Mechanical work and energy transfers while turning patients in bed

The task of pulling and turning a patient in bed using a pique has been identified as potentially risky for female nursing aides and evaluated in terms of its loads on the spine. It was the purpose of the present study to investigate the mechanical work and energy transfers both between and within the body segments, and the relative contribution of the body segments to production of the work. Fifteen female nursing aides took part in the experiment. Different task execution parameters were examined: execution velocity, height of the bed, direction of effort, leg position, support on the bedside. A ‘free’ task and a manual task not involving the use of the pique were also examined. Cinematography and force platforms were used to generate the data. Internal work was calculated on the basis of potential and kinetic segment energy. External work was calculated from the integration of power applied to the patient over time. The results suggest that forces should be applied vertically and at slow speed to minimize energy use; however, speed reduction leads to higher spinal loads and recommendations to this effect should be interpreted with care. The type of task examined was associated with little energy conservation (about 30%). Substantial use of the trunk segment to produce work might account for the back problems female nursing aides encounter with this type of task.     

Examination of biomechanical principles in a patient handling task

Handling patients in bed using a piqué (a waterproof padded sheet placed under the patient) with, in particular, the activity of pulling and turning the patient, is associated with a high incidence of risks for the spine. Six female subjects, not experienced with the task, were evaluated for spinal loadings at the L5/S1 joint, for selected muscular activities in the trunk and shoulders and for work-energy factors. Films, force platforms and EMG recordings supplied the data; dynamic segmental analyses were performed to calculate reaction forces at L5/S1, and a planar single-muscle equivalent was used to estimate internal loads. Three treatments were administered which allowed comparisons to be made for two hand grip positions on the piqué (close to the patient vs. a 15 cm distance) and two movement patterns (continuous vs. interrupted with a pause). It was hypothesized that moving the hand grips away from the patient would favour a straighter-back position and a reduction of spinal loadings; it was also hypothesized that non-interrupted motions involving changes of direction of efforts would be more strenuous for the spine. Analyses of variance with repeated measures were conducted and the locations of significant differences were made with Scheffé method of multiple comparisons. Conflicting results were obtained for the hand grip positions but the results suggest that the partition of a task into several operations (with pauses) is indicated. Recommendations are made to examine more thoroughly trunk postures or back curvatures in relation to spinal loadings.     

Transfer of the horizontal patient: The effect of a friction reducing assistive device on low back mechanics

Recognizing that the transfer of bedridden patients is associated with a high rate of low back injuries, various devices have been developed to assist with sparing the patient handlers. The purpose of this study was to quantify the friction-reducing ability of three different ‘sliding’ patient transfer devices together with the subsequent consequences on the low back loads of people performing the transfers. Coefficients of friction of the devices were determined by ‘transferring’ a standard object and a ‘patient’ over several surfaces common to a hospital setting. Then three participants performed controlled transfers with the various devices. Electromyography to measure muscle activation levels together with external forces and kinematic positional data were collected during push, pull and twist transfers. Spine loads were estimated with a three-dimensional biomechanical static link-segment model of the human body. Simply sliding a patient on a cotton sheet (control condition) produced a coefficient of friction of 0.45. The assistive devices substantially reduced friction by well over one-half (coefficients of 0.18?–?0.21). However, when using the devices the subjects adopted a variety of postures and techniques, such that there were no consistent influences on trunk inclination, low back compression or muscle activation profiles. Direct measurement of reduced friction between the bed and the patient with a friction-reducing device together with measurement of the back loads when actually transferring a patient formed a proof of principle. Specifically, while the device lowers friction, the transfer technique adopted by the lifter must be proper to reduce low back loading and any subsequent risks of back troubles associated with patient transfers. The direction of hand forces and torso position remains important.     

