Background and aims
To systemically review the literature to compare freestyle lifting technique, by muscle activity and kinematics, between people with and without low back pain (LBP).
Five databases were searched along with manual searches of retrieved articles by a single reviewer. Studies were included if they compared a freestyle lifting activity between participants with and without LBP. Data were extracted by two reviewers, and studies were appraised using the CASP tool for case-control studies.
Nine studies were eligible. Heterogeneity did not allow for meta-analysis. Most studies (n = 8 studies) reported that people with LBP lift differently to pain-free controls. Specifically, people with LBP lift more slowly (n = 6 studies), use their legs more than their back especially when initiating lifting (n = 3 studies), and jerk less during lifting (n = 1 studies). Furthermore, the four larger studies involving people with more severe LBP also showed that people with LBP lift with less spinal range of motion and greater trunk muscle activity for a longer period.
People with LBP move slower, stiffer, and with a deeper knee bend than pain-free people during freestyle lifting tasks. Interestingly, such a lifting style mirrors how people, with and without LBP, are often told how to lift during manual handling training. The cross-sectional nature of the comparisons does not allow for causation to be determined.
The changes described may show embodiment of cautious movement, and the drive to protect the back. There may be value in exploring whether adopting a lifting style closer to that of pain-free people could help reduce LBP.
Research funding: Authors state no funding involved.
Conflict of interest: KOS receives income from workshops promoting the biopsychosocial management of low back pain.
Informed consent: Not required for this systematic review.
Ethical approval: No ethical approval was required.
 Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, Carter A, Casey DC, Charlson FJ, Chen AZ, Coggerhall M, Cornaby L, Dandona L, Dicker DJ, Dilegge T, Erskine HE, Ferrari AJ, Fitzmaurice C, Fleming T, Forouzanfar MH, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1545–602.10.1016/S0140-6736(16)31678-6Search in Google Scholar
 James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, Abbastabar H, Abd-Allah F, Abdela J, Abdelalim A, Abdollahpour I, Abdulkader RS, Abebe Z, Abera SF, Abil OZ, Abraha HN, Abd-Raddad LJ, Abd-Rmeileh NME, Accrombessi MMK, Acharya D, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1789–858.10.1016/S0140-6736(18)32279-7Search in Google Scholar
 Stevens ML, Steffens D, Ferreira ML, Latimer J, Li Q, Blyth F, Maher CG. Patients’ and physiotherapists’ views on triggers for low back pain. Spine 2016;41:E218–24.10.1097/BRS.0000000000001193Search in Google Scholar
 Parreira PD, Maher CG, Latimer J, Steffens D, Blyth F, Li Q, Ferreira ML. Can patients identify what triggers their back pain? Secondary analysis of a case-crossover study. Pain 2015;156:1913.10.1016/j.physio.2015.03.2099Search in Google Scholar
 Callaghan JP, McGill SM. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clin Biomech 2001;16:28–37.10.1016/S0268-0033(00)00063-2Search in Google Scholar
 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 2018;33:35–40.10.1016/j.msksp.2017.10.010Search in Google Scholar
 Villumsen M, Samani A, Jørgensen MB, Gupta N, Madeleine P, Holtermann A. 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;58:246–58.10.1080/00140139.2014.969783Search in Google Scholar
 Hagen KB, Hallen J, Harms-Ringdahl K. Physiological and subjective responses to maximal repetitive lifting employing stoop and squat technique. Eur J Appl Physiol Occup Physiol 1993;67:291–7.10.1007/BF00357625Search in Google Scholar
 Hagen KB, Harms-Ringdahl K. Ratings of perceived thigh and back exertion in forest workers during repetitive lifting using squat and stoop techniques. Spine 1994;19:2511–7.10.1097/00007632-199411001-00004Search in Google Scholar
 Verbeek JH, Martimo KP, Karppinen J, Kuijer PP, Viikari‐Juntura E, Takala EP. Manual material handling advice and assistive devices for preventing and treating back pain in workers. Cochrane Database Syst Rev 2011:CD005958.10.1002/14651858.CD005958.pub3Search in Google Scholar
