Don’t Worry About Lifting Technique

The conventional wisdom is that we must not stoop to lift heavy objects. To avoid injury, we should squat down and then lift with our legs, not our backs. About 75% of physical therapists believe this,1 and the number is probably even higher outside that profession. It’s just as common for professionals to blame awkward and uneven lifting of lesser loads, as in this perfect example from a reader:

Every doctor and chiropractor and physiotherapist I have seen for months has told me that I have back pain because I’m carrying around my baby son. I don’t buy it! I had the same back pain for years before he was born. I don’t understand why they can’t understand that logic. It comes and it goes and I just don’t know why, but it isn’t my son, or it’s not just my son.

Her logic was solid: if the pain pre-dated motherhood, then baby-toting is a daft explanation for it.

All those pros who believe in the importance of good lifting technique are probably wrong. I will argue that this is worse than wrong — it’s actually counter-productive. The truth is undoubtedly in the middle, but decades ago the pendulum of public opinion and “common sense” swung all the way to one side and got stuck there; I think it needs a firm (evidence-based) push back towards the centre.

For a more thorough and technical review of both sides of this topic, see Greg Lehman’s excellent review, “Revisiting the spinal flexion debate: prepare for doubt.” This article focusses just on making the case that the conventional wisdom is a myth: stooping to lift is not a significant risk factor for back pain for healthy people, and we don’t need to be taught how to lift simple heavy objects “properly.” Several sub-topics are not covered here, especially the athletic extremes (like powerlifting), special occupational challenges (like nursing or piano moving), or lifting during rehab. I do briefly discuss osteoporosis.

The risks of poor lifting technique have been exaggerated.

Your back isn’t fragile and you already know how to lift things

Many activities are not nearly as dangerous as they seem. Being a Cirque du Soleil acrobat, for instance, is surprisingly safe, with an injury rate “lower than for many National Collegiate Athletic Association sports.”2

Intuition often fails us in musculoskeletal and sports medicine. One of the best important examples is that the bark of back pain is usually much worse than its bite and has surprisingly little to do with structural problems in spines like degeneration and injuries like “slipped” discs, muscle strains, pinched nerves, and so on. Although these things do happen, they are not as common or inevitably painful as most people imagine.3 Back pain is complex. Whether we get back pain is influenced by many non-obvious factors.

Although we can’t lift heavy things just any old way, we don’t really need to be taught either, or just can’t be.4 What matters most is so obvious that it’s hard to get wrong: mostly just keep objects close to the body and balanced, and avoid lifting in awkward postures or when fatigued. These things are probably as risky as they are obvious. Lifting with an awkward posture specifically is a particularly impressive risk factor: a thousand people carefully quizzed about what they were doing before an attack of back pain were almost eight times likelier to have been lifting something heavy with an awkward posture.5

But simply stooping is not an “awkward posture.” As long as we cover those fairly obvious safety bases, there’s not much we can do to improve on it, and in particular neither stooping nor squatting has an obvious safety advantage over the other (the science coming below).

Although some of this still sounds a bit contrarian and radical today, the value of trying to tinker with people’s lifting habits has been under fire for a long time. In 1997, Dr. Nortin Hadler wrote a paper for the journal Spine with the subtitle: “what you lift or how you lift matters far less than whether you lift or when.”6 In 2002, physical therapist Leon Straker wrote:7

Little evidence supports the effectiveness of training programs to change workers’ lifting habits and any attempt at change may just increase risk as workers lose the protection of well practiced and conditioned movement patterns.

That opinion was backed by a 2008 review of several years worth’ of evidence about lifting technique and low back pain:8

There is no evidence to support use of advice or training in [lifting] techniques … for preventing back pain or consequent disability. The findings challenge current widespread practice of advising workers on correct lifting technique.

(I’ll review some more specific and recent evidence below.)

I suspect training people to lift “properly” probably doesn’t work because backs are actually tough as good boots, and what makes backs hurt (or get injured) isn’t influenced all that much — if at all — by lifting technique, as long as you aren’t being really foolish about it. The conventional wisdom is based on an assumption of a fragility that just doesn’t exist in the back, so it’s not too surprising that the training doesn’t make much difference: there’s no vulnerability to avoid.

