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10/6/2010 Sharon Sharpe, ScD, ATC
Targeted Programs to
Reduce Risks of Injury
#1. The Back
10/6/2010 Sharon Sharpe, ScD, ATC
The Problem: Back Pain and Injury
10/6/2010 Sharon Sharpe, ScD, ATC
Back Injuries – Incidence
Since January 10, 2010
• Back Pain non-recordable 7
• Back Pai...
10/6/2010 Sharon Sharpe, ScD, ATC
Causal Factors of Back Pain
• Employee factors (organic)
– Genetics (family History)
– P...
10/6/2010 Sharon Sharpe, ScD, ATC
What goes wrong and Why?
• How is it built?
• How does it work?
• How does it get
injure...
10/6/2010 Sharon Sharpe, ScD, ATC
What does your spine do?
• The base for all
arm/leg activity (“core”)
• Must be both STA...
10/6/2010 Sharon Sharpe, ScD, ATC
How is your spine supposed to work?
10/6/2010 Sharon Sharpe, ScD, ATC
Spine: Like a Tent Pole,
only better (and worse)
• This tent pole is not
straight, and h...
10/6/2010 Sharon Sharpe, ScD, ATC
Structure - Bones
Vertebrae
From Anthony CP, Kolthoff NJ: Textbook of anatomy and physio...
10/6/2010 Sharon Sharpe, ScD, ATC
Structure - Joints between bones
Steven M Lobel, M.D. EVMS Dept of PMR
Small movementSma...
10/6/2010 Sharon Sharpe, ScD, ATC
Structure – Side view of inner spine
Bone
Disk
Bone
10/6/2010 Sharon Sharpe, ScD, ATC
Structure – Discs and Nerves
10/6/2010 Sharon Sharpe, ScD, ATC
What makes the spine hold it’s shape?
10/6/2010 Sharon Sharpe, ScD, ATC
Muscles – Tent Fabric
10/6/2010 Sharon Sharpe, ScD, ATC
Outer Layers - Shoulder Movers
10/6/2010 Sharon Sharpe, ScD, ATC
Mid Layer –
Trunk Movers
Global Muscles
Inner Layer –
Sensors
Local Muscles
10/6/2010 Sharon Sharpe, ScD, ATC
Local Muscles
–When activated,
position/motion
sensors, not motion
generators.
• How muc...
10/6/2010 Sharon Sharpe, ScD, ATC
Summarize: a stable spine….
– Stability
• How much motion is occuring
between any 2 vert...
10/6/2010 Sharon Sharpe, ScD, ATC
Muscle Function Differences
SensorsSensorsTrunk MoversTrunk MoversActivated After
Trunk ...
10/6/2010 Sharon Sharpe, ScD, ATC
Muscle Strength vs Endurance
• Position sensors need to
be ON
– ALL THE TIME, so that
ex...
10/6/2010 Sharon Sharpe, ScD, ATC
Working Example: Posture
• Cause or effect?
– Does the posture cause muscle imbalance or...
10/6/2010 Sharon Sharpe, ScD, ATC
Working Example - Posture
http://www.nlm.nih.gov/medlineplus/ency/images/enc
y/fullsize/...
10/6/2010 Sharon Sharpe, ScD, ATC
Lordosis –
1.Pelvis tilts forward
2.Butt sticks out
Shortened hip flexor ms.
Lengthened,...
10/6/2010 Sharon Sharpe, ScD, ATC
Posture
Forward Head
10/6/2010 Sharon Sharpe, ScD, ATC
Problem Summary
Employee causal factors
• Prolonged position > muscle fatigue > poor
act...
10/6/2010 Sharon Sharpe, ScD, ATC
Recent Evidence
• Bigos et al. Spine, 2009, High quality
controlled trials on preventing...
10/6/2010 Sharon Sharpe, ScD, ATC
LiveWell Job Specific conditioning
program
Pre-shift stretches
• Wellness based
exercise...
10/6/2010 Sharon Sharpe, ScD, ATC
Ongoing Ergonomic Training
X
• Job rotation
• Micro breaks
• Correct lifting
• Proper jo...
10/6/2010 Sharon Sharpe, ScD, ATC
Potential for Risk Reduction
• Evidence shows: back pain incidence could
be prevented wi...
10/6/2010 Sharon Sharpe, ScD, ATC
Fix it
1. Reduce Lordosis (restore muscle balance)
Stretch Tight Muscles (Hip Flexors, q...
