The Effect of Body ow back pain is the most common cause of dis-

Mechanics Instruction L ability in industrial societies (McKenZie, 1981).

An estimated 80% of the American adult popu-
lation experiences back pain (Waddell, 1987). In the
United States, workers' compensation payments for
on Work Performance time lost in 1981 reached $4.6 billion (Dwyer, 1987).
Among Young Workers Persons who have experienced back injury feel the
emotional and physical impact of this disability when
attempting to participate in activities of daily liVing,
leisure pursuits, and the fulfillment of vocational
Maureen McCauley roles (Shotkin, Bolt, & Norton, 1987).
Occupational therapists often treat people with
disabling back injuries. Flower, Naxon, Jones, and
Key Words: primary prevention. work. Mooney (1981) described a two-phase occupational
wounds and injuries therapy program in which a physical disability thera-
pist and a psychiatric therapist worked together to
treat the physical and emotional aspects of chronic
back pain. Body mechanics instruction was an impor-
Thirty young workers (aged 14 to 19 years) em- tant component included in both aspects of the pro-
ployed as groundskeepers and custodians were ran-
gram. Bettencourt, Carlstrom, Brown, Lindau, and
domly assigned to two groups; one group received
body mechanics instruction and the other did not. Long (1986) reported an occupational therapy pro-
The instruction focused on proper spinal alignment gram in which patients were observed and evaluated
in the work environment. Instruction on low back in their use of correct body mechanics during simu-
pain began with one classroom session before the lated work actiVities. In 1986, Caruso and Chan de-
subjects 'first day of work and continued during scribed an occupational therapy program that as-
employment with two on-site sessions. The effect of sessed the patient's knowledge of proper body me-
instruction was evaluated through the observation chanics, analyzed the activities of daily living that
of body mechanics during actual work perfor- increased low back pain, and attempted to facilitate
mance. The results of the study indicate that the the development of problem-solVing skills through
group that received instruction performed signifi- patient training and education. Treatment, including
cantly better than the control group. This paper also
acute pain management techniques, patient educa-
discusses the occupational therapist's role in provid-
ing job-specific body mechanics instruction in the tion, work hardening, and assessment of the injured
work environment as a primary method ofprevent- worker's ability to perform specific work tasks, pro-
ing low back pain. vided the basis for the management of work-related
back pain described by Caruso, Chan, and Chan
(1987). The interventions used by occupational thera-
pists have been aimed at enabling persons to return to
work and reducing their chances of further injury.
Preventive programs that incorporate body me-
chanics instruction may be effective in producing be-
havioral change among workers and thus may prevent
back injuries. By reviewing the efficacy of preventive
programs, occupational therapists can help "imple-
ment strategies that will strengthen the relationship
between clinical medicine and occupational health"
(Rosenstock & Landrigan, 1986, p. 337). The proVi-
sion of instruction in proper body mechanics to new
workers in high-risk job classifications may be an ef-
Maureen McCauley, MS, MOT, is an Occupational Therapist fective forum for primary prevention. Training such
at Sacred Heart General Hospital, Eugene, Oregon. At the workers in correct body alignment during work tasks
time this paper was written, she was a candidate for the early in their careers may reduce the risk of later back
degree of master of occupational therapy, Occupational injury.
Therapy Program, University of Puget Sound, Tacoma,
Washington. (Mailing address: 1412 Hayes Street, Eugene,
Literature Review
Oregon 97402)
The analysis of job demands and the provision of body
This article was accepted for publication August 24, 1989. mechanics instruction to injured workers has become

