2/14/2010

Low Back Pain

The Biomechanics of
Patient Handling
William S. Marras, Ph.D., CPE
H d Ch
Honda Chaired
i dPProfessor
f and
d Di
Director
t
Biodynamics Laboratory
The Ohio State University
Columbus, Ohio

http://biodynamics.osu.edu

Distribution of Nonfatal Occupational

Low Back Pain Injuries by Service Providers (2007)

(BLS, 2008)

Incidence Rate for Nonfatal Injuries in Distribution of Nonfatal Injuries in

Health Care Sector, 2007 Health Care, 2007 (BLS, 2008)

BLS, 2008

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National Statistics Relative The Most Dangerous Jobs in

to Low Back Pain America
In 2007 the trunk was the body part most often injured
Lost work time to back injuries per 10,000 FTEs
accounting for 33% of all injuries and illnesses (BLS, 2008) 200 181.6
Lost time injuries in the U.S. in 2007 (BLS, 2008) 175
1. Laborers & material movers (79,000 cases) 150

2. Heavyy and tractor-trailer drivers ((57,050

, cases)) 125
98 4
98.4
100 90.1
3. Nursing aides, orderlies, and attendants (44,930 cases) 70
75 56.3
Musculoskeletal Disorder Rates in 2007 (BLS, 2008) 50
47.1

Highest National Rate - Nursing aides, orderlies, and 25

attendants (252/10,000 workers) was 7x the National average 0
Laborers and freight handlers (149/10,000 workers) Agriculture Mining Construction
Delivery truck drivers (117/10,000 workers) Truck Drivers Hospital Workers Nursing Homes

Source: Bureau of Labor Statistics, Lost Work Time Back Injuries per 10,000 FTEs. 2000.

Patient Handling and Low Back

Low Back Surgery
Pain Risk (Nursing)
No operation in any field of surgery leaves in its wake
52 % of nurses complain of LBP (Nelson, 2003) more human wreckage than surgery on the lumbar
12% of nurses leave the field because of LBP (Stubbs et. discs (DePalma and Rothman, 1976)
al., 1986) Surgical success rates for discectomy = 42.6% (vs.
20% transfer to a different unit because of LBP (Owen
(Owen, 32 4% non
32.4% non-operative)
operative) (Weinstein et
et. al
al. 2006)
1989) Value of prevention
38% have LBP severe enough to have lost time (Owen,
2000)
38% new LBP cases per year (Yip, 2004)

Overexertion During Lifting

(BLS, 2007)
80
Rate per 10,000 full-time

70
60 Hospitals
50
40
What do We Know About
30
Nursing and
Residential Care Low Back Pain Causality?
20 Facilities
10
0
2003 2004 2005 2006
Year
The cumulative weight lifted by a nurse in one
typical 8-hour shift is equivalent to 1.8 tons
(Tuohy-Main, 1997).

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 2/14/2010

Epidemiologic Reviews Low Back Pain Risk Factors

(NRC/IOM, 2001)

Physical Factors
Biomechanical Loading
Biomechanical / Physiologic Tolerance
Individual Factors
Age, Gender, etc.
Pain Perception
Genetic Factors
Psychological Factors
Psychosocial Factors and Organizational
NRC, 1999 NRC/IOM, 2001
Factors
Job Satisfaction
Job Monotony
Job Control

Low Back Pain Biomechanical

Load Tolerance Logic
Risk Factor Environment
Risk of Injury
Social & Org.
oad

Individual
Factors
Spinal Lo

Factors
Tolerance

Loading Pattern
Physical
Factors

Time
(McGill, 1997)

Disc Degeneration
Intervertebral Disc

The primary source of low back pain is suspected to be

the disc (Nachemson, 1976; Videman and Battie, 1996; An, 2004)
Noxious stimulation of the disc produces symptoms of
low back pain
Annular tears and reduced disc height are associated
with low back pain (Videman et. al., 2003)
Mechanical load can be the stimulus for pain (Marras, 2000)

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How Cumulative Trauma

Develops in the Spine Disc Nutrition Pathways
Vertebral Endplate

Vertebral Body
Vertebral Endplate
Disc

How Cumulative Trauma How Cumulative Trauma

Develops in the Spine Develops in the Spine
Vertebral Endplate Vertebral Endplate

