Typically, the goals of most of our clients in the fitness setting are not necessarily related to overall performance, but rather aesthetics. Results are generally measured by the decrease in body fat percentage or the amount of inches your client has lost. Recently, due to the innovative ideas of fitness leaders in our industry, the concept of functional based training is becoming a staple in our program design for our clients. Even though clients are still predominantly concerned with the superficial results of exercise, proper education from trainers is elevating client awareness of the benefits of functional training to activities of daily living.
The goal of this series is to help trainers view their clients in a different manner when designing programs to suit their specific work and lifestyle needs. How often do we ask our clients where they are currently employed? Probably always! But how often do you factor in what they do for living into your program design? Maybe if we are dealing with a police officer or fire fighter would we alter the routine, but what about the every day laborer like the construction worker or the assembly line employee? Would you design their program differently than the office worker? If you were training a client to be a high-level hockey player, would you train him the same as the elite golfer? The answer is NO. We should not place our clients in 2 respective categories (i.e. athletes and non-athletes) when we all can be consider athletes at some level. Although the primary basis of this series will examine the industrial worker as an athlete, these principles and protocols can be applied to every facet of life from the daily activities of the house mom to the assembly line worker.
The term industrial athlete refers to anyone who makes a living using mental and physical talents to perform jobs that require skill, strength, flexibility, coordination and endurance—just like an athlete. Many similarities can be drawn between the athletic and industrial population. A considerable percentage of injuries in sports are related to overuse, caused by the repetitive nature of skills for a specific sport. These injuries are often the same types of injuries that occur in workers because of the repetitive nature of their jobs; however, the treatment approaches by the rehabilitation specialists can be markedly different. It is time for a conceptual shift in the treatment of these debilitating, and often frustrating injuries.
Athletes and employees use their musculoskeletal system to perform their sport or job. If an athlete is injured, one goal of the rehabilitation team is to return the athlete as quickly as possible without risk of further injury. The contribution by a worker on the production line is no less valuable than the athlete. Therefore, the employee deserves the same commitment and attention from the rehabilitation team as the athlete.
It is generally the view of some rehab consultants to assume that clients with work related injuries have less motivation to get better than injured athletes. Industrial athletes often get negative impressions placed on them due to their unionized environments. However, with more practical experience, most specialists have changed their perspective because persistent pain is a tremendous de-motivator. Most workers will gladly perform their job if they do not have pain, especially if after working a full day they are able to pursue outside interests without disabling pain. Although there are exceptions to the rule, this is generally the perception. Rehab specialists need to rely on a similar model or protocol that they would use in their therapy of athletes to treat clients for workers' compensation. This training protocol requires clients to be active participants in the process, which can be particularly useful when treating workers who seem to lack motivation, blame the company for their injuries or for those who have encountered chronic pain.
It is important to treat industrial athletes as comprehensively and intensely as you would any competitive athlete - providing guidance in safety practices, appropriate prevention, and conditioning practices, as well as facilitating access to innovative approaches to treatment that carry the greatest opportunity to yield positive outcomes (i.e. functional and specific training modules).
To have the greatest impact, you need to have the same level of understanding about the demands of a specific job, just as a sports medicine team physician understands the demands of a specific sport or position. The goal of returning competitive athletes to their functional status before their injuries should be just as aggressively pursued for industrial athletes. In a competitive business environment, it is crucial to have a healthy, strong, highly motivated team to get the job done (7).
So why does recovery from similar injuries take three to four times as long in the industrial arena than in the sports arena? I firmly believe that the reason for the disparity in recovery is based on the approach to treatment. When a member of a sports team is injured, a highly-refined process kicks into action. The severity and type of injury is assessed immediately, most frequently, right on the playing field. This same process needs to be implemented to the industrial athlete, treating their injuries quickly and efficiently. More importantly, these athletes need to be conditioned for the jobs they perform to prevent the onset of new injuries.
Industrial Injuries – A Brief Overview
10,700 workers each day are disabled temporarily or permanently by on-the-job injuries - one every 8 seconds. On-the-job injuries cost the United States $132.1 billion in 2001. The average cost per injury was $565, with the cost for males ($600) higher than that for females ($460).
Males accounted for three-quarters of work-related injuries, according to Injury Statistics 2001/2002: Work-related Injuries. The incidence rate for females was 87 injuries per 1,000 full-time equivalent employees, whereas for males it was 180 per 1,000.
