An evaluation of patient lifting techniques

Abstract

In the present laboratory study five two-person manual lifting techniques were evaluated as to the amount of physical exertion required of the nurses. Ten female volunteers served as nurses; two healthy volunteers (weight: 55 kg and 75 kg) served as passive patients. The working postures and motions were recorded on videotape. The data thus obtained were used in a anatomical-biomechanical analysis. The perceived exertion by the nurses was measured as well. In almost all situations the compressive forces on the nurse's spine exceeded their acceptable limit of 3425 N. Differences between the lifting techniques were most obvious when the 55 kg patient was lifted. Ratings of the perceived exertion (RPE scores) were higher in symmetrical handling than in asymmetrical handling. The three techniques using asymmetrical hand positions produced less subjective stress. RPE scores and rotation of the back were negatively correlated. Rotating the back when moving a patient from one side to the other seems to ease the task. On the whole, the results of the biomechanical evaluation are in line with the subjective perception of the nurses. In both instances the barrow lift appeared to be the most strenuous one; the Australian lift resulted in low compressive forces and a moderate level of perceived exertion     

Workplace design guidelines for asymptomatic vs. low-back-injured workers

While numerous efforts have attempted to provide quantitative guidelines for the prevention of initial low back disorders during material handling tasks, none have appeared in the literature that address the issue of recurrent low back disorders due to materials handling when returning to the workplace. A study comparing the spine loads of low back pain patients and asymptomatic controls was conducted. Subjects lifted weights varying from 4.5-11.4 kg at four vertical heights, two horizontal distances and five task asymmetries collectively representing common industrial lifting situations. Spine loading was calculated using a validated EMG-assisted biomechanical model. Spine loads observed during lifting tasks were compared to spine tolerance values believed to initiate low back injuries. In addition, the percentage of patients successfully performing the lift was noted and used as an indication of the willingness of the subject to perform the task. These evaluations are summarized in a series of three lifting guidelines indicating safe, medium risk and high risk lifting tasks for low back patients as well as asymptomatic workers. It is believed that adherence to these guidelines can minimize the risk of recurrent low back disorders due to occupational lifting.     

Dynamic biomechanical modelling of symmetric and asymmetric lifting tasks in restricted postures

This article describes investigations of dynamic biomechanical stresses associated with lifting in stooping and kneeling postures. Twelve subjects volunteered to participate in two lifting experiments each having two levels of posture (stooped or kneeling), two levels of lifting height (350 or 700 mm), and three levels of weight (15,20, or 25 kg). One study examined sagitally symmetric lifting, the other examined an asymmetric task. In each study, subjects lifted and lowered a box every 10 s for a period of 2 min in each treatment combination. Electromyography (EMG) of eight trunk muscles was collected during a specified lift. The EMG data, normalized to maximum extension and flexion exertions in each posture, was used to predict compression and shear forces at the L3 level of the lumbar spine. A comparison of symmetric and asymmetric lifting indicated that the average lumbar compression was greater in sagittal plane tasks; however, both anterior-posterior and lateral shear forces acting on the lumbar spine were increased with asymmetric lifts. Analysis of muscle recruitment indicated that the demands of lifting asymmetrically are shifted to ancillary muscles possessing smaller cross-sectional areas, which may be at greater risk of injury during manual materials handling (MMH) tasks. Model estimates indicated increased compression when kneeling, but increased shear forces when stooping. Increasing box weight and lifting height both significantly increased compressive and shear loading on the lumbar spine. A multivariate analysis of variance (MANOVA) indicated complex muscle recruitment schemes—each treatment combination elicited a unique pattern of muscle recruitment. The results of this investigation will help to evaluate safe loads for lifting in these restricted postures.     

