Everybody knows someone who has had or is suffering from a ‘bad back’. As Jonathan Backhouse argues, one of the most common causes of back pain is poor manual handling, which is why it’s so important to ensure people follow the best advice.
According to the Health and Safety Executive’s report, Handling injuries in Great Britain, 2013, which tracks the broad range of work-related injuries caused by handling activities, more than one-in-five injuries can be levelled at its door. Handling injuries include those caused by lifting, carrying, pushing or pulling loads; strains; sprains; trapped fingers; and cuts from sharp objects. 
The fallout on the wider economy is tremendous. The estimated days lost for different kinds of injury, according to the same report, was statistically more significant for handling, lifting and carrying (32 per cent) than for any other kind of accident (see figure 1).
Figure 1: Days lost for different kinds of injury 
Since the introduction of a new RIDDOR coding system (2011/12) and a change in the definition of lost-time injuries (2012/13), injury numbers and rates cannot be directly compared with earlier years. Before 2011/12, handling was subdivided into more detailed kinds, such as “lifting or putting down loads”. 
However, while it is difficult to compare annual figures since the recording of accidents changed, it is clear that handling remains a major cause of work-related injuries.
The primary piece of UK legislation that relates to manual handling is the Manual Handling Operations Regulations 1992, which brought into force the requirements of European Directive 90/269/EEC. 
The phrase ‘bend you knees and keep your back straight‘ can be found in a large number of health and safety texts/course books. This advice, however, contradicts the ‘good handling technique’ stated in HSE’s Manual Handling Operations Regulations 1992 Guidance on Regulations L23, which advises:
- think before you lift;
- keep the load close to your waist;
- adopt a stable position;
- ensure a good hold on the load;
- at the start of the lift, moderate flexion (slight bending) of the back, hips and knees is preferable to fully flexing the back (stooping) or the hips and knees (squatting);
- don’t flex your spine any further as you lift;
- avoid twisting the trunk or leaning sideways, especially while the back is bent;
- keep your head up when handling;
- move smoothly;
- don’t lift more than you can easily manage; and
- put down then adjust. 
This same ‘good handling technique’ is included in HSE’s Getting to grips with manual handling: A short guide INDG143 (rev2). 
Developed by Richard Graveling, and his team at the Institute of Occupational Medicine, in Edinburgh, the authors state in their report, The principles of good manual handling: Achieving a consensus, that: “It is important for the subsequent discussion to be clear on the difference between manual handling ‘principles’ and ‘techniques’. Principles can be seen as the safest way for the body to move while technique can be seen as how to obtain these postures or movements.” 
The authors go on to add: “[It] is important as the inclusion of flexing the spine represents a notable deviation from the previous advocacy of a ‘straight’ back. There was general consensus that extreme flexion of any of the joints (for example a full squat) should be avoided. The contribution of research into the biomechanics of the spine to understanding spinal loading is important here. General consensus was that a positive principle ‘should be moderately flexed’ was preferable to the negative ‘don’t over flex’.” 
This good handling technique is also advocated by the National Back Exchange in its publication, The Guide to Handling of People (6th edn). The following quote from the book is the advice used within the care industry: “[The] handler’s lower back should be moderately flexed, but not too flexed that the maximal bending stresses are placed on the intervertebral discs and ligaments.” 
A short literature review of thirty health and safety text/course books (including those leading texts within the health and safety industry, and course books used in health and safety qualifications; for example courses run by the National Examination Body for Occupational Safety and Health (NEBOSH), the Institution of Occupational Safety and Health (IOSH) and the Chartered Institute of Environmental Health (CIEH)), was undertaken by his author to critically review the techniques advocated.
Only four books for general health and safety qualifications follow guidance given by the HSE.  It should also be noted that three of the four books using the ‘good handling technique’ as set out by HSE were from the same publisher and author and are used for three related courses.
Eleven books, which include a reference to manual handling, did not indicate the technique that should be used:
- eight were textbooks 
- two were general health and safety course books 
- one course book having the sole purpose of being used to provide manual handling training for employees does not make reference to the technique that should be used. 
