Are Good Body Mechanics Enough?

Whether assisting someone from a wheelchair to a mat table or the parallel bars, patient transfers are a routine part of all therapy interventions. But did you know that these transfers place a therapist at an extraordinary risk for work-related injury? Statistics show that caregivers engaging in manual patient lifting, transferring and repositioning activities beyond the 35-lb patient lifting maximum set by the National Institute of Occupational Safety and Health (NIOSH) have an injury rate on par with freight handlers and construction workers.^1,2 Work-related injury equals lost time from work or leaving the profession altogether.^2,3 In fact, it was the overwhelming amount of evidence showing the risk of these lifts that gave birth to the Safe Patient Handling and Mobility (SPHM) movement, advocating the use of powered lifts and transfer devices for patient care and intervention, seeking to eliminate all unnecessary and hazardous manual approaches. Although adopted by government funded organizations, the Veteran’s Administration, the Association of Rehabilitation Nurses and the American Physical Therapy Association and even with strong evidence showing its efficacy in preventing caregiver injury, safe patient handling has been slow to catch on among therapists. Most likely this stems from the three common misconceptions among therapists. Let’s take a closer look.

Three Safe Patient Handling Myths

1. Body Mechanics Will Protect You

In the past, physical therapy, occupational therapy and nursing schools focused on teaching manual lifting techniques. It was thought that regardless of the size, gender or physical strength of the care provider and the client, using good body mechanics and lifting techniques would prevent damaging musculoskeletal strain. This is false. Based on current biomechanical research we know that body mechanics alone cannot prevent work-related musculoskeletal disorders.

A landmark study by Marras and colleagues assessed the level of forces that resulted in damage to spinal tissues. They found that even with experienced caregivers performing common manual patient handling tasks such as a two-person transfer with a gait belt or a one-person “hug” transfer, the disc compression and shear forces in the spine routinely exceeded the tolerance limits.⁴ Therapists participating in therapeutic patient handling tasks such as prolonged gait training sessions are even more vulnerable because they are exposing their spinal tissues to high mechanical loads for longer periods of time.^5,6 A study by Daynard corroborated these findings, adding that when caregivers used safe patient handling devices, they reduced the peak spinal compression values during the transfers.⁷ And further studies underlined the benefits and injury-reducing properties of safe patient handling equipment as compared to manual lifting techniques.^8,9 This is not to say that body mechanics are no longer important; they certainly have their place. Maintaining proper body posture at all times is a good habit and therefore a supporting element of safe patient care. This is true especially when positioning and assisting patients into and out of the safe lifting devices.

2. Professional Knowledge Will Protect You

Therapists are notorious for ignoring their own health and safety when caring for and attending to a patient’s needs. What is more, they often believe, even if subconsciously, that extensive knowledge and skills in the prevention and treatment of musculoskeletal injuries will prevent injury while lifting or transferring a patient.¹⁰ But therapists are not immune. Surveys show that as many as 91% of all practicing therapists experience a work-related musculoskeletal injury sometime during their career.³ The leading injury is back pain -- an injury directly related to manual lifting and transfer techniques.^11,12 This results in one out of six therapists leaving the profession and many others changing work settings.^13,14

An interesting interview conducted by Campo in 2010 shows negative effects on productivity and patient care when therapists—with even the best intentions—choose to disregard their own health. Responses to interview questions asking about the quality of patient care in such a situation are revealing: “Sometimes you find yourself using or doing other things with the patients so you don’t have to transfer them,” or “I hate to admit it, but my 4-6 pm patients might be getting gypped.¹⁵” The impact on patient care because a therapist is in pain is a real concern because it can result in substandard intervention and decreased quality patient care. Clearly, although knowledge and expertise in the treatment of musculoskeletal problems is valuable, it is not enough to prevent injury to the therapist.^13,16,17 The best preventative measure for work-related injuries is the use of safe patient handling devices. Used for all patient lifts and transfers, the clinic becomes a safe and productive environment for both the therapist and patient.

