Health Promotion and Preventive Programs

Models of Occupational Therapy Practice

Evelyn Jaffe, Jerry A Johnson

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317940678
• Edition: 1
• Topic: Medicina
• Subtopic: Teoría, práctica y referencia médicas

For occupational therapists who want to incorporate health promotion or prevention into their practices, here is a thought-provoking new volume. Health Promotion and Preventive Programs highlights existing models of occupational therapy practice, targeting populations ranging from infants to the elderly, that incorporate principles of prevention and health promotion into traditional health care practice arenas. This important new book describes a variety of occupational therapy services, each of which uses principles of primary, secondary, or tertiary prevention principles, including a health education program for parents of well babies and toddlers, a community outreach program for preschool children who are at risk for emotional problems, a community support group formed by adults who have been hospitalized for psychiatric illnesses, a program designed to prevent industrial accidents through on-the-job training, and a home safety program for the elderly. The effective case study approach will allow occupational therapists to learn about and compare various models of practice, and includes elements necessary for development, organization, and design of health promotion and disease prevention programs. Together the chapters provide theoretical concepts of health promotion and injury prevention and offer a framework by which professionals can analyze material, determine whether or not programs can be appropriately replicated, or design new and original occupational therapy programs having a focus on health promotion and/or disease prevention.

Cognition and Learning in Industrial Accident Injury Prevention: An Occupational Therapy Perspective

Richard K. Schwartz, MS, OTR

Richard K. Schwartz is Associate Professor of Occupational Therapy and Associate Professor of Physical Medicine and Rehabilitation at the University of Texas Health Science Center in San Antonio, TX. He is also a PhD student in learning and cognition in the Department of Educational Psychology at the University of Texas in Austin. Address correspondence to the author at: Rm 242A, UTHSCSA, 7703 Floyd Curl, San Antonio, TX 78284.

SUMMARY. An industrial accident/injury primary prevention program similar to traditional “back school” training, but based upon educational psychology principles such as “transfer appropriate processing” and the use of “critical tasks,” was conducted for a group of 110 workers at a major grocery distribution center. Occupational therapy prevention principles of environmental modification, work simplification, and proper body mechanics were emphasized. Workers and supervisors were trained in very small groups (4-6 persons) at their actual work stations. Results of the program were positive, and the program has continued to expand into a comprehensive accident/injury prevention project within the company.

Overview

Background and Significance

Back pain and back injuries represent serious health problems which have a significant socioeconomic impact on the country. Chronic back pain is the most frequent cause of activity limitation in Americans under 45 years of age, and it is the third major cause of activity limitation in Americans over 45 years old (Aronoff, 1985). Almost 2% of the total U.S. industrial work force suffers a compensatable back injury every year (Beals and Hickman, 1972 and Beals, 1984). Once an individual has experienced an episode of back pain/impairment, the risk of subsequent injury is increased and it is likely that each recurrence will be increasingly severe (Horal, 1969).

Estimates of the lifetime incidence of low back pain in America range from 65-85%. Of approximately 18 million Americans currently suffering from low back pain, an estimated 8 million are partially disabled and 2.4 million are totally disabled (Bonica, 1982). The number of work days lost due to back pain is approximately 1.4 days per worker per year. This constitutes nearly one quarter of all disabling work-related injuries in the United States (Andersson, 1981). In terms of cost, it is estimated that low back pain accounts for expenditures of over fifteen billion dollars annually.

Collectively, these data suggest that efforts to prevent work-related back injury and its consequences could have dramatic benefits from both social and economic standpoints. In recent years there has evolved a body of evidence which suggests that the etiology of most, but not all, low back pain is due to insidious and chronic deterioration of the intervertebral discs, facet joints, and ligaments of the back due to biomechanical wear and tear (Edgar, 1979; Andersson, 1981; Frymoyer et al., 1983; and Paris, 1983). Frymoyer et al. (1983) have identified three major “risk factors” related to low back pain. These are improper body mechanics during lifting, low frequency vibration (which occurs while driving motor vehicles), and tobacco consumption (which increases coughing and decreases vertebral blood flow).

Back impairment ranges in severity from temporary acute distress, which may require no more than bedrest and aspirin, all the way to intervertebral disk herniation with back surgery and possible total medical disability. Therefore, it is important to intervene early and vigorously with even mild or moderate back impairment to prevent a continuation of biomechanical factors which may lead to repeated and progressively more serious episodes of impairment. It has been suggested previously that those with a history of back pain and/or back-related disability are at increased risk for future episodes of back problems (Horal, 1969). As specific risk factors are identified, risk-reduction activities need to be designed and undertaken.

A number of intervention programs called “back schools” have evolved to prevent initial episodes and/or reduce the recurrence of back pain through education. Such programs typically consist of classroom training in proper use of the body or “body mechanics.” There have been uniformly positive findings that such intervention can reduce the incidence and severity of back pain (Liles, 1985; Moffett et al., 1986; LeBlanc et al., 1987). For example, a controlled study at the Volvo Company in Gothenburg, Sweden showed significant decreases in the duration of symptoms and lost work time among workers taking on-site training to cope with acute low back pain (Bergquist-Ullman & Larsson, 1977). In Chelsea, Massachusetts, workers compensation costs were reduced 90% at American Biltrite, Inc. by a combined early intervention, work training, and job redesign program (Fitzler & Berger, 1982, 1983). Other studies have shown similar results (Mayer et al., 1985; Magliozzi & LeClair, 1981).

