On this episode of Safety of Work, we discuss manual handling training and if it is an effective method.
We use the paper, What Constitutes Effective Manual Handling Training, in order to frame our discussion. The paper is a systematic review that looks at fifty three intervention studies performed over a number of years.
“The idea of having some sort of formalized weighting system, is it gets around the accusation of researcher bias.”
“There’s maybe something to say that some of that training was actually counter to the way that we now understand, maybe, that people can exert safe and maximal force.”
“If you do have residual risk leftover...person-task-fit is directly relevant around this residual risk…”
Drew: You’re listening to the Safety of Work Podcast episode 29. Today, we’re asking the question, does manual handling training work? Let’s get started.
Hey, everybody. My name is Drew Rae and I’m here with Dave Provan. We’re from the Safety Science Innovation Lab at Griffith University. Welcome to the Safety of Work Podcast. If this is your first time listening, then thanks for coming. If this is not your first time listening, then thanks for coming back. The podcast is produced every week, released on a Monday, and the show notes can be found at safetyofwork.com. In each episode, we ask an important question in relation to the safety of work or the work of safety, and examine the evidence surrounding it. So David, what’s today’s question?
David: Today’s question is, does manual handling training work? We thought we’ve done some roundabout sort of episodes over the last five or six and dealt with some really big topics like the effectiveness of teams and theories of graceful extensibility. So, we thought this week we would come back and do something that was a bit more transactional in the sense of a direct workplace intervention and the impact it had on improving the capacity of people to perform a task or two, reduce of getting hurt.
Let’s start with a bit of background. The training itself is (I think) a cornerstone of company safety programs. We do a lot of safety-related training in the workplace and we have done that for decades. We’ve done some previous episodes on training, Drew. Episode 18 on PowerPoint slides, episode 19 on virtual reality training, and by the way, I have an update, Drew. I’m now the proud owner of a VR headset. I cashed in some of my frequent flyer points when it looked like all of the airlines we were going to go broke and bought myself a VR headset. I’ve now got some practical experience to go alongside the theory of virtual reality.
Drew: So, is this an opportunity to carefully test out safety training or an opportunity to play Counter-Strike with full visuals?
David: It’s an opportunity to keep trying to better my time on the street luge at the moment. It does take video gaming to a whole new level, I must admit. The kids love it.
Drew: I actually had VR suggested to me as a possible way of coping with the lockdown. The idea is to put the noise-canceling headphones on, the VR headset on, and just disappear to a space which is not the study.
David: I did see someone on LinkedIn comment that they were sending their school children off on virtual excursions to Antarctica and making them write reports of what they’ve seen. I was looking at all the different experiences that you can download for your VR headset and if the isolation goes on for too much longer I might be doing that.
Drew: So today, we’re not so much talking about virtual training but very physical training. Do you want to tell us a little bit more about the different types of manual handling training that are available?
David: Yes. Let’s talk about training more broadly before we do it. I think in relation to safety, we can broadly talk about two different types of training: vocational training and safety training. Vocational training is training in how to perform a task that your work or job requires, and then safety training is specifically about how to identify, manage the safety risk that might or might not be associated with your task or your work environment.
When we talk about safety training, there are also two types of safety training—we’ll talk about this throughout the paper that we review today—being educational and technique. When we think about manual handling training, you can have educational manual handling training where you sit people in a room and tell them about manual handling, or you can have technique-based manual handling training which is like the typical original intervention where you get a group of people in a room and let it run practice lifting a box by bending their knees. So, education- and technique-based training.
Drew: So David, educational training would be like when I was first working for a department store where they sit you down in a training room and here is a video of someone lifting a box, here is how to place your knees, and here’s how to keep your back straight. Then the other type is where you’re actually lifting the box and have someone correct you when you do it incorrectly.
David: Yeah. I must admit I haven’t been involved in these types of interventions for a long time, but early on in my career, that’s exactly the sort of training programs that I was coordinating in the workplace that I was in.
Drew, when we talk about training and training interventions, do you want to give us a bit of an idea about how we should think about studying and researching training and training interventions for safety?
Drew: Sure. I’m actually grabbing stuff that is directly out of the paper that we’re going to study today. They give some quite good guidelines on what makes a good training intervention study. The first big one is just having some sort of control group. You need to know the difference between are you just measuring people’s capability or are you measuring a difference you’ve made through the training.
