Manual handling injuries could be avoided by using assessment tools, say Walter Brennan and Petrus du Plessis.
According to the Health and Safety Executive’s figures for 2008/09 (HSE, 2009), musculoskeletal disorders accounted for almost 560,000 injuries to employees in the UK. More than 9,500 working days were lost because of musculoskeletal injuries during the same period. Health and social care, along with the construction industry, were identified as two of the major risk areas, so it is essential that employers in these areas endeavour to enhance their safe systems of working.
Between 2001 and 2002, more than one-third of three-day injuries reported to the HSE and local authorities were caused by manual handling – defined by the Manual Handling Operations Regulations 1992 as “transporting or supporting of loads by hand or bodily force”.
At a much lower public profile, but at an increasingly higher cost, cases of civil action involving out-of-court settlements has been conservatively estimated at about £13 million a year.
How many companies can afford to ignore the importance of good assessment of staff competence to carry out such procedures safely and correctly? There is anecdotal evidence that employees are carrying out manual handling operations on a regular basis. NHS employees and social care staff whose lifting is also an extension of their duty of care often expressed anxiety and confusion, feeling that by failing to lift, even unsafely, they are failing to exercise their duty of care and therefore they feel they could be accused of being negligent. In the early 1980s, a paper (Kroemer, 1983) highlighted the links between lifting and injury, stating “increasing numbers of injuries indicate techniques to select persons suitable for material handling need to be improved”.
The article’s authors discussed this issue with 19 occupational health professionals and seven trainers who specialise in teaching restrictive physical interventions (restraint to NHS, social care, prison and security employees). They designed a simple number-based assessment tool to establish an employee’s competence to complete such operations, the Du Plessis (DP) assessment tool.
Alongside this, a review of what is in place and/or used by OH staff found there was a lack of agreed methodology, system or tools to carry out such capability assessments.
Some OH departments use body maps and ask employees to carry out a number of movements, one admitting to asking the member of staff to walk up a staircase and down again to assess their flexibility.
A physiotherapeutic approach was chosen to design the DP scale. It has similarities with the Department for Work and Pensions (DWP) Work Capability Assessment (WCA), which is used in assessments for the employment and support allowance and is designed to establish a person’s capability to work per se rather than in a specific environment. Both tools assess physical abilities and disabilities, but the WCA is a more generic tool.
The HSE has published Manual Handling Assessment Charts to identify how to help prevent musculoskeletal disorders. The charts cannot prevent all musculoskeletal disorders; however, early reporting of symptoms, proper treatment and suitable rehabilitation is essential to minimise the effect and improve the long-term outcome. There is no assessment tool that sets out how to establish employee capability.
The Manual handling guidance on Regulations mentions individual capability: “The ability to carry out manual handling safely varies between individuals. These variations, however, are less important than the nature of the handling operations in causing manual handling injuries. Assessments that concentrate on individual capability at the expense of task or workplace design are likely to be misleading. In general, the lifting strength of women is less than that of men. But for both men and women the range of individual strength and ability is large, and there is considerable overlap – some women can safely handle greater loads than some men.”
The DP tool is designed to complement workplace design and not to replace it. The guidance also cautions against the potential to breach the Disability Discrimination Act 1995 (now subsumed by the Equality Act 2010) when assessing individual capability. In the NHS, several trusts and PCTs have endeavoured to incorporate a self-assessment tool following a musculoskeletal injury where subjective information is used. This is limited in terms of objectivity and, therefore, likely to be biased.
The All Wales Passport Scheme has endeavoured to standardise manual handling by establishing that if an employee is unfit to perform manual handling they should be provided with OH support and advice. The scheme uses a simple six-question self-assessment questionnaire. Employees who may need support are then referred to a back-care adviser or to OH. But there is no evidence in this document of any assessment tool for them to use. This highlights the value of the Du Plessis assessment tool to provide a missing link, which occupational health could use to assess employees in more detail. If required, the employee can then be referred to the back-care adviser for further treatment.