Transfer of the horizontal patient: the effect of a friction reducing assistive device on low back mechanics

Recognizing that the transfer of bedridden patients is associated with a high rate of low back injuries, various devices have been developed to assist with sparing the patient handlers. The purpose of this study was to quantify the friction-reducing ability of three different 'sliding' patient transfer devices together with the subsequent consequences on the low back loads of people performing the transfers. Coefficients of friction of the devices were determined by 'transferring' a standard object and a 'patient' over several surfaces common to a hospital setting. Then three participants performed controlled transfers with the various devices. Electromyography to measure muscle activation levels together with external forces and kinematic positional data were collected during push, pull and twist transfers. Spine loads were estimated with a three-dimensional biomechanical static link-segment model of the human body. Simply sliding a patient on a cotton sheet (control condition) produced a coefficient of friction of 0.45. The assistive devices substantially reduced friction by well over one-half (coefficients of 0.18 - 0.21). However, when using the devices the subjects adopted a variety of postures and techniques, such that there were no consistent influences on trunk inclination, low back compression or muscle activation profiles. Direct measurement of reduced friction between the bed and the patient with a friction-reducing device together with measurement of the back loads when actually transferring a patient formed a proof of principle. Specifically, while the device lowers friction, the transfer technique adopted by the lifter must be proper to reduce low back loading and any subsequent risks of back troubles associated with patient transfers. The direction of hand forces and torso position remains important.     

The assessment of material handling strategies in dealing with sudden loading: The effects of load handling position on trunk biomechanics

Back injury caused by sudden loading is a significant risk among workers that perform manual handling tasks. The present study investigated the effects of load handling position on trunk biomechanics (flexion angle, L5/S1 joint moment and compression force) during sudden loading. Eleven subjects were exposed to a 6.8 kg sudden loading while standing upright, facing forward and holding load at three different vertical heights in the sagittal plane or 45° left to the sagittal plane (created by arm rotation). Results showed that the increase of load holding height significantly elevated the peak L5/S1 joint compression force and reduced the magnitude of trunk flexion. Further, experiencing sudden loading from an asymmetric direction resulted in significantly smaller peak L5/S1 joint compression force, trunk flexion angle and L5/S1 joint moment than a symmetric posture. These findings suggest that handling loads in a lower position could work as a protective strategy during sudden loading.     

A biomechanical assessment of floor and overhead lifts using one or two caregivers for patient transfers

This study investigated the differences in peak external hand forces and external moments generated at the L5/S1 joint of the low back due to maneuvering loaded floor-based and overhead-mounted patient lifting devices using one and two caregivers. Hand forces and external moments at the L5/S1 joint were estimated from ground reaction forces and motion capture data. Caregivers gave ratings of perceived exertion as well as their opinions regarding overhead vs. floor lifts. Use of overhead lifts resulted in significantly lower back loads than floor lifts. Two caregivers working together with a floor lift did not reduce loads on the primary caregiver compared to the single-caregiver case. In contrast, two-caregiver operation of an overhead lift did result in reduced loads compared to the single-caregiver case. Therefore, overhead lifts should be used whenever possible to reduce the risk of back injury to caregivers. The use of two caregivers does not compensate for the poorer performance of floor lifts.     

Lumbosacral loads in bedmaking.

The purpose of this study was to determine whether the introduction of larger and heavier beds which were lower to the floor increased the physical stress on employees responsible for room cleaning and bedmaking in the hospitality industry. More specifically, this study assessed the effect of bed size (single, double and king) and bed height (460 and 560 mm) on dynamic and static estimates of L5/S1 compression force and static L5/S1 shear force for six simulated components of the overall bedmaking task. Results confirmed the view that static models severely underestimate the loads on the lumbar spine under inertial lifting conditions, and also indicated that: (i) tasks with the greatest hand loads were not necessarily associated with the greatest spinal loads due to differences in the way each task was performed; (ii) L5/S1 loads produced during bedmaking may exceed recommended safe lifting limits for certain task-size height combinations; and (iii) the use of larger and heavier beds in the hospitality industry imposes increased loads on the lumbar spine. The investigation of alternative work practices designed to minimise loads on the lumbar spine is recommended.     

Cart pushing: The effects of magnitude and direction of the exerted push force, and of trunk inclination on low back loading

The primary objective of the present study was to quantify the relative effect of the magnitude and direction of the exerted push force and of trunk inclination on the mechanical load at the low back using a regression analysis for correlated data. In addition, we explored the effects of handle height and type of pushing activity (standing or walking) on the magnitude and direction of exerted forces, trunk inclination, and low back loading when pushing a four-wheeled cart on a treadmill. An experimental setup was designed in which nine participants pushed a four-wheeled cart on a treadmill. Kinematics and reaction forces on the hand were measured to calculate the net moment at the L5–S1 intervertebral disc. Results show that the magnitude and direction of the exerted push force and the trunk inclination significantly and independently affect low back load. It is concluded that for the ergonomic evaluation of pushing tasks, the inclination of the trunk should be considered, in addition to the magnitude and direction of exerted forces.

