Lifting restrictions

[Jon Newman]

I'd like to explore the concept of lifting restrictions for people with any variety of pain complaints. Is there a "go to" study that delineates this sort of thing? Is it something that MDs essentially make up, using tradition as a guideline?

I'm aware (but not knowledgeable) of some of the ergonomic assessments PTs offer. Do these determine some sort of physiological/structural limits or simply define what people are currently capable of lifting?

I'm especially interested in studies that suggest "don't lift x amount under y conditions."

Thanks.

[EricM]

Jon, in my experience when a physician places a 'do not lift more than...' sort of restriction it is most frequently based on what the patient tells them they can't lift, and is not in reference to structural failure limits of any tissue. As such physician imposed limits are not particularly helpful, in most cases.

[Jon Newman]

For all you direct access folks: are you in a position to "prescribe" such restrictions or is that still in the realm of MD for some reason?

It seems like an arbitrary act done for liability protection more than biological evidence. If we were in a position of prescribing restrictions would we want to do it?

Some workers may need some relief from their usual job description and lifting restrictions are one way to make that happen. Is there a different way? A better way?

[EricM]

In the insurance game, ideally MD's should comment on risk(restriction), PT/OT's on capacity, and the patient is allowed their say with respect to tolerance. How I'd hate to be an insurance adjudicator.

[Adiemusfree]

This is a wonderfully vexed question! I was a safe handling advisor for a couple of years, and have worked in the accident insurance field, so I recognise the challenges! My specialty field is work rehabilitation, so it's definitely an area I'm comfortable with spouting on about.

My take? Given that there is little if any evidence suggesting that manual handling directly 'causes' low back pain, even less to demonstrate that 'safe handling' (especially based on reducing loads) has had any effect on the prevalence of acute low back pain, and most of us use a range of sloppy methods to do our own lifting, I can't see any rational way to determine lifting limits.
I've personally based my recommendations on the following:
- control of the load (if the person drops the load they could hurt themselves, their coworker - or the load!)
- recruitment of secondary muscle groups (leading to fatigue, which will more quickly lead to loss of control of the load)
- the environment in which the person is lifting
- the characteristics of the load (is it precious? is it human? does it wriggle? is it an awkward shape?)
- the psychosocial characteristics of the person - stress? distraction? attitudes?
- does carrying out the task increase the heart rate beyond what is an acceptable level?
- how long/how often is the person carrying out the task?
- in what positions is the person lifting?

It's simply unhelpful for a doctor to state 'no heavy lifting' without defining what 'heavy' means, and which positions are unsafe!

Pain itself is insufficient to provide grounds for restricting manual handling - it's the effect of pain on fatigue, concentration etc that should be used.
We also have to consider the effect of prescribing restrictions: what does the patient learn? When does it get reviewed? What else is the person to do at work?

So, I think it should not be done without a visit to the workplace, a thorough functional assessment of the person, and ongoing review.
There are some references - I can't recall them at the moment, but I'll do some digging around.

[nari]

From a direct access folksperson, the recommendations handed out by the docs seem fairly arbitrary and generic; PTs do give prescriptions and recommendations, but the OTs seem to have the field well in hand.
We as PTs are bound to manual handling training each year, done by OccHealth&Safety guidelines, but often don't agree with the excessive and unrealistic cautioning handed out.
The recommendations are based more on the patient's current situation, ie, avoid aggravating the pain, stop for a few moments, breathe, continue, etc.

Every person, male or female, has different abilities re lifting, with or without pain present.
-When someone worked this out, the weight limitations were cancelled, just warnings put around the workplace.

Pain is not a total restriction, but exercise induced thoracic and/or chestwall pain has to be differentiated from cardiac. That isn't always accurately done.

If a PT isn't sure about limits of lifting, the OH&S folk are consulted. There are usually specialised PTs and OTs there. We would not ever ask the GP.

Nari

[Jason Silvernail]

I give work restrictions through the US Army, and they usually have a lifting restriction associated with them. This is always a general number, designed to limit overall capacity, and not specifically aimed at any structure. I can't recall a restriction placed by my colleagues in medicine as based on any specific rationale other than that, either for what that's worth.

[Bas Asselbergs]

Yep, we give the restrictions most of the time. We are easier accessed than most doctors and even Workers' Comp accepts our restrictions. There are very few OTs here....
No specific standards that I know of: these things are more based on what the PT observes, the job demands inventory (I used to ask for those) and the timeline of the injury (expected rate of tissue repair etc etc, conditioning). I do much less of that these days. Changing practitioner and changing caseload....

