Effectiveness of Safe Patient Handling Equipment and Techniques: A Review of Biomechanical Studies

Abstract

Objective

This review aimed to evaluate all studies that have evaluated the biomechanical effects when using assistive devices.

Introduction

The physical demands of patient handling activities are well known. One safety strategy for the reduction of the physical risks is use of assistive devices.

Method

The search process identified articles published in English-speaking journals through Google Scholar, Medline, and ISI Web of Science. The included 56 studies contained a biomechanical assessment of a patient handling activity with assistive devices.

Results

The biomechanical effects included four groups: changes in body posture (spinal, other joints), subjective assessment (force, effort, discomfort), measured force (hand force, ground reaction force, spine force, joint torque), and physiological measures. The evidence showed caregivers benefited from using lift hoists, air-assisted devices, and to a lesser extent friction reducing devices for lateral transfers and repositioning, while floor and ceiling lifts were most effective for patient transfers. Some gaps were noted in the evidence and other handling tasks such as sit-to-stand, turning patient in bed, limb lifting, and repositioning and some more high hazard activities like supporting people with limited balance and those that fall need to be investigated with respect to biomechanical outcomes.

Conclusion

There is a growing level of biomechanical evidence to support the use of assistive devices for many patient-handling tasks, but the benefits of equipment use in some transfers remain uninvestigated.

Practical Application

Evidence indicates the best way to lift patients safely is with floor or ceiling lifts, and air-assisted devices for lateral and repositioning tasks.

Introduction

The physical demands required to assist patient movement are both a common nursing activity and have long been recognized (Garg & Owen, 1992; Jäger et al., 2013; Marras et al., 1999). The relationship between the frequent exposure to high load patient handling tasks is a known contributory factor to the musculoskeletal problems of care workers (Davis & Kotowski, 2015). The developing knowledge and practices consider the use of assistive devices as a recognized control measure to reduce the burden on the care worker (Anderson et al., 2014). The direct reduction of force requirements or the replacement of human effort with mechanical means has received strong support and wide implementation. The range of devices commonly seen in care situations can include: the replacement of full weightlifting with a powered lifter (Alamgir et al., 2009; Dutta et al., 2012), the reduction of forces for horizontal transfers with friction reduction devices (Waters, 2011), patient turning (Budarick et al., 2020), or the use of a powered bed to assist repositioning (Zhou & Wiggermann, 2021).

Several literature reviews have cumulated the body of evidence surrounding both the deleterious effects of patient handling and the possible benefits of a range of available interventions (Al Johani & Pascua, 2019; Mayeda-Letourneau, 2014; Nelson & Baptiste, 2006; Teeple et al., 2017). It should be noted that the reported evidence for the use of safety interventions in patient handling risk reduction is in a development phase and early reviews found only small numbers of high-quality papers for inclusion (Bos et al., 2006; Dawson et al., 2007; Martimo et al., 2008), a more inclusive review reported a much higher number of studies (Hignett et al., 2003) but acknowledges a different and less stringent inclusion criteria. The growth of evidence over a decade is reported in better quality of data and analysis in more recent studies (Anderson et al., 2013; Teeple et al., 2017). Even with the increased knowledge that assistive devices can significantly reduce the load on caregivers, some studies still show that the use of devices is not universal (Koppelaar et al., 2011).

Previous reviews of safe patient handling have focused on the effectiveness of programs and lift equipment in reducing musculoskeletal disorders (MSDs) in healthcare system (Al Johani & Pascua, 2019, Hignett et al., 2003; Mayeda-Letourneau, 2014; Nelson & Baptiste, 2006; Teeple et al., 2017). To understand the effectiveness of safe patient handling equipment, a comprehensive assessment of the studies that have investigated the impact on biomechanical responses within the body during safe patient handling tasks is needed. The aim of the review is to collectively report all the biomechanical effects that have been assessed when using assistive devices and lifting training (e.g., proper lifting technique) across all the range of regularly performed patient transfers and movement activities (Crowshaw and Fray, 2018; Smith et al., 2011). Biomechanical assessments can provide a better understanding of the results as compared to epidemiological studies with respect to safe patient handling equipment being protective of MSDs. The accumulated information could be used to further support the purchase, implementation, and use of assistive devices to better protect care workers from musculoskeletal disorders.

Method

Review Approach

The research team searched for published articles (prior to March 2023) that investigated biomechanical outcomes (either subjective or objective) when assessing safe patient handling devices and techniques (e.g., proper lifting). The review was completed using the PRISMA 2020 checklist to ensure quality and reproducibility (Page et al., 2021). Epidemiological studies that did not include biomechanical outcomes were eliminated from consideration, specifically studies that focused on reduced injuries and reported cases were excluded. Others have provided reviews that focused on these outcomes (Anderson et al., 2013; Bos et al., 2006; Dawson et al., 2007; Martimo et al., 2008; Teeple et al., 2017).

Article Inclusion Criteria

While the following will provide the details of inclusion, the inclusion criteria was any biomechanical study that evaluated patient handling equipment and proper lifting techniques. A search for all articles published in English-speaking journals was undertaken through Google Scholar, Medline, and ISI Web of Science. For each of the search engines, the search strategy was to search for the same string of keywords with no filters. The search words included “safe patient handling,” which yielded 13,444 articles. All duplicate articles among the search results were removed. The remaining articles were further screened (by KD) where the title and abstract were assessed for inclusion of biomechanical outcomes (generally) as well as assessment of lifting equipment and proper manual lifting training technique. All articles that meet basic biomechanical assessment were downloaded for additional evaluation of the quality of the study and inclusion of at least one of the specific biomechanical outcomes. Reviews and epidemiological studies investigating the use of lift equipment and safe patient handling programs only were not included in the current review.

