FacebookTwitterLinkedInGoogle+RSS Feed
Fire EMSEMS TodayEMS Insider

Musculoskeletal Injury Prevention: Protect Yourself from on-the-job Injuries


EMS and fire personnel take exceptional care of their equipment because they know an equipment failure could result in the loss of a life. Employers know that if equipment isn't cared for properly, the outcome could be costly in terms of repair/replacement and in the costs associated with injury, disability and liability. But if someone asked you, “What's your most important piece of equipment?” it's unlikely that the answer would be “me.”

In this profession of rescuers who are willing to risk their own lives to save the life of a stranger, it's not surprising that thinking about “self” is at the bottom of the priority list. However, the reality is that personnel are the most important—and least easily replaced—resources in any agency. This concept is more easily understood when the costs are calculated.

First, let's consider what the equation includes. Wrapped up in every employee are the initial costs associated with hiring and training, plus the ongoing costs of salaries and benefits. Plus, a mid to long-term employee possesses that priceless intangible—experience.

When an employee is unable to work, the employer receives no return on their investment, plus they incur the cost of a disability. Disability costs include expenses for medical evaluation and ongoing care, rehabilitation, light-duty time, retraining, shift replacement (usually at overtime rates) and poor morale (everyone suffers when a co-worker is ill or injured). More difficult to calculate are secondary costs, such as increases in insurance premiums driven by an agency's increased risk.

If we look at the big picture, back pain is by far the most common cause of disability for people younger than 45. Approximately 93 million workdays are lost each year in the United States, with an estimated cost of $30 billion to $50 billion annually, according to the National Safety Council. In addition, the World Health Organization anticipates that 25% of health-care expenditures in developing countries will be spent on musculoskeletal trauma-related care by the year 2010. This estimate prompted a proposal to declare the years 2000–2010 as the “Decade of the Bone and Joint System.”

The financial impact of a musculoskeletal injury makes it easy to see why government agencies and employers need to protect their employees. Does your employer have a good prevention program, and is it supported as part of the culture of your department? And what about you? Do you see why you need to take good care of yourself? Do you realize how important it is to those who depend on you—your coworkers and your family?

The younger you are, the more likely you are to feel invincible. But ask anyone who has been around your department for a decade or two if they still feel that way, and the chances are that the more cavalier they've been in the past, the more they've paid, at least once, in terms of pain and time lost from the job. No doubt they've been uncomfortable knowing that someone else had to pick up their slack and that their disability has been an extra burden on their families. To make matters worse, they've had debilitating pain that has caused them to miss some of the “good times” that make life worth living. An even bigger tragedy is that many disabilities follow workers into their retirement and get worse as people age.

What Studies Show 

The International Association of Fire Fighters' annual Death and Injury Survey reveals that sprains and strains routinely account for approximately 50% of all line-of-duty injuries and back injuries account for approximately 50% of all line-of-duty injury retirements each year.Although most musculoskeletal injury studies and statistics don't focus directly on EMS personnel, the NAEMT reports that almost half of the respondents (47% of the 1,356 participating NAEMT members) to a 2005 survey had reportedly sustained a back injury while performing EMS duties. We can further extrapolate the provider's risks by examining other professions with similar manual duties. For example, studies that examine the work-related injuries of health-care providers and firefighters demonstrate a direct correlation between job duties and musculoskeletal injuries.

A study by the University of Illinois found that “work related injury rates in the fire service industry exceed those from most other industries.” In this study, the authors explain that the 1,342 claims collected from 1992 to 1999 point to overexertion, typically of the back, as the agent responsible for more than one-third of the injuries to firefighters, with those injuries resulting in nearly double the cost of all other types of injury claims.