And that’s not the only bogus assumption in this mess.

Your back isn’t fragile … unless it literally is

Osteoporosis is different! The loss of bone density that we often see in older women probably does boost the risk of compression fractures of the spine.9 The “flexion fear” that is so common and silly with regards to healthy people is probably justified for this specific population — like a stopped clock that’s correct twice a day, sometimes it does make sense to be cautious with flexion.

But that which is risky is also by far the best treatment! The flexion exercises that are riskier for these people are also the only realistic hope for recovery. They just have do be done much more slowly and cautiously, in proportion to the severity of the osteoporosis — the babiest of baby steps!

Does heavy lifting actually increase the risk of back pain?

If lifting heavy things at work leads to back pain, then it would make more sense to be careful about how you do it. If.

As much as I appreciate their conclusions, Martimo et al. begin their paper with a whopper of another unjustified assumption, in the first sentence: “Heavy lifting at work increases the risk of back pain.”

If that assumption isn’t correct, the entire discussion is a moot point, right? And yet the authors support it with only a single reference to a 1999 paper published in an obscure journal, International Journal of Industrial Ergonomics10 … and that paper supports nothing of the kind. It does not show that “heavy lifting increases the risk of back pain.”11 It’s a bogus citation! I am not making this up.

But that’s now ancient data in any case. Much more recently, a 2010 review concluded it’s “unlikely” that lifting was a cause of back pain in workers.12 A 2012 review found little to no evidence for any connection between back pain stooping over repeatedly or for long periods13 — a different angle on the same problem. Not enough reviews for you? Okay: a 2011 review of eight reviews “did not support” the conventional wisdom either.14

Never mind the weight: how about just the amount of time spent bending over? The stoopage factor? A 2015 study of 198 workers not only failed to find a link between the amount of back flexion and higher pain intensity, they found the opposite: more time spent flexing beyond 30˚ was linked to lower back pain intensity!15

None of this means that no one will ever hurt their back lifting something at work, but obviously the connection is nowhere near as obvious as everyone assumes. (Even the experts assumed it until quite recent history.) Likely there are major X factors.16

There’s no real smoke around lifting, so there’s probably no back pain fire.

Does stooping even put more load on the spine?

Yes, probably, but it’s quite a bit more complicated than it seems.

The modern flexion fear has many roots, but one major example of its origins is this classic chart, from a 1975 paper by Dr. Alf Nachemson (1931–2006), a giant in back pain research.17 It shows the percentage of loading on intervertebral discs measured in different positions:

Infamously, stooping from a seated position was the loading-est of them all.

Sadly, Nachemson came to believe that diagram to be one of the most misinterpreted and abused studies in the history of the field!18 But his concern was about the clinical implications of the data, not whether or not the data was accurate. In general, discs do indeed get squished a bit when you bend over.

But the data wasn’t exactly perfect either. Sitting is the loading-est? Say what now? That was contradicted by later studies.19 There are really a lot of variables in this equation, and nothing is ever as simple as it seems in this business.

It is almost impossible not to flex your spine when lifting something off the ground, and there is remarkably little difference between spinal loading in different “lifting techniques.” Kingma et al. measured 40˚ of spinal flexion even in a pure squat lift,20 the theoretical ideal lifting technique as understood by most people. Meanwhile, the lumbar spine flexed only ten degrees more when lifting the same way.

Or what if we could measure spinal forces directly? Imagine a pressure meter implanted in your back, completely replacing one of your vertebrae. What would it tell you, if you stooped over to pick up an object instead of squatting down to lift with your legs instead of your back? The nearly universal assumption is that stooping puts much more strain on the spine, and there’s a bunch of old evidence for it (like the 1981 Nachemson paper).

But it isn’t an entirely safe assumption or conclusion. Just as Kingma et al. found, there’s not much difference.