10/6/2010 Sharon Sharpe, ScD, ATC
Wellness Based Programs
• Conditioning for all employees
• Preventive Stretching and Exe...
10/6/2010 Sharon Sharpe, ScD, ATC
Effective Conditioning
1. Loosen up
2. Stretch tight muscles
3. Exercise – activate and
...
10/6/2010 Sharon Sharpe, ScD, ATC
Reduce Lordosis -
Stretching
• Hip Flexors
• Quads
• Hamstrings
• Calves
10/6/2010 Sharon Sharpe, ScD, ATC
Activate Stabilizers of the Spine
Tighten the fabric
Stabilize the Pole
10/6/2010 Sharon Sharpe, ScD, ATC
http://back-exercises.com/
10/6/2010 Sharon Sharpe, ScD, ATC
Learning How to Activate
Draw in Exercise – Activates Inner Abs AND
Position Sensors
Foc...
10/6/2010 Sharon Sharpe, ScD, ATC
Spine Control Strengthening
Progression - example
• Draw ins
• Pelvic Tilts
• Maintain P...
10/6/2010 Sharon Sharpe, ScD, ATC
Resources Needed:
• Space
• Mats
– 1 yoga mat for each team member OR 1
large floor mat
...
10/6/2010 Sharon Sharpe, ScD, ATC
Resources Needed
• Supervision/Training
– Initial Training for Leaders
– Ongoing trainin...
10/6/2010 Sharon Sharpe, ScD, ATC
• Time
– Training of Leaders – 2 sessions x 45 min
– Initial Presentation to teams – 30 ...
10/6/2010 Sharon Sharpe, ScD, ATC
Summary
• Back Injuries are a problem
• Spine needs both stability and mobility
• Exerci...
10/6/2010 Sharon Sharpe, ScD, ATC
10/6/2010 Sharon Sharpe, ScD, ATC
Reference Materials
Bigos, SJ et al. High-quality controlled trials on preventing episod...
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Back Injury Prevention

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Rationale for conditioning program to reduce the risk of back injury.

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Back Injury Prevention

  1. 1. 10/6/2010 Sharon Sharpe, ScD, ATC Targeted Programs to Reduce Risks of Injury #1. The Back
  2. 2. 10/6/2010 Sharon Sharpe, ScD, ATC The Problem: Back Pain and Injury
  3. 3. 10/6/2010 Sharon Sharpe, ScD, ATC Back Injuries – Incidence Since January 10, 2010 • Back Pain non-recordable 7 • Back Pain recordable 3 Days Out Alt Duty – Kitchen 1 4 ? – Bakery 0 – Packing 1 2 – Sanitation 1 90+
  4. 4. 10/6/2010 Sharon Sharpe, ScD, ATC Causal Factors of Back Pain • Employee factors (organic) – Genetics (family History) – Personal History of previous injury – Posture – Muscle imbalances • Employee factors (performance) – Ergonomic (technique) errors • Job Factors – Prolonged positioning – Sudden “unprotected” movements
  5. 5. 10/6/2010 Sharon Sharpe, ScD, ATC What goes wrong and Why? • How is it built? • How does it work? • How does it get injured?
  6. 6. 10/6/2010 Sharon Sharpe, ScD, ATC What does your spine do? • The base for all arm/leg activity (“core”) • Must be both STABLE and MOBILE • Each of the 26 joints contributes to mobility and stability • Muscle support is CRITICAL
  7. 7. 10/6/2010 Sharon Sharpe, ScD, ATC How is your spine supposed to work?
  8. 8. 10/6/2010 Sharon Sharpe, ScD, ATC Spine: Like a Tent Pole, only better (and worse) • This tent pole is not straight, and has many parts – inherently unstable • Spinal curves allow for absorption of impact forces. (Walking, running) • Not really built for prolonged positions
  9. 9. 10/6/2010 Sharon Sharpe, ScD, ATC Structure - Bones Vertebrae From Anthony CP, Kolthoff NJ: Textbook of anatomy and physiology, ed 9, St. Louis, 1975, Mosby. Back Front Front Back
  10. 10. 10/6/2010 Sharon Sharpe, ScD, ATC Structure - Joints between bones Steven M Lobel, M.D. EVMS Dept of PMR Small movementSmall movement between any 2between any 2 vertebraevertebrae There are 26There are 26 jointsjoints…….... Combine forCombine for Large movements.Large movements.