Mi
Microfractures
f t S
Scar Ti
Tissue
Development

Disc Degeneration and

Cumulative Trauma Normal Disc

A
Scar Tissue Vertebral Body
Vertebral Endplate B
Disc Degenerated
Disc

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Spine Compression
Our Early Patient Lifting Studies
Tolerance
3400-6400 N Limit

Limits

Anterior/Posterior
(A/P) Shear
1000 N Limit
Lateral Shear
1000 N Limit

Patient Lifting
Origins/Destinations Transfer Techniques
Bed to/from wheelchair with
arms 1 person hug
Bed to/from wheelchair with 2 person hook and toss
one arm removed
Portable commode chair 2 person gait belt
/
to/from hospital
p chair

Spine Compression as a Function of

Repositioning Techniques Transfer Task
9000
Compression Force (N)

8000

7000
Maximum
6000 Tolerance

5000

4000

Safe Limit
3000

2000
Wheelchair Bed Wheelchair Bed Commode Chair -
w/o Arms wheelchair - Bed Wheelchair - Chair Commode
Bed w/o Arms

Transfer Task
One-Person Two-Person

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Spine Compression as a Function Spine Compression as a Function of

of Transfer Technique Repositioning Technique
12000

ession Force (N)

ession Force (N)

9000 11000

8000 10000

7000 Maximum 9000

Tolerance 8000
6000
7000 Maximum
5000
6000 Tolerance

Compre
Compre

4000 5000
Safe Limit
4000
Safe Limit
3000
3000
2000
2000
Hug HOOK BELT HOOK BELT Hook Hook Thigh & Sheet Hook Thigh & Sheet
Shoulder Shoulder
One-Person Left Side Right Side
One Person Left Side Right Side
2 person 2 person
Two Person Two Person
Transfer Technique
Repositioning Technique

Biodynamics Laboratory Previous

Patient Handling Interventions
Studies
Risk associated with one- or two- caregiver patient lifting

Conclusion - There is no safe way to lift patient manually!

- The magnitude of spine loading is so great any
g proper
benefits of using p p bodyy mechanics is negligible
g g

Suggestion Must employ patient lifting assistance device

Intervention Effectiveness (prospective

observation of 100 units)

Patient Handling Musculoskeletal Disorder Rate Patient Handling Change in MSD Rates per
Changes (#MSDs/employee-hours worked)*200,000 Intervention (baseline to follow-up)
Type of n Baseline Follow-up Rate Ratio
Intervention median median (FU/BL MSD rate) Type of # Units Number of Units P-value
Decreased Increased
Intervention
(Range) (Range) or no change
Reduce 16 9.89 6.65 .66 Reduce 12 4 0.056
Bending (0.0-42.65) Bending
(0.0-59.51) (75%) (25%)
Zero Lift 44 15.38 9.25 .54 Zero Lift 32 12 0.002
(0.0-87.59) (0.0-28.27) (72.7%) (27.3%)
Reduce 8 6.47 0.33 .15 Reduce 7 1 0.031
Carrying (0.0-15.80) (0.0-6.70) Carrying (87.5%) (12.5%)
Multiple 32 11.98 7.78 .56 Multiple 26 6 0.001
Interventions (0.0-60.34) Interventions (81.3%) ( 18.7%)
(0.0-25.94)
All 100 12.32 6.64 .52 All 77 23 <0.001
(0.0-87.59) (0.0-59.51) (77.0%) (23.0%)

(Fujishiro, et al. 2005) (Fujishiro, et al. 2005)

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Lifting Transformed into

Our Previous Studies
Pushing and Pulling
Risk associated with one- or two- caregiver patient lifting
Conclusion - There is no safe way to lift patient manually!
Suggestion - Employ Patient Lifting assistance device
Intervention Effectiveness (prospective
observation of 100 units)
Conclusion Often observe significant reduction in risk
Not all interventions created equally!
27% of zero lift interventions had increased reporting

Pushing and Pulling Research Question

Does changing patient handling from a lifting activity to

a pushing activity eliminate the risk to the caregiver?

Is there a difference in pushing ceiling mounted vs. floor

based patient lifting devices?

Strength Based Push-Pull

Recommendations

What do we Know about Low Back

Pain Risk During Pushing and
Pulling?