Psychophysical and physiological responses to lifting symmetrical and asymmetrical loads symmetrically and asymmetrically

Eighteen adult males (mean age 22·6 years, weight 78·6kg and height 176·6cm) participated in a study designed to investigate the effects of symmetrical and asymmetrical lifting on the maximum acceptable weight of lift and the resulting physiological cost. Each subject performed sixty different lifting tasks involving two lifting heights, three lifting frequencies and five containers. For each lifting task, the load was lifted either symmetrically (sagittal lifting) or asymmetrically (turning 90^° while continuing to lift). The heart rate and oxygen uptake of the individuals at the maximum acceptable weight of lift were measured. At the end of the experiment, subjects also verbally indicated their preference for symmetrical and asymmetrical lifting. When lifting asymmetrically, subjects accepted approximately 8·5% less weight. There was, however, no difference in the physiological costs when lifting symmetrically or asymmetrically. Lifting asymmetrical loads also resulted in lower maximum acceptable weights. No difference in either oxygen uptake or heart rate was observed when the centre of gravity of the load was offset by 10·16 or 20·32 cm from the mid-sagittal plane in the frontal plane towards the preferred hand. All subjects indicated, verbally, that asymmetrical lifting tasks were physically more difficult to perform.     

Significance of biomechanical and physiological variables during the determination of maximum acceptable weight of lift

The aim was to identify which biomechanical and physiological variables were associated with the decision to change the weight of lift during the determination of the maximum acceptable weight of lift (MAWL) in a psychophysical study. Fifteen male college students lifted a box of unknown weight at 4.3 lifts/min, and adjusted the weight until their MAWL was reached. Variables such as heart rate, trunk positions, velocities and accelerations were measured during the lifting, as well as estimated spinal loading in terms of moments and spinal forces in three dimensions using an EMG-assisted biomechanical model. Multiple logistic regression techniques identified variables associated with the decision to change the weights up and down prior to a subsequent lift. Results indicated that heart rate, predicted sagittal lift moment and low back disorder (LBD) risk index were associated with decreases in the weight prior to the next lift. Thus, historical measures of LBD risk (e.g. compression, shear force) were not associated with decreases in weight prior to the next lift. Additionally, the magnitudes of the predicted spinal forces and LBD risk were all very high at the MAWL when compared with literature sources of tolerance as well as observational studies on LBD risk. Our findings indicate that the psychophysical methodology may be useful for the decision to lower the weight of loads that may present extreme levels of risk of LBD; however, the psychophysical methodology does not seem to help in the decision to stop changing the weight at a safe load weight.     

Significance of biomechanical and physiological variables during the determination of maximum acceptable weight of lift.

The aim was to identify which biomechanical and physiological variables were associated with the decision to change the weight of lift during the determination of the maximum acceptable weight of lift (MAWL) in a psychophysical study. Fifteen male college students lifted a box of unknown weight at 4.3 lifts/min, and adjusted the weight until their MAWL was reached. Variables such as heart rate, trunk positions, velocities and accelerations were measured during the lifting, as well as estimated spinal loading in terms of moments and spinal forces in three dimensions using an EMG-assisted biomechanical model. Multiple logistic regression techniques identified variables associated with the decision to change the weights up and down prior to a subsequent lift. Results indicated that heart rate, predicted sagittal lift moment and low back disorder (LBD) risk index were associated with decreases in the weight prior to the next lift. Thus, historical measures of LBD risk (e.g. compression, shear force) were not associated with decreases in weight prior to the next lift. Additionally, the magnitudes of the predicted spinal forces and LBD risk were all very high at the MAWL when compared with literature sources of tolerance as well as observational studies on LBD risk. Our findings indicate that the psychophysical methodology may be useful for the decision to lower the weight of loads that may present extreme levels of risk of LBD; however, the psychophysical methodology does not seem to help in the decision to stop changing the weight at a safe load weight.     