 Coenen P, Gouttebarge V, van der Burght AS, van Dieën JH, Frings-Dresen MH, van der Beek AJ, Burdorf A. The effect of lifting during work on low back pain: a health impact assessment based on a meta-analysis. Occup Environ Med 2014;71:871–7.10.1136/oemed-2014-102346Search in Google Scholar
 Hagen KB, Magnus PE, Vetlesen K. Neck/shoulder and low-back disorders in the forestry industry: relationship to work tasks and perceived psychosocial job stress. Ergonomics 1998;41:1510–8.10.1080/001401398186243Search in Google Scholar
 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;10:554–66.10.1016/j.spinee.2010.03.033Search in Google Scholar
 Laird RA, Gilbert J, Kent P, Keating JL. Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord 2014;15:229.10.1186/1471-2474-15-229Search in Google Scholar
 Geisser ME, Haig AJ, Wallbom AS, Wiggert EA. Pain-related fear, lumbar flexion, and dynamic EMG among persons with chronic musculoskeletal low back pain. Clin J Pain 2004;20:61–9.10.1097/00002508-200403000-00001Search in Google Scholar
 Boston JR, Rudy TE, Mercer SR, Kubinski JA. A measure of body movement coordination during repetitive dynamic lifting. IEEE Trans Rehabil Eng 1993;1:137–44.10.1109/86.279263Search in Google Scholar
 Courbalay A, Tétreau C, Lardon A, Deroche T, Cantin V, Descarreaux M. Contribution of load expectations to neuromechanical adaptations during a freestyle lifting task: a pilot study. J Manipulative Physiol Ther 2017;40:547–57.10.1016/j.jmpt.2017.07.004Search in Google Scholar
 Commissaris DA, Nilsson-Wikmar LB, Van Dieën JH, Hirschfeld H. Joint coordination during whole-body lifting in women with low back pain after pregnancy. Arch Phys Med Rehabil 2002;83:1279–89.10.1053/apmr.2002.33641Search in Google Scholar
 Ferguson SA, Marras WS, Burr DL, Davis KG, Gupta P. Differences in motor recruitment and resulting kinematics between low back pain patients and asymptomatic participants during lifting exertions. Clin Biomech 2004;19:992–9.10.1016/j.clinbiomech.2004.08.007Search in Google Scholar
 Larivière C, Gagnon D, Loisel P. A biomechanical comparison of lifting techniques between subjects with and without chronic low back pain during freestyle lifting and lowering tasks. Clin Biomech 2002;17:89–98.10.1016/S0268-0033(01)00106-1Search in Google Scholar
 Marras WS, Davis KG, Ferguson SA, Lucas BR, Gupta P. Spine loading characteristics of patients with low back pain compared with asymptomatic individuals. Spine 2001;26:2566–74.10.1097/00007632-200112010-00009Search in Google Scholar
 Marras WS, Ferguson SA, Burr D, Davis KG, Gupta P. Spine loading in patients with low back pain during asymmetric lifting exertions. Spine J 2004;4:64–75.10.1016/S1529-9430(03)00424-8Search in Google Scholar
 Rudy TE, Boston JR, Lieber SJ, Kubinski JA, Stacey BR. Body motion during repetitive isodynamic lifting: a comparative study of normal subjects and low-back pain patients. Pain 2003;105:319–26.10.1016/S0304-3959(03)00247-1Search in Google Scholar
 Slaboda JC, Boston JR, Rudy TE, Lieber SJ. Classifying subgroups of chronic low back pain patients based on lifting patterns. Arch Phys Med Rehabil 2008;89:1542–9.10.1016/j.apmr.2008.01.016Search in Google Scholar
 Abboud J, Nougarou F, Pagé I, Cantin V, Massicotte D, Descarreaux M. Trunk motor variability in patients with non-specific chronic low back pain. Eur J Appl Physiol 2014;114:2645–54.10.1007/s00421-014-2985-8Search in Google Scholar
 Asgari M, Sanjari MA, Mokhtarinia HR, Sedeh SM, Khalaf K, Parnianpour M. The effects of movement speed on kinematic variability and dynamic stability of the trunk in healthy individuals and low back pain patients. Clin Biomech 2015;30:682–8.10.1016/j.clinbiomech.2015.05.005Search in Google Scholar
 Asgari N, Sanjari MA, Esteki A. Local dynamic stability of the spine and its coordinated lower joints during repetitive lifting: effects of fatigue and chronic low back pain. Hum Mov Sci 2017;54:339–46.10.1016/j.humov.2017.06.007Search in Google Scholar
 Bauer CM, Rast FM, Ernst MJ, Meichtry A, Kool J, Rissanen SM, Suni JH, Kankaanpää M. The effect of muscle fatigue and low back pain on lumbar movement variability and complexity. J Electromyogr Kinesiol 2017;33:94–102.10.1016/j.jelekin.2017.02.003Search in Google Scholar