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 a central part of occupational therapy's contribution to Linton and Kamwendo (1987) reviewed 16 stud-
the industrial health field. Marshall (1985) pOinted ies of low back schools and found that a general lack
out that "because therapists understand the concepts of information exists to suPPOrt the effectiveness of
of 'doing,' or work, they are able to analyze activities this intervention technique. Low back schools admin-
and assist individuals with skill acquisition" (p. 295). istered as classroom instruction typically included
These unique skills can be used to help reduce the material concerning spinal anatomy, rest positions,
current epidemic of work-related back injuries body mechanics, and strengthening exercises and
through preventive programs designed to provide job were taught to patients already experiencing some
analysis and effective body mechanics instruction tai- degree of low back pain. Many of the studies reviewed
lored to specific work tasks. lacked proper control and measurement techniques,
Mechanical stress of the spine has been identi- so conclusions regarding the efficacy of low back
fied as a major contributing factor in the development schools cannot be made with the existing data. Linton
of low back pain (Magora, 1973; McKenzie, 1981; Na- and Kamwendo suggested that further research is
chemson, 1966, 1975; Wang, 1981). Body mechanics needed to determine the amount of knowledge
instruction to prevent spinal trauma has been sug- participants retain and the amount of behavioral
gested as one of the most effective methods of reduc- change implemented as a result of body mechaniCS
ing industrial low back pain (Dwyer, 1987; Grandjean, instruction.
1980). Dwyer (1987) contended that Carlton (1987) studied body mechanics instruc-
tion and subsequent work performance and found
the 20th century epidemic of low back pain is preventable and
controllable with simple measures. Effective preventative there was little transfer of knowledge to actual work-
methods include proper use of the spine at home, at school, ing conditions He discussed the strength of workers'
and at work. Public education should be used to reinforce preestablished patterns to explain the lack of applica-
proper body mechanics in the schools, in [he media. and in
industrial and community low back schools. (p. 35) tion of training to the work environment and sug-
gested providing intervention early in a person's work
Biomechanical positions that have been found to career to stimulate subcortical learning of proper lift-
increase the risk of low back injUry include (a) main· ing techniques. Carlton also suggested providing job-
taining forward stooping position, (b) lifting loads specific instruction in the work environment.
with straight legs, (c) reaching with spinal rotation, The pre'sent study evaluated the effect of on-the·
and (d) exerting sudden maximal effort (Bergquist- job body mechanics instruction on the work perfor·
Ulmann & Larsson, 1977; Grandjean, 1980; Nachem- mance of newly employed young workers. Training
son, 1966, 1975, 1976; Wang, 1981). To reduce the that was job-specific and reinforced at the job site was
risk of low back injury, body mechanics instruction used to improve biomechanical positioning during
should focus on these areas of movement and posi- the work tasks of lifting, lowering, pulling, and trans-
tioning in the work environment. ferring objects. The follOWing questions were asked:
Low back schools and clinical programs have
been developed by both occupational and physical 1. Is there a significant difference in the use of
therapists to address the need for body mechanics proper body mechanics in the work environ-
instruction in industrial settings. Currently, little is ment between workers who receive instruc-
known about the efficacy of these programs. tion and those who do not receive instruction?
Dehlin, Berg, Andersson, and Grimby (1981) 2. Is there a significant difference between the
studied the effect of physical training and body me- task scores (i.e., for lifting, lowering, pulling,
chanics training on low back pain symptoms among and transferring) of the workers receiVing
nurse's aides and found that the effect was negligible. body mechanics instruction and those not re-
These researchers examined the effect of training on ceiving instruction?
the psychological perception of work; however, they
made no attempt to determine whether lifting tech- Methodology
niques actually changed as a result of the training.
Subjects
A follow-up study of the Swedish Back School
examined whether patients had changed their work- Thirty subjects were selected from a group of young
ing positions as a result of learning the principles of workers participating in a summer youth employment
reducing back strain (Forssell, 1980). Three fourths of program. The subjects ranged in age from 14 to 19
the patients reported that they had corrected their years. Their previous work history ranged from 0 to 24
work positions. No attempt was made to observe and months of part-time employment. I assumed that this
evaluate the patients within their work environment, population had not yet developed maladaptive work
however, because all of the data were gathered postures or poor lifting techniques in the workplace
through self-reports. because of their lack of work experience.