.
References:
26. NRC-IOM, 2001 28. Snook, 1978
34. Hoozemans, 2001 35. Snook and Ciriello, 1991
37. Kumar et al., 1995 38. Kumar, 1995

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 2/14/2010

Risk of Low Back Pain when Spine Biomechanical Loading During

Pushing and Pulling Pushing and Pulling
Pulling L5/S1 compression = 2353N
Odds Ratios
shear = 654 N (Gagnon, 1988)
LBP pushing/pulling OR = 2.6 (van der Beek, et al. (1993) Pushing 22 Kg load at different heights - L5/S1
Push/Pull & high intensity LBP OR = 2.15 (Hoozemans et al., compression (using 2 muscle model):
2002)
2993N @ 58 cm height
Pulling & LBP OR =1.5
1.5 for objects over 56 lbs. (Harkness et
1398N @ 99 cm
al., 2003)
921N @ 141 cm (Gagnon, 1992)
% of Claims Refuse collection pushing and pulling (static model)
As much as 20% of LBD injury claims associated with L5/S1
pushing and pulling (NIOSH, 1981) pushing comp = 2000 N
27% of Ohio BWC LBP claims associated with shear = 160 N (de Looze et. al., 1995)
pushing/pulling (Hamrick, 2005) pulling comp = 2600 N
shear = 300 N

Spine Biomechanical Loading (continued) Spine Loading Model Development

Sagittal Plane
L4/L5 load using Watbak model: Marras and Reilly, 1988; Reilly and Marras, 1989; Marras and Sommerich, 1991a;
1991b; Marras and Mirka, 1993; Granata and Marras, 1993, 1995; Davis et al.,
pushing 65 Kg comp = 822 N 1998; Marras et al., 1999, 2001; Marras and Granata, 1997
Asymmetric Lifting
shear = 202 N Marras et al., 1999, 2001
Fathallah et al., 1998;
pulling 65 Kg comp = 1445 N Granata and Marras, 1993,
Marras and Sommerich, 1991,
shear = 95 N (Schibye,
(Schibye et.
et al.,
al 2001) Late
Lateral al Flexion
Fle ion
L5/S1 comp = 5000 N for pushing carts over 225 Kg Marras and Granata, 1997
(Resnick and Chaffin, 1995) Axial Twist
Marras and Granata, 1995
Gender Adjustment
These spinal loads do NOT explain LBP risk Marras et al., 2001;
Jorgensen et al, 2001
observations Push Pull Adjustments
Theado et al., 2007
(flexion adjustments, standing anthro)
Knapik et al., 2008 (entire lumbar spine)
What is mechanism of LBP? Marras et al., 2009

OSU Biodynamic Model The Control System

Model Structure

Courtesy of
A. Schwartz, 2006

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 2/14/2010

Instrumentation
Whole Body Motion Tracking

Laboratory Assessment of Laboratory Assessment of

Push-Pull Push-Pull

Whole Body Modeling Assessment of Spine Forces

Based Upon Task

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 2/14/2010

Spine Loads at Different Levels Concept Model: Import Specific

Subject Anatomy

Model of Artificial Disc Loads at Different Lumbar

Levels During Pushing
(30% Body Weight, 65% Stature)
2000

1500
Spine Load (N)

1000

500

0
L5/S1 L4/L5 L3/L4 L2/L3 L1/L2 T12/L1
-500
COMPRESSION A/P SHEAR

(Knapik & Marras, 2008)

Pushing/Maneuvering Patients
Relevance to Patient Handling

Are we eliminating risk of LBP or simply changing the

mechanism of risk with patient lift devices?

Is there a difference in risk as a function of the patient

lift device design?
Ceiling lift
Floor based lift

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 2/14/2010

Approach Care Givers

Use OSU Personalized Biodynamic Model to realistically
assess spine loads when pushing patient with ceiling lifts Subjects (10)
vs. floor-based lifts 5 males, 5 females
Age = 24.2 (4.66) years
Height = 175.11 (11.98) cm
Task e g t = 70.66
Weight 0 66 ((16.11)
6 ) Kgg

Push a patient lifting device through a course that

contains many of the typical challenges within a health
care facility

Patient Lift Devices Experimental Conditions

Lift system
Ceiling lift Floor based lift
Ceiling based
Floor based large wheel vs. small wheel
Large wheels (5 inch diameter rear; 4 inch diameter front)
Small wheels (3 inch diameter rear; 2 inch diameter front)
Floor Surface
Hard Floor
Carpet

Likorall 243 ES Liko Viking L

(230 Kg capacity) (250 Kg capacity)