Musculoskeletal Health 

Musculoskeletal health is dependent on strength and flexibility, but it's also dependent on overall good health. The human body can be likened to a magnificent orchestra. When any instrument is out of tune, it threatens the whole performance. Music takes practice and attention to detail. Fortunately, for us, our bodies are more forgiving than the Philharmonic Orchestra and we have infinite back-up systems. In fact, our physiology is designed to instantly regulate functions to maintain balance. But without proper maintenance, this balancing act is far less efficient.Whether sitting, standing, lifting a stretcher or heavy equipment, bending, kneeling, working across a patient, or carrying patients up- and downstairs, good posture is extremely important. For example, sitting in poor posture can put stress on areas of the body that were never designed to hold so much weight by themselves. When the head is positioned forward of the shoulders to read a computer screen, the head is supported only by the neck in flexion. Over time, this posture can cause pain in the neck, upper back, shoulders and lower back. Ergonomically designed desks, monitor stands and chairs help provide the right environment for proper posture. Training and education can also help staff maintain appropriate body alignment.

The musculoskeletal system is not the only system that stands to benefit from a healthy lifestyle. A well-conditioned body, good nutrition and healthy habits strengthen the immune system and discourage a whole host of maladies. A healthy body can better withstand the garden-variety stressors as well as the extreme stressors that are the hallmarks of the EMS profession.

How to Protect your Musculoskeletal System 

Stop smoking: Smoking narrows vasculature, contributes to clogged arteries and causes such respiratory diseases as emphysema. It's a major cause of coronary artery disease and increased blood pressure, and contributes to the tendency of blood to clot, which results in a greater risk of heart attack and stroke. It increases the LDL (“lousy” cholesterol) and decreases the HDL (“healthy” cholesterol). It targets the musculoskeletal system by decreasing exercise tolerance due to the reduced amount of oxygen available to muscle tissue.

Stretch frequently throughout the day: Keep muscles, tendons and ligaments flexible with routine stretching and strengthening movements. Stretching at least every 20 minutes between calls keeps your body warmed up and ready to move at a moment's notice. Give special attention to toning the musculature of the abdomen, quadriceps, shoulders and hamstrings while also keeping them limber and flexible. Yoga and Tai Chi practices are well documented in the literature to improve muscle strength, flexibility and balance.

Know your blood pressure: If it's high, you may not be aware of it because you may not have symptoms until a considerable amount of damage has already been done. If it is high, discuss it with your health-care provider and get your blood pressure under control.

Keep your cholesterol low and maintain a good ratio between HDL and LDL: Research from Johns Hopkins University reviewing the records of 1,300 people over 50 years of age shows that health risk factors associated with chronic low back pain are smoking, high cholesterol and high blood pressure. People with these conditions were nearly twice as likely to have back pain. The suspicion is that these conditions may slow the blood flow to the lumbar spine, causing pain.

Manage your weight: Maintain a healthy weight for your body's frame. Sedentary lifestyles and aging cause the body to lose muscle tone. Added weight and gravity—coupled with little muscle resistance—cause the body to fall out of alignment. This lack of alignment causes undue stress on discs, bones, ligaments and tendons, resulting in microtears in fibers with resultant pain.

Live a balanced life: Life is filled with deadlines, noise, interruptions and thousands of stressors that put us out of balance. Take time to sort out priorities and balance every day with healthy outlets that give you a chance to catch your breath and enjoy life.

Stay hydrated: Drink at least six to eight glasses of water a day (the stuff without caffeine or sugar). Water flushes toxins and waste products from the body.

Sleep: Adequate sleep protects the immune system, repairs cells and makes us feel better. During sleep our bodies have the chance to repair and build new tissue.

Maintain good posture: Good posture when sitting or standing keeps the body in proper alignment. It reduces strain on individual muscle groups and helps keep muscles toned. When standing, imagine a plumb line that drops from the ear to the shoulder to the hips, then to the floor. When sitting, the plumb line will continue from the hip to the floor. Keep your feet flat on the floor.

Prevent osteoporosis: Risks for osteoporosis include smoking, excessive alcohol use, low calcium intake and inadequate exercise. Although men have a lower risk for osteoporosis than do women, they are still at risk, with white men at the greatest risk of all ethnic groups. Other risks include prolonged exposure to certain medications, such as steroids, anticonvulsants and certain cancer treatments.

