Written by Jack S. Kanner
Director of Engineering and Training
P.S.R Corp. - Professional Safeguard Response

xxx The extraordinary disability losses due to back and stability related injuries in California Public Safety Agencies, specifically Fire and Police, has prompted the need to establish safety training relating to the conditions in the emergency response working arena. In fire / emergency medical response the conditions are constantly changing with reoccurring awkward, often extreme physical demands placed on the public safety employee. Nevertheless, the fire / emergency medical response employee must respond quickly and often reflexively in critical circumstances where the interests of public safety and indeed time/survival are setting the precedent.

xxx Public safety agencies are discovering that wellness programs and physical fitness training alone are not the answers to the spiraling cost of worker's compensation and disability retirement losses for these high risk public agency personnel.

xxx In spite of progressive efforts to control injury losses in the ranks of these critically valued human resources, there remains a high incidence of disability injury and related retirement for 'backs', 'knees' and 'ankles' as well as for physical stress related medical disorders such as high blood pressure and related risk. The greatest percentage retire with a back-related, ankle or knee disability injury. Some California Fire Agencies have a disability retirement rate of over 90%.

xxx The cause of these disabilities to infield fire / emergency medical services personnel relates directly to the changing nature of physical demand in the work arena. The demand is not consistent and often involves unanticipated, awkward conditions such as:

In medical responses; extracting limp human weight in the form of cardiac victims from beds, couches, xx bathtubs, or between the wall and water closet where stricken at the time of the emergency.

On site firefighting or at fire drills; pulling deceptively heavy lengths of large diameter hose, lifting and xxcarrying cumbersome generators, heavy hurst tools (hydraulic jaws), one end of a 36 ft. ladder, and xxother apparatus while wearing over 35 pounds of turn out gear and working on changing surfaces.

In medical transports; carrying a litter with shifting victim through and down narrow corridors and xxstairways and then having to lift them quickly over chest high obstacles such as bannisters and balcony xxrailings.

xxx The above activities occur along with multiple other physical actions and responses often requiring spontaneous and extreme exertion, with heightened stability on changing surfaces, and other unanticipated physical response.

Current Biomechanics (Body Mechanics) Safety Practices

xxx The problem with standard body response safety education is that it is symptomatic. An example of symptomatic procedural back safety training is - bend the knees, bring the weight close in, work with the legs.

xxx However seemingly correct these guidelines for safe effort and movement may be in ideal conditions, they each in turn or all together may well produce injury as a first response when applied by a firefighter as a standard formula in the field. It is of course difficult to apply clinical body and back safety response for emergency service employees such as firefighters and expect them to be readily applied in all the less than ideal conditions in the field.

xxx A specific example of routinely awkward emergency response is a firefighter reaching out for a heavy 'cardiac' patient on a couch, in a bed or a bathtub. In this instance bending the knees as a first procedure borders on the irrelevant. It is in this instance that the responder has difficulty establishing footing and leverage while simultaneously reaching for the victim over the impedance in order to bring the limp weight closer. It is here that the responder can and will seriously injure the back.

xxx Indeed for most people the ordinary act of reaching for a cumbersome object out of a car trunk (over the bumper and trunk lip) necessitates reaching for the weight at an uncomfortable distance from the body while it disallows using the first standard positional rule of lifting which states that the legs should be underneath the weight in order avoid back injury.

xxx Commonplace in the environmentally changing, physical demanding work arena is the reaching for awkward or positionally inaccessible weight in which the employee is conditioned into avoiding injury by experiencing discomfort of doing it incorrectly.

xxx A firefighter / EMT , to be free of disability back injury upon retirement, must not be educated by pain or discomfort in the back in order to focus on correct procedure.