 D’Hooge R, Hodges P, Tsao H, Hall L, MacDonald D, Danneels L. Altered trunk muscle coordination during rapid trunk flexion in people in remission of recurrent low back pain. J Electromyogr Kinesiol 2013;23:173–81.10.1016/j.jelekin.2012.09.003Search in Google Scholar
 Ershad N, Kahrizi S, Abadi MF, Zadeh SF. Evaluation of trunk muscle activity in chronic low back pain patients and healthy individuals during holding loads. J Back Musculoskelet Rehabil 2009;22:165–72.10.3233/BMR-2009-0230Search in Google Scholar
 Fabian S, Hesse H, Grassme R, Bradl I, Bernsdorf A. Muscular activation patterns of healthy persons and low back pain patients performing a functional capacity evaluation test. Pathophysiology 2005;12:281–7.10.1016/j.pathophys.2005.09.008Search in Google Scholar
 Gombatto SP, D’Arpa N, Landerholm S, Mateo C, O’Connor R, Tokunaga J, Tuttle LJ. Differences in kinematics of the lumbar spine and lower extremities between people with and without low back pain during the down phase of a pick up task, an observational study. Musculoskelet Sci Pract 2017;28:25–31.10.1016/j.msksp.2016.12.017Search in Google Scholar
 Hagins M, Lamberg EM. Individuals with low back pain breathe differently than healthy individuals during a lifting task. J Orthop Sports Phys Ther 2011;41:141–8.10.2519/jospt.2011.3437Search in Google Scholar
 Hemming R, Sheeran L, van Deursen R, Sparkes V. Non-specific chronic low back pain: differences in spinal kinematics in subgroups during functional tasks. Eur Spine J 2018;27:163–70.10.1007/s00586-017-5217-1Search in Google Scholar
 Lariviere C, Gagnon D, Loisel P. The effect of load on the coordination of the trunk for subjects with and without chronic low back pain during flexion–extension and lateral bending tasks. Clin Biomech 2000;15:407–16.10.1016/S0268-0033(00)00006-1Search in Google Scholar
 Larivière C, Gagnon D, Loisel P. The comparison of trunk muscles EMG activation between subjects with and without chronic low back pain during flexion–extension and lateral bending tasks. J Electromyogr Kinesiol 2000;10:79–91.10.1016/S1050-6411(99)00027-9Search in Google Scholar
 Larivière C, Bilodeau M, Forget R, Vadeboncoeur R, Mecheri H. Poor back muscle endurance is related to pain catastrophizing in patients with chronic low back pain. Spine 2010;35: E1178–86.10.1097/BRS.0b013e3181e53334Search in Google Scholar
 Lin YH, Sun MH. The effect of lifting and lowering an external load on repositioning error of trunk flexion-extension in subjects with and without low back pain. Clin Rehabil 2006;20:603–8.10.1191/0269215506cr971oaSearch in Google Scholar
 Seay JF, Sauer SG, Frykman PN, Roy TC. A history of low back pain affects pelvis and trunk mechanics during a sustained lift/lower task. Ergonomics 2013;56:944–53.10.1080/00140139.2013.781234Search in Google Scholar
 Seay JF, Sauer SG, Patel T, Roy TC. A history of low back pain affects pelvis and trunk coordination during a sustained manual materials handling task. J Sport Health Sci 2016;5:52–60.10.1016/j.jshs.2016.01.011Search in Google Scholar
 Suehiro T, Ishida H, Kobara K, Osaka H, Watanabe S. Altered trunk muscle recruitment patterns during lifting in individuals in remission from recurrent low back pain. J Electromyogr Kinesiol 2018;39:128–33.10.1016/j.jelekin.2018.02.008Search in Google Scholar
 Takahashi I, Kikuchi SI, Sato K, Iwabuchi M. Effects of the mechanical load on forward bending motion of the trunk: comparison between patients with motion-induced intermittent low back pain and healthy subjects. Spine 2007;32:E73–8.10.1097/01.brs.0000252203.16357.9aSearch in Google Scholar
 Wrigley AT, Albert WJ, Deluzio KJ, Stevenson JM. Differentiating lifting technique between those who develop low back pain and those who do not. Clin Biomech 2005;20:254–63.10.1016/j.clinbiomech.2004.11.008Search in Google Scholar
 Shirado O, Ito T, Kaneda K, Strax TE. Flexion-relaxation phenomenon in the back muscles. A comparative study between healthy subjects and patients with chronic low back pain. Am J Phys Med Rehabil 1995;74:139–44.Search in Google Scholar