Prevention includes performing weight-bearing exercises and eating a balanced diet containing 1000– 1200 mg of calcium (contained in green leafy vegetables and dairy products) and 400–800 IU of Vitamin D (from fortified dairy products, egg yolks, saltwater fish, liver, and sun exposure). If you take calcium supplements, take one that includes magnesium and take it in divided doses (600 mg in the morning and 600 mg in the evening).

Guidelines for Proper Lifting


1. Take a moment to observe the scene. Size up the load. Don't be shy—ask for help.

2. Visualize the lift and prepare for it mentally. Determine how you'll approach the object. What parts of your body will you use to protect your back?

3. Position your feet at least hip-width apart for a strong supportive foundation.

4. Never lift and then twist at the waist. Lift and move your feet to turn until you can lower the object to its resting place.

5. Keep the load close to your body.

6. Keep your feet apart and knees bent.

7. Breathe normally throughout the lift.

8. Maintain the normal curvature of your spine. Keep the spine upright, and avoid vulnerable positions.

9. Lift using the muscles in your legs.

Stretching Guidelines


1. Whenever you stretch one side, always perform the same stretch on the other side.

2. Feel the stretch in the “belly” of the muscle, not at its insertion point in the joint. Discomfort in the joint can indicate damage. Stretch only as far as is comfortable. With regular stretching you'll be able to stretch farther as you become more limber.

3. If you feel a burning sensation, you've stretched too far. Reduce the amount of stretching in that area until the burning is gone. Stretching should feel good (otherwise cats wouldn't do it).

4. Maintain proper body alignment in every stretching position. Maintain the normal curvature of the spine. You may need to use props, like pillows and rolled-up towels, to help support your joints while in a flexed position.

5. When performing a stretch, concentrate on where you feel that stretch and relax that area fully. Mentally scan your body to see if you're tensing up in any other area, and relax that area, too.


Create an Effective Injury-Prevention Program 

Start a dialogue
by sharing this article with your employer. Review your agency's injury records for injury types and severity, including days of work lost, so that you can document the need for a program and have a baseline from which to evaluate improvement.A well-thought-out Musculoskeletal Injury Prevention Program (MSIPP) can reduce the incidence of back injuries. If your agency does not currently have a program, or if your program is inadequate, then it's time to develop a process that will help protect you and your peers.

Although anyone in an organization can encourage the development of a program, it requires the commitment and cooperation of staff, administration and union representatives to make it happen. This triad of responsible individuals can develop the structure and support that will make an MSIPP a success.

A weak link or lack of dedication anywhere in this chain will cause a program to fail. If staff members don't feel invested in the program or believe that the program is an excuse for administrators to punish them, they'll do only the minimum required of them. If administrators agree it's a good program but don't fully fund it and don't support it through their own behavior, the staff won't take it seriously. And, of course, the administration and union must both recognize the program as beneficial to their members in order to support it.

Individuals need to see the personal benefits. Often the younger and stronger members of your workforce have a harder time appreciating what can happen to them if they don't take care of their health. Administrators, who are plagued with continuous hits to their budgets, need to calculate the cost-saving benefits of prevention, and union representatives need only to look at the statistics to recognize the importance of safety for their members.

Once a unity of purpose has been established, representatives of all three stakeholder groups can choose the components of a program that will fit their department.

Two important early steps: Review what your department is currently doing, and take an honest look at your own injury statistics. (If you don't have a Safety Committee, this might be the time to start one up.) The Safety Committee can investigate thoroughly every job-related injury or illness claim that has required medical treatment or involved time loss.

When investigating job-related injuries, take note of individual failures to follow safety regulations and look for actions or tools that might have prevented the event. Remember: The investigation should be positive, proactive and directed at the prevention of future incidents and should not be used as an unproductive fault-finding expedition. Recognizing procedural problems is the precursor to developing systems that can reduce the possibility of similar future events.

The Safety Committee can be charged with making prevention recommendations as well as establishing a method for evaluating how system changes have influenced injury statistics. Also, make sure that this committee plays a role in the evaluation of new equipment to ensure that it's ergonomically appropriate.