  11. 11. 10/6/2010 Sharon Sharpe, ScD, ATC Structure – Side view of inner spine Bone Disk Bone
  12. 12. 10/6/2010 Sharon Sharpe, ScD, ATC Structure – Discs and Nerves
  13. 13. 10/6/2010 Sharon Sharpe, ScD, ATC What makes the spine hold it’s shape?
  14. 14. 10/6/2010 Sharon Sharpe, ScD, ATC Muscles – Tent Fabric
  15. 15. 10/6/2010 Sharon Sharpe, ScD, ATC Outer Layers - Shoulder Movers
  16. 16. 10/6/2010 Sharon Sharpe, ScD, ATC Mid Layer – Trunk Movers Global Muscles Inner Layer – Sensors Local Muscles
  17. 17. 10/6/2010 Sharon Sharpe, ScD, ATC Local Muscles –When activated, position/motion sensors, not motion generators. • How much motion is occuring between any 2 vertabrae?? • How fast?
  18. 18. 10/6/2010 Sharon Sharpe, ScD, ATC Summarize: a stable spine…. – Stability • How much motion is occuring between any 2 vertabrae when the trunk moves? – Sensors off – Sensors on
  19. 19. 10/6/2010 Sharon Sharpe, ScD, ATC Muscle Function Differences SensorsSensorsTrunk MoversTrunk MoversActivated After Trunk Movers - Over activatedOver activated Sensors – UnderUnder activatedactivated Proper activationProper activation patternpattern Increased (lessIncreased (less stable)stable) Small, safeSmall, safeMotion in local joint Trunk MoversTrunk MoversSensorsSensorsActivated First Past InjuryPast InjuryNever injuredNever injuredPatient History
  20. 20. 10/6/2010 Sharon Sharpe, ScD, ATC Muscle Strength vs Endurance • Position sensors need to be ON – ALL THE TIME, so that excess movement between bones can be prevented. – ENDURANCE • Trunk Movers need to be ON – For stability most of the time – Higher level when body movement is required – ENDURANCE and STRENGTH
  21. 21. 10/6/2010 Sharon Sharpe, ScD, ATC Working Example: Posture • Cause or effect? – Does the posture cause muscle imbalance or does muscle imbalance cause poor posture?
  22. 22. 10/6/2010 Sharon Sharpe, ScD, ATC Working Example - Posture http://www.nlm.nih.gov/medlineplus/ency/images/enc y/fullsize/9583.jpg ‘Normal’ Spine – Balanced Muscle Groups. Anterior Muscles – Shortened, Strong Posterior Muscles – Stretched, Weak Lordosis
  23. 23. 10/6/2010 Sharon Sharpe, ScD, ATC Lordosis – 1.Pelvis tilts forward 2.Butt sticks out Shortened hip flexor ms. Lengthened, weak Glutes Tight Hamstrings 3.Forward head 4.Tight Calves Factors – Overweight Pregnancy Other….
  24. 24. 10/6/2010 Sharon Sharpe, ScD, ATC Posture Forward Head
  25. 25. 10/6/2010 Sharon Sharpe, ScD, ATC Problem Summary Employee causal factors • Prolonged position > muscle fatigue > poor activation/endurance > poor standing posture > increased RISK. • Lack of understanding of the potential BENEFITS of conditioning and ergo training. – Pre-shift stretching – Micro breaks – Proper work techniques – Preventive conditioning program
  26. 26. 10/6/2010 Sharon Sharpe, ScD, ATC Recent Evidence • Bigos et al. Spine, 2009, High quality controlled trials on preventing episodes of back problems: systematic literature review of working-age adults – Reviewed studies on effects of exercise, education, lumbar supports, shoe inserts and programs to reduce lifted loads – 17 high quality studies – ONLY EXERCISE significantly reduced episodes of back problems
  27. 27. 10/6/2010 Sharon Sharpe, ScD, ATC LiveWell Job Specific conditioning program Pre-shift stretches • Wellness based exercise programs
  28. 28. 10/6/2010 Sharon Sharpe, ScD, ATC Ongoing Ergonomic Training X • Job rotation • Micro breaks • Correct lifting • Proper job technique • Aug. 2010 Training •Still have back injuries
  29. 29. 10/6/2010 Sharon Sharpe, ScD, ATC Potential for Risk Reduction • Evidence shows: back pain incidence could be prevented with exercise. • Exercise which impacts….. Proper muscle activation timing Hamstring and Hip Flexor flexibility Abdominal and sensor muscle endurance