Falling, tripping or slipping were the most common mechanisms of injury, making up 39 percent of all work-related injuries. More than half of the injuries were either sprains and strains (39 percent) or open wounds (16 percent). More injuries affected the hand and wrist (19 percent of the total) than any other part of the body.
Ten percent of work-related injuries were serious enough for the worker to take more than five days off work, and thus receive weekly compensation from Workers’ Compensation. For 98 percent of work-related injuries, the worker was back at work by the end of six months.
The question now becomes how many of these injuries could have been avoided through proper physical training? It is obvious that injuries and subsequent expenses for treatment and lost work time are becoming cumbersome on many corporations, so perhaps it is time to take the proactive approach and begin preventing these injuries before they happen.
Cumulative Effects of Repetitive Work
Anyone who performs work involving repetitive or strenuous activity may be at risk of injury.
Many of the injuries that are seen in industrial workers are the result of 1) over-use and 2) lack of joint stabilization. Physical therapists commonly use the terms repetitive stress injury (RSI) and cumulative trauma disorder to describe tissue breakdown and injury due to repetitive exposure to a particular movement (1). The risk of injury to respective tissues is increased whenever someone performs or conditions using predominantly one pattern of motion. This is particularly true when dealing with assembly line workers who repetitively perform the same job up to 500 times per day. Factor in 5 days per week and approximately 48 weeks per year, and you have 120,000 repetitive motions. Combine this stat with poor postures and conditioning and you get plenty of aches, pains and injuries.
In the work environment, majority of repetitive strain injuries affect the upper body. About 25% are in the neck or shoulder. Another 23% occur in the wrist or hand, followed by the back (19%) and then the elbow or lower arm (16%). The remaining 17% involved a lower extremity or unspecified body part.
Due to the high volume of repetition endured by the worker, the treating exercise specialist must be careful not to prescribe exercises that load the weakened tissues unless there is a specific therapeutic intent (1). Consequently, the worker who performs countless hours of overhead labor coming to the gym may have significant degree of breakdown to the working tissues of the shoulder. Therefore, performing high volumes or high-intensity overhead shoulder presses may significantly increase the chances of sustaining injury to the shoulder musculature and ligaments.
Paul Chek describes pattern overload as injury to soft tissues resulting from repetitive motion in one pattern of movement. Pattern overload also describes restricted movement in one or more planes of motion. This condition primarily results from an inability to properly load share, being isolated or restricted to a specific motion with loss of movement freedom in one or more planes, and overuse of any given pattern of movement, regardless of freedom of joint motion (1). The body will naturally sequence the recruitment of muscles to provide optimal load sharing across as many muscles and joints as possible in an attempt to protect and minimize unwanted injury.
In all humans, the laws of biomechanics determine strength adaptation. Once the body learns a pattern of movement, it becomes more and more efficient at performing it. The efficiency of this learned movement is often seen as an increase in strength and becomes more evident as fatigue sets in. Consequently, the body will look for the most efficient pattern of movement as fatigue becomes more of a factor. Therefore, if one performs a strength-requiring movement several times, the pattern of the movement will change slightly from one repetition to another (6). Over the course of several months of performing the same job, the industrial worker becomes susceptible to injuries due to poor postures, muscle imbalances and overuse. If the worker is not recovering optimally between each job, the presence of fatigue will force them to perform the assigned job with poor mechanics ultimately leading to injury.
An interesting side note is that most injuries in the industrial setting occur in a standing position, or as a result of dysfunction in that position (i.e. falling due to lack of balance). Many injuries occur as a result of not being able to stabilize the body in a multi-planar fashion. The vast majority of the jobs performed in an industrial setting require proficiency of a skill in a standing position (i.e. reaching, stooping, overhead). Very few jobs have a worker in a seated position. Therefore, this rationale should be instrumental in our program design, which will be addressed later in this series.
The Effects of Ergonomics
Ergonomics is the application of scientific information concerning humans to the design of objects, systems and environment for human use. Work systems, sports and leisure, health and safety should all embody ergonomics principles if well designed. Ergonomics has a wide application to everyday domestic situations, but there are even more significant implications for efficiency, productivity, safety and health in work settings (4). For example:
- Designing tasks and jobs so that they are effective and take account of human needs such as rest breaks and sensible shift patterns, as well as other factors such as intrinsic rewards of work itself.