The American Journal olOccupational Therapy 403

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 Instrument school training proVided by an occupational therapist
A criterion-referenced Body Mechanics Evaluation experienced in conducting inuustrial back schools.
Checklist (see the Appendix) was designed with cri- Body mechanics instruction given to the experimen-
teria established by Broer (1973) and substantiated by tal group subjects included information on the anat-
Frederick, Clark, Brown, Nelson-Allen, and Amble omy of the spine and orientation to the principles of
(1979). The checkliSt was used to evaluate each reducing mechanical stress to the spine during lifting,
worker's lifting, lowering, pulling, and transferring of lowering, pulling, and transferring objects. The prin-
objects in the work environment. ciples taught were the straight-back, bent-knee
During the subject's lifting and lowering, the fol- method of lifting and lowering; the maintenance of
lowing factors were evaluated: (a) simultaneous spinal alignment; the establishment of a wide base of
bending of the hips and knees; (b) ear/hip/shoulder support through proper foot placement; the use of leg
alignment; (c) body square to object; (d) feet strength to proVide the power for lifting; and the prin-
shoulder-distance apart; (e) object close to body be- ciple of centering loads when pulling and transferring
fore rising or lowering; and (f) trunk control during objects. A sl ide show demonstrated some of the actual
rise with no spinal torque. The following factors were tasks that the youths would be reqUired to perform on
measured during the subject's pulling of an object: the job. This group participated in the learning pro-
(a) proper foot placement (one foot forward); (b) cess through simulated work Situations, as suggested
body square to load; (c) simultaneous bending of the by Broer (973).
hips and knees; and (d) no forward trunk flexion. The subjects in the control group received 1 hr of
While transferring an object through lateral move- safety orientation training proVided by a representa-
ment at waist level the subjects were rated on (a) tive of the workers' compensation insurance com-
keeping the object close to the body (avoidance of pany. This training included a movie outlining the
horizontal displacement); (b) aligning object in mid- role of the brain in decision making and how a per-
line (maintaining spinal balance); (c) turning as a son's mental state can affect job performance. It also
unit (no spinal rotation); and (d) hip/knee/shoulder included a verbal review of gUidelines, including
alignment. wearing proper footgear, keeping the work area clean,
The subjects were rated on the lifting, lowering, securing ladders, and addressing safety concerns with
pulling, and transferring of an object during the tasks the supervisor. A question-and-answer session was in-
in which these movements were first observed by the cluded to actively involve the subjects in the learning
evaluator. If the task was done correctly, it received a process.
score of 1. A total of 20 points was possible on the I followed the orientation training with two 10- to
body mechanics evaluation. An evaluator trained in IS-min site visits with each subject. During these
the observation of correct body mechanics was hired visits, the experimental group subjects received addi-
to serve as the rater. The evaluator was bl ind to the tional job-specific instruction on body mechanics ap-
workers' assignments to either the experimental or plication, while the control group subjects received a
control group. review of specific safety concerns for their particular
job activity. Two weeks after the on-site visits, the data
Procedure were collected over 1 week. The subjects had been on
Two job classifications were included in this swdy- the job for a total of 4 weeks at the time of the evalua-
custodial helpers and groundskeeper assistants- tion.
both of whom performed frequent lifting, lowering, The independent observer was blind to the sub-
pulling, and transferring motions. Historically, youth jects' experimental or control group status. The sub-
hired within these two classifications in this program jects were unaware of the purpose of the rater's ob-
reported back injuries more often than those in other servations. To avoid the tendency for the workers to
job categories. alter their behavior, the workers and the site supervi-
Prior to hiring, job classifications were randomly sors were told that the observer was performing a job
designated to either the experimental or control analysis for the program and that they should con-
group. Each group consisted of 15 positions. The tinue to perform their regular work routines. During
youths were assigned to the positions according to the course of the program, several agency personnel
program gUidelines and were required to participate were reqUired to do site visits; therefore, the youth
in an orientation session before the 1st day of work. were accustomed to being observed during work
To accommodate all of the subjects, two orientation activities.
sessions were held for the experimental group and
two for the control group; each subject attended only Results
one session. The experimental group consisted of 13 males and 2
The experimental group received 1 hr of back females. Nine of the subjects in this group performed