3. Use of SPHM Techniques Is Not Consistent with Therapy Goals

Therapy intervention necessitates active patient participation for best recovery results and motor learning outcomes. Naturally there is reluctance to using mechanical lifting devices for transfers because of concerns that the equipment substitutes for skill development. However, safe patient handling studies suggest these fears are unfounded. In one of these proactive studies, a rehab department, prior to implementing a SPHM program, evaluated 47 patients at admission and discharge. Then, with the SPHM program in place, the department evaluated 47 additional patients. In all rehabilitation activities evaluated --  sit-to-stand transfers, toilet transfers, tub transfers, locomotion and stairs --  those in the safe patient handling group out-performed the others, demonstrating that safe patient handling programs do not impede functional outcomes but rather improve them.¹⁸ Further research supported these findings noting that safe patient handling and mobility programs also increase options for therapists as well as increasing the participation of the clients.^19,20,21

Then there is the research demonstrating that when in safe patient handling devices patients feel safer and more comfortable. In fact, one study cites lower levels of depression, improved urinary continence, higher engagement in activities, lower fall risk and higher levels of alertness during the day in those using safe patient handling equipment. As Joyce Julien, a physical therapist at St Elizabeth Healthcare in Kentucky, sums it up: “Therapists need to be open-minded towards SPHM. There was some hesitancy thinking that SPHM promotes dependency because everyone is lifted and we don’t do rehab. But with implementing the use of equipment, we found that patients feel safer being moved and we can go on with rehabilitation successfully.”

SPHM Makes all the Difference for a School District in Oregon

The success of High Desert Education Service District’s pilot safe patient handling program is a great example of how taking the first steps towards implementing change can produce amazing results in work-place safety. After noticing an alarmingly high injury rate among special education therapists performing manual transfers, this school district in Oregon managed an experimental SPHM program throughout their schools. This included mandating the use of Rifton TRAMs and other transfer devices for all patient lifts above 30 lbs. At the same, time they ran a before- and after-injury analysis with their workers’ compensation provider. The experiment paid off. Therapist injuries from student assisted transfers dropped to zero -- down from a seven per year average. The director of the study, Jill Barrett, commented that the pilot program turned out to be a win-win situation. The staff was happy using the mechanical lifts (and remaining injury free), the patients felt safer while being lifted and the parents of the students began looking for lifting devices for home use.

More and more rehab facilities—particularly larger ones—that have implemented safe patient handling programs are reaping additional benefits in the form of cost savings through decreased workers’ compensation claims and time away from work.^22,23,24,25

It is no wonder then that evidence-based SPHM policies are being integrated into rehab facilities, clinics, hospitals and schools. Across the country we’re seeing therapists recognizing the necessity of work-place safety and patient comfort and becoming instrumental in advocating for SPHM, creating safe lifting environments and providing equipment in every therapy practice setting.

Here are some good resources on safe patient handling and mobility:

• An Interview with Wendy Weaver, Executive Director of the Association of Safe Patient Handling Professionals
• A research article exploring the perceptions and practices among acute care physical therapists towards safe patient handling.
• Patient Transfer and Lifting Guidelines: Implications for Pediatric Physical Therapists