- Designing equipment and work arrangements to improve working posture and ease the load on the body, thus reducing instances of Repetitive Strain Injury
- Information design, to make the interpretation and use of handbooks, signs, and displays easier and less error-prone.
- Design of training arrangements to cover all significant aspects of the job concerned and to take account of human learning requirements.
Ergonomics deals with the interaction of technological and work situations with the human being. The basic human sciences involved are anatomy, physiology and psychology; these sciences are applied by the ergonomist towards two main objectives: the most productive use of human capabilities, and the maintenance of human health and well-being. In a phrase, the job must ‘fit the person’ in all respects, and the work situation should not compromise human capabilities and limitations.
Some of the benefits of ergonomics in an industrial setting include decreased injury risk, increased productivity, increased efficiency and a decrease in absenteeism. However, ergonomics also has its disadvantages. The major one being that when analyzing a workstation, the ergonomist bases their workstation modifications on a percentile for males and females. In addition, ergonomists have the major problem of accommodating a three-shift plant. Instances such as these can see a short female on one shift and a tall male on another shift, both performing the same job.
In terms of strength, the ergonomist modifies a workstation based on 25 percent female strength, in order to accommodate 75 percent of females and 99 percent of males. When dealing with overhead work, the ergonomist uses 5th percent female for reach standards. A major problem arises with males and females that are above average in height. How are they supposed to perform the same job effectively without sustaining pain or injury?
I won't go too in depth about ergonomics and the goal is not to say that ergonomics is ineffective for the industrial setting. They have had many great advances in the workplace. However, I do want to point out that it ergonomics is not the answer to all the problems and injuries that are sustained in the industrial workplace. It is not uncommon for the worker to blame the workstation setup and ergonomic flaws as the source of the problem for injury sustained. But if ergonomics says the job is within standards for the majority of individuals, the question that needs to be examined is could many of these injuries be avoided if we conditioned the industrial worker and modeled an exercise program based on their respective jobs? I have to believe that the answer is absolutely!
A Switch to Prevention
Unfortunately, we, as a society, are highly reactive to our personal health concerns. Most of us only take action once the health problem has been identified or after an injury has already presented itself. There needs to a shift in the population to begin taking a proactive approach to their health. This is completely evident with the general laborer who is overweight, out of shape and not fit to do the current job he/she has been assigned. I see it on a daily basis working at an on-site health and wellness center for a major automotive maker. The vast majority of individuals that we rehabilitate on a daily basis are physically inactive. There are not too many workers who present themselves with an injury that are not overweight, or that regularly exercise. Having said that, If they are in shape, exercise regularly and do suffer an injury, their return-to-work time period is significantly shorter than the deconditioned worker.
Many injuries sustained in job-related activities can be avoided by early intervention and prevention programs instituted by certified athletic trainers in the work place. Activities such as injury prevention schools, biomechanic evaluations and job placement assistance are currently being carried out by several companies in major industrial settings. For example, Aetna kept their exercisers’ health-care costs $282 lower than non-exercisers by developing five state of the art fitness centers. Dow Corporation reduced on-the-job injury strains by 90% with a preventative health and wellness program designed to get their workers healthier (3). These are just a few examples of some major companies that are starting to realize the potential of a sound health and wellness program to their companies.
The reputation of occupational therapy as a preventive discipline can also embrace a broader definition of injury prevention. Preventing re-injury should be an important goal of an effective rehabilitation plan. It is necessary to determine potential underlying risk factors for injury through effective evaluations and incorporate steps to address them in the treatment plan. Physical deconditioning, poor body mechanics, and poor ergonomic work conditions may all contribute to re-injury for the worker. The conditioning specialist must emphasize the importance of educating the employee and employer with appropriate information to address these issues.
Injury prevention should include continuing with strength and endurance training to build better work fitness, learning how to safely perform work tasks with good body mechanics, and adapting the work environment to promote ergonomically correct work sites. Preventing re-injuries leads to a reduction in medical costs, lost wages, legal and administrative fees, while enhancing the employee-employer relationship. In fact, the underlying the purpose of all forms of conditioning should be injury prevention. An injured worker cannot perform at any level, much less optimally. It is for this reason that we must begin to educate the workforce of the benefits of staying strong and healthy before the onset of injury or disease.