The DP tool aims to enable OH assessments to be carried out consistently and along a standardised method. It was piloted by six assessors who were asked to consider a number of “case studies”. If consistency is achieved then there is a greater chance of the DP scale being adopted by OH professionals.
A major objective of the tool and its design was to establish if it was:
- valid (correctly measuring what it is intended to measure);
- reliable (providing consistent, reproducible results);
- relevant; and
- easy to administer.
How the DP tool works
The Du Plessis tool is a physical assessment and part of the information requires a pre-medical screening consisting of:
- medical history;
- previous treatment and investigations;
- serious illnesses/operations;
- drug history; and
- present physical problems.
It is important to include pain patterns in more depth to establish the current baseline of functioning. The DP tool consists of a physical assessment covering separate body segments. Although all these segments function together in human movement, the developers of the tool believe there is more value in viewing these segments individually to refine pathology.
In each segment, the questions are weighted according to their importance and significance.
- Neck: General movements of the neck are assessed, which are flexion/extension and rotation. Included also are two important vertebra-basilar insufficiency (VBI) tests that will indicate if someone has decreased blood flow to the posterior circulation of the brain.
This is tested by maintaining the neck in a specific position for 10 seconds and then back to neutral. A positive VBI test could result in dizziness, double vision, nausea and even faintness (Jargiello, 1999).
Manual handling may, on occasion, require the employee to hold an unorthodox position for times ranging from a couple of seconds to minutes. If any of these symptoms occur, this could hinder performing manual handling, which could lead to injury. For this reason, this test is weighted as a priority.
- Shoulders: This is to establish the range of movement of the shoulders, covering flexion, external and internal rotation. These are the main movements when performing manual handling with flexion and abduction being used most, therefore scoring higher.
- Elbows and wrists: Establishing the movement of elbows and wrists, covering elbow flexion/extension, forearm pronation/supination and wrist flexion/extension. All movements attract a similar score.
- Hand and fingers: This is to establish if the employee can make a fist, which can indicate if there are any restrictions in range of movement in the fingers. Grip strength is subjective and the assessor may be required to rely on a combination of common sense and personal experience.
The grip strength is assessed by squeezing the assessor’s index fingers enabling the assessor to establish any difference in grip strength between hands and overall general strength. A firm squeeze of the assessor’s index fingers is normal. A positive test is if the employee’s grip is noticeably weakened.
- Hips, knees and ankles: It is important in this section that squatting and kneeling are assessed because this indicates leg strength as well as hip/knee function. There are many limiting factors in kneeling and squatting. Ankles’ range of movement as well as knee pain can limit this. It is also important to establish if the employee can sustain pressure through their knees for an established period of time. The movement in this section is critical to perform manual handling. The questions in this section are weighted more heavily, as well as containing asterisks against some issues. This is because if there are two or more questions that score “no” from this section, this could indicate that further investigation may be necessary because if two or more asterisks are recorded, this will result in the person being referred to a medical professional.
- Lower back: This section consists of assessing lower-back flexion/extension and important “red flag questions”, which generally indicate more serious pathology (Leerar, 2007). Assessing flexion of the lumbar spine as well as coughing/sneezing is likely to indicate disc pathologies (Boissonnault, 1996), whereas extension is more indicative of facet joint pathologies (Sehgal, 2007).
If the employee lacks bladder/bowel control, or has saddle anaesthesia (genital numbness) or gait disturbances, this is more indicative of cauda equina syndrome or narrowing of the spinal chord through various pathologies (Magee 2008; Bratton 1999).
Through trial, error and evolution, it has been established that a score of: 0-15 = safe to perform; 16+ from a combination of all sections or 2* from the same section = refer to health professional for screening of highlighted problems and to follow a treatment programme.
