Is Lifting Technique Important?

A common theme I continue to encounter in clinical practice is the belief from patients, and health care providers, that correct lifting technique i.e. maintaining a lumbar lordosis, is critical in the prevention and rehabilitation of back injuries.

I can recall this belief being around for as long as I have been practicing and studying (nearly 20 years now).

What really interests me is that when we look at the research over the past few years it often presents information that directly challenges this belief.

Even back in 1999 van Dieen et al were reporting in a systematic review that:

The biomechanical literature does not provide support for advocating the squat technique as a means of preventing low back pain.

The following research then flows on from then until now (all emphasis added by me):

Considering internal spinal loads and active-passive muscle forces, the current study supports the freestyle posture or a posture with moderate flexion as the posture of choice in static lifting tasks. Arjmand and Shirazi-Adl (2005).

The (systematic) review identified moderate level evidence from multiple trials that manual handling training in isolation is not effective and multidimensional interventions are effective in preventing back pain and injury in nurses. Dawson et al (2007).

Trials found exercise interventions effective and other interventions not effective, including stress management, shoe inserts, back supports, ergonomic/back education, and reduced lifting programs. Bigos et al (2009)

There is moderate quality evidence that MMH (Manual Material Handling) advice and training with or without assistive devices does not prevent back pain or back pain-related disability when compared to no intervention or alternative interventions. There is no evidence available from RCTs for the effectiveness of MMH advice and training or MMH assistive devices for treating back pain. More high quality studies could further reduce the remaining uncertainty. Verbeek et al (2011).

None of the included RCTs and CCTs provided evidence that training and provision of assistive devices prevented LBP when compared to no intervention or another intervention. Verbeek et al (2012).

When I look at the above I immediately question how important lifting technique is. Rather than jumping the gun and saying that it is completely irrelevant I would point you towards the following research by Hogan et al (2014).

This systematic review investigated the effectiveness of manual handling training on achieving training transfer, leading to a positive change in employee’s manual handling behaviour and a reduction of work-related musculoskeletal disorders (WRMSDs) following training. This systematic review suggests that there has been very little research focusing on the effectiveness of manual handling training on training transfer to employees and the associated behavioural change. This review indicates that whilst employees report understanding and awareness following training, this does not always lead to the expected behavioural change. This review also suggests it cannot be demonstrated that training transfer will lead to a reduction of WRMSDs.

So maybe correct lifting technique is not appearing useful because people are not incorporating it into practice. Maybe…..maybe not.

Where are we at?

Broadly speaking I think we can conclude that:

Lifting technique does not appear to be a one size fits all approach. In some patients correct lifting technique might actually increase the strain on their back.
We probably cannot rule out the importance of correct lifting technique completely given the conclusions that Hogan et al (2014) reached above. Perhaps it might be effective in some people if they change their behaviour and implement it in their workplace.

What should we do with a patient who has low back pain with lifting?

As is often the theme on this blog I think the critical element when approaching someone with pain is to assess their function. In this case have them lift a weight that provokes (tolerable) symptoms. Ask them what their pain levels increase to, and/or note how many repetitions they can do before their pain increases. Once we have this “baseline” measure we can then see if we can improve it. Some of the methods to try might be:

See if their pain/function improves if they follow “correct lifting technique” and maintain a lumbar lordosis.
If they look tight and inflexible in their back, see what happens to their pain with lifting after a trial of “treatment” to improve their range of movement and/or reduce muscle tension. You might try some or all of the following:
1. Manual therapy/soft tissue massage.
2. Stretching of their lumbar area into flexion.
3. Relaxation of posture/abdominals.
4. A period (a minute or so) of diaphragmatic breathing to reduce muscle tension.

The key elements of the above being (sorry to sound like a broken record):

Assess aspects such as their pain levels and/or number or repetitions of lifting before pain increases. Do this before and after trying a treatment/strategy.
If there is a significant improvement in pain/function after doing the above (or something else that you think worthwhile trying) then I would suggest sending them home doing more of it! It also helps the patient (and you the therapist) see that what you are asking them to do is actually of benefit to their pain/function.

Final Thoughts

The above has been, for me anyway, quite a biomechanical post!

Please remember to consider that psychosocial factors such as fear, stress, lack of sleep and faulty beliefs are also critical to screen for, and when present treat or refer for treatment, in all patients with pain. Often one, or a combination, of these factors are what is holding someone back from improving.

For example the patient who has avoided bending their back and lifting because they are afraid a disc will pop out! They will often feel better with stretching/manual therapy etc, but if you don’t assess for and treat the underlying faulty belief system (the disc bit) then you may be missing out on the key factor that will assist the person in gaining sustained improvements and having the confidence to follow your treatment regime.

Thanks for reading.