls).

Assessing the Field: Thinking Critically About What Has Been Done

Traditional approaches to movement injuries have attempted to prevent each type of accident separately. In other words, a company might develop an initiative to prevent slips and falls, launch another program to reduce strains and sprains, and institute a campaign against hand injuries. Or, as is often the case in this environment of limited time and resources, organizations attack one type of injury against which they believe they can have some impact and put aside or make minimal efforts to prevent other, potentially related movement injuries.

Traditional strategies for preventing movement-related injuries have included:

• "Write it off." This assumes that injuries are unpreventable, merely a cost of doing business.
• Preventative maintenance and housekeeping. This is always useful to reinforce, but there are worksites where, due to the nature of the work (i.e. a production line that uses a liquid lubricant to protect the product), slippery conditions are inevitable.
• Tool design and redesign. Such design and adaptations usually focus on:
  • Repositioning targeted work.
  • Suspending weights of tools, so that workers don't have to become "human clamps."
  • Adjusting height of a workstation or making the work mobile.
  • Padding workstations to reduce concentration of forces and to allow workers to move closer to their work.
  • Mixing movement into predominantly static jobs or redesigning tasks to enlarge jobs that previously taxed one part of the body.
  • Switching sides of hand and foot controls, so that left-handed and left-footed workers may better use their predominant side or so that other employees could offload work to their non-dominant side on demand.
• Automate tasks so that it does not put a human at risk. This has other consequences and concerns regarding job loss, use of judgment, etc.
• Training and education. Much movement related training is classroom-based and focuses on lifting a box from the floor (although workers may get exposures from a much wider range of activities) and teaching the anatomy and physiology of the back (which experience has shown seems to be of more interest to those who have already been injured).
• Focus on selection and fit in hiring. Screening out workers who are "more prone" to a movement injury can be difficult, as well as violate laws such as the Americans With Disabilities Act (ADA) or bargaining unit contracts.
• Reminders, such as signs and posters. These can become ignored after a time or focus on what to avoid, rather than behaviors to employ.
• Personal protective equipment to reduce forces from entering the body.
• Medical management strategies, such as optional/light duty, work hardening and return to work. These, of course, are more treatment than prevention-minded.

Each of the aforementioned "traditional" approaches is useful and might to some degree be incorporated into a systematic safety plan. But clearly these strategies have not stemmed the tide of movement injuries. Perhaps an innovative approach may be needed.

Moving Below the Surface: Understanding Similarities in Movement Injuries

All movement related injuries:

• Often involve soft tissue damage.
• Are affected by lifestyle/off-work influences such as condition, personal activities, diet.
• Have a subjective component and are therefore affected by psychosocial factors and are therefore perhaps more controversial than other, "objective" injuries. In addition, there is often finger pointing in movement injuries, with accident investigations blaming workers for not paying attention or attributing injuries to off-work sources; employees, in turn, often condemn management for not creating a safer workplace.
• Have strong behavioral components and therefore may be affected by training.
• Are often interrelated, "chicken and egg" style. For example, an initial loss of balance may turn into a back strain, as the person unsuccessfully seeks to recover their stance.
• Have three contributing factors--environmental, human, organizational/administrative.

Three Contributing Forces in Movement-Related Injuries

1. Environmental factors in movement injuries include:
   • Temperature
   • Humidity
   • Moving across distances
   • Lighting
   • Noise
   • Working in confined spaces
   • Poor grips on handles
   • Surfaces: slippery, border, uneven, mats, loose, levels, hard
   • Vibration
   • Obstacles
   • Unstable center of gravity (bulky, liquid materials)
   • Awkward positions
   • Heavy work
   • Moving distant loads
   • High frequency, duration, pace moving load
   • Frequent bending, twisting
   • Forceful moves
   • Repetitive work
   • Stationary/static design
   • Excessive weight, asymmetric size
   • Lack of adjustable workstations
   • Machine pacing
2. Human factors in movement injuries include:
   • Not aware of hidden risks?
   • Poor balance
   • Smoking (which can lead to hacking coughs and decreased blood circulation)
   • Preexisting injuries
   • Poor body mechanics
   • Condition (out of shape? obese? inflexible?)
   • Footwear, clothing
   • Not warming up
   • Uncorrected or obscured vision
   • Medication (even over the counter medications have some side effects, sometimes affecting balance)
   • Sex (women are more prone to knee injuries)
   • Aging
   • Attitude
   • Experience
   • Strength (especially. abdominal)
   • Height
   • Fatigue
   • Stress that is unmanaged
   • Lack of attention
   • Rushing
3. Organizational/administrative factors in movement injuries include:
   • Write-it-off attitude
   • Unrealistic expectations of workload
   • High pace
   • Forced overtime
   • Poor medical management
   • Blame-oriented accident investigations
   • Training ineffective or not offered
   • Lack of strong communications with employees
   • Not involving workers in safety
   • Supervisors not effective, not trained, not motivated to promote safety
   • Audits that are poorly done, limited or absent
   • Negative organizational safety motivation
   • Management not actively involved in safety

When faced with the daunting task of reducing a significant portion of their injuries, what can organizations do? Especially when many may be "subjective" injuries such as sprains and strains, that are more difficult to diagnose severity and potential lost-time consequences from than "objective," easily visible injuries such as fractures or abrasions. Subjective injuries may be more dependent than objective injuries upon such personal factors as perception, judgment, fitness, pain tolerance, personal use of medication, etc. What may be a minor problem for one worker that she individually manages, may be a lost-time injury for another.

Organizationally, promoting safety in many industries means aiming at moving targets. Because many industries have flattened their management structure, workers--whether field, floor or office staff--are less closely supervised.