Relevance to industry

Pushing carts is a common activity for a considerable part of the workforce and has been associated with musculoskeletal complaints. This paper shows that not only the magnitude of exerted forces determines the low back load but also the direction of the exerted forces and the inclination of the trunk should be considered for ergonomic evaluation.     

Biomechanical exploration on dynamic modes of lifting.

Whatever the lifting method used, dynamic factors appear to have an effect on the safe realization of movement, and NIOSH guidelines recommend smooth lifting with no sudden acceleration effects. On the other hand, inertial forces may play an important role in the process of transfer of momentum to the load. The direction by which these inertial forces may affect the loadings on body structures and processes of energy transfers cannot be determined a priori. A biomechanical experiment was performed to examine if there were differences in the execution processes between a slow-continuous lift and an accelerated-continuous lift, and also between accelerated lifts either executed continuously or interrupted with a pause. The lifts were executed from a height of 15 cm to a height of 185 cm above the head and with two different loads (6.4 and 11.6 kg). Five experienced workers in manual materials handling were used as subjects. Films and force platforms recordings supplied the data; dynamic segmental analyses were performed to calculate net muscular moments at each joint; a planar single-muscle equivalent was used to estimate compression loadings at L5/S1; total mechanical work, joint work distribution, and energy transfers were determined from a kinetic approach based on the integration of joint power as a function of time. Analyses of variance with repeated measures were applied to the three treatments. The results showed that joint muscular moments, spinal loadings, mechanical work, and muscular utilization ratios were generally increased by the presence of acceleration without inducing benefits of improved energy transfers; therefore slower lifts with reduced acceleration may be safer when handling moderately heavy loads. The maximum values of kinematic and kinetic factors were generally not affected by the pause, but the occurrence of jerks in the movement (acceleration, ground forces, and muscular moments) suggests that the pause may not be indicated when considering total exposure to muscular exertion. Full consideration should be given to the dynamics of motion when assessing risk factors in working tasks.     

Foot positioning instruction, initial vertical load position and lifting technique: effects on low back loading

This study investigated the effects of initial load height and foot placement instruction in four lifting techniques: free, stoop (bending the back), squat (bending the knees) and a modified squat technique (bending the knees and rotating them outward). A 2D dynamic linked segment model was combined with an EMG assisted trunk muscle model to quantify kinematics and low back loading in 10 subjects performing 19 different lifting movements, using 10.5 kg boxes without handles. When lifting from a 0.05 m height with the feet behind the box, squat lifting resulted in 19.9% (SD 8.7%) higher net moments (p < 0.001) and 17.0% (SD 13.2%) higher compression forces (p < 0.01) than stoop lifting. This effect was reduced to 12.8% (SD 10.7%) for moments and a non-significant 7.4% (SD 16.0%) for compression forces when lifting with the feet beside the box and it disappeared when lifting from 0.5 m height. Differences between squat and stoop lifts, as well as the interaction with lifting height, could to a large extent be explained by changes in the horizontal L5/S1 intervertebral joint position relative to the load, the upper body acceleration, and lumbar flexion. Rotating the knees outward during squat lifts resulted in moments and compression forces that were smaller than in squat lifting but larger than in stoop lifting. Shear forces were small ( < 300 N) at the L4/L5 joint and substantial (1100 - 1400 N) but unaffected by lifting technique at the L5/S1 joint. The present results show that the effects of lifting technique on low back loading depend on the task context.     