As a result of this initial review, included article count was reduced to 102 relevant articles based on the criteria that some type of biomechanical assessment, either objective or subjective, was utilized and described in the abstract. One of the following outcomes had to be included as an outcome variable to be included in the review: spine posture (flexion, lateral flexion, twist in degrees), whole body motion based on motion capture (joint angles in degrees), specific body movement by other joint position method, physiological measures (fatigue with changes of median frequency of muscle activation, oxygen consumption in ml/min, energy expenditure in Kcal), subjective forces (rating of perceived exertion in Likert scale), discomfort (Likert scale, usually 1–10), ground reaction force (three-dimensional force in N), hand or applied force (force in N), muscle activity (normalized in %MVC), spine loads three dimensional loads in N), and joint torque (moment in Nm). These categories served as the classifications to group the studies for synthesis. Each category included specific biomechanical measures as defined by the individual studies.

The next step was to complete a thorough review of the remaining articles to ensure biomechanical assessment and inclusion (completed by KD and verified independently by MF). Articles were only eliminated if they did not have a biomechanical assessment in one or more of the above categories or did not assess lift equipment/proper lifting training. Finally, the reference lists for all relevant articles were scanned to identify any missing articles, which the above process was undertaken for those identified articles. Starting with a broad search of “safe patient handling” and narrowing with the biomechanical outcomes ensured a broad and comprehensive assessment of the literature for patient handling equipment and proper lifting training.

In total, 57 articles were included in the review and underwent the quality assessment (completed by KD and verified by MF) (see below for details of quality assessment). The review included all relevant articles with no exclusion due to poor quality, although quality was discussed. Figure 1 provides a schematic of the inclusion process.

Figure 1.

Schematic summary of the article search to identify articles included in the review (Figured adapted from Page and associates, 2021).

Quality Assessment of Papers

Mixed Methods Appraisal Tool (MMAT), developed by Pluye and Hong (2014), was used to rate the quality of each article. Based on the criteria for qualitative and quantitative random designs, quantitative nonrandom designs, and mixed methods, each article was rated and scored (by KD, and independently verified by MF). The main questions rated were: (1) Are the participants representative of the target population? (2) Are there complete outcome data? (3) Are the confounders accounted for in the design and analysis? (4) Are outcome assessors blinded to the intervention provided? and (5) Did the participants adhere to the assigned intervention? The articles were then quantified based on the score (each yes for the questions associated with the study design) and whether measurements were valid. The measurement evaluation was based on criteria: sufficient numbers of participants (greater than 20), measures were validated in literature—techniques well established with reliability quantitative measures with calibrated equipment and techniques, using realistic patients—assessments using standardized, noncompliant, realistic patients, and reliable equipment—use of sensitive equipment and surveys. These additional criteria assess the quality of measures and whether conditions were realistic to healthcare settings. Each of the criteria was rated as satisfactory/yes (1) or not satisfactory/no (0) with the total scores providing the overall quality assessment. Based on these scores, the articles were classified in the following quality categories: (1) low (score 0–1), (2) low-medium (score 2–3), (3) medium (score 4–5), (4) medium-high (score 6–7), and (5) high (score 8–9).

Synthesis Methods for Review

In order to evaluate all existing literature for safe patient handling equipment and proper lifting training, all 57 articles were included with none being eliminated. To understand the details of studies included in the review, Table 1 included authors, dates of publication, study population, country where study was collected, study design, and the quality rating of the study was constructed. The study design was particularly important in synergizing the results of the studies as it indicated the outcome measures used and the type of equipment/training. For each of the studies, the team tabulated the results for each biomechanical outcome variable that was measured as a function of the safe patient handling equipment and lifting technique training (see Appendix for the complete results). Based on the results in the tables in the Appendix, a summary table was developed to provide a more global summary of the results so that a more complete assessment of the existing results could be identified (see Table 2).

Table 1.

Summary of Studies Included in the Biomechanical Review: Author, Date, Study Population, Country, Study Design, and Rating of Study Quality