Helping People Make Smart Moves

Back injuries, hand injuries, cumulative trauma and slips, trips and falls have similar contributing human factors--related to balance, alignment, position, coordination, judgment, repetition and leverage--all of which ultimately result in the way forces transfer into the body. Strong natural alignment can reduce concentration of force in a small area (such as the wrists or lower back) and thereby lower the likelihood of wear-down cumulative trauma injuries.

Worldwide experience with organizations such as Alcoa, American Airlines, Amtrak, Anheuser-Busch, Boeing, British Petroleum, General Motors, International Paper, James River Corp, Johnson and Johnson, Kodak, Nabisco, Sikorsky Aircraft, United Airlines and many others has shown that the key to effectively reducing movement injuries is to proactively focus on movement safety. Emphasis should be on putting workers in control of their own movement safety--at work and at home.

A human factors-oriented approach to movement safety is indicated when:

• Work environments are not cost-effectively controllable. For example, for those who operate outdoors or on others' environment (delivery workers, maintenance workers who work on machinery in client-controlled areas) the setting in which they work may not be readily controlled.
• New tools or redesign is too expensive. Capital expenditure budgeting may not allow for instant full-scale implementation of mechanical aids in all departments needing these. While waiting for these to arrive, further injuries may arise.
• Shut downs are not realistic. It may not be fiscally possible to shut down an around-the-clock running plant to implement a safety redesign.
• There are multiple sources of exposure, at work or at home. Sometimes, workers perform a variety of tasks that put them at risk for increased strains and sprains. It may be difficult to engineer out risks from each of these tasks. And because people tend to default behavior (i.e. "are creatures of habit"), they will likely not lift one way at work and another way at home. And, because sources of cumulative trauma can mount during hobbies and personal activities off-work, it is critical to help employees become as safe as possible when performing these movements.
• Personal attention, responsibility and judgment is important. Prevention of many movement-related injuries such as hand and finger problems or back injuries rely on individual motivation to work safe--even in mentally lulling jobs, focused attention and strong judgment. Redesign and retooling alone will not promote motivation, nor good use of attention and judgment. When redesign or retooling is applied, it is still critical to train employees how to adjust these new designs to their "personal ergonomics." One aerospace manufacturer was suffering continued problems with carpal tunnel syndrome among their riveters. Their first attempt to control these injuries was to adopt recoil-less riveting guns. Unfortunately, hand and arm injuries rose as workers, who were unused to the new guns, exerted extra tension to overcome the spring in the recoil-less guns so that they could feel the set of the riveting that they were used to. After appropriate training, hand and arm injuries decreased.
• Heightened performance, not just prevention, is an objective.

A Systematic Strategy for Movement Safety

Some professionals have tried different systems for inducing safe behaviors, but their efforts often end in frustration. Is it even possible to monitor and change behaviors? By thinking strategically and helping workers make smarter moves, you can greatly slash costly strains and sprains, hand and arm injuries, slips, trips, and falls--and boost overall safety.

First, take Administrative Control. See the real nature of the problem. Review medical records, look for trends (are certain sites, shifts, tasks more vulnerable?). Check organizational policies and procedures to see if these support or discourage movement safety.

Second, Modify the Environment. Reduce distracting signs, put strong lighting into place, make standard ergonomic modifications, build major ergonomic design changes into newly planned facilities. notice where appearance has overshadowed movement safety (e.g. hand rails that are beautiful, but too thick to be grasped by most people). Above all, recognize areas that you cannot cost-effectively modify and that still present risk to workers.

Third, Place People in Control. Boost their awareness of the benefits of movement safety and dangers of common movement injuries--both at work and at home. Help them acknowledge personal contributing factors, of which they have control, in movement safety. Provide training that helps them redirect forces more safely, boost balance and usable strength. Help them learn how to recover from potential movement injuries as well as how to minimize damage from unpreventable situations (through best medical and other attention).

Fourth, Recover and Reinforce. Use a wide range of audits--environmental, attitudinal, behavioral, procedural, statistical--to monitor progress. Encourage ongoing attention through coaching and reinforcement systems.

Moving Toward Safer Behavior

If movement safety has strong behavioral component, how can you realistically change individual worker behavior. There are four key objectives for accomplishing this:

Enlist Positive Motivation
Safety should be fun and build work morale. Because it's difficult to force safety on anyone--and especially those that are working with increasingly minimal supervision--it is essential to make safety something staff want to do, rather than just have to. The key is to show safety techniques and methods that they can't wait to use, that will equally help improve performance in their favorite sports and activities and help their family as well as show them how to be safer at work.

Make It Practical
It is important staff learn principles they can use at work and at home. But it is also critical to teach them how to do their own work tasks safer. That means showing rail workers how to more easily open bulkhead doors; assemblers how to put together parts with minimal strain on their wrists; how truck drivers can reenergize to maintain their mental focus and physical comfort during long hauls; how delivery personnel can keep their footing working outdoors; how distribution employees can maneuver racks of product positioned over their heads; how people can lift the specific loads they have to move without wearing down their body.

Build Personal Control
Help all employees become the safety director of their own life by encouraging them to think strategically. Remind them of the control they really have in movement safety.

Deputize the Team
Spread the message through everyone in your organization. Everyone, senior manager, factory floor employee, office staff, walks, reaches, bends, climbs, uses their hands, etc. Experience has shown everyone is interested in movement safety. Get everyone involved, as much as possible in your prevention efforts.

Movement related injuries are prevalent in numerous industries throughout the world. But with effective planning and strategic training, organizations can greatly reduce incidence and severity of movement-related injuries. Even when they are on the move, you can help your people work safer and with greater control.