Effect of foot movement and an elastic lumbar back support on spinal loading during free-dynamic symmetric and asymmetric lifting exertions

The aim of this study was to assess the effect of an elastic lumbar back support on spinal loading and trunk, hip and knee kinematics while allowing subjects to move their feet during lifting exertions. Predicted spinal forces and moments about the L5/S1 intervertebral disc from a three-dimensional EMG-assisted biomechanical model, trunk position, velocities and accelerations, and hip and knee angles were evaluated as a function of wearing an elastic lumbar back support, while lifting two different box weights (13.6 and 22.7 kg) from two different heights (knee and 10 cm above knee height), and from two different asymmetries at the start of the lift (sagittally symmetric and 60°asymmetry). Subjects were allowed to lift using any lifting style they preferred, and were allowed to move their feet during the lifting exertion. Wearing a lumbar back support resulted in no significant differences for any measure of spinal loading as compared with the no-back support condition. However, wearing a lumbar back support resulted in a modest but significant decrease in the maximum sagittal flexion angle (36.5 to 32.7°), as well as reduction in the sagittal trunk extension velocity (47.2 to 40.2°s^-1). Thus, the use of the elastic lumbar back support provided no protective effect regarding spinal loading when individuals were allowed to move their feet during a lifting exertion.     

Injury-induced kinematic compensations within the lower back: impact of non-lower back injuries

With the number of musculoskeletal disorders increasing in the workplace, the potential exists for multiple injuries due to compensations. The objective of this study was to quantify the impact of non-lower back injuries on the trunk motions adopted by the individual during typical lifting tasks. A total of 32 injured subjects (eight for each injury group--shoulder, hand/wrist, knee and foot/ankle) and 32 matched (gender, height and weight) healthy subjects performed laboratory lifting tasks. The independent variables were task asymmetry (clockwise, sagittally symmetric and counter-clockwise), lift origin (waist, knee and floor) and box weight (2.27 and 6.82 kg). The dependent variables were peak trunk kinematics (as measured by the lumbar motion monitor) and moment arm between the box and lower back. The two injuries that had the greatest impact on the lower back kinematics were foot/ankle and hand/wrist. Individuals who suffered a foot/ankle injury produced greater three-dimensional trunk velocities (up to 10 degrees/s) while individuals with hand/wrist injuries slowed down in the sagittal plane but increased the twisting velocity--specifically when lifting from the asymmetric shelves. Knee and shoulder injuries had limited impact on the trunk motions. Overall, the results indicate workplace design must take into account non-lower back injuries.     

The effect of stance width on trunk kinematics and trunk kinetics during sagitally symmetric lifting

Lifting technique can have a significant impact on spine loading during lifting. The sports biomechanics literature has documented changes in trunk and lower extremity kinematics and muscle coactivation patterns as a function of stance width during high force dead lift and squat exercises. The focus of the current study was to explore whether these lifting stance width effects might translate into the occupational setting under more moderate load level conditions. Twelve subjects performed repetitions of a sagittally symmetric lifting and lowering task (10 kg load) under three stance width conditions: narrow (feet together), moderate (feet shoulder width) and wide (feet 150% of shoulder width). As they performed these exertions, trunk kinematics were captured using the lumbar motion monitor while the activity of the trunk muscles (erector spinae, rectus abdominis) and lower extremity muscles (gluteus maximus, vastus lateralis and vastus medialis) were evaluated using normalized electromyography. The results showed that both the range of motion and peak acceleration in the sagittal plane were significantly affected by the stance width. The muscle activation levels, however, were not significantly affected by the stance width. These results collectively would indicate that the stance width effects seen in power lifting activities do not translate well into the occupational environment where more moderate loads are typically lifted.

Relevance to industry

Exploring alternative lifting strategies may provide an opportunity to reduce the incidence of low back disorders. Lifting stance width is one variable that has not been explored in the ergonomics literature.     

Injury-induced kinematic compensations within the lower back: impact of non-lower back injuries

With the number of musculoskeletal disorders increasing in the workplace, the potential exists for multiple injuries due to compensations. The objective of this study was to quantify the impact of non-lower back injuries on the trunk motions adopted by the individual during typical lifting tasks. A total of 32 injured subjects (eight for each injury group—shoulder, hand/wrist, knee and foot/ankle) and 32 matched (gender, height and weight) healthy subjects performed laboratory lifting tasks. The independent variables were task asymmetry (clockwise, sagittally symmetric and counter-clockwise), lift origin (waist, knee and floor) and box weight (2.27 and 6.82 kg). The dependent variables were peak trunk kinematics (as measured by the lumbar motion monitor) and moment arm between the box and lower back. The two injuries that had the greatest impact on the lower back kinematics were foot/ankle and hand/wrist. Individuals who suffered a foot/ankle injury produced greater three-dimensional trunk velocities (up to 10°/s) while individuals with hand/wrist injuries slowed down in the sagittal plane but increased the twisting velocity—specifically when lifting from the asymmetric shelves. Knee and shoulder injuries had limited impact on the trunk motions. Overall, the results indicate workplace design must take into account non-lower back injuries.     