References

1. Waters TR. When is it safe to manually lift a patient? Am J Nurs. 2007;107(8):53-58.
2. Darragh AR, Huddleston W, King P. Work-related musculoskeletal injuries and disorders among occupational and physical therapists. Am J Occup Ther. 2009; 63(3):351-62.
3. Cromie JE, Robertson VJ, Best MO. Work-related musculoskeletal disorders in physical therapists: Prevalence, severity, risks, and responses. Phys Ther. 2000; 80(4):336-51.
4. Marras W, Davis K, Kirking B, Bertsche P. A comprehensive analysis of low-back disorder risk and spinal loading during the transferring and repositioning of patients using different techniques. Ergonomic. 1999;42(7):904-926.
5. Waters TR, Rockefeller K. Safe patient handling for rehabilitation professionals. Rehabil Nurs. 2010; 35(5):216-222.
6. Darragh AR, Campo M, King P. Work-related activities associated with injury in occupational and physical therapists. Work. 2012; 42(3):373-84.
7. Daynard D, Yassi A, Cooper JE, Tate R, Norman R, Wells R. Biomechanical analysis of peak and cumulative spinal loads during simulated patient–handling activities: a substudy of a randomized controlled trial to prevent lift and transfer injury of health care workers. Appl Ergon. 2001; 32(3):199-214.
8. Hignett S. Intervention strategies to reduce musculoskeletal injuries associated with handling patients: a systematic review. Occup Environ Med. 2003; 69(9):e6-e6.
9. Hignett S, Crumpton E, Ruszala S, Alexander P, Fray M, Fletcher B. Evidence-based patient handling: systematic review. Nurs Stand. 2003;17(33):33-6.
10. Cromie JE, Robertson VJ, Best MO. Work-related musculoskeletal disorders and the culture of physical therapy. Phys Ther. 2002; 82(5):459-72
11. Campo M, Weiser S, Koenig KL, Nordin M. Work-related musculoskeletal disorders in physical therapists: a Prospective cohort study with 1-year follow up. Phys Ther. 2008; 88(5); 608-19.
12. Holder NL, Clark HA, DiBlasio JM, et al. Cause, prevalence, and response to occupational musculoskeletal injuries reported by physical therapists and physical therapist assistants. PhysTher. 1999; 79(7):642-52.
13. West DJ, Gardner D. Occupational injuries of physiotherapists in North and Central Queensland. Aust J Physiotherapy. 2001; 47(3):179-86
14. Campo M, Weiser S, Koenig KL. Job strain in physical therapists. Phys Ther. 2009; 89(9):946-56.
15. Campo M, Darragh AR. Impact of work-related pain on physical therapists and occupational therapists. Phys Ther. 2010;90(6):905-920
16. Bork BE, Cook TM, Rosecrance JC, Engelhardt KA, Thomason MJ, Wauford IJ et al. Work related musculoskeletal disorders among physical therapists. Phys Ther. 1996;6(8):827-35.
17. Holder NL, Clark HA, DiBlasio JM, et al. Cause, prevalence, and response to occupational musculoskeletal injuries reported by physical therapists and physical therapist assistants. PhysTher. 1999; 79(7):642-52.
18. Arnold M, Campo M, Radaweic S, Wright L. Changes in Functional Independence Measure Ratings Associated with a Safe Patient Handling and Movement Program. Rehabil Nurs. 2011;36(4):138-44.
19. Campo M, Shiyko M, Margulis H, Darragh A. Effect of a Safe Patient Handling Program on Rehabilitation Outcomes. Arch Phys Med Rehabil. 2013;94(1):17-22.
20. Zhuang Z, Stobbe TJ, Collins JW, Hsiao H, Hobbs G. Psychophysical assessment of assistive devices for transferring patients/residents. Appl Ergon. 2000; 31(1):35-44.
21. Nelson A, Collins J, Siddharthan K, Matz M, Waters T. Link between Safe Patient Handling and Patient Outcomes in Long-Term Care. Rehabil Nurs. 2008; 33(1):33-43.
22. Garg, A. Long–term effectiveness of "Zero–Lift Program" in seven nursing homes and one hospital. 1999. Milwaukee, WI: University of Wisconsin–Milwaukee.
23. Evanoff B, Wolf L, Aton E, Canos J, Collins J. Reduction in injury rates in nursing personnel through introduction of mechanical lifts in the workplace. Am J Ind Med. 2003;44(5):451-57.
24. Stenger K, Montgomery LA, Briesemeister E. Creating a culture of change through implementation of a safe patient handling program. Critical Care Nursing Clinics of North America. 2007; 19(2):213-22.
25. Haglund K, Kyle J, Finkelstein M. Pediatric safe patient handling. J Ped Nurs. 2010; 25(2):98-107.