404 May 1990, votume 44, Number 5

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 groundskeeping work, and 6 performed custodial
• Control
work. The age range was 14 to 19 years, with a mean m Experimental

age of 16.1 years. The grade level ranged from 7th to

11th grade, and the mean grade completed was 8.6.
Within the group, 3 youths had learning disabilities .,
"'
(j 4

and 4 were juvenile offenders. Twelve of the youths in is

::J
(j) 3
this group worked 32 hours per week, and 3 worked '0
20 hours per week. t
J:J
E 2
The control group consisted of 10 males and 5 Z
::J

females. Eight of the subjects performed grounds-

keeping work and 7 performed custodial work. The
age range was 14 to 18 years, with a mean age of 16.1
years. The grade level ranged from 6th to 11th grade,
Total Score
and the mean grade completed was 9.1. Within this
group, ') youths had learning disabilities, 1 was men
Figure 1. Distribution of total scores on the Body Mechanics
tally delayed, and 2 were juvenile offenders. Ten of Evaluation Checklist.
the youths in this group worked 32 hours per week,
and 5 worked 20 hours per week.
The data were analyzed with an independent t
working activities were significantly better than the
test to compare the total scores of the experimental
control group's scores.
and control groups. The experimental group (those
To isolate demographiC characteristics that may
who received body mechanics instruction) obtained a
have influenced the difference in performance be-
significantly higher total score than did the control
tween the two groups, I performed several indepen-
group (p < .01) (see Table 1).
dent t tests between similar groupings of subjects.
In the distribution of total scores, 80% of the
One such independent t test was performed with
control group scored 13 or below, and 86% of the
learning disabled and mentally delayed subjects elim-
experimental group scored 13 or above. None of the
inated from the sample. Without their scores in-
experimental group subjects scored below 10 (see
cluded, a significant difference still existed between
Figure 1)
the total scores of the two groups (p <01) Due to the
During the activity of lifting, the experimental
large number of female subjects in the control group
group's mean score was 4.9 (out of a possible 6
(5) as compared with the experimental group (2), an
points), compared with the control group's mean
independent t test was performed with only male
score of 3.9, thus indicating better overall perfor-
subjects to compare their performance on the body
mance. The difference, however, was not significant.
mechanics tasks. The male subjects who received in-
During the activity of lowering, the experimental
struction in lifting, lowering, pulling, and transferring
group's mean score again indicated better perfor-
techniques (i.e., those from the experimental group)
mance (m = 4.2, out of a possible 6 points) compared
scored significantly better (p < .05) when performing
with the control group's mean score (m = 3.9). The
these tasks than did the male subjects from the control
difference, however, was not significant.
group.
The experimental group's scores for both pulling
(p < .05) and transferring (p < .01) items during
Conclusion
In this study, the young workers who attended a low
Table 1
back scbool program and had their learning rein-
Analysis of Differences Between Subjects on Work forced while on the job performed work activities
Performance Scores using proper body mechanics significantly better than
Score" did the young workers who did not receive such in-
Group M
struction. For specific work tasks, the greatest differ-
SD Range
ences in performance between the groups occurred
Experimenr.al
(n = 15) 15.40 2.823 10 during the activities of pulling and transferring. The
Control youths participating in the low back school program
(n = 15) 11.53 3681 13 applied the information regarding proper ltftlng,
t [est 3.228*
lowering, pulling, and transferring to their job
Note. The experimental group received body mechanics instruc-
tion; the control group did nor
performance. . .
'Highest possible score was 20 paints. The instruction and evaluation occurred wlthlO 1
* p < .01. month. Because a follow-up study was not conducted,

