Thursday 19 July 2012

Manual handling techniques and back pain

Walking from the change rooms to the operating theatres, I go past a series of posters using drawings of animals in funny positions, extolling the virtues of manual handling techniques. Lifting with your knees, bending with your hips, twisting with your elbows, or whatever. And when I arrive in the operating rooms, I am regularly fascinated by the addition of yet another ingenious device to move a patient less than one metre from their bed to the operating table. Last week we used something that was basically a fully functioning hovercraft (here).

There are countless well-meaning guidelines (and rules) on how we should be moving objects (like this, and this) but do they help? I lift a lot of heavy things in awkward positions when I am working in the yard, but really only get back pain when I lie on my back for too long. I see Olympic weight lifters putting a fair bit of weight through their back without much back pain, and I know that the biggest predictors of back pain in the workplace are not physical factors (try this, this and this) but things like job satisfaction. What is the evidence that this advice, or these devices, actually work?

Fortunately, for this review I didn’t need to look very far. There is a Cochrane review (here, and BMJ version here) that reviewed all of the randomised controlled trials on the use of either assistive devices or handling advice in the workplace. Instead of coming to the usual Cochrane conclusion (“Inconclusive, more evidence is needed, etc.”) I was surprised to find that they said:
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.”

So why do we stick with all this stuff? Because it sounds good, and there is an entire industry built around it.


  1. Thank you for sharing about back pain, NJ. Great post, good job.

  2. That may be true - but the example of weight lifters is not exactly accurate. A weight lifter will train over long a period of time in order to be able to lift heavy things safely. Just like other sports there is a lot of technique involved - so there is probably a reason why they don't hurt their backs.

    The techniques listed for "safe lifting" may well work with time and training, it's just that the posters dont work, any more than the "no smoking" signs outside hospitals stop smoking.

    The benefit of the hovermats and similar devices is that a group of very small people can move a ridiculously heavy patient with ease, and with the increasing size of our patients I can only see more such things being used!

    1. Thanks mmv,
      I take your point about the disconnect between efficacy and effectiveness. Smoking may be bad, but that doesn't make quit smoking programs effective. Similarly, we don't know if manual handling techniques really work, only that implementing them doesn't work.

  3. There are more than 60 medications currently being offered to back-pain patients. There are well over 100 different manual techniques in chiropractic, physical therapy, osteopathy, and massage therapy. More than 20 different exercise programs exist. There are more than 9 educational and psychological therapies and more than 20 different injection therapies. In addition, there are a variety of minimally invasive interventions offered as an alternative to surgery, and many surgical approaches. Finally, there are a large number of lifestyle products such as braces and beds, and a constantly changing variety of complementary and alternative medical approaches.

    1. ... and I would estimate that most of them do not provide relief beyond their placebo effect.

  4. I enjoyed reading your articles. This is truly a great read for me. I have bookmarked it and I am looking forward to reading new articles.

  5. This comment has been removed by a blog administrator.

  6. Hello mmv,

    it's a tricky topic, let me see if I can add to the discussion.

    Well, I like the theory that the more strong (physically, structurally) you are, the better you are able to tolerate loads that you face, be it in sports, daily living, work, whatever. And this hypothesis is more specific if you consider muscle strenghtening, as you are not only developing strength, but your bones, cartilage, tendons, well, you musculoskeletal structure gets tougher, more able to receive any kind of loading without "breaking" or developing any kind of pain.

    Therefore, regarding weightlifters, their strong structure protects them against overloads, so that doing "incorrect" movements (movements that generate some extra load onto the structures of your body) they are much less prone to developing pain or tissue damage than, say, a sedentary man of the same age.

    Regarding the manual handling techniques, what they usually try to show is the way that generates less overload on your structure (usually low back). However, on that I don't have a lot to say about their effectiveness, other than I teach my patients to usually load their backs without bending too far forward and keeping the straight spine.

    At the same time that I agree with you regarding evidence based medicine/physical therapy/put any health profession here, I don't think that we really control every factor when we develop research. It is very hard to say if the manual handling folders work or do not work. How to know if people really read them, really followed them, really fololowed them correctly, etc. However, other factors may come first in relation to the manual handling skills, as adequation of overload to the persons strenght/size profile, individuals physical conditioning, amount/frequency of load the person may be exposed to, etc.

    I would not say just because there is evidence that because evidence suggests that manual handling advice and training are useless, they really are. I think that they may be useful, but that usefulness has not been quantified o examined.



  7. Hey Dr. Skeptic,

    I was so focused on writing the reply to your article that I adressed it to mmv. My bad. It was meant as an answer to your blog post, not mmv's message.



    1. Thanks Claudio,
      The idea that the body strengthens in response to the demands/loads placed upon it is well accepted. It gets tricky when we start to modify the loads. The science behind the actual loads we get in certain positions is poor, and isn't there a problem with under-loading the body? Everything has unintended consequences. Sounds like the historic view of the future where we hardly need to lift a finger.
      The other point you raise is a good one, particularly for this topic: that of efficacy versus effectiveness (explanation here: I hate that use of language, but that is what is currently accepted. Is the advice good, but just not taken correctly / adhered to? I am a pragmatist, so my argument is that if people will not / can not use it correctly, then it won't work. Efficiency wins out over efficacy.
      I will challenge your last paragraph though. In my experience, if something is not effective in randomised trials, then it is rarely a matter of doing the trial a little differently to tease out the hidden effect. With all the bias out there making every intervention look good and every trial have favourable results, if you have a negative result, it is likely that you are sitting on a dud.
      Thanks for the comment and keep reading. Might write on ergonomics soon.

  8. Age - Muscles and bones age which can result in less support for the back muscle's.

    Dorsiflex the ankles by pulling your toes up and back towards
    you while pushing your heels down. Although not backed
    by scientific evidence, there have been cases where physical treatments have resulted in faster recovery from lower back pain.

    my webpage กระดูกทับเส้น

    1. Hmmm. Faster than what? Use of a comparative word implies a comparator. Given that most back pain recovers your treatment may not work directly, but indirectly by making use of the time taken in treatment for the back pain to resolve.
      Also, your webpage is dull and unrelated to the topic at hand. I accuse you of being a spammer. What say you?


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