The Ergonomics Society The Society's Lecture 1978. THE DESIGN OF MANUAL HANDLING TASKS

Abstract

Manual materials handling is the principal source of compensatable work injuries in the United States, and 79% of the manual handling injuries affect the lower back. The prevention of low back injuries in industry has traditionally been attemped by (1) careful selection of workers, (2) good training procedures in safe lifting, and (3) designing the job to fit the worker. This paper discusses the latter approach by describing seven studies of lifting, lowering, pushing, pulling, carrying and walking. Among the variables investigated were the height, distance and frequency of the task; the size and weight of the object; the differences in worker sex. age, and physical physique; and the effects of heat stress. The psychophysical methodology used in six of the studies is discussed, and the results are used to develop a series of tables for evaluating the design ofmanual handling tasks. The tables present the maximum weights that are acceptable to 10, 25, 50, 75 and 90% of the working population. The effectiveness of this approach in reducing low back injuries was investigated by analyzing 191 randomly selected back injuries. The results indicate that designing the job to fit the worker can reduce up to one-third of industrial back injuries. Job design is obviously not a total solution to low back injuries, but it was found to be significantly more effective than selecting the worker for the job, or training the worker to lift properly.     

Maximum acceptable weight of lift for an asymmetrical combination manual handling task

This paper presents a study on a combination lift and lower manual handling task and was designed to simulate the loading of grocery bags into car trunks. Eighteen male subjects performed an externally-paced task of lifting grocery bags loaded with steel shots from 15 cm above the floor and over a wooden sill. There were two different sill heights of 70 cm and 90 cm, and for each of these heights there were three different sill depths of 28 cm, 43 cm, and 57 cm. The dependent variables were the maximum acceptable weight of lift. Constant conditions were temperature (23–26°C), humidity (52–62%), horizontal distance of lift (136 cm), and time of day the subjects performed the lifting. A unique lifting sequence and a modified version of the psychophysical methodology were used to determine the maximum acceptable weight that subjects were willing to lift. There were no significant differences in the weights lifted across the two sill heights but weights lifted over the 28 cm sill depth was significantly more than the weights lifted for either the 43 cm depth or the 57 cm depth.     

Kinetic analysis of manual lifting activities: Part II—Biomechanical analysis of task variables

This paper, the second of a series of two papers, presents the results of biomechanical analyses of task variables in manual lifting activities. The three-dimensional dynamic biomechanical model, presented in part I was used to analyze compressive and shear forces generated during symmetrical and asymmetrical lifting, lifting boxes with or without handles, and lifting loads in different size boxes (defined by the box dimension in the sagittal plane). The measured ground reaction forces were also analyzed for the effects of these task variables. The results indicated that even though low-weights are accepted for lifting when lifting loads asymmetrically or in bigger boxes or when handling boxes without handles, the spinal stresses generated are, in general, significantly higher than when lifting loads symmetrically or in compart boxes or when handling boxes with handles. At the maximum acceptable weights of lift, the compressive forces generated were observed to be at least 30% to 50% lower than the compressive failure limit of the spinal structure.     

Maximum acceptable weight of lift reflects peak lumbosacral extension moments in a functional capacity evaluation test using free style, stoop and squat lifting

It is unclear whether the maximum acceptable weight of lift (MAWL), a common psychophysical method, reflects joint kinetics when different lifting techniques are employed. In a within-participants study (n = 12), participants performed three lifting techniques--free style, stoop and squat lifting from knee to waist level--using the same dynamic functional capacity evaluation lifting test to assess MAWL and to calculate low back and knee kinetics. We assessed which knee and back kinetic parameters increased with the load mass lifted, and whether the magnitudes of the kinetic parameters were consistent across techniques when lifting MAWL. MAWL was significantly different between techniques (p = 0.03). The peak lumbosacral extension moment met both criteria: it had the highest association with the load masses lifted (r > 0.9) and was most consistent between the three techniques when lifting MAWL (ICC = 0.87). In conclusion, MAWL reflects the lumbosacral extension moment across free style, stoop and squat lifting in healthy young males, but the relation between the load mass lifted and lumbosacral extension moment is different between techniques. PRACTITIONER SUMMARY: Tests of maximum acceptable weight of lift (MAWL) from knee to waist height are used to assess work capacity of individuals with low-back disorders. This article shows that the MAWL reflects the lumbosacral extension moment across free style, stoop and squat lifting in healthy young males, but the relation between the load mass lifted and lumbosacral extension moment is different between techniques. This suggests that standardisation of lifting technique used in tests of the MAWL would be indicated if the aim is to assess the capacity of the low back.     