Author	Date	Study Population	Country	Study Design	Study Quality Rating
Allen, Jackson, Marsden, McLellan, Gore	2002	6 female trained nurses	United Kingdom	Laboratory study: Evaluated compression, for transferring devices: no equipment, belts, turntables, slings, and transfer boards	Medium
Al-Qaisi, Tannir, Younan, Kaddoum	2020	16 male nurses	Lebanon	Laboratory study: Evaluated muscle activity and perceived exertion when transferring from operating table (tilted and flat) with a draw sheet, a plastic bag, and a slide board	Low-medium
Bacharach, Miller, von Duvillard	2016	3 clinical nurses from the university who were trained in patient transfer	United States	Laboratory study: Evaluated frictional forces for transfer devices (roller tray slide board, nylon tube, and roller board)	Low-medium
Bartnik, Rice	2008	29 male and female participants	United States	Laboratory study: Evaluated hand forces, compression, and shear forces for three friction reducing sheets (disposable fabric slide sheet and MaxiSlide sheet) versus draw sheet when performing repositioning	Medium
Blaauw, Greenhalgh, Vegter, Bass, Kulich, Grindle, Cooper, Koontz, Cooper	2020	20 caregivers (15 female and 5 male)	United States	Laboratory study: Evaluated muscle activity of erector spinae, latissimus dorsi, sternal portion of the pectoralis major, and anterior deltoid when transferring patients (toilet, bench, and shower chair) with the strong arm and Hoyer Advance	Medium
Budarick, Lad, Fischer	2020	17 female and 8 male caregivers	Canada	Laboratory study: Evaluated hand force, shoulder and trunk moment, and spine force when using turn-assist surfaces relative to manual patient turns	High
Cheung, Dai, Cheung, Cho, Chow, Fung, Lam, Lia, Ng, Ngan, Szeto	2020	10 female nursing students	China	Laboratory study: Evaluated kinematics, muscle activities, and perceived physical exertion during patient transfers between a bed and a wheelchair, with or without a transfer belt	Low-medium
Daynard, Yassi, Cooper, Tate, Norman, Wells	2001	36-unit assistants	Canada	Field study: Assessment of spine force during transfer tasks: Bed-to-wheelchair transfer, bed-to-stretcher transfer, bed boost, chair boost, and bed turn using two size people: 55-kg weight bearing cooperative and 100 kg passive	Medium-high
Drew, Kozey, Moreside	2015	10 females	Canada	Laboratory study: Evaluated low back muscle activity, hand force, and perceived effort when using standard sheet, slide sheet, and modified slide sheet.	Low-medium
Dutta, Holliday, Gorski, Baharvandy, Fernie	2011	21 female caregivers	Canada	Laboratory study: Evaluated peak external forces and moments generated at the L5/S1 joint when maneuvering loaded floor-based and overhead mounted patient lifting devices for bed to wheelchair and back to a bed	Medium-high
Dutta, Holliday, Gorski, Baharvandy, Fernie	2012	21 caregivers had at least one year experience in patient lift/transfer activities	Canada	Laboratory study: Measured hand forces and external moments at the L5/S1 joint when moving a patient from a bed to a wheelchair and back to a bed using floor and overhead lifts	Medium-high
Elford, Straker, Strauss	2000	22 female nurses	Australia	Laboratory study: Measured trunk kinematics while transferring patient from chair using two-person lift with and without slings	Medium-high
Gagnon, Sicard, Sirois	1986	6 male physical education students	Canada	Laboratory study: Estimated spine loads and mechanical work and energy during patient handling tasks	Low-medium
Garg, Owen	1992	38 nursing aides (36 females and 2 males)	United States	Field study: Measured the pain levels, static compression, and perceived stress when using lifting hoist and walking belt in a nursing home	Medium
Garg, Owen	1994	Laboratory study: 6 female nursing students with at least 1-year experienceField study: 57 nursing assistants	United States	Laboratory study: Estimated compression forces and measure trunk posture when lifting by two persons, gently rocking and pulling the patient with a gait belt and walking belt by two persons and rocking and pulling the patient with a walking belt and using a sling by one person and three mechanical hoists.Field study: Investigated use of ergonomic handling equipment: Hoist, lifting belt on injury rates, perceived exertion and acceptability rates	Medium
Garg, Owen, Beller, Banaag	1991a	6 female nursing students	United States	Laboratory study: Measured pull forces and estimated spine compression and shear forces when transferring patients to and from the bed with and without lifting assist devices	Medium
Garg, Owen, Beller, Banaag	1991b	6 female nursing students	United States	Laboratory study: Measured pull forces and estimated spine compression and shear forces when transferring patients between a wheelchair and shower with and without lifting assist devices	Medium
Grevelding, Bohannon	2001	2 men	United States	Laboratory study: Measured push force when using slide devices (none, easy glide, Minislide or both) while pushing a passive patient	Medium
Hess, Kincl, Mandeville	2007	16 clinicians	United States	Laboratory study: Measured trunk kinematics, perceived exertion, and hand force for modified standing pivot, a transfer board technique, and the scoot transfer	Medium
Hodder, MacKinnon, Ralhan, Keir	2010	12 female untrained individuals and 10 female experienced nurses	Canada	Laboratory study: Measured muscle activity and trunk posture during 3 patient transfers comparing trained and untrained individuals in proper body mechanics	Medium
Howard, Bao, Kim, Silverstein	2013	2 female caregivers	United States	Laboratory study: Measured muscle activity during transfer tasks using ceiling lift, scoot transfer, modified scoot transfer, and manual lift	Low-medium
Hwang, Ari, Matoo, Chen, Kim	2020	20 professional caregivers (18 females and two males)	United States	Laboratory study: Measured muscle activity, trunk posture, and trunk moment during turning tasks in two turning directions (toward vs. away relative to caregivers) using five device conditions: Draw sheet, friction-reducing turning sheet, air-assisted transfer device, air-assisted turning device, and no assistive device	Medium-high
Hwang, Kuppam, Chodraju, Chen, Kim	2019	20 professional caregivers (18 females and 2 males)	United States	Laboratory study: Measured hand force; shoulder and trunk posture; shoulder moment; muscle activity and usability ratings from four devices: a Draw sheet, a repositioning sheet, a slide board, and an air-assisted device during repositioning	Medium-high
Iridiastadi, Vani, Yamin	2020	12 nurses who worked at local hospital for at least a year	Indonesia	Laboratory study: Measured postural assessment, static spinal load, and perceived exertion from Borg scale	Medium
Jager, Jordan, Theilmeier, Wortmann, Kuhn, Nienhaus, Luttmann	2013	2 female caregivers with extensive professional experience	Germany	Laboratory study: Estimated spine load and identified load reduction by applying biomechanically ‘optimized’ transfer modes	Medium
Katsuhira, Sasaki, Asahara, Ikegami, Ishihara, Kikuchi, Hirai, Yamasaki, Wada, Maruyama	2008	10 male students	Japan	Laboratory study: Measured body postures and ground reaction forces and predicted trunk moments during transfers from wheelchair to bed using low back belt on patient, on caregiver, and on both	Medium