Patients Course Path and Required Control

CONFINED TURN

Patient weight GRADUAL TURN

125 lb (56.8 Kg) BATHROOM

160 lb (72.7
(72 7 Kg)
360 lb (163 Kg) END

START

STRAIGHT SHARP TURN

NOTE: All dimensions are in inches

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 2/14/2010

Experimental Conditions
Course Path and Required Control
Lift system
Ceiling based
Floor based
large wheel vs. small wheel
Large wheels (5 inch diameter rear; 4 inch diameter front)
Small wheels (3 inch diameter rear; 2 inch diameter front)
Floor surface
Hard floor
Carpet (short pile)
Patient weight
125 lb (56.8 Kg)
160 lb (72.7 Kg)
360 lb (163 Kg)
Course control required
Straight
Sharp (90 deg) turn
Gradual turn
Sharp turn in confined space (bathroom)

Spine Loads Determined by Model Ceiling Lift Trial and Analysis

Vertebral endplate compression, disc lateral shear, and
disc A/P shear at the superior and inferior vertebrae
levels from T12 to S1

Inferior endplates Superior endplates

Floor Based Lift used on Carpet Floor Based Lift used on Carpet

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 2/14/2010

Spine Force Compression

3400-6400 N Limit
Results: Tolerance
Limits
Spine Load Magnitudes

Anterior/Posterior
(A/P) Shear
750-1000 N Limit
Lateral Shear
750-1000 N Limit

Compression as a Function of Lateral Shear as a Function

Vertebral Level of Vertebral Level
1400
6000 1200
Latteral Shear (N)
mpression (N)

5000 1000
4000 800
3000 600
2000 400
Com

1000 200
0
0
Su or

Su or

r
r

L1 rior

r
r

rio

rio

rio
rio

io

rio

io

rio
rio

ri

ri
er

L1 per
fe

fe

fe

fe

2/ Infe
fe

L2 pe

pe

pe
L4 pe

p
In

In

In

In
In

Su
Su

Su

Su
1

2
/S

/L

/L

/L

/L

L1
1

2/
/S

/L

/L

/L

/L
L3
L5

T1
L4

L3

L2

L1
L5

T1

A/P Shear as a Function of Significant Effects

Vertebral Level Lateral Compression A/PShear
Shear
1400
1200
PatientHandlingSystem 0.003* 0.015* 0.060
(System)
Shear (N)

1000
800 PatientWeight(Weight) 0.124 0.069 0.057
600
A/P S

RequiredControlover
R i dC t l 0 006*
0.006* 0 105
0.105 0 005*
0.005*
400
200
System(Control)
0 System*Weight 0.015* 0.189 0.133
System*Control 0.106 0.002* 0.001*
Su or

Su or

Su or

Su or

r
r

3 i or

r
r
rio

o
rio

io

rio
rio

rio
L1 feri
ri

ri

ri

ri
r

r
fe

fe

fe

fe
fe

L 3 pe

L 2 pe

L 1 pe

pe

pe
L4 upe
In

In

In

In

n
In

Weight*Control 0.496 0.695 0.497

Su
T1 1 I
S
1

2
/L

/L

/L

/L
/S

L
1

2
2/
/L

/L

/L

/L
/S
L5

2/

System*Weight*Control 0.154 0.081 0.070

T1
L4

L3

L2

L1
L5

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 2/14/2010

Significant Effects L3 A/P Shear a Function of

Required Control
Lateral Compression A/PShear
Shear
PatientHandlingSystem 0.003* 0.015* 0.060 1400
(System) 1200

hear (N)
1000
PatientWeight(Weight) 0.124 0.069 0.057
800
0 006*
0.006* 0 105
0.105 0 005*
0.005*

A/P Sh
RequiredControlover
R i dC t l 600
System(Control) 400
200
System*Weight 0.015* 0.189 0.133
0
System*Control 0.106 0.002* 0.001* Straight Gradual Turn Sharp Turn Bathroom
Weight*Control 0.496 0.695 0.497
Required Control
System*Weight*Control 0.154 0.081 0.070

* Significant (p<0.005)

L3 A/P Shear as a Function of L3 A/P Shear as a Function of

System and Required Control Lift System, Floor, and
Required Control
1400
Required 1400
1200 Control Required
1200
Control
A/P Shear (N) .