Of the 15 books that make reference to straight back, or similar:
- two advocate straight back/back kept straight 
- 10 advocate keeping the back upright/straight back/backstraight/do not bend your back 
- two, by the same author, advocate, “Lean slightly forward…” however one of the two books also states a straight back 
- one book having the sole purpose of being used to provide manual handling training for employees advocates the need to keep the back straight. 
Only 13 per cent of books (4 out of 30) reviewed were in line with HSE guidance : “At the start of the lift, moderate flexion (slight bending) of the back, hips and knees is preferable to fully flexing the back (stooping) or the hips and knees (squatting)”.
It is not surprising therefore that when you ask someone how they would lift something; for example, a box of five A4 reams of paper – they will respond with “Bend your knees and keep your back straight”. If you watch them doing the task without doing it, they might even stoop fully over the box.
The Manual Handling Operations Regulations 1992 Guidance on Regulations L23 provides information on what a training course should cover. It states that the content should include:
a) manual handling risk factors and how injuries can occur;
b) how to carry out safe manual handling, including good handling technique;
c) appropriate systems of work for the individual’s task and environment;
d) use of mechanical aids; and
e) practical work to allow the trainer to identify and put right anything the trainee is not doing safely. 
Many employees are not correctly taught the good handling technique. There are many factors why this is the case; for example, as shown above, a significant proportion of the course books do not include the good handling technique.
When I surveyed my own students on a range of health and safety courses and then posed the question: “How would you lift a box of five reams of A4 paper off the floor and put it on a table?” the clear majority of students’ answers mentioned the need to “keep your back straight”. In many cases the students will inform me that they have been taught to bend the knees and keep the back straight.
The wording of back straight/upright/vertical and so forth can be, and has been, misleading. There has possibly been too much focus on the position of the back and less on whole body biomechanics and the body’s ability to tolerate the load in a particular handling task. What people often remember as the key message is the back in this or that position from a training session or reading a book.
When someone lifts a box of five A4 reams of paper with a straight back (i.e. a squat lift) or bends the back over the load (i.e. a stoop lift) this potentially increases the risk of injury. Excessive pressure is placed on the knees during the squat lift, especially if lifting from the floor and placing hands under the load means the arms will become over extended. Likewise the stoop lift causes excessive force on the lower back. 
While flexing hips and knees are necessary (if the load is low), over flexion must be avoided i.e. more than 90 degrees – beyond that and there is substantial loss of mechanical advantage – simple physiology / biomechanics relation to equation between muscle length and efficiency.
Taking all of this into account, it is advisable, whenever it is practicable, to state: “At the start of the lift, moderate flexion (slight bending) of the back, hips and knees is preferable to fully flexing the back (stooping) or the hips and knees (squatting).
The latest HSE figures show that elementary storage occupations had the highest numbers of handling injuries (2,000), followed by sales and retail assistants (709). 
Would those working in such environments benefit from being provided with the correct information, instruction and training in manual handling? Many of those working in the care industry will have received training based on The Guide to Handling of People (6th edn).
Ask yourself – what were you taught; what were your staff taught?
Three easy steps to better manual handling
Stewart Cruikshank from Pristine Condition, manual handling experts who draw on 19 years of weightlifting experience to deliver a different type of training, gave three easy steps to better manual handling:
Too many injuries happen in the workplace due to lifting in the wrong way. Weightlifters avoid injury even though they are routinely handling loads that are greater than so-called ‘recommended limits’, because they know the right way to lift. Pristine Condition have applied this experience to industry and manual handling.
Cruikshank went on to explain why conventional instruction techniques are not only technically flawed, but also that individuals don’t buy into it. People get stuck in bad habits, or have been trained incorrectly in the first place, leading to back pain and other long-term injuries.
Cruikshank offered three simple steps that businesses can follow in order to better protect their workers from injury.
Three steps to success:
- Training: This is key to getting individuals to stop relying on bad habits and buy into good behaviour. It’s important to remove the myths associated with lifting and handling. Correct technique doesn’t just have to be work related, it can carry over into the home as well.