 Szpalski M, Michel F, Hayez JP. Determination of trunk motion patterns associated with permanent or transient stenosis of the lumbar spine. Eur Spine J 1996;5:332–7.10.1007/BF00304349Search in Google Scholar
 McIntyre DR, Glover LH, Conino MC, Seeds RH, Levene JA. A comparison of the characteristics of preferred low-back motion of normal subjects and low-back-pain patients. J Spinal Disord 1991;4:90–5.Search in Google Scholar
 Marras WS, Ferguson SA, Gupta P, Bose S, Parnianpour M, Kim JY, Crowell RR. The quantification of low back disorder using motion measures: methodology and validation. Spine 1999;24:2091.10.1097/00007632-199910150-00005Search in Google Scholar
 Geisser ME, Ranavaya M, Haig AJ, Roth RS, Zucker R, Ambroz C, Caruso M. A meta-analytic review of surface electromyography among persons with low back pain and normal, healthy controls. J Pain 2005;6:711–26.10.1016/j.jpain.2005.06.008Search in Google Scholar
 Nachemson A. The influence of spinal movements on the lumbar intradiscal pressure and on the tensile stresses in the annulus fibrosus. Acta Orthop Scand 1963;33:183–207.10.3109/17453676308999846Search in Google Scholar
 Gunning JL, Callaghan JP, McGill SM. Spinal posture and prior loading history modulate compressive strength and type of failure in the spine: a biomechanical study using a porcine cervical spine model. Clin Biomech 2001;16:471–80.10.1016/S0268-0033(01)00032-8Search in Google Scholar
 Adams MA, McNally DS, Chinn H, Dolan P. The clinical biomechanics award paper 1993 posture and the compressive strength of the lumbar spine. Clin Biomech 1994;9:5–14.10.1016/0268-0033(94)90052-3Search in Google Scholar
 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;49:890–5.10.1016/j.jbiomech.2015.09.034Search in Google Scholar
 Thomas JS, France CR, Lavender SA, Johnson MR. Effects of fear of movement on spine velocity and acceleration after recovery from low back pain. Spine 2008;33:564–70.10.1097/BRS.0b013e3181657f1aSearch in Google Scholar
 Matheve T, De Baets L, Bogaerts K, Timmermans A. Lumbar range of motion in chronic low back pain is predicted by task-specific, but not by general measures of pain-related fear. Eur J Pain 2019;23:1171–84.10.1002/ejp.1384Search in Google Scholar
 Caneiro JP, O’Sullivan P, Smith A, Moseley GL, Lipp OV. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending. Scand J Pain 2017;17:355–66.10.1016/j.sjpain.2017.09.012Search in Google Scholar
 Caneiro JP, O’Sullivan P, Lipp OV, Mitchinson L, Oeveraas N, Bhalvani P, Abrugiato R, Thorkildsen S, Smith A. Evaluation of implicit associations between back posture and safety of bending and lifting in people without pain. Scand J Pain 2018;18:719–28.10.1515/sjpain-2018-0056Search in Google Scholar
 Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial. Eur J Pain 2013;17:916–28.10.1002/j.1532-2149.2012.00252.xSearch in Google Scholar
 O’Sullivan K, Dankaerts W, O’Sullivan L, O’Sullivan PB. Cognitive functional therapy for disabling nonspecific chronic low back pain: multiple case-cohort study. Phys Ther 2015;95:1478–88.10.2522/ptj.20140406Search in Google Scholar
 Brox JI, Sørensen R, Friis A, Nygaard Ø, Indahl A, Keller A, Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, Riise R. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913–21.10.1097/01.BRS.0000083234.62751.7ASearch in Google Scholar
 Brox JI, Reikerås O, Nygaard Ø, Sørensen R, Indahl A, Holm I, Keller A, Ingebrigtsen T, Grundnes O, Lange JE, Friis A. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain 2006;122:145–55.10.1016/j.pain.2006.01.027Search in Google Scholar
 Brox JI, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis 2010;69:1643–8.10.1136/ard.2009.108902Search in Google Scholar
 Nolan D, O’Sullivan K, Stephenson J, O’Sullivan P, Lucock M. How do manual handling advisors and physiotherapists construct their back beliefs, and do safe lifting posture beliefs influence them? Musculoskelet Sci Pract 2019;39:101–6.10.1016/j.msksp.2018.11.009Search in Google Scholar
 Martimo KP, Verbeek J, Karppinen J, Furlan AD, Takala EP, Kuijer PP, Jauhiainen M, Viikari-Juntura E. Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review. Br Med J 2008;336:429–31.10.1136/bmj.39463.418380.BESearch in Google Scholar
©2020 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.