Keir, MacDonell	2004	7 participants: 4 novice males, 1 experienced female, and 2 experienced males	Canada	Laboratory Study: Measured muscle activity patterns during manual transfers and transfers using floor and ceiling lifts	Low-medium
Koppelaar, Knibbe, Miedema, Burdorf	2012	186 nurses in nursing homes (179 females and 7 males)	The Netherlands	Field Study: Direct observation of nurses in nursing homes, quantifying postures and estimating forces	Medium
Kothiyal, Yuen	2004	10 participants	Australia	Laboratory study: Measured muscle activity and perceived exertion when conducting patient transfer tasks with and without patient sling assist device	Low-medium
Kotowski, Davis, Marras	2019	16 participants (8 males and 8 females)	United States	Laboratory study: Estimated spine load during repositioning and lateral transferring with 6 devices (draw sheet, reusable air-assisted device, disposable air-assisted device, dual friction-reducing sheets, slide board, and friction-reducing covered board (lateral transfer only)	Medium
Law, Ridzwan, Ripin, Hamid, Law, Karunagaran, Cajee	2022	6 nurses with minimum of 6 months experience	Malaysia	Laboratory study: Measured full body kinematics, ground reaction forces, and hand forces	Medium
Lloyd, Baptiste	2006	1 male	United States	Laboratory study: Estimated spinal loads and joint moments from 11 different lateral transfer technologies and techniques	Low-medium
Marras, Knapik, Ferguson	2009	5 male and 5 female inexperienced students	United States	Laboratory study: Estimated spine loads during pushing and pulling with two types of floor and ceiling lifts	Medium
McGill, Kavcic	2005	3 male subjects trained in patient handling	Canada	Laboratory study: Measured muscle activity and applied force, estimated spinal loads using 3 lateral sliding transfer devices	Medium
Muono, Vartiainen, Karjalainen, Räsänen	2022	2 experienced nurses	Finland	Laboratory study: Measured ground reaction forces and rating of perceived exertion	Medium
Nelson, Lloyd, Menzel, Gross	2003	134 nursing personnel (registered nurses, licensed practical nurses, nursing assistants) with 71 in control group and 63 in intervention group	United States	Laboratory study: Measured muscle activity, hand forces, and perceived exertion, predicted spine forces and joint moments for interventions for 9 common patient handling tasks	Medium
Nevalaa, Tamminen-Peter	2004	12 healthy female nurses	Finland	Field study: Measured muscle activity and muscle strain for adjustable versus traditional shower trolley	Low-medium
Nussbaum, Torres	2001	24 female students with no experience in patient handling	United States	Laboratory study: Measured perceived exertion and estimated spine loads when performing patient handling tasks with two levels of training	Medium
Omura, Hirati, Yochimine, Nakatani, Inoue	2022	28 clinical nurses and care workers	Japan	Laboratory study: Measured trunk flexion and rating of comfort and fatigue	Medium
Potvin	2017	Simulated female (50th percentile)	Canada	Laboratory study: Estimated spine compression and shear forces, torques on arms, knee, and hip, and shoulder trunk posture when transferring patient out of recliner, bed, and chair with and without gait belt	Low-medium
Riccoboni, Monnet, Eon, Lacouture, Gazeau, Campone	2021	9 caregivers (7 females and 2 males)	France	Laboratory study: Measured forces and torques in lumbar spine, perceived exertion, and discomfort when standing patient and sitting patient in chair manually (single and two-person) versus motorized lift	Medium
Rice, Woolley, Waters	2009	1 standard male participant did pushing/pulling	United States	Laboratory study: Measured push, pull and rotating forces for lifting devices (floor-based power stand-up lift, floor-based full body lift with a divided-leg sling, and overhead mounted full body lift with a high-back sling	Medium
Santaguida, Pierrynowski, Goldsmith, Fernie	2005	5 female registered nurses	Canada	Laboratory study: Predicted spine loads and measured perceived exertions for bed to chair transfer comparing overhead and floor powered lifts	Medium
Schibye, Hansen, Hye-Knudsen, Essendrop, Bocher, Skotte	2003	9 female health care workers	Denmark	Laboratory study: Estimated spinal loads and measured perceived exertion for different transfers and devices	Medium
Silvia, Bloswick, Lillquist, Wallace, Perkins	2002	6 subjects (4 females and 2 males) who were formally trained in patient handling	United States	Laboratory study: Estimated spine loads for transfer tasks with and without lift assist devices	Medium
Tang, Holland, Milbauer, Olson, Skora, Kapellusch, Garg	2018	28 students	United States	Laboratory study: Estimated spine loads, strength requirements, and perceived exertion for bed-to-wheelchair transfers with walking belt versus gait belt	Medium
Theou, Soon, Filek, Brims, Leach-MacLeod, Binsted, Jakobi	2011	5 healthcare providers	Canada	Laboratory study: Measured muscle activity for arm and shoulder muscle and assessed rating of perceived exertion	Low-medium
Ulin, Chaffin, Patellos, Blitz, Emerick, Lundy, Misher	1997	2 nursing students	United States	Laboratory study: Estimated spine loads, strength requirements, and hand forces when transferring patients with screw activated lift, hydraulic lift, and electric lift versus manual lifting	Medium
Vinstrup, Jakobsen, Madeleine, Andersen	2020	52 female healthcare workers from 16 different departments at 5 Danish hospitals	Denmark	Field study: Measured muscle activity and trunk posture during a full workday	Medium
Walls	2001	1 staff member acted as nurse and 1 staff member acted as patient	New Zealand	Field study: Measured trunk kinematics for electrical beds and manual beds	Medium
Waters, Dick, Lowe, Werren, Parsons	2012	1 female operator	United States	Laboratory study: Measured hand forces and estimated spinal loading for overhead-mounted lifts and floor-based lifts across various floor surfaces and patient weight conditions	Low-medium
Weiner, Kalichman, Ribak, Alperovitch-Najenson	2017	12 nurses	Israel	Laboratory study: Measured torso kinematics and perceived exertion when performing 27 patient transfers	Medium
Wiggermann	2016	9 female nurses	United States	Laboratory study: Measured compression, shear forces, hand forces, and shoulder strength for with and without turn assist when turning and laterally repositioning patients	Medium
Wiggermann, Zhou, McGann	2021	10 female participants	United States	Laboratory study: Measured hand forces and ground reaction forces to estimate compression spine force for repositioning, turning, and lateral transferring with different lift aides	Medium
Wiley	2001	18 female occupational Therapy students	United States	Laboratory study: Measured trunk flexion, knee flexion, and elbow flexion for lifting belt versus no belt during patient transfers	Low
Zakerian, Afzalinejhad, Mahmodi, Sheibani	2021	60 staff members of the ICU	Iran	Field study: Measured rating of perceived exertion	Medium
Zhuang, Stobbe, Hsiao, Collins, Hobbs	1999	9 nursing assistants	United States	Laboratory study: Evaluated of nine battery-powered lifts, a sliding board, a walking belt, and a baseline manual method for transferring nursing home residents from a bed to a chair	Medium