Don't forget to budget for safety. No matter how good the ideas might be, if there's no budget to support a program, the whole idea may be scrapped. If this happens, try to think outside the box. Review the gold standard program that you want, and determine what components you can afford now and how you can phase in other important parts over the next couple of years. Perhaps you can partner with another agency or a hospital to develop a program and help share the costs of training and implementation. If you live close to a university, you might contact the physical therapy, nursing or medical department to request assistance. A graduate student may be looking for a project and be willing to develop a program for your agency.

It may also be possible to obtain grant funding. You'll find grant-writing experts in most social service agencies. Get to know them and ask them how to find grant sources and write a grant that will support this type of program. A little creativity and a lot of perseverance can open doors never before considered.

Elements of a Successful MSIPP


Some components you might consider including in your MSIPP are the following:

• Pre-employment screening;

• Initial orientation training;

• Routine staff training;

• Ancillary staff training;

• Peer support; and

• Injury identification and rehabilitation.

 Pre-employment screening should include an evaluation of the potential employee's ability to meet all of the physical challenges of the job. If you don't have a job description that delineates the physical responsibilities, consider adding a section on the physical demands.


MSIPP Components

Ancillary staff training:
Ancillary staff will receive ergonomic training based on their job description and a review of the importance of healthy lifestyle choices at least once per year. Staff will be encouraged to incorporate stretching and strengthening into their daily routine.

Training of EMS personnel: Staff will review the techniques of body mechanics and the importance of healthy lifestyle choices at least once per year. Staff will be encouraged to incorporate stretching and strengthening into their daily routine.

Peer support team member and supervisor training: Peer support team members and supervisors will receive an advanced body mechanics training course once per year to teach them how to immediately identify and correct any poor body mechanic techniques they observe in staff. Providing such feedback will reduce the likelihood of injury and integrate the proper techniques into daily routines, thereby providing a safer work environment for all employees.

Student training: Initial back safety training will be provided to students during EMS training.

Injury investigation: Refer to the King County Medic One Accident Prevention Plan.

KC back safety video: Videos/DVDs will be viewed by all paramedic staff at least once per year.


Presented by a qualified health-care professional, training topics and practical lessons include the following:

1. Importance of back safety;

2. Anatomy of the spine and proper posture;

3. Resting positions at work and at home; correct sitting and standing; correct lifting, carrying, moving and use of adjunct equipment;

4. Correct body mechanics in a variety of routine situations. Practice of good body mechanics while performing job-specific activities and work-site situations;

5. The importance of physical fitness, good nutrition, stretching and healthy lifestyle choices;

6. The role of stress and exhaustion in injury; and
7. The importance of adequate rehabilitation following an injury.

Program Evaluation


Measurable indicators include the following:

1. Reduction in incidence of back injury, time loss and claims;

2. Acceptance and approval by staff and supervisors. This will be measured by evaluations completed by staff following annual training; and

3. Use of good mechanics and healthy habits is supported by staff and considered routine behavior. This will be measured by staff participation in Health Risk Management Programs.

MSIPP training should be presented to all new employees and reviewed several times a year for existing employees. By incorporating MSIPP training early in your orientation, you clearly show the new employee that personal safety is important to your organization. In addition, you provide them with the tools they need to protect themselves.

Routine staff training serves as a reminder of the importance of personal safety, correct body mechanics and healthy lifestyle habits. Unless you have a musculoskeletal expert on your staff, consider bringing in a consultant to guide the training experience. Musculoskeletal experts can be found among physical therapists, exercise physiologists, sports medicine practitioners, nurses and chiropractors. Whatever their discipline, the consultant must have experience with musculoskeletal programs and an accurate idea of what the job entails so the training will be relevant to the work performed. The consultant should be aware of the job description and may do a ride-along to see the conditions under which you practice.

It's helpful if musculoskeletal training includes verbal, visual and return demonstration training. Set up an obstacle course that includes frequently performed actions, such as carrying patients upstairs and downstairs, lifting a stretcher into and out of an ambulance, and bending, kneeling and working across a patient. These skills can be practiced under the watchful eye of the training expert. Tip: A powerful technique for teaching good body mechanics is to videotape an employee doing a lift and have them critique themselves.