The second big one is having some sort of follow-up. What people can do immediately after the training isn’t particularly relevant. That’s not why we train people. We have trained them for the hour after they’ve been trained. We train them for ongoing workplace practices, so to evaluate training you’ve really got to come back and see what people are doing in six months’ time, and ideally what injuries have people experienced over that time. If you get those two key things in and then you report everything else clearly, you’ve got the basics of a good evaluation.
David: Thanks, Drew. That’s how I think about training, whether it’s manual handling or not. Now, when we think about manual handling and the background to that, manual handling is a big problem in the workplace. Often, we might be talking more about major accident events and fatality risks than other occupational injuries, like muscle strains caused by manual handling or slips, trips, and falls.
I just want to point out that not for a minute do I think that we shouldn’t be researching, investing, and trying to solve these problems. Particularly, some of these incidents that are the result of manual handling incidents, they are permanently disabling for people. I think it’s the number one cause of workers’ compensation claims over the last 20 years in almost all countries with a compensation system.
I think anyone or any of our listeners with a bad back, bad shoulder, or a bad knee would absolutely agree that sometimes we can’t dismiss these types of injuries in favor of major accident events, but it’s really an end-proposition, not an all-proposition when it comes to health and safety.
Drew: Yes. There’s none fair stereotype that links pain-type injuries almost with malingering. There are people who are permanently on workers’ compensation, but the reality is that these are injuries that do leave people for six months, a year, possibly never returning back to their original job. Often, these are good workers. These are the people who are working really hard at the workplace, that we want to keep them making a contribution. They want to be at work but just the pain alone, forget about your physical disability is disabling.
David: I’m sure that, as I mentioned earlier, we’ve all been involved in manual handling training at some point. Now, [...] participating in it, I personally have arranged several of these types of sessions. I’m not sure what these programs look like today. I haven’t been involved in recent years, but I’ve been an absolute staple of our programs for decades manual handling training in the workplace. Let’s see what the research says about these interventions. Do you want to introduce the paper for today, Drew?
Drew: Okay. The paper is titled, What constitutes effective manual handling training? A systematic review. The paper was published in 2010 in the Journal of Occupational Medicine. This is a good journal that’s focused on the medical side of safety as opposed to safety management and [...] in prevention. The research was funded by the UK Health and Safety Executive. The authors are Stacy Clemes, Cheryl Haslam, and Roger Haslam. They were all from the Work & Health Research Centre at Loughborough University in the UK.
No red flags in the background of the paper, good group, reasonable funders, reasonable place to publish it. The paper is a systematic review. It looks at 53 intervention studies published between 1980 and 2009.
David: So Drew, the systematic review, they searched multiple databases. Just for people’s understanding, I think we’ve spoken about a number of systematic reviews on the podcast, but they selected their databases and they had a whole string of search words, like manual handling, training, lifting, effectiveness, reduction in injuries, et cetera, and they pulled out a total of 1827 papers. They then narrowed that down to 221.
To do that, you first get a search result, then you have a quick look at the abstract, and then you have a criteria by which you are trying to select your study. Here, they wanted the primary aim of the paper to be about the effectiveness of manual handling training and they want an intervention study. So, that narrowed it down to 221. Once they went into all of those papers, they ended up with 53 papers that met that criteria.
On the first pass, 53 intervention research papers over 30 years on a very specific topic like manual handling training intervention seems like a good body of literature, Drew?
Drew: It’s certainly not a topic that has been ignored. As listeners may know from other times we’ve looked at systematic reviews, coming up with something that has been reviewed that many times is good. Even better is the fact that these are not old, rubbish studies. Some of them are really quite good both in terms of their method and in terms of their size.
David: One of the things we haven’t talked about on the podcast yet is when you end up with these 53 papers, not all studies are created equal; they’re not all of the same quality. What I liked in this study—we haven’t spoken about it yet on the podcast—was that they applied a quality checklist to each of the studies. The quality checklist was a standard research quality checklist (I suppose if you like), had 27 items, and added a few extra ones. What they did is they just applied this checklist to each of the papers.
For example, they would check questions like the sample size, the representativeness of the sample, whether confounding variables were identified, whether there was a control group, whether there was a follow-up period of the study. All of these items to try to categorize each of the 53 studies into quality categories.
