What a frightening thing is the human, a mass of gauges and dials and registers, and we can only read a few and those perhaps not accurately.
― John Steinbeck, The Winter of Our Discontent
Over the five-year period between 2009-2010 and 2013-2014 there were 360,180 serious musculoskeletal disorder claims, made up of injuries and diseases (Safe Work Australia (SWA), 2016). Musculoskeletal disorders are conditions and diagnoses that affect joints, the spine, muscles, tendons and connective tissues. Musculoskeletal disorders are identified as priority concerns in the Australian Work Health and Safety Strategy (SWA, 2023), where the prioritisation of disorders is based on the severity of consequences for workers, the number of workers affected, or the availability of prevention. In the 2024 reporting period, the greatest number of injuries experienced by workers were traumatic joint / ligament and muscle / tendon injuries (49,300), wounds, lacerations, amputations and internal organ damage (20,500) and fractures (14,200). The greatest number of diseases experienced were musculoskeletal and connective tissue diseases (20,200), ahead of mental health conditions (14,600) and infectious and parasitic diseases (8,300) (SWA, 2024). The most common mechanism for work-related injury and illness was body stressing (32.7% of all injuries), ahead of falls, trips and slips (21.8%) or being hit by moving objects (15.8%). In this period, body stressing injuries had a median lost time of 9.2 weeks, and incurred median compensation of $17,800. The trunk was identified as the third-most common region for injuries, behind the upper and lower limbs, however the report does not stratify the proportion of injuries to region by mechanism of injury as well. The Australian Bureau of Statistics (ABS) notes that in 2021-2022 the most common causes of work-related injuries were lifting, pushing, pulling or bending (24%) (ABS, 2023).
About 1 in 6 Australians report having back problems, which include a range of musculoskeletal conditions related to the back, of which lower back pain is the most common form, accounting for 4.3% of Australia’s disease burden overall in 2023, and accounting for 23% of expenditure for all musculoskeletal conditions (Australian Institute of Health and Welfare (AIHW, 2024). Safe Work Australia notes that in the 2019-2020 reporting period, the median time lost in working weeks for body stressing generally was 7.9 weeks (SWA, 2022). Physical injuries exact a physical, financial, psychological, and social toll on the injured worker, their families, and their workplaces, creating a nuanced and dynamic situation that requires engaging with these elements of care in a rehabilitative context (Connaughton, Lai, & Low, 2006). Lower back pain is a clinical bugbear that is one of the most intensely studied and discussed pathologies in healthcare in Australia and worldwide - this is completely understandable when considering that in Australia, back problems are the leading cause of lost work productivity, early retirement and income poverty (Australian Commission on Safety and Quality in Health Care, 2022).
The term “Lower back” colloquially refers to the lowest five mobile bones of the spine, called the Lumbar vertebrae, as well as the soft tissues of the discs inbetween the bones, rightly called the intervertebral discs. The Lumbar vertebrae, discs, and the scaffold of ligaments and muscles surrounding the spinal column contribute to movements of the body such as bending forward and backward, tilting left and right, and turning left and right. The topmost bone of the Lumbar spine meets the base of the last spinal bone of the rib cage, and the bottom-most bone of the Lumbar spine meets the top of the Sacrum, which is part of the pelvis. The rib cage and the pelvis are firm structures that are continuous from front to back and so can stabilise themselves. The lower back is stabilised by the muscles that run in parallel along the spine from the pelvis to as high as the ribs and the neck, from the muscles of the core which originate from the lower back and travel horizontally, diagonally, and around the viscera of the abdomen to knit together in the body midline, as well as other muscles including the diaphragm. The curvature of the lower back in combination with the action of muscles, all of which is controlled by feedback from the nervous system, optimises the Lumbar spine to bear the heavier load of the trunk in stationary and moving postures and transfer that weight through the hips into the legs, allowing an ambulant person to participate in work, play, and relaxation throughout the day, every day of the human life (Adams & Dolan, 2005; Wilke & Volkheimer, 2018). When a person is sleeping, the muscles of the lower back and core maintain tone and activity, even in a relaxed and unconscious state. Strength in the lower back helps functional participation, as well as to maintain an upright posture (Skundric, Vukicevic & Lukic, 2021), breathing (Csepregi et. al., 2022). This is why lower back pain can be so disabling, and why its management is so nuanced - lower back pain affects and is affected by functional, psychological, and individual factors which wax and wane in effect over the course of the treatment cycle.