Changes in lifting dynamics after localized arm fatigue

The purposes of this study were (1) to compare the lifting strategies during arm fatigue and non-fatigue conditions and (2) to evaluate the effects of localized arm fatigue on L5/S1 compressive forces during lifting. The hypothesis was that isometrically induced arm fatigue can alter the lifting strategy selection resulting in an increase in the initial acceleration and leading to an increase in lower back stress. Biomechanical analyses of lifting were done before and after the performance of holding activity to induce arm muscle fatigue. Differences in the lifting strategies used including the accelerated effect, pre-lifting technique, and stiffening of the arms were monitored to determine their influence on L5/S1 compressive forces under various load and range conditions. The results show that lifting strategy changed significantly after arm fatigue, especially when the load was less than 20 kg. These changes included the use of increasingly stooped and accelerated techniques adopted at the beginning of the lift and stiffening of the arms at the end of the lift. Arm fatigue resulted in increased compressive forces at the L5/S1 disc due to the use of accelerated techniques and the inherent disadvantage of these techniques in the pre-lifting posture. In this study, lifting strategies changed as a function of arm fatigue, resulting in increased lower back loading. These findings suggest that whole-body lifting should be avoided after localized arm fatigue in order to decrease the risk of injury to the lower back.

Relevance to industry

Some industrial activities rely on the lifting of objects after arm holding or carrying tasks. Such tasks may lead to localized arm fatigue and become a dominant factor in workers choice of a lifting strategy. This study investigated the strategies adopted in response to changes in arm fatigue and their effects on the L5/S1 compressive forces during lifting. The results may have implications for lifting job design and provide useful information for further study in the prevention of low-back injuries.     

Assessment of an EMG-based method for continuous estimates of low back compression during asymmetrical occupational tasks.

Variables, such as peak and accumulated moments and spine compression forces, have been shown to be risk factors for occupational low back pain. Estimates of these forces during prolonged, dynamic, asymmetric tasks using biomechanical models is complex and time-consuming. A simple technique for continuous measurement of these variables over a prolonged period is needed to measure the distribution of spinal loading during both sagittal plane lifts and complex asymmetrical jobs. The aim of this study was to determine whether a linear normalization of erector spinae EMG to spine compression force, called compression normalized EMG (CNEMG), could be used to estimate spinal loading for simulations of asymmetrical occupational tasks. The estimates of spine compression force obtained using the normalized EMG are presented in the form of an amplitude probability distribution function and are compared with estimates of a three-dimensional biomechanical model. The per cent time a worker spends above particular levels of spinal loading of interest, such as the NIOSH action limit for compression, are displayed. Five males performed simulated occupational tasks. The exposure time at a specific level of spine compression force for a combination of three tasks, estimated by CNEMG, was, on average, within 6.5% of the time calculated by the biomechanical model. However, if the task combination was dominated by an axial twisting moment, then the difference was, on average, 13.4%. The difference in magnitude of spine compression at a specific probability was, on average, 14.9% and when axial trunk twist dominated, 30.7%. It is concluded that CNEMG can estimate probability at a specific level of spine compression force when the task combination is characterized by a predominant extensor moment in the sagittal plane. Estimates of spine compression at a specific probability, and estimates obtained during task combinations dominated by an axial twisting moment, are poor.     

Acceptable weights and physiological costs of performing combined manual handling tasks in restricted postures

Eight healthy, male underground coal miners (mean age = 36.9 yrs +/- 4.5 SD) participated in a study examining psychophysically acceptable weights and physiological costs of performing combined lifting and lowering tasks in restricted head-room conditions. Independent variables included posture (stooping or kneeling on two knees), task symmetry (symmetric or asymmetric), and vertical lift distance (35 cm or 60 cm). All tasks were 10 min in duration and were performed under a 1.22 m ceiling to restrict the subject's posture. Subjects were required to raise and lower a lifting box every 10s, and asked to adjust the box weight to the maximum amount they could handle without undue strain or fatigue. During the final 5 min of each test, data were collected to determine the energy expenditure requirements of the task. Results of this study demonstrated that psychophysical lifting capacity averaged 11.3% lower when kneeling as compared to stooping. Subjects selected 3.5% more weight in asymmetric tasks, and lifted 5.0% less weight to the 60 cm shelf compared to the 35 cm shelf. Heart rate was not significantly affected by posture, but was increased an average of 4 beats/min in asymmetric conditions, and by 3.5 beats/min while lifting/lowering to/from the high shelf. Oxygen uptake was increased by 9% when stooped, by 10% when lifting/lowering asymmetrically, and by 8.2% when performing the task to the high shelf. Results of this study indicate that, wherever possible, materials that must be lifted manually in low-seam coal mines be designed in accordance with the decreased lifting capacity exhibited in the kneeling posture.     