Those meters are actually a thing! Instrumented vertebral body replacements (VBRs) are high-tech gadgets installed in place of a vertebrae. Very cyborg! (Stronger, faster, more … measured?) In a 2016 experiment,21 three patients with VBRs did a bunch of lifting, and their implants measured the forces in squats versus stoops. Not only was the difference was negligible… it was actually in favour of stooping! Squatting is the supposedly “correct” and safe way to lift, but it actually caused 4% more load on tissues. Not a big number, but it’s in exactly the wrong direction if you were trying to support the conventional wisdom.

The current in vivo biomechanical study does not provide evidence that spinal loads differ substantially between stoop and squat lifting.

This is not perfect evidence, or the only evidence, but it’s enough to cast a lot of doubt on the value of advice to “lift with your legs, not your back.” And that’s all we need to make the case that the importance of lifting technique has been exaggerated.

What about back braces and support belts?

No one lifts more than bodybuilders and powerlifters. And bodybuilders must wear those big thick belts for some reason!22 If it makes sense for them, it must make sense for occupational lifting too. Surely.

Unless it doesn’t make sense for them. Siewe et al. found that the use of weight belts increased the injury rate of the lumbar spine in powerlifters.23 Ruh roh!

And major recent reviews of the science have shown that there’s little or no prevention benefit to such belts in the workplace.2425 •sad trombone•

Interestingly, even hard braces are amazingly ineffective at reducing the forces on the spine!26 See Spinal Fracture Bracing and Fixation: My wife’s terrible accident, and a whirlwind tour of the science and biomechanics of her spine brace — fascinating topic.

Supports, braces, and belts mostly just provide some novel sensory input that reinforces the idea of security and stability — a sensation-aided placebo. That is, you don’t just hope that it supports your back, it feels like it does. Unfortunately, this also strongly encourages the insidious idea that backs need stabilizing in the first place. And that’s how you lose The Mind Game in Low Back Pain.

Another lesson from powerlifting

Deadlifts do not remotely look like a “safe” way to lift something heavy with your back. And yet the sport of powerlifting demonstrates that it’s possible to do deadlifts regularly without any obvious pattern of vulnerability to back pain. These guys and gals are stooping over and picking up dramatically more weight than anyone is ever going to lift at work.27 For fun. With, science says, less injury than other sports!28

Most powerlifters try to minimize spinal flexion, especially lumbar flexion, but it’s not clear that many of them are actually succeeding … and for sure many amateurs definitely fail, either because of poor training and/or because it is biomechanically difficult to achieve. Remember, it is nearly impossible not to flex your spine when lifting something off the ground.29 And so most deadlifts and strongman lifts bear a striking resemblance to how people are not supposed to lift, and yet the sport is amazingly safe.

But this isn’t about powerlifting: I’m just using powerlifting as an example to make a point about saner loads. I am definitely not saying that it’s safe for an untrained person to try to lift huge loads willy nilly — technique does matter when you’re trying to get several hundred pounds off the ground! It’s a completely different thing than schlepping stuff around in a warehouse. I am only saying that the range of what it’s possible to do surprisingly safely is just huge. If backs were actually prone to injuries when lifting 20-40 kilos with poor technique or training, it’s unlikely that people could ever safely multiply that by 3-10 times in deadlifts, but they clearly do, even with imperfect elimination of flexion, if that is even possible.

The point is that backs are naturally sturdy and non-fragile, and powerlifting is a great demonstration of that.

Don’t worry about how you lift … but don’t be a fool either!

Obviously you can hurt yourself if you are reckless with heavy loads. And obviously technique does matter for extreme loads (the kind of loads no one would ever be expected to deal with at work). Strain hard enough and you will get a muscle strain (a tear), or worse. And although disc herniations may be less common and less serious and less related to either lifting or back pain than people think, that doesn’t mean you want one.

But training for lifting technique is probably not important because heavy lifting itself probably does not actually increase the risk of back pain significantly in the first place — and so there’s no problem to solve with better technique, and no evidence that there is even any way to significantly improve on our technique. Doubtless heavy lifting is at least a little bit of a factor in back pain, just not a major one — not the kind of factor that generates a nice clear statistical signal.