*Under Study Design, the table provides the assessments for the quality ratings: SPART—participants representative of population, CODATA—complete outcome data, CONF—confounders accounted for, BINT—Outcome assessors blinded to intervention, ADHERE—adherence to intervention, SUB20—sufficient numbers of subjects (N >20), VALM—validated measures, REALPAT—realistic patients being moved, and REQUIP—reliable equipment.

Table 2.

Summary of the Number of Studies That Found a Decrease (↓), No Difference, or Increase (↑) Relative to Manual or Draw Sheet and the Various Safe Patient Handling Equipment or Techniques for Each of the Outcomes

	Proper Lifting	Slide Board and Roller Board	Gait belt and Walking Belt	Friction Reducing Sheets and Plastic Bags	Air-Assisted Device	Floor Lifts	Ceiling Lifts
Spine posture		↓: 1	No Diff: 1 ↓: 1	No Diff: 1	↓: 1	No Diff: 1
Motion capture	↓: 2 No Diff: 1	↓: 2 No Diff: 2	↓: 5	No Diff: 2	↓: 1	↓: 2	↓: 1
Other joint position			No Diff: 1			↓: 1 No Diff: 1
Physiological measures			↑: 1			No Diff: 1
Subjective force	↓: 1	↓: 5 No Diff: 5	↓: 5 No Diff: 1	↓: 5 No Diff: 1	↓: 4	↓: 5 ↑: 1	↓: 2
Discomfort		↓: 2	↓: 2	↓: 2	↓: 1	↓: 3	↓: 1
Ground reaction force		↓: 2	↓: 1
Hand or applied force		↓: 7 No Diff: 1	↓: 5 No Diff: 1	↓: 4 No Diff: 2	↓: 5	↓: 1	↓: 3
Muscle activity	↓: 1	↓: 6 No Diff: 1	↓: 1 No Diff: 1	↓: 6 No Diff: 1	↓: 4	↓: 1	↓: 4
Spine loads	↓: 3	↓: 1 No Diff: 3	↓: 5 No Diff: 3 ↑: 1	↓: 5 No Diff: 2	↓: 5	↓: 5	↓: 2
Joint torque	↓: 3	↓: 2 No Diff: 3	↓: 1 No Diff: 2	↓: 2 No Diff: 1 ↑: 1	↓: 3 No Diff: 1	↓: 2	↓: 1

Overview of Included Articles

Table 1 provides a summary of the studies with respect to subject population, country where study was performed, study design, and quality of study rating. Studies have been collected at a consistent pace over the years: 1980 to 1999: 7, 2000 to 2004: 13, 2005 to 2009:8, 2010 to 2014: 8, 2015 to 2019: 8, and 2020 to 2023: 13. Studies were conducted across the world with most being in the United States (27) and Canada (10) followed by The Netherlands (3), Australia (2), Denmark (2), Finland (2), Japan (2), and the rest of the countries had one study (China, Germany, Indonesia, Iran, Israel, Lebanon, Malaysia, New Zealand, United Kingdom). Majority of the studies included in this review were laboratory based (49), while one was both laboratory and field, and the remaining were field (7). The quality assessment yielded one high quality studies, 6 medium-high quality studies, 13 low-medium studies, and 1 low study. The vast majority were rated medium quality (36).

FINDINGS AND DISCUSSION

Table 2 provides a summary of the results for the different modalities of safe patient handling. One interesting finding was that there are few studies (4) reporting a negative result (e.g., increase in outcome variable) for any safe patient handling modality. This indicates that in the worst case, the patient handling equipment was equivalent to manual lifting. There was one high, six medium-high quality studies, thirty-six medium quality studies, and thirteen low-medium quality studies, and one low quality study.

Proper lifting has been a target for safe patient handling due to being a cheap and easy to implement intervention. The concept is to use proper body mechanics to limit the stress on the body, specifically on the spine, by keeping the patient close, bending the knees, and keeping the back upright. Biomechanical studies have shown a reduction in joint postures—more neutral postures (2 studies), trunk moments (3 studies), and spine loads (3 studies) when using proper lifting as compared to no training. Only one study found no difference in joint postures between proper lifting technique and nontraining lifting. Under controlled laboratory conditions (all have been rated medium quality), proper lifting appears to be effective in reducing the stresses on the body. Basically, healthcare givers were more upright and closer to the patient which reduced the trunk moments, muscle activity, and corresponding spine loads when using “proper lifting technique.” However, caution should be taken as training has limitations in the real world when work demands are high, fatigue sets in, and returning to normal lifting. Most biomechanical laboratory studies utilize a compliant simulated patient that will often minimize the biomechanical responses for the caregivers (Marras et al., 1999). Sudden changes in the patient due to losing balance, sudden strength imbalance, or mental impairment may result in a sudden load on the caregiver who is holding them. Lifting or transferring a noncompliant patient is much different than compliant as sudden movements or dead weight of a patient can produce significant additional force requirements for the caregiver, oftentimes unexpected and rapidly. Further, Nelson and Baptiste (2006) provided significant evidence that proper lifting mechanics and safe lifting techniques are not effective in controlling injuries due to patient handling. The bottom line, there is no way to safely manually handle patients (Nelson et al., 2007; Wilson & Davis, 2016). Finally, there are relatively few biomechanical studies (only medium quality studies) investigating proper lifting training to really form a decisive conclusion on training effectiveness to protect caregivers during patient handling.

