Lifting techniques: why are we not using evidence to optimize movement?

Key Points

1. Contrary to the beliefs of most physiotherapists, squat lifting has not been shown to be superior to stoop lifting for prevention of low back pain.
2. Each lifting technique has specific advantages and disadvantages, and clinicians should consider these when advising clients about lifting.

BACKGROUND & OBJECTIVE

Frequent lifting from the ground is a risk factor for low back pain. Although the vast majority of clinicians believe that the safest way to lift is to avoid low back flexion by using a squat technique, there is no good evidence to support this belief.

This paper reviewed the available evidence on the relationship between lifting technique and back pain and offers clinical suggestions for applying the evidence.

Frequent lifting from the ground is a risk factor for low back pain.

A program of progressive loading could be used to create adaptations that improve tolerance for lifting patterns that are painful.

REVIEW OF EVIDENCE

The authors distinguished two basic lifting techniques: squat lifting and stoop lifting. Squat lifting embodies the common advice to “lift with your legs” by bending the knees and trying to keep the spine upright and neutral. Stoop lifting is basically the opposite pattern because it involves relatively little knee flexion and allows the spine to bend forwards and round. In between these two extremes, there are a spectrum of different options for lifting, the middle of which could be called semi-squat lifting.

Research on each lifting technique has found the following:

• Squat lifting causes significant low back flexion, even with attempts to keep the lumbar spine extended (1).

• Although stoop lifting may cause more low back flexion than squat lifting, it is not clear that this results in heavier loads on the spine (2).

• Stoop lifting may have greater neuromuscular efficiency than squat lifting (2).

• When lifting heavy weights, people tend to select a semi-squat technique, but strength capacity under each lift is similar (2).

• Frequent lifting from the ground is a risk factor for low back pain (3).

• Using greater amounts of low back flexion during lifting does not increase the risk for back pain (4).

• Interventions that recommend squat lifting do not reduce the risk of back pain (4).

Despite the above evidence, the vast majority of physiotherapists (75%) believe squatting is safer than stooping because it reduces stress on the low back (5). Therefore, it appears there is a disconnect between the available evidence and clinical practice.

CLINICAL IMPLICATIONS

Frequent lifting is a risk factor for low back pain, and it is also a common task in daily life and training for athletes. Therefore, clinicians should provide accurate advice to patients on this subject.

The research has not established that one lifting technique is superior to others for all people and all contexts. But it does provide information that may help clinicians tailor their advice based on specific individuals needs and context.

For example, stoop lifting may be preferable for individuals who need to avoid fatigue, because it is metabolically more efficient. It also reduces stress on the knees, making it preferable for someone whose knees are sensitive to load. Whereas squat lifting might be a good option for someone with back pain aggravated by forward bending, which is common in people with acute low back pain.

Changing lifting technique to avoid pain should be considered a short-term strategy to allow healing and reduce sensitivity. In the longer term, a program of progressive loading could be used to create adaptations that improve tolerance for lifting patterns that are currently painful.

To implement the above considerations in a common-sense manner, the authors recommend a phrase from the physiotherapist Greg Lehman: “calm tissue down, build tissue back up, improve work capacity” (see Figure 1).

+STUDY REFERENCE

Washmuth N, McAfee A, Bickel C (2022) Lifting Techniques: Why Are We Not Using Evidence To Optimize Movement? Int J Sports Phys Ther, 17(1), 104-110.

SUPPORTING REFERENCE

1. Aasa U, Bengtsson V, Berglund L, Öhberg F. Variability of lumbar spinal alignment among power- and weightlifters during the deadlift and barbell back squat. Sports Biomech. Published online 2019:1-17. doi:10.1080/14763141.2019.1675751.
2. Straker LM. A review of research on technique for lifting low-lying objects: Evidence for a correct technique. Work. 2003;20(2):83-96.
3. Goncharenko IM, Komleva NE, Chekhonatsky AA. Lower back pain at workplace: Prevalence and risk factors. Russ Open Med J. 2020;9(2). doi:10.15275/rusomj.2020.0207.
4. Denis D, Gonella M, Comeau M, Lauzier M. Questioning the value of manual material handling training: A scoping and critical literature review. Appl Ergon. 2020;89. doi:10.1016/j.apergo.2020.103186.
5. Nolan D, O’Sullivan K, Stephenson J, O’Sullivan P, Lucock M. What do physiotherapists and manual handling advisors consider the safest lifting posture, and do back beliefs influence their choice? Musculoskelet Sci Pract. 2018;33:35-40. doi:10.1016/j.msksp.2017.10.010.
6. Saraceni N, Kent P, Ng L, Campbell A, Straker L, O’Sullivan P. To Flex or Not to Flex? Is There a relationship between lumbar spine flexion during lifting and low back pain? A systematic review with meta-analysis. J Orthop Sports Phys Ther. 2020;50(3):121-130. doi:10.2519/jospt.2020.9218.