- Monitoring: Training should not be the end of the line, workers still need to be monitored and checked to make sure they are not falling back on bad habits. People also need to feel confident in challenging another worker’s bad technique – and demonstrate how it should be done.
- Support: Good manual handling techniques should be under constant review, with the option of refresher courses and additional training if needed. Pristine Condition offer continuous support for their clients, and this support should be maintained within the workplace.References:
Note: over 40 references are stated below, some are linked together.
1. HSE (2013). Handling injuries in Great Britain, 2013. [online]. Available from http://www.hse.gov.uk/statistics/causinj/handling-injuries.pdf p.3
2. HSE (2013). Table INJKIND2 – 2012/13. [online]. Available from www.hse.gov.uk/statistics/lfs/injkind2.xls
3. HSE (2013). Handling injuries in Great Britain, 2013. [online]. Available from http://www.hse.gov.uk/statistics/causinj/handling-injuries.pdf p.3
4. Great Britain (1992). Manual Handling Operations Regulations 1992 ; Statutory Instruments 1992 no. 2793. Available from http://www.legislation.gov.uk/uksi/1992/2793/made
5. HSE (2004). Manual Handling Operations Regulations 1992 Guidance on Regulations L23, 3rd Edition [online]. Available from http://www.hse.gov.uk/pubns/books/l23.htm p44-46.
6. HSE (2006). INDG143: Getting to grips with manual handling. [online]. Available from http://www.hse.gov.uk/pubns/indg143.pdf p6.
7. Graveling R, Melrose AS, Hanson, MA (2003). The principles of good manual handling: Achieving a consensus. Edinburgh, Institute of Occupational Medicine. [online]. Available from http://www.hse.gov.uk/research/rrpdf/rr097.pdf p1.
8. Graveling R, Melrose AS, Hanson MA (2003). The principles of good manual handling: Achieving a consensus. Edinburgh, Institute of Occupational Medicine. [online]. Available from http://www.hse.gov.uk/research/rrpdf/rr097.pdf p46.
Hughes P, Ferret E (2011). Introduction to Health and Safety at Work, 5th edn, Oxford, Taylor and Francis.
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NEBOSH (2010) The NEBOSH Award in Health and Safety at Work, Leicester: NEBOSH.
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Ridley, Channing (2008). Safety at Work, Oxford, Elsevier.
IOSH (date unknown). Working Safely: your Workbook, version 3, Leicester, IOSH.
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ECITB (no date). Work Safety Handbook, Hertfordshire, CCSNG.
Fellows et al (2011). Level 2 Health & Safety Made Easy, Qualsafe.
Ferret E (2012). Health and Safety Revision Guide, 2nd edn, Oxon, Taylor and Francis.
Hartley (2003). Heath and Safety: Hazardous Agents, Leicester, IOSH.
Phelstead J (2012a). NEBOSH Certificate, NGC2, London, Rapid Results College.
Phelstead J (2012b). NEBOSH National Diploma, Unit B Vol. 2, London, Rapid Results College.
Springer (2011). Health and Safety Handbook (Level 2), Doncaster, Highfield Ltd.
Leeson, revised by Bryant (2006). Health and Safety First Principles, 2nd edn (revised by: Bryant, D.), London, CIEH.
18. Graveling R, Melrose AS, Hanson MA (2003). The principles of good manual handling: Achieving a consensus. Edinburgh, Institute of Occupational Medicine. [online]. Available from http://www.hse.gov.uk/research/rrpdf/rr097.pdf
19. HSE (2004). Manual Handling Operations Regulations 1992 Guidance on Regulations L23, 3rd Edition [online]. Available from http://www.hse.gov.uk/pubns/books/l23.htm p40.
21. HSE (2013). Handling injuries in Great Britain, 2013. [online]. Available from http://www.hse.gov.uk/statistics/causinj/handling-injuries.pdf p.4
Jonathan Backhouse is a chartered safety and health practitioner. The author can be contacted at firstname.lastname@example.org