Slide boards and roller boards have been found relatively ineffective (no difference) with slightly more studies that found them to reduce the biomechanics as compared to manual lifting (25 reduced vs. 15 no difference) (Table 2). For many of the outcomes, slide/roller boards were found to be equivalent to manual handling. The two biomechanical outcome variables that did see consistent benefit of slide/roller boards were hand forces (7 studies found decrease hand forces, 1 no difference) and muscle activity (6 studies found decrease muscle activity, 1 no difference). These reductions in hand force and muscle activity do not seem to translate to reductions in trunk moments and spine loads. While the friction force between the boards and body are likely reduced, the caregiver must still move significant body weight. Further, the roller board devices are only viable during lateral transfers while slide boards can be utilized in lateral transfers and repositioning. The studies evaluating slide/roller boards were generally medium quality with two being medium-high quality and one high quality. The medium-high and high quality studies found decreases in shoulder and trunk flexion, reduced perceived effort, reduced hand forces, lower muscle activations, and low spine loading for slide board as compared to draw sheet (Budarick et al., 2020; Hwang et al., 2019, 2020). Overall, except for reducing hand forces, slide boards and roller boards appear to be a marginally viable solution in protecting caregivers during handling patients.

The use of a belt (gait or walkingbelts) has had mixed results for biomechanical outcomes. Belts have been shown to reduce nonneutral postures (5 studies) and hand forces (5 studies, 1 no difference), but to a lesser extent, limited impact on spine loads (5 studies decrease, 3 studies no difference, and 1 study increase). There were few studies that were rated medium quality investigating gait/walking belts, thus providing further support that belts have limited utility in patient handling. Studies for gait and walking belts have the same concerns as research for proper lifting technique as noncompliant patients can still pose significant risk for the caregiver. Furthermore, gait and walking belts are predominantly used during transfers of patients (e.g., bed to standing, bed to chair, bed to toilet, and bed to wheelchair) and are not applicable to repositioning and lateral transferring. With about equal as many studies finding no difference or worse results as lifting manually, gait and walking belts do not appear to be viable safe patient handling devices.

Friction reducing sheets or use of plastic bags have similar results to the slide/roller boards where these devices were effective in reducing the hand forces (4 studies found decrease, 2 found no difference) and muscle activity (6 studies found reduced, 1 study with no difference), These changes did appear to reduce the biomechanical loading on the spine (5 studies report decreases and 2 study no difference). Two medium-high quality studies (Hwang et al., 2019, 2020) found lower hand forces, less muscle activity, and lower spine loads for frictionless sheets as compared to manual lifting. Several medium rated quality studies found no difference in friction reducing sheets and manual lifting (Kotowski et al., 2022; Weiner et al., 2017). The friction reducing sliding devices can only be utilized for repositioning and lateral transferring of patients, not actual transfers in and out of bed. Overall, there appears some utility for these devices as they reduce the resistant forces between the bed and patient (e.g., friction and shear forces), ultimately reducing the biomechanical requirements and loads on the caregivers.

Air-assisted devices have been shown to be effective in reducing the biomechanical stress on the caregivers but are restricted to repositioning and lateral transfers. All but one study (trunk moments) revealed reductions in the outcomes when compared to manual handling (with decreases in 2 studies for postures, 5 studies for hand forces, 4 studies for muscle activity, 5 studies for spine loading, and 3 studies for trunk moments). Most of the studies investigating air-assisted devices were rated medium or better (Hwang et al., 2019, 2020; Kotowski et al., 2022; Omura et al., 2022; Wiggermann et al., 2021) and yielded the positive results. These devices provide an air cushion between the body and bed/stretcher that allows the caregiver to easily slide the patient over the bed with minimal effort. One concern for these devices is the need to place the air mattress under the patient, which requires additional movement and handling (e.g., need to roll and place under patient and requiring manual movement of patient) or placing the air mattress under the patient when arriving at the facility and leaving under until needed. One concern with these air mattresses under the patient for long-term periods is concern for infection and bacteria control. The air mattress studies did not evaluate the biomechanical responses during the positioning of the air mattresses under the patient, but rather focused on the transfer and repositioning tasks.

Mechanical lifts, floor and ceiling, were found to be effective in reducing many of the biomechanical outcomes with few “no difference” outcomes (2 studies relating to positional outcomes) (see Table 2). All studies that investigated ceiling lifts found decreases in biomechanical outcomes, by far the most effective patient handling device. Most studies that compared floor lifts to ceiling lifts found ceiling lifts to be superior in reducing spine loads and trunk moments as well as other biomechanical outcomes (Dutta et al., 2011, 2012; Marras et al., 2009; Santaguida et al., 2005; Waters et al., 2012). Ceiling lifts have also been found to be the preferred method for reducing actual injuries (Asuquo et al., 2021; Chhokar et al., 2005; Engst et al., 2005; Lee & Rempel, 2020; Villeneuve, 1998). Overall, mechanical lift studies were rated at medium or better quality and found lifts to be effective in reducing biomechanical loading, for all types of patient handling: transfers, repositions, and lateral transfers.

The review provides insight into the benefit of lifting devices as it was apparent that manual lifting was not safe, no matter how good your proper lift mechanics. Based on the current evidence, the best way to protect healthcare workers is to utilize lifts, preferably ceiling lifts.

