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Author Affiliations: Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill.
In this issue of THE JOURNAL, Wassell and colleagues1
present the results of a prospective cohort study evaluating the potential
benefits to workers who wear back belts when handling materials. They discern
none. Not only of interest to workplace, health, and safety policymaker, the
article offers lessons to those interested in regional backache. The science
is noteworthy as is the social construct it serves. When regional backache
thwarts physical performance, should the task(s) be viewed as hazardous and
the worker injured?
In assessing the effectiveness of an intervention, cohort studies are
often considered inferior to randomized controlled trials (RCTs). Therefore,
since an RCT published in THE JOURNAL 2 years ago2
showed that wearing back belts for 6 months afforded no advantage to airline
baggage handlers, why publish a cohort study? It is possible that workers
who choose to wear belts may be at different risk for back pain in ways that
the previous investigators could not identify. If a worker finds a health
intervention unacceptable, that intervention cannot benefit that worker. The
study by Wassell et al is thus a test of the effectiveness of back belts among
workers who choose to wear them and is a design most likely to identify a
benefit, if one is present. Management, labor, and government are testing,
rather than contesting, their preconceived notions at some expense and risk.
The informed consent requires management to donate the cost of the time involved
in worker assessment. The workforce is to consider volunteering. Regulators
are subjugating inference and consensus regarding ergonomic remedies to establish
In the study by Wassell et al, approximately 9000 workers at 160 retail
sites comprised the population at risk. At some sites, the use of back belts
was required; at others it was voluntary. About two thirds of the workers
in the stores with the first policy reported nearly daily use of a back belt;
about a third of the workforce did so when offered the back belt as an option.
There were 2 main health outcomes: the likelihood after 6 months of recalling
1 or more episodes of back pain and the likelihood of filing workers' compensation
claims for back injury. The incidence of either outcome was no different between
the 2 groups, regardless of the store policy or the magnitude of physical
demand of the job. The findings suggest that back belts should be viewed as
no more than an option in apparel. Furthermore, any recommendation to wear
back belts when exposed to tasks with this range of physical demand should
be met with skepticism; the burden of proof should be on those who might still
The lack of prophylactic benefit of back belts may seem counter-intuitive.
Shouldn't the lumbar lordosis be bolstered when lifting? This rationale has
long been questionable on biomechanical grounds. It has been difficult to
demonstrate that back belts influence paraspinous muscle force or fatigue.3,4 Although it is possible to inflate
a back corset so that in vivo intradiskal pressure is diminished, the corset
must be inflated to the limit of comfort.5
Yet, back belts and other unproved remedies abound in workplaces. All this
is driven by the social construction that underlies the 2 health outcomes
assessed in the study by Wassell et al: What is it that renders backache memorable?
What is it that renders backache compensable?
It has taken more than 2 decades for the entrenched common wisdom to
yield to the systematic test of science. Unfortunately, it can take as long
or longer for the superseding inferences to inform the common wisdom in the
workplace and the physician's office. The belief that the principal reason
most episodes of backache are recalled is related to their severity and the
belief that the reason a worker finds an episode of regional backache incapacitating
relates to the magnitude of injury both need to be discounted.6
Regional musculoskeletal disorders afflict otherwise well working-aged adults
who have had no physical exposure unusual for them.7
Whether occurring during work or off hours, back pain seldom results from
a fall, direct impact, or extraordinary physical demands. In these instances,
an injury has occurred. Efforts to render workplaces and other environments
safe should be encouraged. For instance, some remedies involve workplace modifications
such as using mechanical aids for lifting or redesigning tasks. Are such efforts
relevant to regional musculoskeletal disorders?
Regional low back pain is a ubiquitous intermittent and remittent predicament
of life. Surveys in many countries have shown that 11% to 45% (depending on
the definition of back pain) of adults experience an episode each year, and
most people with back pain can expect recurrences.8,9
Regional back pain is exacerbated mechanically, thereby rendering many activities
of daily living a challenge. Backache is never trivial and, when present,
can be as incapacitating as many ailments, including congestive heart failure
and renal insufficiency.10
It remains unclear whether certain subsets of individuals, based on
genetic predisposition or environmental influence, are more or less likely
to experience morbidity associated with back pain. Regardless, the experience
profoundly depends on whether the individual has the ability to cope with
the episode. It is unusual for coping to be thwarted solely by the magnitude
of pain. However, the pain is enhanced if an individual cannot readily find
a way and a reason to get on with life despite the compromise in physical
capacity. Back pain that is enhanced in this fashion is more memorable and
more likely to stimulate seeking "care" in the medical system.11,12
However, the need also to seek caring is seldom realized; empathy and consideration
of alternatives for coping at home and at work are the foundation on which
to base the therapeutic contract.
If coping is thwarted in the workplace and results in work incapacity,
the ready recourse is to the care indemnified by workers' compensation insurance.
Access to workers' compensation requires that the back pain arose out of and
in the course of employment and by "accident." If so, medical care, rehabilitation,
short-term wage loss, and future income loss consequent to permanent disability
are compensable. This recourse has been available since regional backache
was deemed an "injury" some 70 years ago.13,14
Common wisdom holds that incapacitating regional backache must have arisen
out of and in the course of the work for which physical capacity is compromised.
It follows that an "accident" has occurred and the consequence is a back injury.
However, simply because a particular biomechanical challenge exacerbates back
pain does not mean that such usage is the proximate or principal cause. By
analogy, although stair climbing can exacerbate angina it would not be logical
to infer that stair climbing causes coronary artery disease, to countenance
a construct such as "stair climbers chest," or to replace stairs with escalators
as a public health measure. However, backache and other regional musculoskeletal
disorders have been viewed this way and continue to be so despite studies
such as an RCT that found providing biomechanically oriented training to postal
workers had no effect on the incidence of memorable or disabling back pain.15
The article by Wassell et al also includes economic assertions regarding
the costs of back pain that are reiterated throughout the literature on back
injuries.16 However, the human cost also must
be considered. The social construction of ascribing disabling regional back
pain to an injury is potentially iatrogenic and likely to have lasting effects
on the individual's sense of invincibility.6
Furthermore, the perpetuation of this social construction has impeded attempts
at reform. In the past decade, a considerable scientific literature has accumulated
probing the influences of both the physical demands of tasks and the psychosocial
context of work on the likelihood of finding a backache incapacitating. The
evidence for the major role of the latter is substantial.17,18
Multiple psychosocial aspects of life in the workplace can prove challenging.
Many relate to interpersonal relationships, a sense of being valued, autonomy
and security on the job, and management styles. Whenever the context of work
is personally challenging, coping with the next backache will be confounded.
It is no wonder that in addition to the lack of benefit from back belts, Wassell
et al could show that job dissatisfaction and prior workers' compensation
claims were associated with memorable and compensable backache. The challenge
is to fashion employment that is comfortable when workers are well and accommodating
when they are ill or incapacitated, including those with regional back pain.
It is time to relegate back belts and other such physical adaptations
to the realm of design, not safety. Moreover, it is time to focus on the psychosocial
elements of life, on and off the job, that render too much of back pain so
intolerable that it is memorable and even incapacitating. Therein lie potentially
effective remedies to one of the most pressing public health issues facing
Hadler NM, Carey TS. Back Belts in the Workplace. JAMA. 2000;284(21):2780–2781. doi:10.1001/jama.284.21.2780
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