Stay ahead of trends in work injuries and prevention

Occupational injury expert offers advice

[Editor's note: Rehab Continuum Report asked occupational injury expert Terrence Sullivan, PhD, to participate in a question-and-answer session to discuss the latest trends in work injuries and the effectiveness of rehabilitation programs aimed at preventing workplace injuries. Sullivan is president of the Institute for Work and Health in Toronto, Ontario. The organization conducts population-based studies investigating the effective treatment of musculoskeletal injury in the workplace. Sullivan also has written books about workers' compensation and health reform, including Injury and the New World of Work, published in 2000 by the University of British Columbia Press in Vancouver, Canada. His comments are quoted in this issue of Rehabilitation Outcomes Review.]

RCR: How have the causes of workplace injuries and prevention efforts changed in the past decade?

Sullivan: There are a number of ways they've changed. First of all, the patterns of injury continue to show decline in acute injuries, that is, unambiguous injuries involving crush puncture, broken bones, etc. The pattern is toward soft-tissue injuries, or mostly slow-onset injuries involving strains and sprains of the muscles, bones, and joints, and in particular, those involving lower back pain and those involving injuries of the upper extremities: arms, hands, shoulders, wrists, neck.

So those injuries have continued to grow as the proportion of all injuries and the more acute forms of injury have continued to decline. The nature of the injury has changed, and this appears to be associated with changes in the demands of work and the composition of the work force and the kinds of work that we're doing.

The challenges for prevention of these are not typically unequivocal, monocausal, event-related injuries. These are typically problems that are multicausal and have slower onset. Work is a contributing factor and, in some cases, a clearly dominant factor; in other cases, work may be involved instead of threshold events for genesis of the disability claim.

Prevention doesn't come easy

Prevention of these injuries is not a simple matter. If you were to look at recent workplace studies that suggest where there are opportunities for reducing such injuries, we'd find three promising bundles of work. I say promising because even though they're promising, we don't have good intervention studies showing that these pay off good dividends.

The first promising area is management and organizational practice. Companies that have strong management commitment to health and safety, an employee-friendly work environment, the delegation of decision making related to health and safety practices, and strong management commitment to health and safety issues have lower injury rates, and return-to-work rates also are better following injury. So there's a promising line of activity that really involves improving the organizational management practices of the firm.

The second promising area involves ergonomic solutions to adverse exposures in the workplace that either involve unusual postures for lifting or turning, in the case of back injury, or better managing the condition of the workstation for people who are doing white collar work, ensuring you have ergonomically optimal workstation arrangements. The pace of work, in the case of keyboarding, for example, or another repetitive task of the upper limbs, is measured in a way that respects ergonomic guidelines.

For example, there are a number of things one can do to introduce a brief rest period for competitive work for the upper extremities or to measure out in the case of keystroking the work over a period of time. So, highly compressed deadlines, which we know from our research in the newspaper industry are associated with repetitive strain injuries, are distributed over longer periods of time rather than simply being compressed into short periods of time.

Using common sense

Rather than trying to push everything to produce a lot of paper really fast and requiring people to be on keyboard for hours at the end of the week to meet a deadline, you try to distribute the work more evenly over the course of the week so that you don't have intense keyboarding pressures. It's just common sense, but it turns out to be epidemiologically verified common sense.

The employees required to stay on keyboard for hours at a time are more likely to have injuries than those who are distributing work over a broader period of time. So there are a number of ergonomic interventions that look promising, but again this is mainly based on risk information.

The third promising line of prevention work involves looking at the psychosocial demands of the job, and this is, in a way, the most challenging — but also the most promising — area if we're looking at soft-tissue injury prevention. For example, we know there are strong relationships especially between job control, the degree to which individuals have discretion and use a range of skills in their jobs, and back injuries and some other musculoskeletal injuries.

And these issues relating to job control have a lot to do with how repetitive the job is, how much discretion and latitude people have in the way they organize and see the path of their jobs. The less job control they have, the more likely they are to have musculoskeletal injuries, and the more likely they are to have cardiovascular disease, too.

Trying to organize the work so that it's enriched and more diverse and allows a greater amount of personal discretion on the part of the worker holds promise for reducing injuries at work. This is something, again, where we don't have much intervention research to say that having done that works automatically; this is just based on the fact that these are known to be some risk factors for such injuries.

Currently, there's some modest work being done in Scandinavia showing that organizations that modify the kind of psychological/psychosocial risks actually are likely to bring down injury rates, too.

One area not mentioned, which we believe is very promising based on research, is interventions oriented to the workplace but precipitated by injury. It's not an attempt to adjust the exposure directly in the workplace before an injury occurs, but to enter the workplace after an injury occurs and make changes to the workplace.

We know now from a range of studies that everybody's attention is focused once an injury has occurred. So small adjustments to the workstation and small job modifications, which are typically inexpensive, significantly affect the duration of disability on subsequent re-injury patterns in a working population. Injuries can generate opportunities to reduce the duration of disability and also the subsequent re-injury patterns.

RCR: How important of a role can rehabilitation facilities play in these interventions and also in prevention efforts, and has their role been growing in recent years?

Sullivan: Let's talk about that. That is a very good question, and of course everyone wants to say, "Of course they can." But the role that they can play in prevention is generally at the level of secondary prevention, or what you do now that an injury has occurred.

