Life is full of patterns, from how you sit to what leg you lead with to climb or descend stairs. We all possess unique patterns that we have spent a life time reinforcing. The next time you are standing for a while, make a note of what hip you shift your weight to the most–is that your strong side, your tight side or your weak side?
We need to not only determine, but understand the patterns that we are exposed to. These patterns have a profound effect on your underlying biomechanics and will often contribute to tissue loads that far exceed what the body can safely handle.1 Take an EMT who has to lift a spine board from the ground, carry it over uneven terrain and then set it down on a stretcher. Just the spine board lift alone, the deepest and heaviest lift of almost any profession (EMS is one of the only jobs where it’s acceptable to dead lift more than 250 lbs. from toe height) can produce spinal torques and compression loads exceeding 3,200 lbs.2 And that’s only assuming a 250 lb. patient.
Many train for lifts by simulating job strength with Olympic bars or maybe a kettle bell, the handle of which places the initial hip-hinge lift position at roughly mid-shin height. The conundrum with this is two-fold. First, if we constantly train from the floor with heavy lifts we will quickly expose the responder to spinal torques that are dangerous and injury producing. The first rule of exercise is that it should never cause injury.
Second, almost all the responders I have trained with across the country have deeply seated biomechanical patterns that inhibit safe deep lifting. We teach hundreds of classes per year, and less than 10% of our first responders can work safely from the floor. Of course, the easy answer is to not lift from the floor. There are techniques that can alter this lift height and make it safer, but in many cases patients have to be lifted and no tool can help in all situations.
What we have learned is that most responders have similar patterns that can often be tied back to the job task. On top of that, many responders possess patterns that are both repetitive and static/chronic. Soft tissue traumas occur in the public sector from three major causes:
- Over-exertion Trauma: Over-exertion injury occurs when the external force that is encountered produces torques and compressive loads that the tissue is unable to handle. When the failure tolerance is met, the tissue can fail outright or sustain micro traumas that will weaken the tissue, causing it to fail over time. This is often manifested when a responder has to pick up a patient from a bath tub to move them into a hall where medical treatment can begin. The poor working environment and the weight of the patient causes the tissue to sustain forces that it cannot dissipate and the tissue fails as a result.
- Repetitive Motion Disorder: Repetitive movements will ultimately lead to tissue failure from countless repetitions of faulty and dangerous movements. A common pattern we see is how responders enter and exit their vehicles. Years of rapid entry and exit–often weighted down with gear, SCBA or vests–will fatigue the tissue to the point of failure. We see the same effect from faulty lifting. In EMS we often see repetitive rotator cuff strain after lifting the 40 lb. ECG monitor from the floor to the top of the cot in a swinging motion. The repetitive traumas of the job add up.
- Prolonged Static Positioning: As children we went to school and sat at little tables, hunched forward. As adults we essentially do the same thing except now it’s hunched over a computer or a steering wheel. The bottom line is that repetitive static postures like sitting, standing and desk work will over time “program” the body to believe the faulty postures to be normal. Folks, it’s not normal to have a forward head posture.
What This Means for EMTs
A common pattern prevalent among EMTs is when the hip flexors become very short and tight. As they tighten, they cause an anterior pelvic rotation or translation that inhibits the abdominal wall. As the abdominal wall weakens, the spine takes additional loads. We also see the hamstrings getting tight; as the glutes become tight and weak, the hamstrings tighten to attempt to pull the pelvis back into place (this is known as an agonist-antagonist relationship with the hips flexors).
As this pattern becomes more and more severe (lower-crossed syndrome), the EMT loses the ability to lift properly. The most common manifestation of this is when lifting a cot into the ambulance. Almost all EMTs will pick up the cot (empty weight is 95 lbs. for a manual and 145—165 lbs. for a powered cot) and as they stand up will use the lumbar spine as a hinge. We catch all of them using profound spinal extension, a hinge mechanic, instead of the hips to lift the cot.
Active stretching of the hip flexors followed by a long duration low-load stretch of the hip flexor group will almost immediately reduce the tightness that many EMTs experience daily. Tie that into some simple gluteal integration exercises like single leg bridges, lateral step-ups and hip exercises called hydrants, and this can have an immediate positive effect. We often see EMTs with active back pain who are pain-free after less than 10 minutes of resetting and reactivating the glutes.
Fire-rescue personnel often display tightness in the calf, foot and ankle from standing on concrete floors, spending hours in duty boots, training and working in fire-specific boots/gear and spending even more hours on ladders and pitched roofs. We also see that how first responders enter and exit their apparatus affects the foot and ankle. We know that when the ankle joint is tight and/or restricted, the ability to squat and climb steps is altered.3 Plus we have seen that many first responders neglect to roll and stretch the gastrocnemius, soleus and peroneal-posterior tibialis (calf muscles). When tight, this complex cluster of muscles will affect the distal and proximal joints and contribute to anterior tibial stress syndromes (shin splints) and patella-femoral disorders (knee tendonitis).
Pre-shift and pre-training stretching is a must for all fire-rescue personnel. Active foot and ankle glide stretches followed by static stretching tied into foam rolling will rapidly correct this issue, reduce pain and ultimately prevent injury from climbing and lifting.
The take home is simple: Without job-specific mobility that is practiced and trained constantly, responders will continue to sustain injury. Without teaching and preaching simple tools to manage trigger-point pain from repetitive postural traumas, responders will continue to ignore their symptoms. Without teaching simple-yet-effective exercise that is married to job task–so that when they are in dangerous ergonomic situations they possess the physical ability to get it done–injury will continue to plague them.
One lesson we have learned is that for the 60% of responders who do not exercise or stretch regularly or at all, if we make the path too complicated or scary they will simply not do it. To be effective, training does not have to be fancy. Simple yet focused coaching interventions and exercises are far superior.
References
1. Oregon OSHA. (n.d.) Firefighter and emergency medical services ergonomics curriculum. Retrieved Oct. 12, 2016, from http://osha.oregon.gov/OSHAGrants/ff_ergo/index.html.
2. Swanson S. (n.d.) Preliminary evaluation of human factors and ergonomics in a novel backboard design (EZ Lift Rescue System) for use by emergency medical personnel. EMS Safety Grants. Retrieved Oct. 12, 2016, from http://emssafetygrants.org/pdf/EZ%20LIFT%20RESCUE%20STUDY-Orthopedic%20Specialty%20Hospital,%20Utah%202012.pdf.
3. Boyle M. (2011) Functional Strength Coach 4.0. Retrieved Oct. 12, 2016, from http://functionalstrengthcoach4.com/.