Back pain that starts with a lifting trauma probably occurs less than most people think, and isn’t as severe, and when it does occur it probably often seems worse than it is due to the common problem of trigger points in back pain.

About Paul Ingraham

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

SUBSCRIBE

Get PainSci updates in your inbox, mostly small, 0–2/week depending on coffee dosage. More info.

Related Reading

• Neuropathies Are Overdiagnosed — Our cultural fear of neuropathy, and a story about nerve pain that wasn’t
• Chronic Low Back Pain Is Not So Chronic — The prognosis for chronic low back pain is better than you think
• The Tyranny of Yoga and Meditation — Do you really need to try them? How much do they matter for recovery from conditions like low back pain?
• 6 Main Causes of Morning Back Pain — Why is back pain worst first thing in the morning, and what can you do about it?
• Does Posture Matter? — A detailed guide to posture and postural correction strategies (especially why none of it matters very much)
• The Trouble with Chairs — The science of being sedentary and how much it does (or doesn’t) affect your health and back pain
• Your Back Is Not Out of Alignment — Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain
• MRI and X-Ray Often Worse than Useless for Back Pain — Medical guidelines “strongly” discourage the use of MRI and X-ray in diagnosing low back pain, because they produce so many false alarms

Notes

1. 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. 2017 Oct;33:35–40. PubMed 29078081 ❐

   This survey found that about 75% of physical therapists believe that lifting with a straight back is safer … because lifting with a rounded back is more risky. Unsurprisingly, professionals with this opinion also have more “negative back beliefs” (that is, they tend to believe the back is more fragile and vulnerable).

2. Shrier I, Meeuwisse WH, Matheson GO, et al. Injury patterns and injury rates in the circus arts: an analysis of 5 years of data from Cirque du Soleil. Am J Sports Med. 2009 Jun;37(6):1143–9. PubMed 19286913 ❐

   Cirque du Soleil stunts look dangerous — but how dangerous are they really? This study found that there are a lot of minor injuries, almost ten per show. But less than one acrobat per show is hurt badly enough to miss more than 15 performances — and Cirque du Soleil puts a lot of people on stage. That injury rate is actually “lower than for many National Collegiate Athletic Association sports.”

   Apparently being an acrobat is not particularly dangerous. Not in Cirque du Soleil in the late 2000s, anyway.

   (Learning circus tricks might be a totally different matter. More recently, a 2018 study of circus arts students found… 184 injuries in 41 students in one year?! 😬 “The burden of injuries is high in this population.” You don’t say! And I thought playing ultimate [the disc sport] was bad…)

3. The evidence on this point is reviewed extremely thoroughly in my low back pain book, but you can also get a good free dose of it from this article: MRI and X-Ray Often Worse than Useless for Back Pain: Medical guidelines “strongly” discourage the use of MRI and X-ray in diagnosing low back pain, because they produce so many false alarms.
4. Of course things get expontentially more complicated with heavier and/or more awkward objects (sofabeds, patients in a hospital), or working on unstable or uneven surfaces (lugging sofabeds up stairs!). People who move a variety of awkward, heavy things around for a living almost certainly get good at many non-obvious techniques. One of the best examples: lifting patients safely (for both patient and nurses) is definitely a complex skill. Again, technique certainly matters … but for most lifting chores, there are just too many variables for there to be any clear “right” way to do it.
5. Steffens D, Ferreira ML, Latimer J, et al. What triggers an episode of acute low back pain? A case-crossover study. Arthritis Care Res (Hoboken). 2015 Mar;67(3):403–10. PubMed 25665074 ❐
6. Hadler NM. Back pain in the workplace. What you lift or how you lift matters far less than whether you lift or when. Spine (Phila Pa 1976). 1997 May;22(9):935–40. PubMed 9152441 ❐ “Before we persist for another 50 years in the quest for the ‘right way to lift,’ we should consider … alternative approaches. … The more reasonable and humane quest might be for workplaces that are comfortable when we are well and accommodating when we are ill.”
7. Straker LM. A review of research on techniques for lifting low-lying objects: 1. Criteria for evaluation. Work. 2002;19(1):9–18. PubMed 12454347 ❐
8. Martimo KP, Verbeek J, Karppinen J, et al. Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review. BMJ. 2008. PainSci Bibliography 55880 ❐
9. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. 1984 Oct;65(10):593–6. PubMed 6487063 ❐