For ease of use and speed, the tool aims to function as a screening device that can be used by a clinician or trainer. The assessment tool has undergone revisions after being piloted by several OH practitioners and takes into consideration the guidance contained in the HSE’s Manual handling guidance on
Regulations, which state: “An employee’s manual handling capability can be affected by their health status, for example care needs to be taken when considering placing an individual with a history of back pain in a job that involves heavy manual handling. In cases of doubt, the help of an occupational health professional should be sought.”
This is one of the major factors in designing this tool to assess employee capability.
The Du Plessis assessment tool was then used by six assessors. Some variation in scores was found but was not significant.
Manual handling injuries are no longer viewed as simply occupational hazards. Employees who move and handle people may also have to restrain them to prevent them from hurting themselves or someone else.
The DP assessment tool aims also to assess these kinds of manual handling requirements. It strives to make capability assessment valid, fast and simple. In an increasingly litigious workplace, it pays to be able to underpin assessment with an evidence-based tool.
The Disability Discrimination Act 1995 makes it clear that individuals should not be excluded from work unless there is a good medical reason for restricting their activity. Some work environments are high risk and are likely to make high demands on employees’ manual handling abilities. This is why regular and objective assessment is vital.
Walter Brennan is an independent training consultant for Oliver Brennan Training specialising in conflict and mental health issues. He is also an expert witness.
Petrus du Plessis is a chartered physiotherapist, training consultant and a professional rugby player.
Health and Safety Statistics (MISC896 07/10 C90).
Manual handling. Manual handling operations Regulations 1992 (as amended). Guidance on Regulations L23 (Third edition) HSE Books 2004 ISBN 0 7176 2823 X.
Kroemer K H E (1983). Human Factors: The Journal of the Human Factors and Ergonomics Society, Volume 25, Number 5, October 1983,
Department for Work and Pensions (2009). Work Capability Assessment, Internal Review October.
Getting to Grips with Manual Handling – A Short Guide (2006). Health and Safety Executive.
Disability Discrimination Act 1995 (c 50). The Stationery Office 1996. ISBN 0 10 545095 2.
All Wales NHS Manual Handling Steering Group (2007). Training Passport and Information Scheme www.wales.nhs.uk/Documents/433.
Jargiello T, Pietura R, Rakowski P, Szczerbo-Trojanowska M, Szajner M, and Janczarek M (1999). Power Doppler imaging in the evaluation of extracranial vertebral artery compression in patients with vertebrobasilar insufficiency. Department of Interventional Radiology and Neuroradiology, University School of Medicine, Jaczewskiego 8, 20-950.
Leerar P, Boissonnault J, Domholdt W, Roddey E&T. Documentation of Red Flags by Physical Therapists for Patients with Low Back Pain: Journal of Manual and Manipulative Therapy. 2007; 15(1): 42-49.
Boissonnault W, Fabio RP (1996). Pain profile of patients with low back pain referred to physical therapy. Journal of Orthopaedic & Sports Physical Therapy. Oct;24(4):180-91.
Sehgal N, Dunbar EE, Shah RV, Colson J (2007). Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: An update. Pain Physician 2007; 10:213-228.
Magee DJ (2008). Orthopedic Physical assessment: Musculoskeletal rehabilitation series, Ed 5Ed. Saunders Elsevier, St Louis.
Bratton RL (1999). Assessment and management of acute low back pain. American Academy of Family Physicians; 60:2299-2308.
In June 2008, Eileen, a social care worker, was injured when a service user (David, 24, with learning difficulties) placed himself on the ground in the middle of a busy road. An emergency lifting technique was part of Eileen’s action plan. With her colleague, Linda, the couple started the lift.
However, Linda was not trained in the technique as she
Linda had refused to undergo the moving and handling training because she said she had a long-term back problem that made her incapable of undertaking such procedures. She had informed her manager of this but there was no evidence of any capability assessment being carried out contained in the court papers.