The American journal a/Occupational Therapy 405

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 the long-term effects of this intervention are un- youthful population. Further study is needed to docu-
known. During the evaluation of job performance, the ment the effectiveness of body mechanics instruction
rater scored the participants on the first observed job on long-term behavioral change and on the reduction
tasks involving lifting, lowering, pulling, or transfer- of risk factors among young workers . .&
ring. A longer observation period could provide a
more in-depth view of a worker's ability to maintain AppendiX
proper positioning throughout the workday. Body Mechanics Evaluation Checklist
Job-specific instruction may be an effective ser- Possible
vice that occupational therapists can provide to Task Criterion Score Score
workers to reduce the risk of on-the-job back injuries. Lifts object from Bends hips and knees
Given increased knowledge of proper spinal align- floor simultaneously
ment early in their careers, workers may be able to Ear/hip/shoulder
develop a greater capacity for identifying positions aligned 1
Body square to object 1
that could lead to chronic back problems. The expan- Feet shoulder
sion of the occupational therapist's role to include distance apart
preventive back education programs could lead to a Object close to body
future reduction in low back injuries if workers can prior to rise 1
implement behavioral change during work perfor- Trunk control during
rise, no torque 1
mance, as indicated by this study. Total 6
Lowers object Bends hips and knees
Summary Simultaneously
Ear/hip/shoulder
Carlton (1987) suggested that teaching body me- aligned
chanics before maladaptive work patterns develop Body square to object
could effectively preclude their development. The Feet shoulder
findings from the present study support the idea that distance apart
Object close to body
back education should begin during the early years of prior to lowering
employment and should include body mechanics in- Trunk control during
struction specific to the work activities being per- lowering, no torque 1
formed on the job. Total 6
job-specific instruction can aid workers in devel- Pulls object Proper foot placement
oping biomechanical rules to follow for their particu- Body Square to object
lar work setting. Skills and knowledge may also be Bends hips and knees
developed to help workers cope with difficult job- simultaneously
No forward trunk
specific situations. On-site instruction can acknowl- flexion 1
edge the combination of awkward posture and weight Total 4
distribution facing the person in the work situation.
Transfers object Object close to body 1
Modification of the task, the environment, or both can Object in midline 1
be suggested to reduce spinal strain (Anderson, Turns as a unit 1
1980). Hip/knee/shoulder
Managers within the health care and insurance aligned 1
industries in the United States have been looking for Total 4
answers to the current epidemic of low back injuries. Total Evaluation Score 20
Effective body mechanics training programs for re- Name: _
ducing the economic and psychological impact of Job Title: _
back pain may be one solution. Occupational thera- Worksite: _
Address: _
pists, with their combined knowledge and skills in
Date of Evaluation: _
anatomy, kinesiology, and job activities analysis, can Evaluator: _
help by proViding effective preventive education.
Comments: _
Mapa (1980) suggested that therapists begin to
accept responsibility for helping to prevent back
problems by recognizing and treating the underlying
biomechanical problems that are apparent in young
people. The present study supports the concept that Acknowledgments
body mechanics instruction can be effective in pro- I thank the staff of the Looking Glass Summer Youth Em-
ducing behavioral change during work activities in a ployment Program for participating in this research project,

406 May 1990, Volume 44, Number 5

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 including Cheryl ZWillinger, Pris Howarth, and the 1988 Forssell, M. Z (1980). The Swedish Back School. Phys-
caseworkers; Ron Stone, OTR, for his many hours of consul· iotherapy, 66(4), 112-114
tation; and Dr. Margo B. Holm, OTR, for her research advice. Frederick, B. B., Clark, V. 1.., Brown, B. E., Nelson-
This study was done in partial fulfillment of the re- Allen, C. E., & Amble, D. S. (1979). Body mechanics in-
quirements for the degree of master of occupational therapy slruction manual: A guide for therapists. Lynwood, WA:
from the University of Puget Sound, Tacoma, Washington. Bafac Enterprises.
Grandjean, E. (1980). Fitting the task to the man: An
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The American journal of Occupational Therapy 407

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