No support: Back belts, wrist splints sharply criticized
No support: Back belts, wrist splints sharply criticized
Manufacturers say they work, but few others agree
Back-support belts and wrist splints are falling out of favor with many professionals, but don't be surprised if you see workers walking around your hospital wearing the devices anyway -- even if you don't endorse them.
The criticism of belts and splints has been so strong that manufacturers are fighting back against what they call "misleading information and scientifically insupportable positions" from government agencies and professional groups that have criticized the usefulness of the devices.
Criticism has been frequent and severe over the past three years or so, with the result being a significant change in the way hospital employee health professionals view back and wrist supports. The supports had become extremely popular among some hospitals as a way to prevent back injuries and cumulative trauma injuries, but many ergonomic professionals feared that too much confidence was being put in the devices.
With federal agencies declaring that belts and splints may not be all they are cracked up to be, some employee health providers became reluctant to prescribe their use. That meant fewer sales for manufacturers, so now they are mounting an effort to show that the federal criticism was hasty and based on bad information.
Seven manufacturers have formed the Practical Ergonomics Coalition, based in Washington, DC. The group is headed by Tom Votel, president and chief executive officer of Ergodyne in St. Paul, MN.
"There is a bias in these agencies that opposes personal protective equipment in favor of ergonomic and administrative controls," Votel says. "For that reason, they disregarded positive studies in favor of flawed research that confirms what they already thought."
Not a black-and-white issue
It might be easy to dismiss the coalition's efforts as self-serving, but Votel says the message should not be obscured by his admission that the manufacturers have a financial interest in the issue. Manufacturers do not agree with the research that shows the devices are not effective, Votel says, but they also do not argue with the fact that some employers have used the belts and splints inappropriately.
The National Institute for Occupational Safety and Health and the Occupational Safety and U.S. Health Administration, both in Washington, DC, have concluded that even if the devices are proved effective, many employee health professionals rely on them too much. Votel says that is true, but manufacturers never intended the devices to be "a magic pill."
"Overdependence is a concern with any type of personal protective equipment, but that is a process problem within the workplace and doesn't mean the device is not effective," Votel says. "Just because you dispense a hard hat to a worker doesn't give him a license to go stand under a dangling I-beam."
The criticism from NIOSH and OSHA has been so definitive, however, that some employers have felt discouraged from using the devices at all, Votel says.
Criticism justified, HEH doctor says
The growing skepticism about back belts and wrist splints is entirely justified in the mind of Wendy E. Shearn, MD, MPH, chief of occupational medicine at Kaiser Permanente in San Francisco. Shearn says she has never believed the devices work prophylactically.
"I never hand out back belts to our hospital's employees, and I would only consider it in unusual circumstances following an injury," Shearn tells Hospital Employee Health. "They definitely don't offer any help in preventing injuries, and I'm not so sure they do much even after an injury."
The physician feels similarly about wrist splints, but she does sometimes prescribe the use of splints following an injury. Shearn's main fear with both back belts and indiscriminate use of wrist splints is that the devices may inadvertently lead to injuries. Some research has suggested that back belts may cause back injuries instead of preventing them, and an immobilized wrist may stress other parts of the body.
Shearn points out an important fact concerning the use of back belts: The decision to use them often is made by non-health care professionals. Even though Shearn has never recommended the belts, she occasionally has seen them pop up in various hospital departments.
In each case, the belts were ordered by department managers who sincerely thought they were helping their employees prevent back injuries. She attributes the use of back belts to the fact that they seem like a simple solution to a bad problem, and a solution that apparently does no harm even if it does not work.
Shearn also cites the ubiquity of back belts throughout communities. Not only are the belts seen in many workplaces, but hospital employees frequently see them in use at such popular retail outlets as Target and Home Depot stores.
"The belts have really taken off in popularity, but it's based on people just assuming they work," Shearn explains. "They're industrial sheep following a trend."
If back belts or wrist splints are in use in your facility, Shearn advises putting a stop to it but also taking the opportunity to investigate injury hazards in that area. Remember that the department managers who implement the use of back belts or indiscriminate use of wrist splints have good intentions.
"I would call up the department manager and ask why they started using the devices," she notes. "You might find out that there is a problem in that department that needs your attention, and that's why they tried the belts."
Shearn recently contacted a department manager at the hospital who had implemented the use of back belts, and she found a good response. The doctor asked why the belts were necessary and suggested more effective means of addressing the problem. The manager had assumed the belts were effective, but she was open to Shearn's explanation that the research suggests otherwise.
"Approach them with the attitude that they're trying to do the right thing even if they don't have enough information," she says. "Fill them in on the facts, and they probably will see your point."
Still no proof of effectiveness
There is ample reason to discourage the use of back belts and splints, says Sheree Gibson, BSME, MSE, PE, CPE, an ergonomics consultant in Simpsonville, SC, and vice chair of the ergonomics committee of the American Industrial Hygiene Association (AIHA) in Fairfax, VA. The AIHA issued a report in 1994 that concluded there was no reliable evidence to support the use of back belts and wrist splints.
"I don't think anything has really changed in terms of biomechanics or a strong link between the devices and injury reduction," Gibson says. "Employers might see a decrease in injuries temporarily, but we tend to see that any time they introduce an education program in proper lifting."