   This 1984 experiment divided 60 osteoporotic women with back pain into four groups doing three different kind of exercise, plus a “lazy” control group that did nothing. One group did spinal flexion exercises, another did spinal extension exercises, and a third did a combination. On follow-up an average of 1.4 years later, 33% of the control group was worse off — more compression fractures had developed in that time. But in the flexion group? 89% were in worse condition! The combo-group roughly split the difference at 53% worse. The authors concluded: “Exercises that place flexion forces on the vertebrae… tend to cause an increased number of vertebral fractures in these patients.”

   Oddly, this seems to be the only data of its kind.

10. Kuiper JI, Burdorfb A, Verbeek J. Epidemiologic evidence on manual materials handling as a risk factor for back disorders: a systematic review. International Journal of Industrial Ergonomics. 1999 Aug 23;24(4):389–404. PubMed 10569458 ❐ PainSci Bibliography 55881 ❐
11. The International Journal of Industrial Ergonomics paper (which is another analysis of other research), comes to underwhelming conclusions about the relationship between low back pain and heavy lifting at work. Even though “a considerable number of epidemiologic studies investigated the risk of lifting,” the authors obtained “only a moderate insight” into the relationship between lifting and low back pain. Mostly what they found is that the available evidence was of low quality and “inconsistent” and “limited.”
12. 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 Jun;10(6):554–66. PubMed 20494816 ❐
13. Ribeiro DC, Aldabe D, Abbott JH, Sole G, Milosavljevic S. Dose-response relationship between work-related cumulative postural exposure and low back pain: a systematic review. Ann Occup Hyg. 2012 Jul;56(6):684–96. PubMed 22356808 ❐
14. Kwon BK, Roffey DM, Bishop PB, Dagenais S, Wai EK. Systematic review: occupational physical activity and low back pain. Occup Med (Lond). 2011 Dec;61(8):541–8. PubMed 21727180 ❐
15. Villumsen M, Samani A, Jørgensen MB, et al. Are forward bending of the trunk and low back pain associated among Danish blue-collar workers? A cross-sectional field study based on objective measures. Ergonomics. 2015;58(2):246–58. PubMed 25374330 ❐
16. Something like this is likely: you’ll hurt your back only if you sloppily lift something heavy and you’re under an extraordinary amount of emotional strain as well — like being miserable at work, perhaps. Or it’s just the seriously sleep-deprived lifters who “tweak” their backs. This is what we mean about lifting not being an independent cause: it almost certainly takes more than a bad lift.
17. Nachemson AL. Disc pressure measurements. Rheumatol Rehabil. 1975 Aug;14(3):129–43. PubMed 125914 ❐
18. The Back Letter. A Tribute to Alf Nachemson: The Spine Interview. The Back Letter. 2007 Feb;22(2):13,18–21. PainSci Bibliography 52022 ❐

    Many years later, shortly before his death, Dr. Nachemson expressed his regrets:

    This experiment has been misinterpreted as evidence that the disc is a significant pain generator and that increasing the biomechanical load leads to greater pain. But this study merely showed how the lumbar spine responds to normal physiologic loading in various positions of the body. It does not give any indication as to where the pain actually comes from.

    This quote is also from that interview, and it’s too great not to include:

    One of the main goals of my career has been to determine the cause of non-specific back pain. And in this I have failed. I didn’t know the origin of back pain in those days, and I don’t know now.