Drew, I don’t see this too often in safety literature of use, but for me, it was really important. If you start making claims in your literature review based on one or two papers, you want to make sure that there are one or two good papers that you’re making that claim about.
Drew: Yes, and then the idea of having some formalized waiting system is it gets round the accusation of research bias. It’s not their opinion, or at least not their unfiltered or unstructured opinion, that one paper is better than another. They can point back to the scoring criteria and say, “Look. Several researches all apply the same criteria. We all got to the same score. It’s official that this paper is better than that paper, at least as far as the quality of evidence that it provides.”
There are a few different ways you can set up these scoring systems. This particular one really weighs up two things: how well did you evaluate the manual handling training, and how clearly did you write up the paper afterward to describe precisely what it was that you did both in terms of the training and in terms of how you evaluated it. So, it gives points for all sorts of things that you’d expect to make it a better paper.
There are points for did they use a control group. There are points for how many participants they’ve used. There are points for whether they did follow-up measurements. There are points for clearly describing how people were selected for the study. One thing I like about these sorts of questions is that they’re a bit less rigid than some of the ways that often get used to weight papers, that tend to be overly dogmatic about particular ways of designing your study.
One thing that happens in a lot of reviews, for example, is they say that anything that’s got a pre- and post-measure, scores higher than anything that’s only got a post-measure. It ignores the fact that there might be really good reasons why you’ve only measured people afterward instead of beforehand. In the case of manual handling training, obviously you’re checking out how good someone is at lifting before they do the training, is going to really distort your results because even that measurement is like a form of training.
The downside of this point system is that even a bad study can still collect a reasonable number of points just by ticking enough of the boxes even if they’re not the most important ones. It’s a pretty weak study and they still got reasonable scores. I think it’s really good at separating out the really good papers and the really bad papers and the middle of the scores don’t really mean a lot.
David: Yes. I think we spend a bit of time on this, but I think it’s a good part of the research methods that’s worth just understanding or at least an understanding. The scoring system they put into percentage, so these 53 intervention papers got scored between 31% and 84%. That's a big discrepancy in terms of the quality of research. This was all limited to peer review academic published papers.
With this in mind, papers that score between 0% and 49% would be described as poor, and as you mentioned, some of those criteria typically had a small sample size, no control group, and no follow-up. In papers between 50% and 59% were described as medium quality, and then 60%–69% were described as good quality. Then, there were some papers that scored over 70% that the authors described as high quality. These papers typically contain large samples, randomization of participants into either an intervention or control group, a sufficient duration of the intervention period, and a follow-up assessment which makes it a fairly rigorous study.
Drew: Yeah, I pretty much said that anything that didn’t get above 70% had something wrong with it, that it was seriously flawed, and really should be discounted as evidence. I think we’re lucky, though, because after we’ve gone through those 53 papers we’re still left with enough papers that we can draw conclusions, which is a pleasant surprise given some of the systematic reviews that we’ve looked at.
David: In the note, Drew, you’ve got 6 with exclamation marks, so 6 out of 53 studies are, in your words, “not seriously flawed.”
Drew: Yeah but that’s a good six.
David: That’s a good six. I suppose if you are doing manual handling training intervention research, having a decent sample, randomizing your participants, having a sufficient period of intervention, and a follow-up assessment are the fundamental building blocks of your research. Six out of 53 is probably not a great result there for the academic community.
Drew: Yeah, and if you think we’re being overly harsh here, we’re talking here about studies that had two participants are included in that 40%–49% bracket.
David: Drew, let’s go in. There are some interesting findings here and we do have a fairly about as relatively straightforward a topic as we get in safety. Like I said, each of these 53 papers had the primary aim of investigating the effectiveness of manual handling training. They categorized the papers into subgroups of findings.
The first subgroup was specifically research that was dealing with manual handling in the healthcare sector and was particularly research with nurses who are exposed to high levels of patient handling. We know that the nursing occupation and patient handling has a long history of manual handling risks and challenges. It was scary when you read some of the background to this that the rate of prevalence of back pain in the nursing population is 50% every year. One in two nurses suffers an injury and back pain every year. The lifetime prevalence is up to like 80%. So, a huge opportunity to make that work safer for the nurses.
The studies that were reviewed in this review basically concluded that there is very little evidence that education-based training improves safe patient handling. Now, that was both whether you trained the nurses during nursing school before they ever went to work as a nurse, or whether you gave the training to qualified staff who are already in the workplace. Basically, no evidence that training is having an impact on reducing the risk of manual handling injury.