Effects of posture on dynamic back loading during a cable lifting task

This study evaluated spinal loads associated with lifting and hanging heavy mining cable in a variety of postures. This electrical cable can weigh up to 10 kg per metre and is often lifted in restricted spaces in underground coal mines. Seven male subjects performed eight cable lifting and hanging tasks, while trunk kinematic data and trunk muscle electromyograms (EMGs) were obtained. The eight tasks were combinations of four postures (standing, stooping, kneeling on one knee, or kneeling on both knees) and two levels of cable load (0 N or 100 N load added to the existing cable weight). An EMG-assisted model was used to calculate forces and moments acting on the lumbar spine. A two-way split-plot ANOVA showed that increased load (p < 0.05) and changes in lifting posture (p < 0.05) independently affected trunk muscle recruitment and spinal loading. The increase in cable load resulted in higher EMG activity of all trunk muscles and increased axial and lateral bending moments on the spine (p < 0.05). Changes in posture caused more selective adjustments in muscle recruitment and affected the sagittal plane moment (p < 0.05). Despite the more selective nature of trunk EMG changes due to posture, the magnitude of changes in spinal loading was often quite dramatic. However, average compression values exceeded 3400 N for all cable lifting tasks.     

Trunk motion during lifting: The relative cost

The cost of lifting motion to back loading has been investigated traditionally by monitoring the electromyographic (EMG) recordings of trunk muscle during a controlled lift. When subjects are tested on an isokinetic dynamometer, the EMG activity decreases as the velocity increases and trunk torque production also decreases with added velocity. However, during an actual lift, the necessary torque needed to handle the load remains constant regardless of the lift speed. This research has investigated the muscle force per unit torque which is needed to support a load under various trunk velocities. Forty-five subjects were tested for maximum torque production under various velocity and angle conditions. The relative trunk loading cost of velocity was evaluated and described in an equation for slow velocity (0–30 deg/s) trunk exertions. These results were used to discuss how static lifting models might be adjusted to account for the added trunk load due to velocity.     

Trunk kinematics of one-handed lifting,and the effects of asymmetry and load weight

Abstract

This study investigated trunk kinematic differences between lifts performed using either one hand (unsupported) or two hands. These effects were studied while beginning the lifts from different asymmetric starting positions and while lifting different load weights. Each subject lifted a box from a lower to an upper platform under one- and two-handed lifting conditions. Subjects wore a lumbar spine electrogoniometer, from which relative motion components were calculated in the trunk's three cardinal planes. Results of this study showed that one-handed lifting resulted in significantly higher ranges of motion in the lateral and transverse planes and greater flexion in the sagittal plane. Back motion characteristics previously found to be associated with low back disorders were all significantly higher for one-handed lifts. The two-handed lift technique, on the other hand, produced overall faster trunk motions in the sagittal plane and equal or larger acceleration and deceleration magnitudes in all planes of motion. Increases in load asymmetry affected trunk kinematics, in that magnitude values for range of motion, velocity and acceleration became much greater with increasingly asymmetric load positions. Increasing the load weight appeared to have less of an effect on trunk kinematics, with increases in position mostly occurring during sagittal and lateral bending. These results suggest that unsupported one-handed lifting loads the spine more than two-handed lifts, due to the added coupling. Applying these results to a previously developed model, one-handed lifting was also found to increase one's risk of suffering a low back disorder.     