While initial reports have indicated that targeted educational programs reduce the incidence and severity of back pain, such programs often have not been sustained by employers either because of failure to recognize the importance of repeated training or because the programs were not viewed as cost-beneficial. It is important to note that most programs using a “back school” approach offer either comprehensive training of large groups of workers at-risk for back problems or training to those workers who have had a back pain episode of some kind. None of the studies reported in the literature used any form of targeting of subpopulations at risk based on prior history.

Each medical profession approaches problems from a distinct disciplinary perspective. The program described here was strongly guided by such a perspective, that of occupational therapy. First, even though proper body mechanics were taught (which a physiotherapist might have done also), the emphasis was not on exercise or physiologic considerations, but rather upon work simplification (using the largest and strongest muscles for each task), energy conservation (pacing of work), and the analysis of lifting tasks to eliminate hazards and determine an effective lifting strategy. Secondly, group dynamics and interpersonal relations were recognized as important determinants of success of the training program. For this reason, small groups of co-workers were trained together rather than assembling workers at random and training them in a traditional classroom. This is one of the first programs ever reported in which all of the training took place at the employees’ work, stations under actual employment conditions’.

Corporate management, industrial safety engineers, and others responsible for health maintenance and medical cost containment must contend with limited information when they plan comprehensive prevention/risk management programs. This is because well-conceived empirical studies are not available on cost effectiveness of most forms of intervention. In those cases where an attempt has been made to evaluate savings attributable to preventive measures, a combination of methodological problems (most notably Hawthorne effects), and relatively brief assessment periods (typically 1 year) may have yielded overestimates of the true financial benefits of these programs. A prospective cost-benefit analysis which examines productivity, lost-time, retraining costs, and wage and tax implications of prevention has not yet been published. Accurate cost-benefit data would be of considerable utility for those faced with decisions regarding the prevention and treatment of back pain. Providing such data is a long-range goal of this program.

Character of the Program

The prevention program described here was developed by the author in the Fall of 1986 for the primary distribution center (warehousing and shipping operation) of a major retail grocery chain. Although this company employs close to 23,000 persons, the initial program was developed for a division with only 110 workers. This group of workers was known to have a disproportionately large number of back problems. It was decided that in addition to targeting a high-risk subpopulation that the program would focus on providing primary prevention services to asymptomatic individuals. Although not anticipated at the time, this program became the first step in a series of efforts that have continued to develop and elaborate upon a new model of industrial accident/injury prevention (Schwartz and Christiansen, 1988).

While subsequent efforts have incorporated additional forms of preventive intervention, including prophylactic back bracing (orthotics), and physical conditioning (work hardening), the primary focus of the initial program was educational. One of the largely unexplored areas related to the design of effective occupational therapy interventions has been the application of learning concepts and theories to therapy (Schwartz, 1985). The author had been formally trained to offer classic “back school” programming and incorporated much of this content into the program. Yet this program was quite unique in that it was based upon educational psychology strategies and methods which have not previously been reported in an accident/injury prevention context.

Environment and System Influences

In February of 1986 the author initiated an “Industrial Wellness-Back Pain Prevention Program” at the University of Texas Health Science Center in San Antonio. Open training sessions were held in which all employees, faculty, staff or students were invited to attend. Later, specific work groups were targeted and trained in back pain prevention. As a result of this program, local television stations featured the author on a news special about back pain and on a sunrise “talk” show. Management personnel from Distribution Center Services at the H. E. Butt Grocery Company (HEB) contacted the author and indicated that they were interested in designing a program to prevent back problems and control escalating costs attributable to such injuries.

It is of paramount importance to recognize that the company expressed its interest in designing a prevention program and was already committed to this type of programming prior to the author’s involvement. All too often it has been therapists (both physical and occupational) who have approached companies and “marketed” a package of prevention services which are “tailored” to the client company’s needs. In such cases, if the motivation of the company is solely to save dollars, the philosophy and scope of the “packaged” prevention program may be quite different from the one described here.

It cannot be overemphasized that the concern of this company (HEB) for their employees, (who are referred to as “partners” rather than employees by the company), was of paramount importance. While the potential to reduce costs of injuries was recognized, this was not a major issue nor were the established goals for the program stated in financial terms. HEB’s goals were simply to reduce the incidence and severity of back problems and lost time due to such problems through primary prevention measures.

As mentioned earlier, “back school” or employee training programs for back pain/back injury prevention have widespread recognition as effective means for reducing the incidence and severity of back problems. Therefore, it was surprising to learn that when an upper-level manager at the H. E. Butt Grocery Company contacted his counterparts at several companies where published studies of “back school” intervention had been conducted, none of the companies contacted had continued with their programs as described. Apparently the cost-effectiveness of their programs significantly decreased after initial and often dramatic improvements. Based on this information it was decided to pilot a nontraditional prevention program on a work group with a high risk for back problems, based on both job requirements and prior history.

Frame of Reference

Traditional back schools have been used as both primary and tertiary prevention measures. Most primary programs work with small groups of 10-20 workers in one or two sessions lasting from one to two hours each. Lectures, demonstrations, films, slides, models, and group practice in exercises and proper body mechanics are employed during the training sessions. Participants are usually trained in a classroom environment, taking notes as they are instructed and referring to manuals provided during the session. Tertiary prevention programs (often called “re-education” programs), are offered to those already having suffered back impairment of some kind. These differ from primary programs mainly in that they are often conducted either one-on-one or in small groups at a therapy or rehabilitation facility, and emphasize the precautions related to each participant’s particular injuries or condition.

Educational Flaws in Traditional “Back School” Approaches to Prevention

The successes of training programs in comparison with n...