Assessment of an EMG-based method for continuous estimates of low back compression during asymmetrical occupational tasks

Variables, such as peak and accumulated moments and spine compression forces, have been shown to be risk factors for occupational low back pain. Estimates of these forces during prolonged, dynamic, asymmetric tasks using biomechanical models is complex and time-consuming. A simple technique for continuous measurement of these variables over a prolonged period is needed to measure the distribution of spinal loading during both sagittal plane lifts and complex asymmetrical jobs. The aim of this study was to determine whether a linear normalization of erector spinae EMG to spine compression force, called compression normalized EMG (CNEMG), could be used to estimate spinal loading for simulations of asymmetrical occupational tasks. The estimates of spine compression force obtained using the normalized EMG are presented in the form of an amplitude probability distribution function and are compared with estimates of a three-dimensional biomechanical model. The per cent time a worker spends above particular levels of spinal loading of interest, such as the NIOSH action limit for compression, are displayed. Five males performed simulated occupational tasks. The exposure time at a specific level of spine compression force for a combination of three tasks, estimated by CNEMG, was, on average, within 6.5% of the time calculated by the biomechanical model. However, if the task combination was dominated by an axial twisting moment, then the difference was, on average, 13.4%. The difference in magnitude of spine compression at a specific probability was, on average, 14.9% and when axial trunk twist dominated, 30.7%. It is concluded that CNEMG can estimate probability at a specific level of spine compression force when the task combination is characterized by a predominant extensor moment in the sagittal plane. Estimates of spine compression at a specific probability, and estimates obtained during task combinations dominated by an axial twisting moment, are poor.     

Maximum acceptable weights and maximum voluntary isometric strengths for asymmetric lifting

A laboratory study was conducted to determine the effects of asymmetric lifting on psychophysically determined maximum acceptable weights and maximum voluntary isometric strengths. Thirteen male college students lifted three different boxes in the sagittal plane and at three different angles of asymmetry (30,60 and 90°) from floor to an 81-cm high table using a free-style lifting technique. For each lifting task, the maximum voluntary isometric strength was measured at the origin of lift.

The maximum acceptable weights and the static strengths for asymmetric lifting were significantly lower than those for symmetric lifting in the sagittal plane for three box sizes (P<0·01). The decrease in maximum acceptable weight and static strength from the sagittal plane values increased with an increase in the angle of asymmetry (P < 0·01). Box size had no significant effect (P≥ 0·05) on the percentage decrease in maximum acceptable weight or voluntary isometric strength from the sagittal plane values. Correction factors of 7,15 and 22% for maximum acceptable weights and 12, 21 and 31% for static strength at 30, 60 and 90% of asymmetric lifting are recommended. Lastly, in the absence of epidemiological data, a comparison of maximum acceptable weight and static strength in the sagittal plane with the NIOSH guidelines for action and maximum permissible limits indicates that the guidelines may be conservative.     

