Lumbar flexion is bad when lifting or at least we must always keep our back in extension when lifting is the simple blanket statement used. --I think this was brought about 20+ years ago when manual handling took off in the workplace---The idea here is if we keep our back in neutral or extended positions, we will avoid unwanted compression and shear forces on our spines, and this will mitigate injury.
My theory is we must allow people to bend their lower back (or lift how it is comfortable to them) as they will become exposed and habituate and make their back stronger over time ---the problem here is some people get too caught up in lumbar extended positions and using their legs only instead of their back --this makes their back weaker not stronger and actually more susceptible to injury when they might on occasion forget to lumbar extend and bend to pick up something in a awkward position: In most studies people who are trying to extend their lumbar spines when lifting are still in 25-30 degrees of lumbar flexion anyway. (Some can’t even get into neutral anatomically). The neutral spine (which is debatable in itself) allows for some load reduction or reduced compression and/or shear forces on the spine, but it is not that significant I believe, and these studies were all done on dead animal vertebrae meaning these spines could not adapt to the forces placed on them. This assumes load is bad. 100lbs load on the spine is not bad for the spine but it may be if we do it right off the bat on day one of lifting as people have not been exposed and are underprepared, but this does not mean it should be off limits forever. Therefore, I do not teach “neutral spine". This is an outdated cue that was designed to prevent or mitigate load and therefore injury on our spines. Neutral is a range, not a single position for all athletes/people in all lifts. Some elite powerlifters demonstrate gross lumbar flexed position in some instances, this may be due to how tall they are, or their hip range of motion ranges however lumbar flexed positions can bring the load closer to the body by excessively flexing at the lower spine, by bringing the load closer you are making the movement more efficient as the object is closer to your centre of gravity, but some would advocate this is now dangerous due to the excessive lumbar flexed position. However, if the lifter had done these lifts and is adequately prepared, he/she should be safe. Sometimes however even with all this knowledge injury can still happen. Another common thing is that lifting and load is always blamed as the culprit in injury but I cannot tell you how many times people have said to me in clinic, “I was only tying my shoe lace “or “I was only picking up something off the floor when my back went” “I was just getting up out of the chair”---there is more to back pain than just force and how we lift something.
The same with lifting load away from the spine with long lever. Short lever lifts are the most efficient (achieving maximum productivity with minimum wasted effort or expense) way to move product/objects but sometimes we need to do longer lever lifts depending on our environment. These do add more load and more load too quick to an underprepared tendon muscle can result in injury.
However, we are not robots and we must get into awkward positions at times so to counteract this perhaps we should be training in these positions low loads first and building up slowly. I am not advocating to this this all the time as it is not efficient but maybe doing it sometimes to build up a tolerance would reduce injury more as opposed to avoiding these positions all the time.
Statements like "never use your back" and "always use your legs" and "never flex your lower spine" needs to be revisited
Constantly avoiding lumbar flexion and other spinal positions under load is not only very limiting but it is not even practical, possible or sensible and can induce excessive protective and avoidance behaviors to a pretty robust and adaptable structure not to mention the self blame and finger pointing some people do when injury does happen. This type of ego has no place in the physiotherapy or medical world as our whole knowledge base is based on current theories and beliefs which can change at any moment and to say injury happens form poor lifting technique alone is just not valid as injuries are multifactorial.
New ideas would be to limit long levers (which is essentially reducing the load) keep neutral wrist positions and keep the back in neutral ranges (ie not excessively flexing or not excessively extending)initially but to gradually encourage more long levers movements, back flexed and wrist radial and ulnar deviated positions over time. This assumes people are robust and adaptable. Obviously, people with fractures or true disc herniations may not adapt and they need surgery. Nothing is that simple but they are the exception the rule.
We are demonizing these movements but really, we can do these movements but when we do them, we are underprepared sometimes resulting in injury (of course along with other factors) so we advise to limit or avoid them altogether.
I understand not many people have time to prepare for these movements before starting heavy laborious work so cross over and adherence would be hard, but if you are in a warehouse job maybe we could build up slowly while at work. Some back pain is because of too much keeping in neutral or perceived lumbar extended positions. People can become sensitized from doing the same movement repetitively. Its a bit like telling someone after a posterior lateral disc herniation to avoid flexion (this is a good idea if it is painful initially) but never telling the person that it is okay to now bend and flex once the initial insult starts to settle is detrimental to some and creates fear avoidance behaviors and catastrophizing in some. This is where our critical reasoning must come in.
Think about sitting posture --- would I tell someone to sit in a sloughed position all day long ---no, would I tell someone to sit in a lumbar extended neutral spine position all day long—no, so why are we still teaching to always avoid lumbar flexed positions in manual handling training? It is really working? Have back injuries in the workplace declined since manual handling was introduced? I personally don’t think so because it is more complex than we think. Their age ability, stress, capacity, capability, confidence, experience and exposure are all factors too.
Maybe we teach these things and adherence is poor, maybe how the training is conducted is poor, maybe it is poor advice in the first place or maybe we struggle to determine who is injury prone. Back pain is multifactorial and not easily solved by asking people to pick things up in a certain way.
Telling someone to keep their hand in a fist all day long, kind of like telling someone to keep their lower back in an extended position all day long when lifting is poor advice as the same position can make our back sensitive and even painful --motion is lotion, variety is the spice of life.
Your best posture is your next posture--perhaps avoiding excessive lumbar flexion and excessive lumbar extended positions (even when we are in what we think is lumbar extended positions we are still flexed 25-30 degrees) is wise when initially beginning to lift but they should never be off limits all the time especially if they are needed to complete a task or patient goal --encourage adaptability by moving into these postures --this can be difficult to implement in a ware house setting as most companies are after quicks performance KPI in the form of moving product quickly which means making more money for the company and we know too much load too quick leads to muscle under preparedness and this is one reason why back injuries' re still occurring not to mention poor motivation and stress of these jobs especially after the new skills have been learnt. Lack of fun and a bigger self purpose in life might also be considerable factors in lower back injury in t these work settings.
How long does it take to expose and adapt ??? I don't know and everyone is different
Final points---
1
Injuries are not always solely related to how we lift something --it can be due to lack of sleep, stress, previous back injuries, genetics, beliefs etc.,
2
Perhaps lifting with both our back and legs and having more variety in how we lift lumbar extended or lumbar flexed positions is okay—too much of any one posture is probably not good.
3
Always telling people to lift with their knees and never with their back is a bit of a blanket statement and this may cause the person to be more protective of their spines and hyper focused on these positions causing excessive bracing and sensitization of their back.
4 There is massive variety in the human body, we learn to lift things when we are 2 years old, the is called implicit motor learning, explicit motor learning is where new knowledge is needed to acquire a new skill and then learn a new motor pattern.
It is my belief that most people have a natural innate ability to lift an object from the ground safely.
Combining implicit and explicit learning one could observe someone lifting an item form the ground and be okay with lumbar flexed positions. The main thing is to lift the item close to your Centre of gravity and perhaps not go into excessive lumbar flexed positions when preparing to lift and to build up slowly.
If we avoid using our back and avoid lumbar flexion we will not adapt and we will become prone to injury when lifting I believe.
There are of course times where we must avoid lumbar flexion and/or extension if these movements are painful in the term and then slowly build our tolerance to these movements again.
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