Subjective and Objective Observations
Performing an initial consultation is essential to developing an effective program. The next two articles in this series are going to focus on rehabilitating the injured industrial worker. In order to properly assess the injured worker, we must conduct subjective and objective tests to better determine what is potentially causing the injury. A correct diagnosis of an injury depends on knowledge of functional anatomy, biomechanics, pathophysiology, an accurate client history and diligent observation. Subjective testing involves determining an accurate history of the injury, the mechanism of injury, and the nature of the pain. For example, questions such as what is the patient’s age, was the onset of the problem slow or sudden, has the condition occurred before, how long has the client had the problem, and is the pain constant, periodic or occasional are all important for determining an accurate history. After your subjective questioning, we must get an objective point of view through confirming tests and altered movement patterns. You should try to note how the client is moving as well as general posture, manner, and willingness to cooperate. You should look for any obvious deformities, any obvious deviations or asymmetric qualities, any differences in muscle tone, any scars to indicate recent surgery, any abnormal sounds when the client moves the affected joints and any swelling or redness in the affected area. Make sure to position yourself such that both sides of the client can be compared simultaneously. Please note that if a client is presenting with symptoms that are beyond your expertise, they should be referred immediately to the appropriate specialist. Future articles in this series will offer a more in-depth exploration of the subjective and objective testing with the common injuries of the industrial worker (5).
Critical Analysis of the Workstation
In addition to the subjective and objective testing, our goal with the industrial worker is to address their current job station and model their training program after it. Santana’s unbiased eyes theory is a great tool for trainers to implement. Unbiased observation to human movement is the beginning of understanding what type of training would provide optimum performance (6). Picture the example of the 5’0 ft woman on an assembly line leaning into a car installing bolts for the front seat. Visualize the kyphotic curve through the lumbar and thoracic spine she uses to complete the task. In exercise, we always recommend a lordotic posture for any lifting tasks. However, if you look at this job or other activities such as the golf swing or baseball throwing, you can clearly see natural kyphotic postures being used to absorb or produce force, and therefore we need to functionally train these positions. It may be physically impossible for this woman to complete this job with a perfect lordotic curve. We should review this job and her postures and effectively model our program design. Flexion and rotation of the lumbar spine have always been looked upon as back killers. Yet it is a very common movement pattern. Positions such as these are not always dangerous – the lack of preparation for them however is.
In addition to the kyphotic curve of this woman, we must look at the actual woman who is reaching into the car in this position. Although the reaching does not appear strenuous on the musculature of the shoulder complex, if we had this woman stand up straight while maintaining this reaching position, we will soon realize that this woman is actually working overhead. Looking at these jobs with unbiased eyes will allow you to better assess the workstation and to properly condition or rehab the worker for the job.
Below is a sample list of questions that you can use to help you better assess the job station:
- How many times per day do you complete the required task?
- What is the work/rest ratio (i.e. are there any rest periods)?
- What is the weight of the part that you are lifting?
- Do you have a partner for any of the tasks?
- Do you have to use a gun to secure any parts?
- Are you standing on a smooth or uneven surface?
- Do you have to climb in and out of anything to complete the task?
- Can you demonstrate how you complete the task 3 times?
Program Design for the Job
Once you have determined the nature of the injury and have a basic understanding of the job your client is performing, it is time to take this information and design a fitness program to either rehabilitate the injury or prevent future injuries from occurring. Most workstations in the industrial arena involve ground contact, utilize multiple planes of motion, multiple planes of stabilization, integrated movements, involve the expression of power and utilize gravity to load and unload the muscle systems (6). Many jobs involve rotation of the trunk, which our bodies are designed for, yet many training protocols today do not address this issue of rotational training.
Unfortunately, clients are still being treated with conventional methods developed 20-30 years ago. These methods (i.e. passive therapy) are often shown to be ineffective in terms of returning the injured workers to their original jobs without restrictions. Despite what is considered to be the definitive treatment, workers are often left with considerable impairment, and are unable to return to their original job.
An effective treatment program includes three primary objectives:
- Management or reduction of pain associated with an injury.
- Return of full non-restricted range of movement to an injured part.
- Maintenance or perhaps improvement of strength through the full range of motion.