Lower back pain arises from the intersection of physical, occupational, personal, and social factors. Fast-onset lower back pain can occur as the result of trauma such as a blow to the back from an external source, from overloading strain of the muscles and structures of the lower back, spine, and core which cause stress to those structures, or from damage to those structures such as from a fracture, a muscular tear, or a disc rupture. Slow-onset back pain can result from structural changes to the spine that occur as a consequence of lifestyle, age, occupational factors, and obesity. Most studies find the highest incidence of lower back pain in the third decade of life, (Patrick, Emanski & Knaub, 2016; Noonan & Brown, 2021), and other studies show that back pain in adolescents has become increasingly common (Jeffries & Milanese, 2007). Lower back injuries and irritation can occur from using the lower back in exertion - doing sport, in work, lifting heavy objects, or interacting with the world. Lower back injuries and irritation can also result from weakness of the lower back or physical weakness generally, as well as due to other medical conditions such as osteoporosis, or from age as has been noted. Where the inciting incident is not readily identifiable, like a discrete injury while lifting, a fall, or an impact, the link between cause and effect becomes more muddied due to the number of other factors which may contribute to its presentation. This is important in an occupational context - work requires workers to maintain stereotyped postures and physical activities depending on the nature of their work, and the combination of load, time, and repetition give rise to discomfort. That being said, for most individuals, lower back pain is self-limiting, not representative of a broader pathology, and does not require medical treatment (Carey et. al., 1996) - typically resolving in the first month following injury (Pengel et. al., 2003). The likelihood of ongoing lower back discomfort changes owing to a combination of the biomechanics of the irritation or injury, as well as a patient’s personal characteristics (Diamond & Borenstein, 2006). In summary, lower back injuries and irritation arise from excess or inappropriate loading - either too much too quickly or too little over time - of the lower back, which can be complicated by nonmedical factors and which consequently affect management (Greene & Brandon, 2000).
While lower back pain can originate from a constellation of physical and nonphysical factors, there are other individual characteristics that can make a person more or less vulnerable first to experiencing lower back pain, and secondly to experiencing complications with their recovery. Among occupations, back pain is most commonly associated with manual production and physically strenuous service occupations, such as plumbing, pipefitting, and nursing (Hildebrandt, 1995; Schneider, Lipinsky & Schiltenwolf, 2006). In Australia, healthcare and social assistance followed by construction, manufacturing, and public administration reported the highest numbers of serious claims in the 2022-2023 reporting period (SWA, 2024). By occupation, labourers, community and personal service workers, trades workers and machinery operators experienced the highest numbers of serious claims by group in the same period, wherein 61.8% of serious claims were accounted for by just 3 of the top 8 occupation groups (SWA, 2024). This may be due to co-exposure to hazards that magnify the effect of physical stress or which complicate risk management, such as whole-body vibration in the case of lorry and bus drivers’ presentations (Lings & LeYeboeuf-Yde, 2000), noise and light for general workers (Torp et. al., 2001), and changed temperature (Harkness et. al., 2003). There is also a clear association between psychological variables and experienced back pain, where monotonous tasks, work relations, demands and stress have been found to relate to back pain, along with work pace, the control a worker has about their work, as well as a worker’s beliefs about their workplace safety (Linton, 2001). When examining a population of German workers, there was increased strength of association with portering of heavy loads, maintaining a single working posture, and experience of environmental stress with incidence of back pain (Schneider et. al., 2005). That association was again significantly higher in women, persons of lower socioeconomic status, and workers who were depressed. The relationship between lower socioeconomic status and low income indicators is consistent across data from the USA, UK, Denmark, Canada, and the Eurozone (Cavelaars et. al., 1998). Workers who worked in unhealthier conditions and who had poorer access to medical care were also understandably at increased risk of lower back pain, where increased time of exposure appears to be the most determinant variable. Lastly, experienced occupational stress and back pain appear to cause a chicken-and-egg problem, wherein occupational stress may precipitate back pain which may itself precipitate occupational stress, creating a feedback loop that develops into a vicious cycle (Buer & Linton, 2002; Caneiro et. al., 2021). It would appear that the incidence of back pain itself is the realisation of the combined effect of an ecosystem of occupational stressors which in synergy create treacherous ground which a worker must negotiate in the doing of their work.