Foot positioning instruction,initial vertical load position and lifting technique: effects on low back loading

This study investigated the effects of initial load height and foot placement instruction in four lifting techniques: free, stoop (bending the back), squat (bending the knees) and a modified squat technique (bending the knees and rotating them outward). A 2D dynamic linked segment model was combined with an EMG assisted trunk muscle model to quantify kinematics and low back loading in 10 subjects performing 19 different lifting movements, using 10.5 kg boxes without handles. When lifting from a 0.05 m height with the feet behind the box, squat lifting resulted in 19.9% (SD 8.7%) higher net moments (p < 0.001) and 17.0% (SD 13.2%) higher compression forces (p < 0.01) than stoop lifting. This effect was reduced to 12.8% (SD 10.7%) for moments and a non-significant 7.4% (SD 16.0%) for compression forces when lifting with the feet beside the box and it disappeared when lifting from 0.5 m height. Differences between squat and stoop lifts, as well as the interaction with lifting height, could to a large extent be explained by changes in the horizontal L5/S1 intervertebral joint position relative to the load, the upper body acceleration, and lumbar flexion. Rotating the knees outward during squat lifts resulted in moments and compression forces that were smaller than in squat lifting but larger than in stoop lifting. Shear forces were small ( < 300 N) at the L4/L5 joint and substantial (1100 – 1400 N) but unaffected by lifting technique at the L5/S1 joint. The present results show that the effects of lifting technique on low back loading depend on the task context.     

Stories of modern technology failures and cognitive engineering successes

Tasks associated with patient handling may present nursing aides with some risk of injuring the lumbar spine. The purpose of this study was to estimate the forces at L5/S1 and to assess mechanical work and energy transfers in a task consisting of raising a patient (a 72·6thinsp; kg manikin) from a chair using three different methods: (A) with the hands; (B) with the forearms behind the patient's back at shoulder level; and (C) with a belt held at waist level. Six male subjects took part in the experiment. Spinal forces were estimated from a static and planar mathematical model used in conjunction with cinematography techniques, a force platform and EMG recordings. External forces and the internal forces (compression and shear at L5/S1) were determined from free-body diagrams and static equations. The model was analysed for its sensitivity in estimating patterns of EMG forces, intra-discal and musculo-ligamentous forces, intra-abdominal pressure and inertial forces. The model was found to discriminate between the relative demands imposed on the spine by the different lifting methods, but the absolute values of the forces remain uncertain because of the uncertainty residing in many of the model's hypotheses. The method requiring a belt to lift the patient was found to be considerably more strenuous for the spine and also to require a larger amount of work; it should therefore not be recommended as a task for nursing aides.     

A study of the difference between nominal and actual hand forces in two-handed sagittal plane whole-body exertions

Given a task posture, changes in hand force magnitude and direction with regard to joint locations result in variations in joint loads. Previous work has quantified considerable vertical force components during push/pull exertions. The objective of this work was to quantify and statistically model actual hand forces in two-hand, standing exertions relative to the required nominal horizontal and vertical hand forces for a population of widely varying stature and strength. A total of 19 participants exerted force on a fixed handle while receiving visual feedback on the magnitude of force exerted in the required horizontal or vertical direction. A set of regression equations with adjusted R(2) values ranging from 0.20 to 0.66 were developed to define actual hand force vectors by predicting off-axis forces from the required hand force magnitude. Off-axis forces significantly increase the overall magnitude of force exerted in two-hand push/pull and up/down standing force exertions. STATEMENT OF RELEVANCE: This study quantifies and statistically models actual hand forces in two-hand, standing exertions. Inaccuracies in hand force estimates affect the ability to accurately assess task-oriented strength capability. Knowledge of the relationship between nominal and actual hand forces can be used to improve existing ergonomic analysis tools, including biomechanical simulations of manual tasks.     

How to lift a box that is too large to fit between the knees

Many studies compared lifting techniques such as stoop and squat lifting. Results thus far show that when lifting a wide load, high back loads result, irrespective of the lifting technique applied. This study compared four lifting techniques in 11 male subjects lifting wide loads. One of these techniques, denoted as the weight lifters' technique (WLT), is characterised by a wide foot placement, moderate knee flexion and a straight but not upright trunk. Net moments were calculated with a 3-D linked segment model and spinal forces with an electromyographic-driven trunk model. When lifting the wide box at handles that allow a high grip position, the WLT resulted in over 20% lower compression forces than the free, squat and stoop lifting technique, mainly due to a smaller horizontal distance between the l5S1 joint and the load. When lifting the wide box at the bottom, none of the lifting techniques was clearly superior to the others.