Not a quick fix
In recent years, employee health professionals have tended to use back belts as a "quick fix" that allowed them to think they had addressed back injuries, Gibson says. She calls the more recent move away from the use of back belts reassuring.
It is difficult to deny that the research critical of back belts and wrist splints is more voluminous and more current than the research supporting their use. In a recent literature search, HEH found that many of the studies cited in favor of back belts and wrist splints are older, and studies supporting the use of wrist splints are particularly scarce.
The studies cited by the manufacturers' coalition as supportive of wrist splint prophylaxis often mention only the use of wrist splints in passing, without providing any evidence of their value. (See related story on p. 100 for the pros and cons of back belts and wrist splints.)
"I'm not trying to paint the manufacturers as folks in black hats, but they are pointing to evidence that really is anecdotal," Gibson explains. "There are no studies showing improvement from using these devices, or showing negative effects either."
In her own anecdotal example, however, Gibson says she has seen how the use of back belts and wrist splints can have negative effects on workers. When a manufacturer implemented the use of back belts, workers suddenly began experiencing shoulder injuries that had not been seen at all in the workplace. Gibson surmises that because the employer did not make ergonomic changes to address lifting hazards, the belts prompted workers to lift more with their arms. (Before Gibson could intervene, the workers stopped wearing the belts because they were uncomfortable.)
In another example, she has seen workers use wrist splints that stopped the movement of the wrists but caused the elbows to rise. That simply moved the injury from the wrists to the arms and shoulders.
An argument in favor of back belts has been that they remind the user to lift properly. Gibson says that claim is doubtful, but she is certain that some workers become overconfident when the belts are used.
"Some people think they have an 'S' on their chest when they're wearing that belt and will swear that it makes them stronger," she explains. "They will tell you that even after you've emphasized that the belt does not enable them to lift heavier items."
Votel says that in addition to selectively citing research that does not support belt or splint use, the federal agencies and the AIHA based their criticisms on assumptions that do not apply to all workplaces. The worst assumption, he says, is that all workplaces are represented by the manufacturing model.
That assumption fits nicely with the agencies' preference for ergonomic and administrative changes to reduce workplace hazards, instead of using a protective device like a belt or splint. In a manufacturing setting, it often is possible to make changes in the workstation or work requirements, as well as providing workers with equipment that reduces the ergonomic stress.
The problem, Votel says, is that not everyone works in a factory.
"You can't really use a scissor lift table or an overhead crane to lift a child and change a diaper," Votel explains. "That worker is going to be lifting the baby, but the employer is being told not to provide a back belt to help reduce injuries."
Can't always 'lift with your legs'
Gibson agrees with Votel's argument that there will be many situations in which the classic "back straight, lift with your legs" approach is not possible, and some in which it is not even advisable. But in such awkward situations, the addition of a back belt does not help and might even make the lift more difficult, she says.
Many of those situations force the worker to bend at the waist because there is just no other way to lift the object. Adding a back belt can force the user to "work against his own body" without decreasing the risk of injury, Gibson says.
"Have you ever tried to do heavy labor in tight jeans?" Gibson asks. "The 'support' doesn't help. It just makes your work harder."
Gibson advises employee health professionals not to use back belts unless they are the last addition to a comprehensive approach to reducing back injuries through ergonomics. Even then, she says, "don't expect a miracle, because it isn't going to happen."
Wrist splints also are overused, she says, but there are some instances in which they might provide an effective prophylaxis. If the worker has previously suffered a wrist injury, the splint might provide a small placebo effect in helping the worker think the problem is being addressed. But again, that is no substitute for addressing the real problem.
Splints also can be helpful in cases in which the only problem is the worker's technique, Gibson suggests. If the worker is flexing the wrists too much or holding them at an improper angle, the splint can be used as a training device to remind the worker about the proper wrist position. Even that use, however, should require a doctor's approval.
In almost all cases, Gibson says only flexible wrist splints should be used. The lace-up style with a stiff metal insert should be prescribed by a doctor and usually only after an injury.
More education needed
Votel also complains that the federal government has declared back belts and wrist splints are not "personal protective equipment." When the AIHA questioned the use of belts and splints in 1994, it pointed out that they don't lower a worker's exposure to the harmful environment. A respirator, by comparison, prevents most of the harmful air particles from reaching the worker's lungs, but a back belt doesn't diminish the load the worker handles.
The manufacturers just formed their coalition in November 1995, and Votel says they intend to increase education efforts among employers and occupational health professionals. He advises occupational health professionals to let employers know that back belts and wrist splints can be an effective part of an injury reduction program, but that overdependence should be avoided.
Votel also points out that OSHA cannot cite employers for using back belts, even if the official OSHA position is that the belts' effectiveness has not been proved. He expects further research to dispel any doubts about the effectiveness of the devices.
Gibson's assessment is less generous. While the AIHA takes a neutral position, not condemning belts and splints but pointing out the lack of evidence in their favor, Gibson says further research probably would not support the devices.
"I think we're seeing what is pretty much the case with these devices," she says. "Even if we had excellent, highly regarded research, I would not expect it to show the major biomechanical advantage that the manufacturers have been claiming all along." *
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