Workplace Safety Programs would appear to be a strong approach with which to address the prevalence and incidence of lower back pain in working populations. It is estimated that over one-third of lower back pain globally may be due to work-related risk factors (Punnett et. al., 2005). While workplaces may not be able to affect nonoccupational determinants of health such as lifestyle choices including smoking or alcohol consumption, proactive workplace safety assessment and intervention is effective. Increased job demands, increased sitting time, and increased postural strain (Alshehri et. al., 2024) are antecedents of spinal pain in computer workers (Malińska, 2019), where social support, office work design, and supervisor support have been found to be protective against the incidence of lower back and neck pain (Malińska at. al., 2021). Interventions engaging with the physical, mechanical, chemical, and psychosocial, and organisational elements of workplace operation can, based on a proactive survey of pain antecedents, orient employers and managers to risk points at which excessive occupational exposures can be minimised (Malińska, 2019). When considering upper extremity musculoskeletal disorders, there is consistent evidence for resistance training being able to prevent and manage upper extremity musculoskeletal disorder symptoms (Van Erd et. al., 2016), with evidence also supporting the use of stretching exercises, but the applicability of these findings is limited by the substantial difference in the workplace contexts of studies examined, worker demographics, sustainability of the intervention, and occupational postures (Bontrup et. al., 2019). Additionally, studies also note the diversity of risks is reflective of the diversity of workplaces. Not all workplaces are financially and consciously mature enough to put an exercise based intervention in place, and it may not be sustainable to recommend that workers undertake exercises outside of their working hours. The themes of these findings may be generalised to lower back pain populations with some validity, as strength training has been found to be effective in the reduction of the risk of lower back pain episodes alongside education (Steffens et. al., 2016; Sowah et. al., 2018). Interestingly, this meta-analysis suggests that exercise alone is ineffective. In the context of work-related lower back pain specifically, clinical occupational interventions as well as early return to planning using modified duties were effective in returning workers to work faster, reducing pain and disability, and decreasing the rate of back injuries (Williams et. al., 2006), however, by using modified duties and graded return to work, these interventions are less clinical and more contextual. These findings are further complicated by other studies which suggest that technical modifications and education based on practical training are more effective than behavioural or physical training (Roman-Liu et. al., 2020).This may be due to the fact that practical training in tasks is more specified and thus more effective than generalised strength or conditioning training. Ultimately, there is no simple solution to preventing lower back pain in an occupational context - a combination of selection of workers to fit their roles, designing jobs to fit the role capability of the worker, and supporting the capability of the worker through training and education must be used to address individual experiences of discomfort in the workplace.
Out of the three variables mentioned; task demands of workers, worker fit to task, and worker capabilities - the workplace and manager is able to manipulate task demands and worker fit. Worker capabilities can be increased through training and education, and therefore improve fit, but by changing the physical elements of the task, the workplace is able to decrease demand and so improve the effectiveness of training. Beyond workplace safety programs, “Good work” is where the design of workplaces, work systems, and job tasks optimises human performance, job satisfaction, and productivity (SWA, 2015). By proactively considering how work is performed, the work context, the physical environment, and the workers, it is possible to radically transform the workplace in ways that can benefit businesses, workers, and others in the product chain. Something as simple as enacting load limits, lifting frequency limits, or even removing lifting altogether can decrease the incidence of lower back pain by 22-25% (Coenen et. al., 2014). Approaches using participatory ergonomics, where workers engage in training, feedback, and provide input to work and task design, have been found to be useful in this regard (Yuan, 2015). Engaging with workers to design work processes encourages reflection, engagement, feedback and adherence to interventions at the organisational and task-based levels (Loch et. al., 2010; Eaves et. al., 2016), and that these improvements are maintained over a clinically significant timeframe (Sormunen, et. al., 2022). A participative design approach also means that job and task assessment and arrangement can be grounded in workers’ lived experiences, because at the end of the day, it is the worker that does the work. This is doubly important when working alongside workers who have already experienced back pain that has required time off work active communication with employers, claims managers and others is needed to achieve safe and sustained return to work, while in most instances, simple efforts to identify and discuss work issues directly with the patient can lead to better work outcomes (Costa-Black et. al., 2010). With respect to return to work specifically, coordinating the process using trained personnel, empowering the injured worker in decision making, mediating practical solutions and considering stakeholder opinions have all been identified as necessary elements of an effective safety program (Ammendolia et. al., 2009), and should be undertaken in line with codes of practice or best guidance, such as manual handling guides (SWA, 2019; SWA, 2020).
Lower back injuries and irritation arise as the result of the combined effect of human, occupational, social, and immediate factors that produce pain. Regardless of whether the pain is the result of a traumatic injury due to safety failure, the development of a pattern of discomfort that impinges on a person’s ability to meet the demands of their life, or a fluctuating baseline of discomfort, lower back pain is neither an inevitability or an absolute thing. A working adult will spend more time at their place of work than they do with their families, their spouses, their friends, or their peers. A working adult will therefore experience and be required to address the risks that accompany that extended exposure, for the length of their working lives and for the health of their at-home wellbeing. Employers and business owners cannot protect the health, wellbeing, and dignity of an individual when they are not on the clock, on the job site, or otherwise engaged, but in addressing their obligation to provide safe working conditions and roles for those in their employ, as far as is reasonably practicable, consideration should be given to the impact of occupational exposures on a person’s non-occupational life.
None of this information constitutes medical, legal, occupational health and safety, best guidance, standard, or other guidance, instruction, or prescription.
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