Cumulative Results Of Allowing Body Effort To Be Incorrectly Focused

xxx The Back: The smallest amount of back pain during effort may produce damage to the discs. It is important to note that the discs, which separate the vertebrae (the joints of the spinal column), act as shock-absorbers and spacers. The discs haven't any nerve endings or blood circulation within them and therefore will neither signal directly nor regenerate significantly when damaged.

xxx Each time the spine is overloaded to the point of back pain, vertebrae in the area of the back affected (usually the lower back) are forced together and subsequently will compress a disc between them. The disc is likely to suffer, to a lesser or greater degree, some irreversible tearing from the inside out. The pain signal is sent by nerves which have been affected outside the disc, and usually instantaneously after the damage has occurred. In other words the pain to the back is not an effective warning system by which to be guided by to prevent back injury, for, by the time the pain mechanism occurs it may well be after the initial more serious injury to the disc. Most back overloading is transferred to the lumbar spine - low back.

xxx Medical studies indicate that one out of three employees in a physical occupation over fifteen years will have disc degeneration in the low back. There has been repeated damage to the same area and in effect the same injury is reoccurring over the employee's career. The back condition is becoming chronic.

xxx At the least the basic causes of most back-related injuries do not disappear with first time recovery unless there is some significant modification of the body's mechanical functioning. "A mechanism is only as strong as its weakest link." Within the fire services there are countless stories of personnel who one day, while reaching for a relatively light weight - a breathing apparatus or a coil of hose - herniated a disc. This was the same progressive injury that started earlier in the career with the first "back strain" years prior to that moment.

xxx The preventative remedy lies in breaking into the reoccurring pattern of body response, and will be considered after the two other reoccurring types of disability injuries are briefly reviewed.

xxx Stability Related Injury - Falls: Whether they are the random type of incident told in many fire agencies of the weary firefighter who after returning from a routine call, stepped off the engine, ankle gave out, and fell backwards sustaining a serious disabling injury. Or the on-site repeated incident of knee or ankle injury occurring during mopping up, or indeed while playing basketball. In each occurrence the supporting ligaments of the ankle or knee will to some degree stretch. Ligaments do not tighten once stretched. This translates to the probability of reoccurrence increasing significantly with each occurrence. The ankle/knee injury potentially becomes, without some form of movement reeducation, "a permanent disability waiting to happen."

xxx Physiological Stress Response - Adrenaline/Anxiety: Tense and stressful physical response in crisis or otherwise, such as holding the breath therefore holding tension in the chest, neck, and shoulders, has often been identified as one of the primary factors in high blood pressure and related medical disorders. Included in the down side of stressful response is the greater potential for error in tactical and critical judgment.

xxx The emergency responder / crisis manager's physical control of breathing along with upper body reaction has significant effect on the output of adrenaline and therefore on the physical control of blood pressure which relates directly to the body's adrenal output. This is also the greater part of psychological control of emotion and judgment.

Occupational Work Hardening For Professionals To Prevent Back, Stability, And Controllable Stress Related Disability Injury Loss

xxx The first element necessary to establish in the process of body safety education for the high risk employee is the physical experience and ongoing physical memory of: where and how is the correct effort initiated and maintained with the first breath of action. The second element is how is this then integrated into the body's functioning together as one whole, stable unit. This physical knowledge is a reflex action relating directly to the first activity of effort - breathing.

xxx When pushing a stalled car the first significant human action is taking a breath, "getting set". This means stabilizing the spine and center of gravity and force. We automatically push through the hips and legs first and arms last, otherwise the car doesn't move.

xxx There is a basic law of human physiology, very clear to both the boxer and opera singer. The key element to body control, stability, and the capacity to adapt through changing circumstance lies in the physical awareness and control of where and how the effort must be initiated, experienced, and maintained to allow the correct reaction margins necessary for performance.

xxx What the two occupations above have in common is that they enter into the demands of their respective work arenas, physically and reflexively aware of a common mechanism: the control of breathing. Breathing is controlled by the voluntary (and involuntary) muscle action of the diaphragm. The diaphragm controls respiration and initiates a unified body effort by linking the front of the body to the back and helping coordinate the action of upper and lower body. Effective effort and stability begins with firstly coordinating the breath (diaphragm) muscle action with the large muscle groups of the hips and legs and lastly with the use of the upper body muscle groups of the shoulders and arms.

xxx This establishes a low center of gravity and leverage. That is the reason why in the science of Judo, a 100 lb. person is able to throw a 200 lb. person with relative ease. It is leverage not upper body strength which achieves this. The coordinated strength of the hips and legs initiate an effort which is further supported and directed by the shoulders and arms.

xxx Virtually all technical, safety, or fitness training for the fire/emergency services does not address this appropriately. The standard symptomatic back safety training statement is "use the legs and arms". This is not the same theory as "initiate the hip/leg action first and use the shoulders/arms as a supporting mechanism." In the latter - lower body to upper body methodology - we are developing correct habitual effort pattern with an in-built margin for safe response before reaching body capacity limits. The effort is experienced and maintained through hip action, stability, and breath, guided by the pull of gravity, and not discomfort in the back.