Effect of an on-body ergonomic aid on oxygen consumption during a repetitive lifting task

The purpose of this study was to determine if an on-body personal lift assistive device (PLAD)¹ affected oxygen consumption during a continuous lifting task and to investigate if any effect could be explained by differences in muscle activity or lifting technique. The PLAD, worn like a back-pack, contains a spring-cable mechanism that assists the back musculature during lifting, lowering, and forward bending tasks. Males (n = 15) lifted and lowered a box loaded to 10% of their maximum back strength at 6 times/minute for 15-minutes using a free-style technique under two conditions: wearing and not wearing the PLAD. Oxygen consumption was collected continuously for the first condition; then the participants rested until their heart rates returned to resting levels before repeating the protocol for the second condition. Knee flexion was monitored using Liberty sensors at the hip, knee, and ankle. EMG of the thoracic and lumbar erector spinae (TES, LES), biceps femoris, rectus femoris and gluteus maximus were gathered using a Bortec AMT-8 channel system. VO2 measures were averaged across the duration (15 min) for each condition. Results showed no differences between oxygen consumption during the PLAD and no PLAD conditions. When wearing the PLAD, the TES demonstrated an 8.4% EMG reduction when lowering the box while the biceps femoris showed a 14% reduction while lifting the box. Knee angles, used as a proxy for stoop or squat lifts, were highly variable for both conditions. In conclusion, the PLAD had no effect on oxygen consumption and, therefore, neither workers nor employers should increase the tasks demands when wearing this ergonomic aid.     

Effects of posture on dynamic back loading during a cable lifting task

This study evaluated spinal loads associated with lifting and hanging heavy mining cable in a variety of postures. This electrical cable can weigh up to 10 kg per metre and is often lifted in restricted spaces in underground coal mines. Seven male subjects performed eight cable lifting and hanging tasks, while trunk kinematic data and trunk muscle electromyograms (EMGs) were obtained. The eight tasks were combinations of four postures (standing, stooping, kneeling on one knee, or kneeling on both knees) and two levels of cable load (0 N or 100 N load added to the existing cable weight). An EMG-assisted model was used to calculate forces and moments acting on the lumbar spine. A two-way split-plot ANOVA showed that increased load (p<0.05) and changes in lifting posture (p<0.05) independently affected trunk muscle recruitment and spinal loading. The increase in cable load resulted in higher EMG activity of all trunk muscles and increased axial and lateral bending moments on the spine (p<0.05). Changes in posture caused more selective adjustments in muscle recruitment and affected the sagittal plane moment (p<0.05). Despite the more selective nature of trunk EMG changes due to posture, the magnitude of changes in spinal loading was often quite dramatic. However, average compression values exceeded 3400 N for all cable lifting tasks.     

The effects of a sloped ground surface on trunk kinematics and L5/S1 moment during lifting

There are many work environments that require workers to perform manual materials handling tasks on ground surfaces that are not perfectly flat (e.g. in agriculture, construction, and maritime workplaces). These sloped ground surfaces may have an impact on the lifting strategy/technique employed by the lifter, which may, in turn, alter the biomechanical loading of the spine. Describing the changes in kinematics and kinetics of the torso is the first step in assessing the impact of these changes and is the focus of the current research. Subjects' whole-body motions were recorded as they lifted a 10 kg box while standing on two inclined surfaces (facing an upward slope: 10 degrees and 20 degrees), two declined surfaces (facing a downward slope: -10 degrees and -20 degrees), and a flat surface (0 degrees) using three lifting techniques (leg lift, back lift and freestyle lift). These data were then used in a two-dimensional, five-segment dynamic biomechanical model (top-down) to evaluate the effect of these slopes on the net moment about the L5/S1 joint. The results of this study showed an interesting interaction effect wherein the net L5/S1 moment was relatively insensitive to changes in slope angle under the back lift condition, but showed a significant effect during the leg lift and freestyle lifting conditions. The results show that under the freestyle lifting condition the peak L5/S1 moment was significantly higher for the inclined surfaces as compared to the flat surfaces (6.8% greater) or declined surfaces (10.0% greater). Subsequent component analysis revealed that both trunk flexion angle and angular trunk acceleration were driving this response. Collectively, the results of this study indicate that ground slope angle does influence the lifting kinematics and kinetics and therefore needs to be considered when evaluating risk of low back injury in these working conditions.     

The distance between the load and the body with three bi-manual lifting techniques

Studies were made of two different techniques of bi-manual lifting with bent legs (A and B) and a technique of lifting with the back bent and the Knees almost extended (C). With technique A, the trunk was almost vertical, while with B it was erect and more forward inclined and the heel of the front foot kept in contact with the support. Two healthy subject samples (n = 18 and n = 16 respectively) were studied, both employing a force platform; with the second sample the back muscles were also evaluated by electromyography. The distance Delta L between the lines of gravity of the body and the load at the start of the lifts was shortest with technique A and longest with C. This was true whether the position of the feet was chosen spontaneously or was identical for all three techniques. The distance of the load from the body during the lifting movement was directly related to the distance at the start of the lift: the further away the load was at initiation of the lift, the further away it remained throughout the rest of the lift. A request to lift as close to the load as possible had a positive effect in shortening Delta L , but the amount of previously received instruction in lifting technique did not correlate with the spontaneously chosen Delta L.     