1000 Straight
N) .

1000 Straight
g
800
A/P Shear (N

Gradual Turn
800 Gradual Turn
600 Sharp Turn
600 Sharp Turn
Bathroom
400
Bathroom
400
200
200
0
Ceiling Lift Floor Based Systems 0
Ceiling Lift Carpet Hard Floor

* Significant (p<0.001)

L3 A/P Shear as a Function of L3 A/P Shear as a Function of Floor

System Wheel Type and Based Systems and Required Control
Required Control 1800 Required
1400 1600 Control
Shear (N) .

Required 1400
1200 Straight
Control 1200
1000 Gradual Turn
A/P Shearr (N) .

1000 Straight 800 Sharp Turn

A/P S

800 Gradual Turn 600

Bathroom
Sharp Turn 400
600
200
Bathroom
400 0
200 Ceiling Sm Sm Lg Wheel Lg Wheel
Lift Wheel Wheel Carpet Floor
0 Carpet Floor
Ceiling Lift Small Wheel Large Wheel

* Significant (p<0.001)

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Discussion
Ceiling lifts impose lowest (and safest) load on the spine
No risky conditions were identified for this condition
Floor-based lifts can impose significant biomechanical
risk to spine but depends upon conditions of use
Risk occurs primarily to the upper lumbar vertebrae (L3
and above)
Previous studies have not studied those levels
May help explain the 27% of LBP associated with pushing and
pulling
These results may explain why interventions are not
always effective
Discussion
A/P shear is mechanism of risk when pushing patients
Floor based risk increases with increased required
control
Controlling lift in confined space (bathroom) poses greatest risk
Turning (gradual or sharp turn) poses next greatest risk
Pushing without turning has minimal risk (but greater than
ceiling lift)
No increased risk with ceiling lift as a function of control
Operating floor based lifts on carpet or with small wheels
greatly magnifies risk
Small wheels and carpet together create hazardous conditions
when control is required.

L3 A/P Shear as a Function of

Low Back Pain
Patient Weight
Risk Factor Environment
1400
1200
A/P Shear (N) .

1000 Social & Org. Individual

800
Factors Factors
600
400
200
0
125 lbs 160 lbs 360 lbs Physical
Patient Weight Factors

*Not statistically significant

The Influence of Psychosocial Stress,

Gender, and Personality on Mechanical
Loading of the Lumbar Spine (Marras et al., 2000)
Non Physical Work Factors
Affecting Spine Loading: Study Procedure
Psychosocial Factors
1. Un-Stressed Session - Perform Lift Tasks
2. Experiment Interruption / Experimenters
Called Out of Room
3. Stressed Session - Perform Same Lift Tasks

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 2/14/2010

Variability of Biomechanical Responses Differences in Spinal Loads Between

to Psychosocial Stress (Marras et al.2000) Personality Traits in Response to
Psychosocial Stress (Marras et al., 2000)
C om prression Force

90
Per U nit Mom ent

70 30
(N/N m )

50 25

30 20

% Increase
e
15 Compression
10 Lat Shear
1 4 6 8 10 12 14 16 19 21 23 25 10
Subject Number
5
Unstressed Stressed 0
Extraverts Introverts

Differences in Spinal Loads Between Musculoskeletal Control and

Personality Traits in Response to Tissue Load
Psychosocial Stress (Marras et al., 2000)
30

25

20
% Increase
e

15 Compression
Lat Shear
10

5 Agonist Contraction
Antagonist Contraction
0
Sensors Intuitors Antagonist Cocontraction Leads
to Increased Tissue Load

Conclusions Conclusions
There is no safe way to lift a patient manually (loads are
too great for body mechanics to make a difference) Low back forces and pain are initiated by spine loading
There is surveillance evidence that interventions can due to A MIX OF:
help control risk Physical Work
Lifting devices can help but the degree of control Psychosocial and Organizational
Individual Factors
q
required greatly
g y influences risk
Appreciation for
f trunkk muscle
l coactivity is the
h key
k to
Use ceiling lifts if at all possible understanding loading conditions
When using floor mounted lifts
Use extreme caution when turning and controlling patient within
the bathroom (this is where the risk occurs)
Use extreme caution when using these systems on carpet
Dont use small wheels with floor based systems!

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Concern for man and his fate must

always form the chief interest of Thank You!
all technical endeavors...

Never forget this in the midst of Website:

W b it http://biodynamics.osu.edu
htt //bi d i d
your diagrams and equations e-mail: marras.1@osu.edu

- Albert Einstein

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