Missing Evidence

There are several shortcomings of the current studies. First, there are several biomechanical outcomes that have had limited investigation. Most safe patient handling interventions have had limited physiological assessment that will provide evaluation of fatigue. Additionally, for any one intervention modality and specific biomechanical outcome, few studies were found (at most 7 studies) with most of these being rated medium-low to low quality (40 out of 56 studies, 71%). Second, all of the studies evaluated the patient handling intervention have concentrated on transfers (e.g., from bed), repositioning, and lateral transfers. Other handling tasks such as sit-to-stand, turning patient in bed, limb lifting, and repositioning and some more high hazard activities like supporting people with limited balance and those that fall need to be investigated with respect to biomechanical outcomes. Third, there is a need for more comprehensive investigations that include basic biomechanical outcomes (e.g., hand forces, positions, and muscle activity) as well as more complex outcomes (e.g., joint moments and spine loads) as many of the studies relied on a single simple assessment. Fourth, one of the most disturbing results was that very few studies investigate nonnursing healthcare workers. With the focus on mobility now being undertaken by physical therapists (PT) or occupational therapists (OT), future studies need to understand the differences in patient handling demands for PT/OT versus nurses. Thus, the current review provides a plethora of evidence about many patient handling equipment but there remains a tremendous amount of future work that needs to be done for a more complete picture.

Limitations of the Review

There are several potential imitations that should be considered with the current review. First, the review only covers articles published in English. While most journals fall into this category, several additional studies may have been overlooked. Second, biomechanical outcomes are only one type of outcome that relates to safe patient handling. Other factors such as patient safety, patient comfort, risk of injury, cognitive demands, and time to complete the handling task should be reviewed for a more comprehensive understanding of patient handling devices. Finally, most of the studies included in this review were rated below high quality, which limits the ultimate understanding of the effectiveness of patient handling devices. Some people feel reviews should only contain the highest quality, but we wanted to include all biomechanical studies. Future research should strive to have high quality by including well-validated measures such as complex spine loading models, recruit actual healthcare workers for participants with large numbers, use an actual person simulating a noncompliant patient, and use a strong study design.

Conclusion

Current best practice guidelines adopted by many international governmental systems suggest that the use of assistive devices is an essential step to risk reduction for care workers. This review shows an increase in the volume of studies and higher quality evidence that the use of assistive devices does indeed reduce the physical loads on caregivers. This cumulative knowledge should support the increased use of suitable assistive devices in care delivery. Some areas of patient handling still require further investigation to further reduce the overload of care workers form specific transfers such as a sit-to-stand, walking and falling patients, and other postural static loads that are evident in care work.

Author Biographies

Dr Mike Fray holds first degrees in ergonomics (Loughborough University, 1987) and physiotherapy (Leeds University, 1993). After a few years working in the transport field (Ford, ICE Ergonomics) for many years he specialized in the areas of occupational physiotherapy, rehabilitation, and injury prevention for healthcare workers. Since 2006, Dr Fray has been conducting research in HEPSU, now in Loughborough Design School. In 2010, he completed part-time a PhD study which developed an outcome measurement tool to compare all types of interventions for patient handling in healthcare. In summary his research interests are in the improvement of the delivery of healthcare activities with a special focus on the physical risks to staff and the delivery of the highest quality care for the patient.

Dr. Kermit Davis is a professor at the University of Cincinnati where he is the graduate program director of the Environmental and Occupational Hygiene and Occupational Safety and Ergonomics programs at the University of Cincinnati. Dr Davis is a past-President of the Human Factors and Ergonomics Society (HFES) and a Fellow of HFES (2013) and American Industrial Hygiene Association (2019). His research has concentrated on reducing ergonomic stressors of healthcare workers and patients in healthcare settings (e.g., hospitals, long-term care facilities, and home healthcare). In the last year, his research has focused on virtual offices.

APPENDIX.

Table A1.

Summary of the Quantitative and Subjective Results for Safe Patient Handling Interventions.