Acceptable weights and physiological costs of performing combined manual handling tasks in restricted postures

Eight healthy, male underground coal miners (mean age=36·9 yrs±4·5 SD) participated in a study examining psychophysical acceptable weights and physiological costs of performing combined lifting and lowering tasks in restricted headroom conditions. Independent variables included posture (stooping or kneeling on two knees), task symmetry (symmetric or asymmetric), and vertical lift distance (35 cm or 60cm). All tasks were 10min in duration and were performed under a 1·22 m ceiling to restrict the subject's posture. Subjects were required to raise and lower a lifting box every 10 s, and asked to adjust the box weight to the maximum amount they could handle without undue strain or fatigue. During the final 5 min of each test, data were collected to determine the energy expenditure requirements of the task. Results of this study demonstrated that psychophysical lifting capacity averaged 11·3% lower when kneeling as compared to stooping. Subjects selected 3·5% more weight in asymmetric tasks, and lifted 5·0% less weight to the 60 cm shelf compared to the 35 cm shelf. Heart rate was not significantly affected by posture, but was increased an average of 4 beats/min in asymmetric conditions, and by 3·5 beats/min while lifting/lowering to/from the high shelf. Oxygen uptake was increased by 9% when stooped, by 10% when lifting/lowering asymmetrically, and by 8·2% when performing the task to the high shelf. Results of this study indicate that, wherever possible, materials that must be lifted manually in low-seam coal mines be designed in accordance with the decreased lifting capacity exhibited in the kneeling posture.     

An ergonomic evaluation of nursing assistants' job in a nursing home

Thirty-eight nursing assistants (NAs) in a nursing home ranked and rated 16 different patient handling tasks for perceived stresses to the low back. The nursing assistants were observed for 79 4?h shifts and were videotaped for 14 4?h shifts to describe a typical workday and to determine the number of patient-handling tasks performed per shift, the use of assistive devices, and biomechanical stresses to the low back. In addition, data were collected on nursing assistants' and patients' characteristics.

The top eight ranked tasks included transferring patient from toilet to wheelchair (WC), WC to toilet, WC to bed, bed to WC, bathtub to WC, chairlift to WC, weighing patients and lifting patients up in bed. The mean ratings of perceived exertion for these tasks were between ‘somewhat hard’ and ‘hard’. The estimated compressive force on L5/S1 disc for the 50th percentile patient weight ranged from 3·7 to 4·9 KN. Nursing assistants worked in teams of two and performed 24 patient transfers per 8?h shift by manually lifting and carrying patients. Assistive devices (a hydraulic lift and gait belt) were used less than 2% of the time. Patient safety and comfort, lack of accessibility, physical stresses associated with the devices, lack of skill, increased transfer time, and lack of staffing were some of the reasons for not using these assistive devices. Environmental barriers (such as confined workspaces, an uneven floor surface, lack of adjustability of beds, stationary railings around the toilet, etc.) made the job more difficult. Nursing assistants had a high prevalence of low-back pain and 51 % of nursing assistants visited a health care provider in the last three years for work related low-back pain.     

An ergonomic evaluation of nursing assistants' job in a nursing home.

Thirty-eight nursing assistants (NAs) in a nursing home ranked and rated 16 different patient handling tasks for perceived stresses to the low back. The nursing assistants were observed for 79 4 h shifts and were videotaped for 14 4 h shifts to describe a typical workday and to determine the number of patient-handling tasks performed per shift, the use of assistive devices, and biomechanical stresses to the low back. In addition, data were collected on nursing assistants' and patients' characteristics. The top eight ranked tasks included transferring patient from toilet to wheelchair (WC), WC to toilet, WC to bed, bed to WC, bathtub to WC, chairlift to WC, weighing patients and lifting patients up in bed. The mean ratings of perceived exertion for these tasks were between 'somewhat hard' and 'hard'. The estimated compressive force on L5/S1 disc for the 50th percentile patient weight ranged from 3.7 to 4.9 KN. Nursing assistants worked in teams of two and performed 24 patient transfers per 8 h shift by manually lifting and carrying patients. Assistive devices (a hydraulic lift and gait belt) were used less than 2% of the time. Patient safety and comfort, lack of accessibility, physical stresses associated with the devices, lack of skill, increased transfer time, and lack of staffing were some of the reasons for not using these assistive devices. Environmental barriers (such as confined workplaces, an uneven floor surface, lack of adjustability of beds, stationary railings around the toilet, etc.) made the job more difficult. Nursing assistants had a high prevalence of low-back pain and 51% of nursing assistants visited a health care provider in the last three years for work related low-back pain.