As part of the training program, staff and supervisors should be encouraged to point out incorrect body mechanics or unsafe techniques. All members of a team should ensure there are enough individuals to move and carry patients and that responder musculoskeletal safety is considered before every lift and maneuver.

Remember to provide ancillary staff, such as clerical and maintenance workers, with training to meet their musculoskeletal challenges. Clerical staff generally sit for most of their work day. Although we may think that sitting in a chair is easy, the truth is that our bodies aren't designed to sit all day. Sitting for long periods of time can cause deterioration in muscle strength and flexibility and decreased extremity tone and circulation. Under the right circumstances, inactivity can also cause a deep vein thrombosis, which can lead to permanent disability or death.

Establish a peer support program to help incorporate MSIPP into the “culture” of your department. Each member of your department should have a part in developing the MSIPP so they'll feel invested in the process.

When everyone is encouraged to make musculoskeletal health a priority, a gradual shift toward safer, healthier practices will occur. With the emphasis on prevention, staff will learn to appreciate having a potentially dangerous lift or practice recognized and addressed before it leads to an injury.

Injury Follow-Up


Although most back pain is related to an injury or overexertion, there can be other causes. Back pain can be caused by cancer, cardiovascular disease or abnormalities close to the spine. When pain is associated with the musculoskeletal system, the body is warning us that the area is fragile and prone to an even worse injury if we ignore the warning. Musculoskeletal pain that is persistent or caused by an injury from a significant mechanism requires an evaluation by a health-care specialist. It may necessitate rest, medication and/or physical therapy to resolve the injury.

Every significant pain or injury deserves early medical evaluation and treatment. It's important to be evaluated so a plan for recovery can be designed and the chance for re-injury reduced.

Rehabilitation takes time and physical effort. With busy lives and multiple commitments, it's neither easy nor convenient to allow for the time needed to heal an injury. Also, when a department is short-staffed personnel can feel added pressure to return to work early. However, without proper rehabilitation and the healing time necessary to completely recover, re-injury is almost inevitable.

A second injury to an inflamed and already unstable musculoskeletal structure will most likely be more serious and more painful, and will require a longer leave of absence. In some cases, it can be a career-ending event.

Evaluate Success 

A well-researched baseline, written program objectives and measurable evaluation parameters can show if injuries have been reduced. As part of the evaluation process, be sure to poll your staff for their opinion of the program. The willingness of the staff to participate in and support a program will be the strongest evidence that the program should continue.The final component of MSIPP is possibly the most important—program evaluation. Without supporting documentation of success, it will be difficult to get continued funding for your program. In addition, a comprehensive evaluation can further encourage support and identify program improvements.


Despite good posture, weight management and safe lifting practices, there will always be an event that puts the body in an awkward position that doesn't allow for good support of the body's structural integrity. Therefore, it's imperative for the musculoskeletal system to be strong, lean and flexible in preparation for these events.



1. 1 Survey of 1,356 NAEMT members, jointly commissioned by NAEMT and McNeil Consumer & Specialty Pharmaceuticals.
 This article originally appeared in the April 2006 issue of JEMS as "Musculoskeletal Injury Prevention: Protect your Personnel from on-the-job Injuries."





Understanding Why EMS Systems Fail

Learn to recognize trigger points that could ruin your system.

West River Ambulance Receives New Rig

West River Ambulance in Hettinger, ND recently received a much-needed upgrade from their 1992 rig. A 2014 Ford/AEV Type III Custom Conversion rig with a 6.8 ...

Unlikely Pairing Leads to Health Care Education Wins

The University of Texas Health Science Center at Houston (UTHealth) School of Nursing and Harris County Emergency Corps (HCEC) have formed an unlikely pairin...

Know When and How Your Patient Can Legally Refuse Care

Refusal of care straddles the intersection of ethical, legal and scientific domains of prehospital practice.

Reflecting on 35 Years of Innovation in JEMS

Take a walk through the last 35 years of EMS in JEMS.

Readers Sound Off About Glove Use After Patient Care

How often are you susceptible to potentially unclean surfaces?

Features by Topic

JEMS Connect




Blogger Browser

Today's Featured Posts

Featured Careers