Drew: I want to throw in a little bit of nuance here because this is the group that had the largest number of high-quality studies. Of the ones that dealt specifically with patient handling, there were five high-quality studies. Three of those did report positive results. They said the training was effective. But when we look closer at what was effective, it’s not giving people education.
One of the studies included both a calisthenics program and an education component, and they didn’t sort of separate those out. They said that the combination of the two was effective. Another one of them was about comparing an exercise program to a training component. The positive result was that the exercise program was better than training.
The third one involved 35 hours worth of on-site visits by an ergonomist. The ergonomist was doing all sorts of things. They were helping with selecting equipment. They are providing some training, they are providing some redesign of the workplace. That was effective, but again, it’s really not clear which part of all of those many things that they were doing caused the effectiveness.
There were two good studies that just directly tested training. They’re not just two hours of training. One of them was an hour a week over two years. Those ones found that there was no benefit to the training.
David: I appreciate you going digging up those references and you’ve done that for each of the findings. That’s a big study to design and that’s a big commitment from an organization to do an hour a week of manual handling training for two years and not to receive benefits. I suppose that starts to maybe answer our question for the week, but let’s keep going.
Their next subgroup included studies in non-healthcare personnel. These are the studies where we’re not in the healthcare sector. The goal of the study was actually to improve manual handling training. These were generally low quality. Many of the low quality or poor quality studies fit into this group, where there was no control group, there was no follow-up, it wasn’t necessarily pre-post. Even in this group of papers, there was little evidence for the effectiveness of training.
There was a further finding in this subgroup that the principles taught during training are not carried over into the work environment. I’m interested in your views on this because maybe is it that the training is ineffective or is it that the training doesn’t result in changes to the way people work which doesn’t make it effective?
Drew: I’ve done a little bit of reading around this and it seems to be almost at every point, manual handling training doesn’t tend to change the way people actually lift things. There are quite a few studies that say that even if the training did actually cause people to change the way they lifted, that traditional training of ‘you keep your back straight, lift from the knees’ doesn’t actually result in lifting techniques that reduce your chance of injury.
David: Yeah, I must admit I’ve done a little bit of gym throughout my life and I know that going back well over 10 years there was always that in the gym, that was always told to keep your head up and lift with a straight back. I know that that’s changed over the last decade where it’s actually no, you’re far better off lifting and moving with what they call the natural curvature of your spine and not hyper-extending your back or your neck and things like that when you’re lifting heavy equipment. Maybe something to say that some of that training was actually accounted to the way that we now understand (maybe) that people can exert safe and maximal force.
Drew: Also, a lot of the things that people are trying to lift a nice, neat parcel sitting flat on the floor between their knees that facilitate following exactly what the diagram in the video says.
David: Yeah. So, that was interesting, but again, we’ve got a group of studies in non-healthcare that’s concluding that training doesn’t change the way people work and it doesn’t change their risk of manual handling injuries.
The next subgroup involves studies that investigated the effectiveness of physical training to improve the capabilities for manual handling. This was based on an earlier research finding that proposed that in this piece of research, it said that most manual handling injuries result from a mismatch between a worker’s strength and their job requirements. They’re affording studies in this group are all but one was relatively short interventions of equal to or less than six weeks. Basically, you get a group of people, you give them calisthenics, flexibility, strength, or gym training for 4–6 weeks and assess their capacity to perform the manual handling exercises they need to on the job.
There was one high-quality longer study and the research concluded a beneficial effect of exercise training for improving people’s physical capacity to perform the manual handling tasks in their work, but there was a pretty strong limitation on this research in the paper that it hasn’t been thoroughly tested in the workplace setting. A lot of these research papers were using university students and people who put their hands up and volunteered for six weeks of going to the gym for a research study. We also don’t know how long the effects last following the discontinuation of training. We don’t have many studies that have tried this in the workplace over longer durations.
Drew: We don’t have that direct evidence, but remember the reason why they were separating this out is that some of the other long-term studies did seem to show that if there was a benefit, the benefit was coming from that exercise and conditioning portion. For example, there was a high-quality study that mixed education with calisthenics.