For the sports therapist, it is essential to understand the scientific basis and the physiologic effects of various treatment approaches on a specific injury. The consultant needs to take into account the nature of the activity that the worker is preparing for. When looking at the target activity, look for the basic characteristics. Analyze the skill demand of the job. Little skill equates to ineffective participation. Analyze the symmetry and cyclic nature of the movement being performed. If ambidexterity will boost performance and minimize injury, then training that ability will almost certainly yield beneficial results. Analyze the strength component; it may play an important factor in the design of your program. Although ergonomics has had a positive effect on reducing the amount of weight lifted during any one cycle of a job, lifting a 15 pound muffler 500 times per day requires a great deal of strength. In addition, muscular endurance may also be a high priority for your industrial worker. Examine every facet of the job and train your worker accordingly. Ultimately, the goal of any training program you design should be pain free, progressive improvement in work performance.
Based on all the variables presented above, it is obvious that a functional approach must be implemented to our program design in order to train the body to work as a unit. Functional training will train the body in a manner that is consistent with the operational environment that the worker functions in. It prepares the worker to effectively deal with all the various elements of the job environment by taking into account the integrated nature of the human body (6). When you perform any functional compound exercise unsupported while standing, you are virtually using every striated muscle in your body. Performing these types of functional exercises is what will best prepare the worker for their assigned job.
Two important variables that need to be addressed in program design are 1.) viewing the overall mechanism of the injury and 2.) retraining the individual in the position that they were injured in. For example, the small muscles of the extremities (i.e. forearm and associated elbow and wrist muscles) are forced to take on the job of the big core musculature if the worker has dysfunctional spinal kinematics leading to an unstable shoulder position, especially in repetitive work. This postural problem often manifests itself as some form of tendonitis at the wrist or elbow. Therefore, if a client presents with a sore wrist, we must look to the potential source and other problems that may be contributing to this pain (i.e. protracted shoulders and thoracic kyphosis). For example, current and future pains at the wrist may be alleviated by focusing on postural retraining and scapular repositioning. ‘Causative cures’ is the idea that whatever caused the initial injury must eventually be part of the cure or rehabilitative process (6). Therefore, if a knee injury occurred as a result of a stepping on an uneven surface, then stepping on an uneven surface must eventually be part of the latter portion of rehabilitation. When progressed to effectively, performing balance and squatting movements on a wobble board can utilize the position that caused the injury to rehabilitate the injured structure and prevent future injuries from occurring. This is especially true in the industrial setting because as a line worker, you own the job you are assigned to. Consequently, the odds of changing to a better job or to one that will not affect your current injury are slim due to seniority issues. Therefore, retraining in that original injured position is essential.
Future articles in this series will focus on training the worker in a manner that will increase their effectiveness and reduce their risk of injury in the operational environment. Exercises will focus on maintenance of center of gravity over the base of support (i.e. balance training); use of movements that have a high carryover to work and resemble the job, open/closed chain compatibility, and last but certainly not least, proprioception (2). Our body uses proprioception to protect itself from injury. Proprioception is the input from the various systems of the body, which tells the body how it is positioned. Proprioception also provides a safety mechanism by which it inhibits the body from producing too much force that can ultimately lead to injury (6). Therefore, designing a training program for the industrial athlete without proprioception provides little in the way of developing functional strength.
The next section of this series will deal with injuries associated with overhead work and the upper extremities. We will look at common injuries of the upper extremities, their potential causes, the therapeutic modalities necessary to treat these injuries and progression programs designed at rehabilitation and prevention of future injuries. The final section will deal with lower back injuries and common lower extremity injuries in the industrial worker. Until the next article, begin reviewing your clients’ occupations with regards to your program designs. These practices can be implemented to any job, not just the assembly line worker.
- Chek, P. (2003). Pattern Overload. C.H.E.K. Institute.
- Chek, P. (2003). What is functional exercise? C.H.E.K Institute.
- Chenoweth, D. (1998). Worksite Health Promotion. Human Kinetics.
- Ergonomics.org – Posture, Movement and Ergonomics.
- Magee, D. (1992). Orthopedic Physical Assessment. W.B. Saunders Company.
- Santana, J.C. (2000). Functional training: Breaking the bonds of traditionalism.
- Sevier, T. (2000). The industrial athlete? Occupational and environmental medicine, 57, p. 285.