xxx Some employees will of course spontaneously improve the body's mechanical mechanisms without formal training, "finding a better way to do it". However most others will be injured when brought "closer to their overload limit" for which they have not established physical guidelines other than pain to pre-alert them.

xxx Weight / fitness training in the gym provides muscle strength but an incorrect orientation to leverage in the work arena because it compartmentalizes efforts. Each body part is strengthen separately not as working body unit. In fact although these employees benefit greatly from enhanced cardiovascular health and some lowered orthopedic risk through joint strength; they are at least as prone to injury of the lumbar spine (lower back) if not more. This is because of their altered sense of body power in the arm/shoulder without specific integration of all the body muscle groups to work together in a united response.

xxx Movement education for fire emergency responders (in regards to stability) exists primarily in the protocol training for entering smoke filled environments or climbing ladders. Existing habits as applied to functional movement to enhance ankle and knee stability - stationary and moving with apparatus, or on changing surfaces - is not addressed in standard training.

xxx Additionally, effort, endurance, and emotional output are fueled by the adrenals - the control of output of which, as stated, is triggered by how we continue to breath. Repetitive breath oriented training during leveraged effort, along with stability enhancement during changing circumstances, establishes habitual patterns using voluntary/involuntary actions as the foundation for job specific action. This leads to involuntary reflexive body behavior. The correct career orientation depends on the relevance of the input.

Awareness Of The Correct Mechanism To Perform

xxx Everytime we commence to push a stalled car, we "take a breath", actually holding our diaphragm not our lungs which are simply air sacs. If you reflect on it for an instant it becomes obvious that this action initiates the whole 'unit' body working together - largest muscle groups taking the most effort i.e. the hips and legs. It is difficult to push a car any other way.

xxx Without a very strong diaphragmatic action, the boxer may have the 'punch' to win but be unable to maintain spinal stability or the balance (center of gravity) to receive blows. He trains to control his breath related action in tightening to quickly lower center of gravity and not have the "wind knocked out him" and slightly relaxing it in order to measure out endurance and move more quickly.

xxx The defensive linebacker in football works from the same physical start point to lock in his hips and legs first and then shoulders and arms in order to establish a very low center of gravity with "the whole body behind it" Indeed, the running back may be able to leap high in the air to throw or catch a ball but if - when simultaneously tackled by 300 pounds form behind - he is unable to reflexively stabilize his body (make it "one unit"), his spine will "give" and he may be seriously injured or crippled.

xxx The opera singer or speaker maintains the ability to project forcefully, softly, and control other forms of expression, endurance, and mood, by maintaining the effort focused and controlled by the action of breathing. Endurance, power and control, as well as poise and presence of mind are critically influenced by this type of training in many types of professions.

xxx This pivotal first response to action and movement is common to all breathing humans. In other words - it is a readily learned mechanism since already a natural human function. If the diaphragm does not already function well at the primary breathing level, a respirator is needed.

xxx What must be established in the profession of emergency response are employees with a basic physical awareness of:

How to focus effort, maintain stability, and control anxiety beginning with the first breath of action

How to coordinate this focus of effort together with stability in order to establish leverage in all job xxspecific situations

How to spontaneously identify physical responses along with situations adversely affecting leverage, xxstability, and physical stress controls

xxx In summary, establish within the emergency services employee a margin for safe response during action and reaction.

xxx There already exists the spontaneous mechanism for body preparedness before action, or injury would occur every instant. This can be elevated through specialized work hardening, career orientation training.

Can It Be Accomplished With Anyone Other Than An Athlete?

xxx Most people will successfully push a stalled car without injury if they are able to move it at all. If this physical experience of leverage and stability can be carried over and adapted to other push like situations - such as holding down a 2 1/2 inch charged fires hose - we have significantly expanded the margin between action and injury for body safe response, which may be particularly relevant if one of the two people on the hose is actually doing most of the holding and it suddenly whips back.

xxx Breath related effort distinctions are taught to pregnant women prior to childbirth in order to better control effort and pain during labour. Ultimately this breath related training is applied during actual childbirth when the woman is least able to consciously control her actions. Is this not a reflexive mechanism improved with training?

xxx The career firefighter has at least as much motivation to prepare for the risks in the changing situations of emergency physical demand in the "street".