Statement of Relevance: Lifting low-lying and large objects results in high back loads and may therefore result in a high risk of developing low back pain. This study compares the utility of a WLT, in terms of back load and lumbar flexion, to more familiar techniques in these high-risk lifting tasks.     

Lumbar spine forces during manoeuvring of ceiling-based and floor-based patient transfer devices

Patient handling continues to represent a high risk task for low back pain (LBP) among health caregivers. Previous studies indicated that manual transfers of patients impose unacceptable loads on the spine even when two caregivers perform the transfer. Patient lift devices are considered a potential intervention; however, few biomechanical analyses have investigated the spine loads and LBP risk associated with these transfer devices. This study analysed the 3-D spine forces imposed upon the lumbar spine when 10 subjects manipulated ceiling-based and floor-based patient lifts through various patient handling conditions and manoeuvres. The results indicated that ceiling-mounted patient lift systems imposed spine forces upon the lumbar spine that would be considered safe, whereas floor-based patient handling systems had the potential to increase anterior/posterior shear forces to unacceptable levels during patient handling manoeuvres. Given these findings, ceiling-based lifts are preferable to floor-based patient transfer systems.     

The load on the lumbar spine during asymmetrical bi-manual materials handling.

Previous biomechanical analyses of typical load manipulation tasks were mainly limited to sagittal-plane activities or to static cases. This paper includes the biomechanical determination and assessment of lumbar load during asymmetrical bi-manual materials handling tasks which involve lateral turning of the body, trunk inclination, and sagittal flexion and lateral bending of the spine. Diagonal lifting tasks were analysed for different values for load weight (0-40 kg) and task duration (0.75-1.5 s). Whereas a constant grasp height of 15 cm was assumed, the height for releasing the load differed (50, 100, 150 cm). A dynamic spatial human model ('The Dortmunder') was used for calculating the torque in the sagittal, frontal, and transversal planes through the lumbosacral joint and for determining the compressive and the sagittal and lateral shear force at the L5-S1 disc. The trajectories of body segments and load are computer-simulated on the basis of postures adopted during the movement. During diagonal lifting of loads, lumbosacral torque in the sagittal plane is considerably larger than the lateral bending and torsional torque components. Dynamic analyses result in higher maximum values in the lumbar-load time curves than static analyses. The shorter the time for task execution, the higher the resultant dynamic effects and, in consequence, the higher the lumbar load. Lumbosacral compression and shear increase with increasing load-release heights due to higher acceleration and retardation of body and load when the same grasp position and task duration are assumed. The maximum load-bearing capacity of the lumbar spine was determined on the basis of strength data for isolated lumbar segments provided in the literature. The compressive strength falls within the same range as the compressive forces calculated for asymmetrical lifting of loads up to 40 kg. On account of the wide scattering of the compressive strength values, the main influences were determined (age and gender). At an age of 40 years, strength is approx. 6.7 kN for males and 4.7 kN for females (decrease with age per decade: 1.0 kN males, 0.6 kN females). In order to avoid overestimating an individual's lumbar compressive strength, predicted values should be reduced, e.g., by the standard deviation in the male or female samples (2.6 kN or 1.5 kN). Although only a few maximum shear force values are available in the literature, comparison with the calculated values for diagonal lifting leads to the conclusion that sagittal and lateral shear should not be ignored in the assessment of lumbar load during asymmetrical handling tasks.     

The effects of caregiver experience on low back loads during floor and overhead lift maneuvering activities

This study investigated the effects of caregiver experience on peak external forces and moments generated at the L5/S1 joint of the low back when maneuvering loaded floor-based and overhead-mounted patient lifting devices. Twenty caregivers were divided into more-experienced and less-experienced groups based on the product of two factors: their years of lifting experience and the frequency of lifting the caregivers had done in the past. Ground reaction forces and moments as well as motion capture data were recorded while caregivers performed five different maneuvering tasks with both lifts in each of three conditions (caregiver subjects worked alone, as the primary caregiver in a pair, and as the secondary caregiver in a pair). Six outcome measures (net external forces and moments at the L5/S1 joint) were recorded. Multivariate analyses of variance of all net external forces and moments were done separately for the floor and overhead lifts. A significant effect of experience level was found for the floor lift (p = 0.006) but not for the overhead lift (p = 0.163). A follow-up univariate analysis of floor lift activities found significant differences between more-experienced and less-experienced caregivers for Turn, Push and Legs Up activities.