David: We’ve got 53 manual handling training intervention studies. Six of those are good, high-quality research papers. We’ve got three groups of findings. We’ve got the healthcare sector which has said don’t really bother training your nurses to reduce the risk of manual handling injuries. We’ve for the study in the non-healthcare setting which concludes the same and extends that to say that people aren’t going to take what you give them in educational training and change the way they work. And then, you got his third group of papers which say there might be some benefit from improving the strength flexibility capacity of people to be able to perform the manual handling task they have to perform.
In the first two sentences of the conclusion, the paper states, “This systematic review found that manual handling training is largely ineffective in reducing back pain and back injury. Furthermore, there is considerable evidence supporting the idea that the principals learned during training is not applied in the working environment.”
Drew, both technique- and education-based manual handling training, telling someone what you think they should do in a classroom or even showing them how to lift or move something in a classroom is unlikely to have any effect on their work performance or their injuries.
Drew: I feel like we need to have an audio version of that MythBusters busted logo coming slamming on to the screen here. I do want to caution that pretty much all of these studies confirm the fact that this is a real genuine problem that organizations are trying to solve by introducing the training. The type of training that’s covered in these studies ranges a lot and it certainly doesn’t seem to be the case that just two hours of training doesn’t work, put in place a bigger program. Even the bigger programs didn’t have increased effectiveness.
What makes the difference is either moving in the strength and conditioning direction or moving in combining the training with actual workplace redesign and selection of equipment, to assist and reduce the amount of manual handling.
David: I think it’s that’s a great segue into our practical takeaways because, like you said, it is a problem for organizations. They should invest and they do invest in trying to do something about it. The paper does make some suggestions. The paper suggests taking the money—basically what my summary of what the papers suggest—you’re spending on your manual handling training, and basically invest it in equipment and job redesign.
This paper’s 10 years old. If you do go into a hospital these days—although with COVID-19 I sure hope that listeners don’t have to visit a hospital—you will see over the last 10 years a lot of investment that’s gone into a patient lifting aids, the design of beds, the design of wards to really try to minimize and assist our patient handling in the healthcare setting. I think we’re probably saying since this paper was published 10 years ago, we’ve probably seen organizations adapt the way that they’re thinking about managing the recent manual handling, and if you haven’t then now is a good opportunity to refocus yourself a little bit further up the hierarchy of controls.
Drew: Yeah. I think there are some really good practices that involve ergonomists coming to the site and spending time walking around with people, looking at the types of tasks they do, looking at where things get lifted, and basically going through that. Can we remove the need for this task? Can we reposition the stuff that needs to get frequently lifted? Can we, where we have to label things clearly as requiring multiple people to lift or requiring special care in lifting? That combination of raising awareness about lifting at the same time as you do practical things to reduce the need for lifting and make lifting easier does seem to be the way that this is moving.
David: So, if you do have your residual risk leftover when you’ve taken those opportunities to redesign the work process and redesign or provide lifting aides and equipment, person task fit is directly relevant to around this residual risk. For those in your workforce who are inclined toward strength-based exercise training, then rather than sending you people off on training, subsidize that new membership and you’ll probably get a better risk outcome when it comes to manual handling.
Drew: I think you’ll certainly get a more positive response from your staff to your safety spending.
David: Yeah. Drew, how about an invitation to our listeners? You’ve got some ideas here, things that you’d be interested in from our listeners?
Drew: Okay. We had a fairly straightforward question this week and we got fairly straightforward listeners coming out of it. Do you at your workplace have any sort of manual handling training? What does it look like? Both David and I think we’ve shown through this episode our knowledge of exactly what organizations are doing is not fully up to date. This research is surveying a very old school approach. What are you doing now for manual handling? How much does it match that old ‘educate people how lift’ or what innovations does it have? Do you have any exercise or fitness program at your work?
Lots of organizations have got sort of general fitness, but do you have anything specifically targeted at fitness for work, at building people’s capability to do the work that you’re giving them? Where are you doing training of any sort? How do you evaluate it? How do you measure it? How do you know it’s working?
David: The question for this week was, does manual handling training work? Do you want to have a go at the answer?
Drew: Nope, it doesn’t.
David: There you go. That’s it for this week. We really hope you found this episode thought-provoking and ultimately useful in checking the safety of work in your own organization. Please leave us a review; it really helps people find the podcast. And send any comments, questions, or ideas for future episodes to us at firstname.lastname@example.org.