Worksite Exercise Interventions for Low Back Injury Prevention in Firefighters

Low back injury is one of the most common and disabling disorders in firefighters (IAFF,
2008). Thus, novel interventions are needed to counteract the adverse consequences of this
disorder and its impact on firefighter safety. Our long-term research objective is to develop
and test interventions to reduce the incidence, morbidity, economic, and other adverse
consequences of low back injury and illness in firefighters. Our previous studies funded by
the FEMA Assistance to Firefighters Grant Program demonstrated that: 1) a relationship exists
between poor back muscular endurance and increased prevalence of low back pain in
firefighters (Verna, 2010); and 2) a worksite intervention including back and core exercise
training is safe and effective in improving back and core muscular endurance in firefighters
(Mayer, 2015). The purpose of the current study, which builds upon our previous work, is to
assess the clinical effectiveness of back and core exercise interventions for low back injury
prevention in firefighters.

Specific Aims (Purpose) Aim 1. Compare the effectiveness of 2 worksite exercise interventions
(supervised, web-based) relative to control to reduce lost work days related to low back
injury and illness in firefighters.

Hypotheses: Primary - The supervised exercise intervention will reduce the number of lost
work days related to low back injury and illness over the 12-month intervention period by 40%
compared with control. Secondary - The web-based exercise intervention will reduce the number
of lost work days related to low back injury and illness over the 12-month intervention
period by 40% compared with control. No difference between the supervised and web-based
exercise interventions in lost work days will be observed.

To test the hypotheses, a 3-arm, cluster randomized controlled trial will be conducted in
career, full active duty firefighters from 76 stations of 3 fire rescue departments in the
Tampa Bay region of Florida. Firefighters (n = 345) will be randomly assigned (by fire
station) to 1 of 3 exercise intervention groups - 1) supervised, (n = 115), 2) web-based (n =
115), or 3) control (n = 115). Participants in the supervised and web-based exercise groups
will perform back and core exercises previously tested in our recent FEMA-funded grant
(EMW-2009-FP-00418), twice per week for 12 months, in addition to their usual physical
fitness routine. All participants at a given fire station will receive the same intervention
and interventions will be completed during normal shift hours at the fire station. The
supervised group will perform back and core exercises with on-site, 1-on-1, direct
supervision by certified exercise specialists (e.g. peer fitness trainers from the partner
fire departments) for each exercise session using an identical strategy as our previous
study. The web-based group will be provided an interactive web-based delivery, guidance, and
monitoring system for back and core exercises using technology developed by our group and
partners, along with remote interaction with and guidance from exercise specialists. The
control group will not perform back and core exercises, but will continue their usual
physical fitness routine and receive brief education on general exercise and physical
activity principles.

Outcome measures to test these hypotheses include low back injury and illness data obtained
and cross-checked from various sources, including administrative data (primary outcome), such
as reports from the fire departments and workers' compensation data, and participant
self-reported questionnaires in accordance with departmental, Occupational Safety and Health
Administration (OSHA), and fire service standards. Numerous other clinically relevant
measures for low back pain injury and illness, comorbidities, risk factors, and prognosis
will also be collected and analyzed, such as incidence, frequency, severity,
chronicity/duration, physical function, psychological measures (e.g. fear avoidance), back
and core muscular endurance, body mass index, Functional Movement Screen, physical activity
and exercise measures, and cost-effectiveness. In order to inform implementation efforts
throughout the fire service, we will conduct a health economic analysis, such as cost
effectiveness, and collect data to gain a better understanding of the context for
implementation of the exercise interventions.

Potential impact on firefighter health and safety. The proposed study will provide pivotal
evidence for dissemination and implementation throughout the fire service. Assuming positive
results, this study will deliver an evidence-based exercise intervention for low back injury
prevention specifically for firefighters and assessed in a full-scale randomized controlled
trial.. The innovative, efficient, and effective exercise intervention will reduce the
adverse consequences of low back injury and illness in firefighters, and will be ready for
national implementation throughout the fire service for fire departments with similar
characteristics as those tested. If successfully implemented, this low back injury prevention
program will improve firefighter safety and health in order to enhance resilience and
preparedness, so they can more effectively carry out their duties to protect the community.
Further, this low back injury prevention program will help improve off-duty and long-term
quality of life for firefighters.

Unique contribution to body of knowledge. Knowledge gaps exist in evidence-based approaches
for low back injury prevention in firefighters, particularly regarding interventions for
clinical effectiveness, costs, and implementation. The proposed study will assess such an
intervention, and is responsive to 4 health and wellness priorities of the 2011 National Fire
Service Research Agenda (NFFF, 2011): 1.0: Health and disease related to firefighter wellness
and fitness; 3.0: Implementation / translational research; 7.0: Optimization of performance
and reducing risk; and 8.0: Cost effectiveness of health and safety systems.

Inclusion Criteria:

- Age 18 years or older.

- Full duty, regular service, career firefighter housed at a standard fire station from
Hillsborough County Fire Rescue, St. Petersburg Fire & Rescue, or Tampa Fire Rescue.

Exclusion Criteria:

- Current workers' compensation or personal injury case or litigation

- Research personnel (e.g. firefighter peer fitness trainers).

- Participant in the exercise intervention group of our previous FEMA-funded study
(EMW-2009-FP-00418).