Dave Nolan is a clinical specialist physiotherapist working in occupational health. Dave works within the NHS, and he’s trying to help modernise the message we give staff about their bodies when handling load. He wrote a piece for the National Back Exchange on the impact of the biospsychosocial view on lifting techniques.
People with back pain move and lift differently. They move slower, bend less and typically have increased muscle activity (Geisser et al 2004, 2005; Slaboda et al 2008). Traditionally this cautious way of moving has been viewed as a result of spinal damage or degeneration, an adaptive change which should be encouraged, or at least not altered (Rudy et al 2003).
Contemporary research has challenged this theory. Disabling back pain is now viewed as an interaction between a number of factors across the biopsychosocial spectrum. These can still involve structural changes (e.g. disc prolapse) but also an interacting range of biological (e.g. tissue inflammation, sensitisation), physical (e.g. altered movement patterns, muscle guarding, deconditioning), psychological (e.g. negative beliefs, low self-efficacy, depression, anxiety), lifestyle (e.g. exercise, sleep) and social (e.g. work, family and other relationship) factors.
Persistent and disabling back pain, pain that lasts longer than normal tissue healing time, is common. Further, most acute episodes of pain reflect episodic “flare-ups” of an underlying chronic disorder (Henschke et al 2009). In line with this, there is growing evidence that persistent and disabling back pain is associated with unhelpful behaviours (cognitive, movement and lifestyle) that promote a vicious cycle of pain and disability (O’Sullivan et al 2005; Dankaerts et al 2009; Vlaeyen et al 1999). For example, fear regarding back pain is associated with less back flexion and more muscle guarding when bending leading to greater back loading (Geisser et al 2004, 2005; Moseley & Hodges 2006; Karayannis et al 2013). This is also commonly associated with avoidance behaviours linked to physical activity and work. These protective and avoidance strategies vary between individuals, highlighting the need for targeted treatments.
Evidence is mounting that targeting these unhelpful beliefs and behaviours in those with disabling back pain can improve outcomes (Vibe Fersum et al 2013).
What does this mean for training people with back pain to lift?
Traditional advice to keep a neutral or lordotic lumbar spine and brace the “core” when lifting is based on a belief that back pain is linked to a disc injury (Callaghan & McGill 2001; Wade et al 2014). The disc injury model for understanding back pain is based on in-vitro studies and hasn’t been validated in-vivo. Because of this, the relevance of this model to a back pain population remains unclear.
Our intention when training lifting strategies is to reduce the pain and disability associated with back pain based on contemporary evidence. It is possible that basing training on the disc injury model gives messages that spines are vulnerable and easy to injure unless they are protected. This message is not congruent with the contemporary evidence and could have unintended consequences. Indeed, disability associated with back pain has been proposed as being, at least partly, an iatrogenic disorder with negative encounters with healthcare professionals being associated with disabling back pain (Lin et al 2013; Vingard et al 2002). It is likely that, as a profession, a more nuanced message needs to be provided when educating people regarding back care associated with manual work.
Teaching those with back pain to lift becomes more than just recommending postures. In light of the current evidence, teaching should involve the following:
- Reducing the fear associated with lifting
- Reassuring people regarding the robustness of the spine
- Giving the message that pain does not equal damage
- Training efficient and variable lifting strategies, often involving relaxing the back
- Building sufficient strength and conditioning to lift
- Enhancing awareness of the impact of a healthy lifestyle
While it is true that lifting is often painful for people with back pain, it is likely that there is no magic lifting strategy that can prevent pain. This may go some way to explain why teaching lifting techniques has not been shown to reduce back pain incidents (Hignett 2003; Maher 2000; Van Poppel et al 2004; Bos et al 2006; Martimo et al 2008). We are not suggesting that lifting heavy loads should be done by people who have no experience or exposure to these loads. Rather, we are simply highlighting that a comprehensive risk assessment should encompass the wider biopsychosocial spectrum.
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