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.     

Maximum acceptable weights for asymmetric lifting of Chinese females

This study used the psychophysical approach to evaluate the effects of asymmetric lifting on the maximum acceptable weight of lift (MAWL) and the resulting heart rate, oxygen uptake and rating of perceived exertion (RPE). A randomized complete block factorial design was employed. Twelve female college students lifted weights at three different lifting frequencies (one-time maximum, 1 and 4 lifts/min) in the sagittal plane and at three different asymmetric angles (30 degrees, 60 degrees, and 90 degrees ) from the floor to a 68-cm height pallet. This lifting experiment was conducted for a 1-h work period using a free-style lifting technique. The MAWLs for asymmetric lifting were significantly lower than those for symmetric lifting in the sagittal plane. The MAWL decreased with the increase in the angle of asymmetry. However, the heart rate, oxygen uptake and RPE remained unchanged. Though the MAWL decreased significantly with lifting frequency, both the physiological costs (heart rate and oxygen uptake) and rating of perceived exertion increased with the increase in lift frequency. The most stressed body part was the arm. Lifting frequency had no significant effect on the percentage decrease in MAWL from the sagittal plane values. On average, decreases of 5%, 9% and 14% for MAWL at 30 degrees, 60 degrees and 90 degrees asymmetric lifting, respectively, were revealed. This result was in agreement with the findings of Chinese males studied by Wu [Int. J. Ind. Ergonom. 25 (2000) 675]. The percentage decrease in MAWL with twisting angle for the Chinese participants was somewhat lower than those for Occidental participants. In addition, even though there was an increase in heart rate and RPE with the increase in the symmetrical lift angle for Occidental participants, it was different from the Chinese participants. Lastly, the 1991 NIOSH equation asymmetry multiplier is more conservative in comparison with the results of the present study.     

Preparation of dynamic posture and occurrence of low back pain.

Improper posture is considered as one of the causes for low back pain. This study focused attention on low back pain that occurs when people adopt a dynamic posture. Low back pain in attendants was investigated as a typical example of low back pain in a dynamic posture. When multi-dimensional quantification III was applied to the results of the investigation, low back pain was found to occur in six postural patterns: bending knee posture, the posture of lifting and holding a light object, the posture of tilting the trunk, working posture to push a cart, the posture of turning or lifting a cart, and the posture of stretching. This survey found that low back pain frequently occurred when an unexpected load was imposed on the lumbar region and experiments were conducted to simulate the unexpected loading of this region. The experimental results showed that lumbar muscular activity was not fast enough to cope with the load and resulted in an increased swaying of the trunk. This swaying was considered to induce a load on the lumbar region. It is concluded that low back pain can be prevented if an appropriate preparatory set is taken.     

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.     

An investigation of perceived exertion via whole body exertion and direct muscle force indicators during the determination of the maximum acceptable weight of lift

The objective of this study was to identify the perceived exertion mechanisms (direct muscle force and whole body exertion) associated with the decision to change the weight of lift during the determination of the maximum acceptable weight of lift (MAWL). Fifteen males lifted a box of unknown weight at a rate of 4.3 lifts/min, and adjusted the weight until their MAWL was reached. Variables such as the predicted muscle forces and heart rate were measured during the lifting exertion, as well as the predicted spinal loading in three dimensions using an EMG-assisted biomechanical model. Multiple logistic regression techniques were used to identify variables that were associated with the decision to change the weights up and down prior to a subsequent lift. Results indicated that the force in the left erector spinae, right internal oblique, and left latissimus dorsi muscles as well as heart rate were associated with decreases in the weight prior to the next lift. It appears that a combination of local factors (muscle force) and whole body exertion factors (heart rate) provide the feedback for the perceived exertion when decreasing the weight. The up-change model indicated that the forces of the right erector spinae, left internal oblique, and the right latissimus dorsi muscles were associated with the decision to increase the weight prior to the next lift. Thus, local factors provide feedback during the decision to increase the weight when starting from light weights. Collectively, these findings indicate that psychophysically determined weight limits may be more sensitive to muscular strain rather than spinal loading.     