Tactical & Critical Body Response Safety

xxx This above mentioned approach to physical safety training is derived from principal elements of the oriental physical sciences and martial arts. It is termed "tactical" and "critical body response". Whether the effort is routine or emergency the critical factor in self-safety is to establish and maintain the body's mechanical advantage prior to and during action - a breath related * autonomic reflex self-safety response while still focused on the task at hand.

* Autonomic reflex nervous system - the voluntary / involuntary action of the body nervous system controlling breathing.

The Statistical Results

xxx The statistics indicate this system of using autonomic reflex based mechanisms with leverage and stability as procedural tools works most effectively and in the most demanding range of work exposures. The 'physical' occupations are highly receptive and have had outstanding results.

xxx The system described and designed for emergency services is called P.S.R - Professional Safeguard Response. It has produced significant statistical reductions in disability injury losses in the emergency services of government agencies.

xxx In Federal, California State, Municipal, and public regulated agencies-back and stability related losses have been those most conclusively improved.

xxx Substantiating examples of this in a brief overview are:

xxx The U.S. Dept. of Energy together with the University of California at Lawrence Livermore National Laboratories (Hazards Control Department) : chronic back injury losses and falls at the Fire emergency services for the facility of 10,000 were reduced to virtually nonexistent 1 year after implementation.

xxx The USDA Plumas National Forest after implementing 1 clinic per group of 20 to 30 personnel in the fire protection and engineering force, achieved significant reductions in back injury losses during the subsequent California fire season "the Fire siege of '87", where fire associated injuries increased from 40% to 60% and back injuries decreased from 33% to 9%.

xxx The U.S. Airforce Fire Protection Group Headquarters has recommended this training to all its commands worldwide.

xxx California Municipal Fire Departments from Sausalito FD in Northern California to Pasadena FD in Southern California have disability injury loss trends.

xxx Other high risk public safety agencies such as Alameda Police Department - where "back" risk exposures vary from lifting awkward objects to wrestling resisting offenders - reduced back related injuries in the agency of approximate. 100 personnel to none in the first seven months after being trained.

xxx Thousands of utility company high risk personnel such as those of the Pacific Gas & Electric Co., and the Sacramento Municipal Utility District, have had their employees trained in this job specific, developmental system of leverage and stability. Many working situations do not lend to symptomatic back safety procedure. For example, a person working up on a pole, strapped in at the waist, with a ten pound (insulator) at the end of an eight foot hot stick is not readily able to "bend his knees and keep his back flat" in order to do the job of hanging the weight.

xxx A key element to the successful safety training of any high risk or emergency services employee is the person's ability to then apply the training on site while focused on the task at hand.

On The Advice Of Experts - Medical, Insurance, Reinsurance

xxx Such a system of job specific, developmental training does not exclude a participant having preexisting injury. The P.S.R system is applied post injury and surgery to the recovery and return to work of patients of primary neurospinal and orthopedic back surgeons. Specialized 'critical response' movement stabilization training is given to patients returning to the demands of their occupation subsequent to serious 'back' injury or surgery. These may include emergency services employees as well as professional football and baseball players who are returned to the real demands of their own working arena.

Summary

xxx The capacity to recover from body injury has to do with many more variables than the activity of prevention.

xxx In order to control losses of career personnel as well as human and financial resources: public safety agencies must consider the work hardening/loss prevention training of the employee with the risk potential for disability injury. This attention should be consistent and parallel to procedural technical training for the occupation, be it firefighting or emergency medical response.

xxx The average back injury costs a U.S. public agency or insurance carrier $8,000.00 before surgery or retirement. 1 in 2 fire agency employees will suffer a disability related "back", "knee", or "ankle" injury in their career. One half a day of specialized occupational and developmental training in order to trigger the correct ongoing professional, self safety response as a career orientation, will return a measurable saving of fiscal resource and an immeasurable saving in human resource over the career of the participant.

Close

This article was reprinted from California Fire Journal December Issue 1989 Vol. 4 No. 2

About the author:

Jack S. Kanner

Jack S. Kanner CEO, is director of engineering work behavior modification and career loss control for the PSR® Corp. , a nationally recognized public-sector oriented training agency based in
Corte Madera, California