[Jon Newman]

Usually the act of placing lifting restrictions comes from an explicit or implicit desire of the patient to get relief, usually temporary, from their current job description because of their pain. How much of this decision is put to the patient in terms of exact job duties, time frames, etc? I'm assuming the answer is that while the patient chats with the MD (or PT) the answer is "not much." Does the patient have an exit strategy going into this battle? Do they even have a battle plan? What "intel" are they using to create these strategies?

I'm not so naive that I don't realize that the manner in which work is accomplished in many many jobs result in a very small degree of variation from some standard. (Although I think it is much wider than initial impressions might indicate.) Being a PT, most of the literature I come across focuses on medical solutions. How is the business world trying to solve the problem of the painful worker? Are they still under the impression that the solution is better ergonomics? Are the workers?

[Adiemusfree]

Is the business world even worried about workers who are in pain?
I think the bottom line is that some employers are only concerned about manual handling restrictions in terms of whether it limits their H&S liability.
If a worker gets given a list of restrictions, it makes it a whole lot easier for the employer to say 'but we don't have light duties'.
If a worker doesn't like their job, thinks their employer is unfair etc, the restrictions will confirm that s/he 'shouldn't' return to that job. If they have a biomedical focus, they'll also tend to use it as justification for remaining inactive 'the physio/OT/Doctor/Health nurse said I shouldn't...'

In the H&S model, which is primarily based on OSHA, NIOSH and 'ergonomic' principles based on levers and strain, the 'solutions' are to restrict lifting, lighten the load, train the workers to use lifting devices or 'safe lifting' methods, and insert gadgets or equipment. In business this means employers either pay for machines and training, or they get lumbered with a fine/sued if someone gets hurt.

Sorry to sound so cynical, but I spent four years hammering the message in industry that most ALBP gets better quickly on its own, isn't directly caused by lifting, and more training is NOT the answer, and made not one jot of difference! Employers and H&S systems are set up to follow the orthodox message that 'people shouldn't lift' because 'lifting causes back injury' - and the reality is that in many workplaces it's impossible to avoid manual handling (ever tried moving a 40 gallon barrel of paint without heaving, shoving or pushing? or a 25kg sack of cement? or install a heat pump into the roofspace without climbing up a ladder carrying a 25 kg pump?!)

One study by Hazard many years ago (can't remember the exact reference, it was in the 1980's) found that giving restrictions on RTW slowed the pace of RTW, while not giving them increased the pace of RTW and there were no differences in terms of reported disability and pain intensity at the end of the study! So do we do our patients any benefits by giving restrictions?

[Bas Asselbergs]

Not cynical at all, Bronnie. I call that realistic.
I am sure that RTW restrictions are not useful for all injured people in any job; however, there are injured people with significant issues who do require some careful guidance to help them become more tolerant of the loads required.
Over all though, I am tempted to say that that particular group is small.....

[Adiemusfree]

Thanks for that reassurance - sometimes I get a little bit intolerant - emphasis on the rant!
I wonder whether the guidance needs to be in terms of what to do, what not to do, or whether it's more around thoughts/beliefs/behaviours/relationships at work.
eg if someone finds it difficult to tolerate doing some aspect of their job, is it better to delay them doing it, or is it more more helpful to work through
- what their beliefs are about that activity (in reln to hurt vs harm for example?),
- help them communicate their desire/need to do it differently to their supervisor/coworkers,
- keep a lid on coworkers reactions to 'someone being allowed to get away with doing less',
- deal with their family when they get home feeling tired

I wonder who does do these things - it used to be part of my job, but I'm not so sure that all return to work providers do this. From some of what I've seen some do little more than specify the tasks the person should not do and then leave them to it, gradually increasing the intensity of the work almost without consultation with the person (or the workplace).
What do others see?

And what do you make of the 'gadget queen' syndrome - people who have loads of 'let's make it easy' devices at work - like the 'ergonomic' chair, desk, keyboard, handling trolley etc etc

[BB]

Great and timely conversation for me. This is currently what I spend a lot of my week working on and thinking about.

I provide on-site services to a paper mill and I'm still working on figuring out my role and solidifying it in the workplace in as useful a way as possible.

There is definitely still a strong ergonomic focus in the workplace. Also, I see huge culture problems that I feel physicians sometimes use lifting restrictions and close control as a means to ensure that their patients aren't wrongly fired.

[Jon Newman]

I just found this: Psychologists are working on their weakness. Starters to your marks...

(Hat tip: BPS Research Digest)

[lakeab]

I used to laugh to myself when I heard surgeons tell their patients they aren't able to lift more than 10 lbs. I'm pretty sure they were exerting more energy than that everytime they got out of bed or a chair.