  30. 30. 10/6/2010 Sharon Sharpe, ScD, ATC Fix it 1. Reduce Lordosis (restore muscle balance) Stretch Tight Muscles (Hip Flexors, quads, Hams, calves) Strengthen weakened muscles (Hip Extensors) 2. Learn muscle control Activate local sensors FIRST 3. Work on muscle endurance of these systems 4. Report back pain EARLY
  31. 31. 10/6/2010 Sharon Sharpe, ScD, ATC Wellness Based Programs • Conditioning for all employees • Preventive Stretching and Exercise, both initial injury and RE injury. • In addition to the Core 6 pre-shift exercises
  32. 32. 10/6/2010 Sharon Sharpe, ScD, ATC Effective Conditioning 1. Loosen up 2. Stretch tight muscles 3. Exercise – activate and strengthen weak/strained muscles
  33. 33. 10/6/2010 Sharon Sharpe, ScD, ATC Reduce Lordosis - Stretching • Hip Flexors • Quads • Hamstrings • Calves
  34. 34. 10/6/2010 Sharon Sharpe, ScD, ATC Activate Stabilizers of the Spine Tighten the fabric Stabilize the Pole
  35. 35. 10/6/2010 Sharon Sharpe, ScD, ATC http://back-exercises.com/
  36. 36. 10/6/2010 Sharon Sharpe, ScD, ATC Learning How to Activate Draw in Exercise – Activates Inner Abs AND Position Sensors Focus on: Pull belly button DOWN toward the spine while abs are RELAXED.
  37. 37. 10/6/2010 Sharon Sharpe, ScD, ATC Spine Control Strengthening Progression - example • Draw ins • Pelvic Tilts • Maintain Pelvic Tilt, raise 1 arm over head – Both arms • Maintain Pelvic Tilt, lift single leg bent – Single leg straight – “Cycle” legs • Maintain Pelvic Tilt, Hands and Knees progression
  38. 38. 10/6/2010 Sharon Sharpe, ScD, ATC Resources Needed: • Space • Mats – 1 yoga mat for each team member OR 1 large floor mat • Need to be cleaned after each use. • Committed Leaders – Trained in the exercises – Give immediate, ONGOING feedback and coaching on exercises • Buy-in, ATTENDANCE/participation by employees
  39. 39. 10/6/2010 Sharon Sharpe, ScD, ATC Resources Needed • Supervision/Training – Initial Training for Leaders – Ongoing training for Leaders – Coaching/feedback with teams – Outcomes measures collected/analyzed • Ability to control pelvis • Measures of comfort/discomfort (1 -10) • Days missed • Days limited/alternative duty • Days full duty but with pain • Others??
  40. 40. 10/6/2010 Sharon Sharpe, ScD, ATC • Time – Training of Leaders – 2 sessions x 45 min – Initial Presentation to teams – 30 min – Time for teams to exercise – 15 min • Daily - optimal • 3x/week - minimal – Ongoing supervision/coaching -1-2 hrs/wk • Sharon > Leaders • Sharon > Teams Resources Needed
  41. 41. 10/6/2010 Sharon Sharpe, ScD, ATC Summary • Back Injuries are a problem • Spine needs both stability and mobility • Exercise programs reduce incidence of LBP – Stretch tight muscles, strengthen weak muscles – Prevent excessive local joint motion • Activate small sensors (“draw in”) BEFORE activating LARGE MOVERS. – Control Pelvis (muscle balance) • Program must have proper resources to be successful.
  42. 42. 10/6/2010 Sharon Sharpe, ScD, ATC
  43. 43. 10/6/2010 Sharon Sharpe, ScD, ATC Reference Materials Bigos, SJ et al. High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine Journal. 2009 Feb;9(2):147-68. Herzog,W., 2000. The Mechanical, Neuromuscular, and Physiologic Effects Produced by Spinal Manipulation. In: Herzog,W. (Ed.), Clinical Biomechanics of Spinal Manipulation, pp. 191-207. Churchill Livingstone, Philadelphia. Margo, M. http://ebm.bmj.com/content/14/4/117 Mendoza, G. “Diagnosis and Treatment in the Lumbar Spine” Powerpoint presentation, Boston University, Sargent College of Health and Rehabilitation Science. Feb 2005.

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