Is bending dangerous if you have back pain?

Many people believe that their back pain is linked in some way to having lifted something heavy. Oftentimes, on delving deeper, the patient reports having lifted something a day or two prior to the onset of pain. Claiming that something that occurred a couple of days prior to onset is the cause of back pain is no different to someone playing a match & thinking that they injured their hamstring 24 or 48 hours after playing a match. In other words, in my experience, bending & lifting has far less responsibility for inducing back pain than is commonly perceived.

The approach of lifting with the legs and avoiding bending from the back is “common knowledge” as a key method for protecting the back from injury. However, the question is: does research back this approach up?

How many times have you heard someone being advised to “keep the back straight” and “bend from the knees”?
Is this actually effective or should it be largely ignored? Questioning such firmly entrenched beliefs is part of the scientific process. So let’s delve into what happens when we are bending & lifting in order to answer this question.

Should I Bent My Knees & Keep My Back Straight When I Lift?

Spinal compression and the pressure present within the spinal discs does not appear significantly different whether squatting or bending from the spine when lifting. Research suggests that the forces were equal or slightly higher in squatting when compared to bending from the back when lifting. 

In fact, a recent review of the science actually found that flexing from the lower back improved lifting capacity and muscle coordination when compared to a straight spine lift. This research brings into question the traditional advice to lift with a flat or slight backward arch of the back (Mawston et al. 2021). 

Should I Squat or Bend My Back When Lifting?

Study Title: 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

Here, the authors reviewed all the literature on spinal flexion when lifting.

They found that there was low-quality evidence that greater spinal flexion during lifting was not a risk factor for LBP onset or persistence.  

Does Ergonomic/Lifting Technique Training in the Workplace Prevent Back Pain? 

Study Title: Wai EK, Roffey DM, Bishop P, Kwon BK, Dagenais S. Causal assessment of occupational lifting and low back pain: results of a systematic review. Spine J. 2010;10(6):554-566. doi:10.1016/j.spinee.2010.03.033

This research included 35 studies. They found moderate evidence of an association for specific types of lifting and LBP.

The authors reported that ‘based on these results, it is unlikely that occupational lifting is independently causative of LBP in the populations of workers studied.’

Study Title: Luger T, Maher CG, Rieger MA, Steinhilber B. Work-break schedules for preventing musculoskeletal symptoms and disorders in healthy workers. Cochrane Database Syst Rev. 2019 Jul 23;7(7):CD012886. doi: 10.1002/14651858.CD012886.pub2. PMID: 31334564; PMCID: PMC6646952.

The evidence collected indicates that manual handling training is largely ineffective in reducing back pain and back injury.

Study Title: Clemes SA, Haslam CO, Haslam RA. What constitutes effective manual handling training? A systematic review. Occup Med (Lond). 2010 Mar;60(2):101-7. doi: 10.1093/occmed/kqp127. Epub 2009 Sep 4. PMID: 19734238.

In this review that included 53 papers the authors found that ‘the evidence collected indicates that manual handling training is largely ineffective in reducing back pain and back injury.’ 

Study Title: Sundstrup E, Seeberg KGV, Bengtsen E, Andersen LL. A Systematic Review of Workplace Interventions to Rehabilitate Musculoskeletal Disorders Among Employees with Physical Demanding Work. J Occup Rehabil. 2020 Dec;30(4):588-612. doi: 10.1007/s10926-020-09879-x. PMID: 32219688; PMCID: PMC7716934.

The evidence synthesis recommends that implementing strength training at the workplace can reduce injury among workers with physically demanding work.

Based on the scientific literature, participatory ergonomics and multifaceted workplace interventions seem to have no beneficial effect on reducing musculoskeletal disorders among this group of workers. 

Does Lifting Technique Training Help to Decrease Back Pain?

Unfortunately, education on lifting technique has not been shown to reduce the incidence of low back pain. Despite this, proper lifting technique is taught in workplaces across the globe, and also frequently, in clinics.

As mentioned, bending the back more when lifting has not been shown to be linked to back injury!

Do Ergonomic Work Supports Help for Shoulder & Arm Pain?

Study Title: Van Eerd D, Munhall C, Irvin E, Rempel D, Brewer S, van der Beek AJ, Dennerlein JT, Tullar J, Skivington K, Pinion C, Amick B. Effectiveness of workplace interventions in the prevention of upper extremity musculoskeletal disorders and symptoms: an update of the evidence. Occup Environ Med. 2016 Jan;73(1):62-70. doi: 10.1136/oemed-2015-102992. Epub 2015 Nov 8. PMID: 26552695; PMCID: PMC4717459.

This literature review showed moderate evidence for amending mouse setup, use of forearm support, & stretching programmes in preventing shoulder & arm pain.

Interestingly, they did find that a resistance training programme had strong evidence in preventing upper limb disorders.

What About Work Breaks?

Study Title: Luger T, Maher CG, Rieger MA, Steinhilber B. Work-break schedules for preventing musculoskeletal symptoms and disorders in healthy workers. Cochrane Database Syst Rev. 2019 Jul 23;7(7):CD012886. doi: 10.1002/14651858.CD012886.pub2. PMID: 31334564; PMCID: PMC6646952.

We found low-quality evidence that different work-break frequencies may have no effect on participant-reported musculoskeletal pain, discomfort and fatigue.

For productivity and work performance, evidence was of very low-quality that different work-break frequencies may have a positive effect. 

Do People with Back Pain Lift Differently to Those Without Back Pain?

Study Title: Saraceni N, Campbell A, Kent P, Ng L, Straker L, O’Sullivan P. Exploring lumbar and lower limb kinematics and kinetics for evidence that lifting technique is associated with LBP. PLoS One. 2021 Jul 21;16(7):e0254241. doi: 10.1371/journal.pone.0254241. PMID: 34288926; PMCID: PMC8294511.

21 patients with low back pain & 20 participants without low back pain (LBP) completed a 100-lift task, where lumbar and lower limb kinematics and kinetics were measured during lifting, with a simultaneous report of (LBP) intensity every 10 lifts.

Workers with a history of LBP, lift with a style that is slower and more squat-like than workers without any history of LBP.

Common assumptions that LBP is associated with lumbar kinematics or kinetics such as greater lumbar flexion or greater forces were not observed in this study, raising questions about the current paradigm around ‘safe lifting’.

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