Relevance to industry

Previous work has shown that overhead lifts reduce the loads on caregivers compared to floor lifts. The findings of this study further underscore the need to purchase overhead lifts to protect less-experienced caregivers (including informal family caregivers) who are at increased risk of back injury when maneuvering floor lifts.     

Designing ergonomic interventions for EMS workers - part II: lateral transfers

The objective of the current work was to test ergonomic interventions aimed at reducing the low back musculoskeletal loads experienced by firefighters/paramedics (FFPs) providing emergency medical services (EMS) when performing lateral transfers between a bed and a stretcher or between a stretcher and a hospital gurney. The interventions, developed using focus groups, were a bridgeboard to reduce the frictional force resisting the lateral sliding of the patient, the use of rods along each side of the patient to facilitate the grasping and handling of the bedsheet on which the patient is typically transferred, and a single rod that, when rolled in the bedsheet, resulted in the task being changed from a lifting task to a pulling task. Eleven two-person teams laterally transferred a 75 kg dummy with each intervention between a bed and simulated stretcher. Two roles were defined. For the two-sided transfers, the FFP roles were termed "stretcher-side" and "bed-side." Surface electromyographic (EMG) data were collected from 8 trunk muscles from each participant along with spine kinematic data. Additionally, kinetic data were obtained for the FFP in the stretcher-side role. Trunk flexion moments and Erector Spinae activity were reduced for the FFP in the stretcher-side role when using the bridgeboard and the single rod both individually and in combination. The single rod reduced the Erector Spinae activity in the FFP who typically would have been on the bed. For FFPs in both roles the single rod increased Latissimus Dorsi activation relative to the standard bedsheet transfer condition, although, this effect was moderated when the single rod was used in combination with the bridgeboard. Ratings of perceived exertion also supported the use of the single rod relative to the corresponding control condition.     

The load on the lumbar spine during asymmetrical bi-manual materials handling

Previous biomechanical analyses of typical load manipulation tasks were mainly limited to sagittal-plane activities or to static cases. This paper includes the biomechanical determination and assessment of lumbar load during asymmetrical bi-manual materials handling tasks which involve lateral turning of the body, trunk inclination, and sagittal flexion and lateral bending of the spine. Diagonal lifting tasks were analysed for different values for load weight (0-40 kg) and task duration (0·75-1·5 s). Whereas a constant grasp height of 15 cm was assumed, the height for releasing the load differed (50, 100, 150 cm). A dynamic spatial human model (‘The Dortmunder’) was used for calculating the torque in the sagittal, frontal, and transversal planes through the lumbosacral joint and for determining the compressive and the sagittal and lateral shear force at the L5-S1 disc. The trajectories of body segments and load are computer-simulated on the basis of postures adopted during the movement. During diagonal lifting of loads, lumbosacral torque in the sagittal plane is considerably larger than the lateral bending and torsional torque components. Dynamic analyses result in higher maximum values in the lumbar-load time curves than static analyses. The shorter the time for task execution, the higher the resultant dynamic effects and, in consequence, the higher the lumbar load. Lumbosacral compression and shear increase with increasing load-release heights due to higher acceleration and retardation of body and load when the same grasp position and task duration are assumed. The maximum load-bearing capacity of the lumbar spine was determined on the basis of strength data for isolated lumbar segments provided in the literature. The compressive strength falls within the same range as the compressive forces calculated for asymmetrical lifting of loads up to 40 kg. On account of the wide scattering of the compressive strength values, the main influences were determined (age and gender). At an age of 40 years, strength is approx. 6·7 kN for males and 4·7 kN for females (decrease with age per decade: 1·0 kN males, 0·6 kN females). In order to avoid overestimating an individual's lumbar compressive strength, predicted values should be reduced, e.g., by the standard deviation in the male or female samples (2·6 kN or 1·5 kN). Although only a few maximum shear force values are available in the literature, comparison with the calculated values for diagonal lifting leads to the conclusion that sagittal and lateral shear should not be ignored in the assessment of lumbar load during asymmetrical handling tasks.