An investigation of perceived exertion via whole body exertion and direct muscle force indicators during the determination of the maximum acceptable weight of lift

The objective of this study was to identify the perceived exertion mechanisms (direct muscle force and whole body exertion) associated with the decision to change the weight of lift during the determination of the maximum acceptable weight of lift (MAWL). Fifteen males lifted a box of unknown weight at a rate of 4.3 lifts/min, and adjusted the weight until their MAWL was reached. Variables such as the predicted muscle forces and heart rate were measured during the lifting exertion, as well as the predicted spinal loading in three dimensions using an EMG-assisted biomechanical model. Multiple logistic regression techniques were used to identify variables that were associated with the decision to change the weights up and down prior to a subsequent lift. Results indicated that the force in the left erector spinae, right internal oblique, and left latissimus dorsi muscles as well as heart rate were associated with decreases in the weight prior to the next lift. It appears that a combination of local factors (muscle force) and whole body exertion factors (heart rate) provide the feedback for the perceived exertion when decreasing the weight. The up-change model indicated that the forces of the right erector spinae, left internal oblique, and the right latissimus dorsi muscles were associated with the decision to increase the weight prior to the next lift. Thus, local factors provide feedback during the decision to increase the weight when starting from light weights. Collectively, these findings indicate that psychophysically determined weight limits may be more sensitive to muscular strain rather than spinal loading.     

Progressive fatigue effects on manual lifting factors

The purpose of this study was to evaluate the effect of progressive fatigue on factors that previously have been associated with increased risk of low back pain in various occupational settings, during a repetitive lifting task where a freestyle lifting technique was used. A laboratory experiment was conducted to evaluate electromyography amplitude, kinematic, and kinetic parameters of repetitive freestyle lifting during a 2‐hour lifting period. Subjective fatigue rating increased over time, indicating that the participant “felt” increasingly fatigued as the experiment progressed. Static composite strength decreased an average of 20% from the beginning to the end of the experiment. Effect of lifting posture (semi‐squat, semi‐stoop, and stoop) was observed on peak trunk flexion angle, trunk flexion angle at initiation of the lift, and knee angle at initiation of the lift indicating that, in freestyle lifting, participants assume quantitatively different lifting techniques. A significant effect of the time–posture interaction was observed on the dynamic leg lift floor to knuckle height strength, indicating that dynamic strength may change over time depending on lifting posture selected. © 2009 Wiley Periodicals, Inc.     

Preparation of dynamic posture and occurrence of low back pain

Abstract

Improper posture is considered as one of the causes for low back pain. This study focused attention on low back pain that occurs when people adopt a dynamic posture. Low back pain in attendants was investigated as a typical example of low back pain in a dynamic posture. When multi-dimensional quantification III was applied to the results of the investigation, low back pain was found to occur in six postural patterns: bending knee posture, the posture of lifting and holding a light object, the posture of tilting the trunk, working posture to push a cart, the posture of turning or lifting a cart, and the posture of stretching. This survey found that low back pain frequently occurred when an unexpected load was imposed on the lumbar region and experiments were conducted to simulate the unexpected loading of this region. The experimental results showed that lumbar muscular activity was not fast enough to cope with the load and resulted in an increased swaying of the trunk. This swaying was considered to induce a load on the lumbar region. It is concluded that low back pain can be prevented if an appropriate preparatory set is taken.     

Static and dynamic lifting strength at different reach distances in symmetrical and asymmetrical planes.

Postural and therefore biomechanical standardization in strength testing has not been rigorously and consistently applied. To develop a quantitative relationship between strength and posture (body position, symmetry, and reach) 30 normal subjects (18 male and 12 females) were required to stoop and squat lift or exert in the relevant posture against a standardized instrumented handle. The isometric lifting efforts and isokinetic lifts were studied. The isokinetic lifts were done at a linear velocity of 50cm/s of the hand displacement from the floor to the knuckle heights of the respective subjects in stoop and squat postures. The isometric stoop lifting efforts were exerted in two standardized postures: (a) with 60 degrees hip flexion; and (b) with 90 degrees hip flexion. The isometric squat lifting efforts were also exerted in two standardized postures: (a) with 90 degrees knee flexion; and (b) with 135 degrees knee flexion. All isometric lifting efforts and isokinetic lifts were performed at half, three-quarters, and full horizontal reach in sagitally symmetrical, 30 degrees left lateral, and 60 degrees left lateral planes. Isometric stoop and squat lifting efforts were also measured in self-selected optimal postures. These 56 conditions were tested in random order. The analysis of variance revealed that the gender, the mode of lifting, the postural asymmetry and reach of lifting affected the strength significantly (p less than 0.0001). Most two-way and three-way interactions were significant (p less than 0.01). Of 108 prediction regression equations, 103 were significant with up to 90% of the variation explained by anthropometric variables and sagittal plane strength. The reach affected the strength most profoundly followed by postural asymmetry and the mode of lifting.