This is because most rehabilitation specialists only get paid when they're dealing with injury. We have to be careful with payment methods to make sure the incentives aren't there to promote disability, which even though that seems rather intuitive or even inhumane, we sometimes inadvertently design poor payment structures for health care professionals.

The best role rehab facilities and rehab providers can play is to provide the constructive optimistic presentation of what the favorable natural outcomes are for soft-tissue injuries and then use evidence-based rules in treating and managing these conditions.

These rules are based on not overinvestigating or overtreating or overmanaging these conditions, which is the concern many providers have about how soft-tissue injuries are treated and managed. For uncomplicated injuries of the lower back, for example, there's no evidence in the absence of certain red flag conditions like tumor, fracture, or infection that there's any benefit from ordering X-rays. Yet in our jurisdiction, between 30% to 40% of all first encounters with a primary care physician for lower back injury result in an X-ray being ordered.

Not only is this unnecessary and not useful long term, but it also exposes workers to a radiation dose they don't need and could potentially be harmful. Applying rules of evidence providing a summary of evidence for the best treatment and management of back injury or injuries of the upper extremity is the best way we can ensure they are doing the optimal job in minimizing disability.

Another way rehab facilities can play a role is by maintaining an active relationship with the workplace, which often doesn't happen because rehab professionals typically are not paid to do that. Payment structures and relationships are extremely important in terms of what the incentives are for the rehabilitation professional. We have to make sure there's an alignment on those incentives for the rehab professional.

RCR: I've heard of some situations where rehab facilities are being paid directly by the employer to intervene when there is an injury and also to prevent workplace injuries. They base this on their own studies that it saves them a considerable amount of money. Is the trend of direct payment from employers increasing?

Sullivan: It is happening more frequently, especially for large companies because they feel they have a better measure of control this way. The one area of concern is that in unionized shops, which are a smaller proportion of all workplaces, trade unions are sometimes reluctant to have the employer charged with the care of injured workers because employers sometimes argue against the presence of injury conditions or — in extreme instances — against the presence of industrial disease.

The dominant trend still is toward that model, which is to have firm-specific contracting with rehab providers to promote optimal management and early return to work for injured employees.

RCR: Including prevention programs?

Sullivan: Yes, but this is one of those areas where everyone needs to be from Missouri in the sense that you want to be able to evaluate whether these really are making any difference. Sometimes what we see is the effects of good personal attention, not necessarily large-scale prevention efforts, as being effective.

We want to be able to evaluate carefully when these interventions are being effective, and there's good evidence that small modifications in the workplace with the involvement of rehab professionals can actually make a big difference in prevention, particularly in ergonomics.

RCR: You led an international congress on creating healthy workplaces. What were the congress' chief determinations about prevention and rehab in work settings?

Sullivan: There are so many lessons to be learned from different jurisdictions. Much of what we discussed at the congress is relatively well agreed-upon across the world. You find in North America we're a bit more skeptical about health professionals and the way they're paid and the benefits that accrue from them, than, say, the people in Europe.

I think that the issues involved in healthy workplaces are an engaged and motivated work force where the company shows concern, active participation and the delegated process of decision making, and an employee-friendly culture. These are recognized everywhere now as being important elements.

A high safety culture on the part of management is important. A number of people say that the presence of internal health and safety committees is important, too. And this is an area where the U.S. departs from rest of the world. Most countries have some form of mandated health and safety committee with the power to stop unsafe work, the power to refuse unsafe work, and they are protected by law. This is not a prominent feature of the landscape in the U.S.

RCR: From a rehab facility directors' perspective, what are some trends or changes that may help them focus their services and market in that direction?

Sullivan: One of these is the changing structure of the workplace itself. Services can be offered to small businesses, for example, where typically there hasn't been the same market as large businesses. That's because small businesses haven't necessarily seen the benefits, and in some cases, the margins, to buy these services, but they are a growing portion of the work force — small- and medium-size companies in particular. So there is a market segmentation issue.

Also, the segregation of home contract and contingent workers is a growing portion of the labor force. Being able to provide services to those organizations and the people who work there is a kind of specialty need that is not well-developed. Most of the rehab providers that I know are selling to medium- and large-size companies because they are the legacy we've got and they are also the first market leaders.

However, we have nonstandard employment arrangements now, and we have to figure out ways to make sure they can benefit from these services, too. The other big challenge is people who have chronic problems and developing the capacity to build successful return-to-work programs for people who have been off of work for a long time. There's a high demand for these services, but we don't have a lot of successful program models we can point to.

Bringing the long-term disabled back to work can pay huge dividends even though they're only a tiny percentage of disabled employees. That is one market segment that looks very promising.

RCR: Do you have any specific suggestions for ways to reach the small and contract businesses?

Sullivan: One way to do it is to look at pooling, some kind of sectoral pooling, which involves trying to bring groups together to purchase your services in a consortium model. This involves the providers doing a little work to organize the groups so they're in a better position to respond to the rehab providers because they don't necessarily have effectual organizations allowing them to work as a consortia to purchase such services or to get rate breaks in purchasing.

[For more information about Sullivan's book, you may contact the publisher at this e-mail address: info@ubcpress.ubc.ca. For more information about Sullivan's discussion, contact him at the Institute of Work & Health, 250 Bloor St. E., Suite 702, Toronto, Ontario M4W 1E6, Canada. Or call (416) 927-2027, ext. 2118. Fax: (416) 927-4167. E-mail: tsullivan@ iwh.on.ca.]