19. Wilke HJ, Neef P, Caimi M, et al. New in vivo measurements of pressures in the intervertebral disc in daily life. Spine. 1999 Apr 15;24(8):755–62. PubMed 10222525 ❐

    This study contradicts some of the rather infamous findings of Nachemson 1975, which showed intradiscal pressure in various positions. From the abstract:

    Good correlation was found with Nachemson's data during many exercises, with the exception of the comparison of standing and sitting or of the various lying positions. … It can be cautiously concluded that the intradiscal pressure during sitting may in fact be less than that in erect standing, that muscle activity increases pressure, that constantly changing position is important to promote flow of fluid (nutrition) to the disc, and that many of the physiotherapy methods studied are valid, but a number of them should be re-evaluated.

20. Kingma I, Faber GS, van Dieën JH. How to lift a box that is too large to fit between the knees. Ergonomics. 2010 Oct;53(10):1228–38. PubMed 20865606 ❐
21. Dreischarf M, Rohlmann A, Graichen F, Bergmann G, Schmidt H. In vivo loads on a vertebral body replacement during different lifting techniques. J Biomech. 2016 Apr;49(6):890–5. PubMed 26603872 ❐
22. Injury prevention is certainly the main casual reason cited by the average bodybuilder. It gets a bit more complex for serious powerlifters. The reasons I’ve seen (example) are a mish-mash of speculation about performance enhancement and/or injury prevention, with a strong common denominator: the belief that belts support the spine. Often the mechanism cited is that this facilitates very high abdominal cavity pressures, which in turn supports the spine anteriorly, which in turn makes it possible to lift heavier loads — “without injury” is stated by some and just implied by others. With loads like that there are only a hair-splitting difference between what can be done and what can be done without hurting yourself. I haven’t read enough to know, but I bet there’s plenty of debate about whether the belts actually help (in a biomechanical way), or if they are a placebo that “just” gives lifters a feeling of safety and confidence — which is exactly like the debate about rehabilitative bracing.
23. Siewe J, Rudat J, Röllinghoff M, et al. Injuries and overuse syndromes in powerlifting. Int J Sports Med. 2011 Sep;32(9):703–11. PubMed 21590644 ❐
24. Kurustien N, Mekhora K, Jalayondeja W, Nanthavanij S. Trunk Muscle Performance and Work-Related Musculoskeletal Disorders among Manual Lifting with Back Belt Wearing Workers. J Med Assoc Thai. 2015 Jun;98 Suppl 5:S74–80. PubMed 26387415 ❐ “Low correlation was found between back belt use and work-related musculoskeletal disorders.”
25. Steffens D, Maher CG, Pereira LSM, et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016 Jan:1–10. PubMed 26752509 ❐ Back belts “do not appear to prevent LBP.”
26. Rohlmann A, Bergmann G, Graichen F, Neff G. Braces do not reduce loads on internal spinal fixation devices. Clin Biomech (Bristol, Avon). 1999 Feb;14(2):97–102. PubMed 10619096 ❐

    To determine how much a back brace really braces, German researchers used “telemeterized” implants — steel fixation rods with meters on them! so cyborgy! — to measure the effect of common braces on spinal forces. This is a good experiment. If you have implants stabilizing your spine internally, measuring the stresses on them directly is a pretty clever way of checking to see if an external brace is doing anything.

    Three types of braces were examined: Boston overlap brace, reclination brace, and a lumbotrain harness. Unsurprisingly, they found that “none of the braces studied were able to markedly reduce the loads” on the implants. There was some reduction — just not “marked,” nothing to write home about.

    More surprisingly, some of their measurements showed that bracing increased loading on the implants! That does seem possible. The spine is an extraordinarily dynamic structure. Somewhat like slouching into a comfortable chair, a brace may actually cause some sloppiness of spinal function, resulting in “resting” on the fixations, rather than using muscle to support and control the spine. That’s just a guess, but it seems like a reasonable one to me.

27. The world record in 2015 was Eddie “The Beast” Hall’s 463kg lift. That’s 1020 lbs for you Yanks.
28. Siewe 2011, op. cit. “The injury rate is low compared to other sports.” Not nonexistent, of course: “0.3 injuries per lifter per year,” or injury per thousand hours of training.
29. Kingma 2010, op. cit.