Author	Spine Posture	Motion Capture	Other Joint Position	Physiological Measures	Subjective Force	Discomfort
Al-Qaisi et al., 2020					↓ effort when OR table tilted versus flat; ↓ effort when using plastic bag and slide board versus sheet
Bacharach et al., 2016					↓ effort to move using the nylon tube, roller board, and roller tray compared with the cotton sheet and slide board versus sheet
Cheung et al., 2020	No difference between gait belt and no gait belt				↓ effort for gait belt versus no gait belt
Drew et al., 2015					↓ effort for slide sheet and modified slide sheet versus sheet
Dutta et al., 2012					↓ effort for ceiling lift versus floor lift
Elford et al., 2000	↓ 3D trunk postures and velocities for PH sling versus no sling					↓ discomfort for most body parts for PH sling versus no sling
Gagnon et al., 1986				↑ work and energy for gait belt versus no gait belt
Garg & Owen, 1992						↓ lift versus walking belt for shoulder, low back, and upper back discomfort
Garg & Owen, 1994		↓ sling, gait and walking belts versus 2-person manual for lateral bend and twist of trunk			↓ sling and gait walking belts versus 2-person manual for perceived stress; j ↓ lift versus gait belt, sling, and 2-person manual for perceived stress
Garg et al., 1991a		↓ sling and gait and walking belts versus 2-person manual for lateral bend of trunk			↓ perceived stress for sling and walking belt versus 2-person manual for perceived stress; ↓ lift versus gait belt, sling, and 2-person manual; no difference for perceived stress for Hoyer lift versus two-person manual	↓ lifts, sling, and gait and walking belt versus 2-person manual for discomfort
Garg et al., 1991b		No difference between sling and gait walking belts versus 2-person manual for trunk posture			↓ lift, sling and walking belt versus 2-person manual for perceived stress; ↑ Hoyer lift versus walking belt, sling, and 2-person manual for perceived stress	↓ lifts, sling and walking belt versus 2-person manual for discomfort
Hess et al., 2007	No LBD risk between pivot, scoot, and slide board transfer to wheelchair; ↓ sagittal flexion for slide and pivot versus scoot; ↓ lateral flexion for slide and scoot versus pivot; ↓ twist for pivot versus scoot and slide				No difference for RPE between pivot, scoot, and slide board transfer to wheelchair
Hodder et al., 2010		↓ sagittal flexion and lateral bend between trained (proper lifting techniques) versus untrained for repositioning; No difference for transfer from bed to wheelchair
Hwang et al., 2020		↓ trunk flexion for air-assisted device, slide board, and frictionless sheet versus no device for turning towards and away tasks; ↓ shoulder flexion for air-assisted device versus no device for turning towards task			↓ effort of use for air-assisted device versus no device for turning towards and away tasks
Hwang et al., 2019		↓ shoulder flexion and abduction for air-assisted device versus slide board, draw sheet and frictionless sheet for lateral transfers and repositioning; ↓ trunk flexion and abduction for air-assisted device versus slide board, draw sheet and frictionless sheet for lateral transfers and repositioning			↓ effort to use for air-assisted device versus slide board, draw sheet and frictionless sheet for lateral transfers and repositioning
Iridiastadi et al., 2020					↓ effort with floor lift as compared to manual
Katsuhira et al., 2008		↓ sagittal trunk flexion when wearing back belt versus no back belt during seated transfer
Koppelaar et al., 2012			↓ nonneutral trunk posture for lift device versus no lift device for repositioning; no significant difference for transfer
Kothiyal & Yuen, 2004					↑ perceived effort in low back and shoulders for gait belt versus no gait belt
Kotowski et al., 2022					↓ perceived exertion with air-assisted device versus slide board, dual friction sheets and draw sheet for repositioning; ↓ perceived exertion with air-assisted device versus slide board, friction reducing board, dual friction sheets and draw sheet for lateral transfers; manual lifting had highest	↓ discomfort with air-assisted device versus slide board, dual friction sheets and draw sheet for repositioning; ↓ discomfort with air-assisted device versus slide board, friction reducing board, dual friction sheets and draw sheet for lateral transfers; manual lifting had highest
Muona et al., 2022					↓ perceived exertion with slide film as compared to regular sheet
Nelson et al., 2003						↓ discomfort with ceiling mounted lift, friction reducing device, and stretcher that converts to a chair versus manual for transfer tasks
Nevala & Tamminen-Peter, 2004				No difference in heart rate electrically adjustable with shower trolley versus traditional shower	↓ perceived strain in neck/shoulder, back, arms, and legs with electric trolley versus traditional show for shower tasks
Nussbaum & Torres, 2001		↓ knee, elbow, and trunk angles for training in good lifting versus none			↓ perceived exertion in whole body, shoulder, low back for training in good lifting versus none
Omura et al., 2022	↓ spine flexion angle for air-assisted turn device compared to manual				↓ perceived fatigue for air assisted turn device compared to manual
Silvia et al., 2002					↓ effort to use for Barton System versus 2-person draw sheet for bed to chair and chair to bed transfers; ↓ effort to use for Barton System versus 2-person draw sheet for lateral transfers
Santaguida et al., 2005					↓ perceived effort with ceiling lift versus floor lift for bed to wheelchair transfers
Tang et al., 2018		↓ trunk flexion for gait belt versus walking belt for males; ↓ lateral flexion for walking belt versus gait belt for males and females			↓ perceived effort for walking belt versus gait belt
Theou et al., 2011					↓ perceived effort with slider system versus traditional bed sheet
Ulin et al., 1997					↓ perceived effort for mechanical assist device (screw-activated, hydraulic, and electric) versus manual (pivot, slide board, and gait belt) for patient transfers
Vinstrup et al., 2020		↓ trunk flexion with ceiling lifts and intelligent beds versus manual, draw sheet, sliding sheet, and sliding boards during patient transfers; ↓ lateral bending with ceiling lifts versus manual, intelligent beds, draw sheet, sliding sheet, and sliding boards during patient transfers
Walls, 2001	No difference between electric bed versus manual bed for LBD risk
Weiner, et al., 2017	No difference between sliding sheet, lifting hoist, and draw sheet for LBD risk for repositioning				↓ perceived effort with lift hoist and sliding sheet versus draw sheet for bed to wheelchair transfers for repositioning
Willey, 2001		↓ sagittal trunk flexion when wearing back belt versus no back belt during patient transfer; No difference between belt and no belt for elbow and knee position
Zakerian et al., 2021					↓ perceived effort with lift belt versus manual	↓ discomfort in neck, shoulders and arms, waist, hands and wrists, buttocks, thighs, knees and legs. With lift belt versus manual No difference in discomfort in elbow and forearm between lift belt and manual
Zhuang et al., 1999		↓ sagittal flexion, lateral flexion, and twist for trunk when placing sling and using ceiling lift versus manual with gait belt when positioning for transfer; ↓ sagittal flexion, lateral flexion, and twist for trunk when stand-up lift and sliding board versus manual with gait belt when positioning for transfer

Table A2.

Summary of the Biomechanical Loading Results for Safe Patient Handling Interventions.

Author	Ground Reaction Force	Hand or Applied Force	Muscle Activity	Spine Loads	Joint Torque
Allen et al., 2002				No difference in compression for belts, turntables, slings, transfer boards versus no equipment
Al-Qaisi et al., 2020			↓ trapezius and erector spinae muscle activity when OR table tilted versus flat; ↓ trapezius and erector spinae muscle activity when using plastic bag and slide board versus sheet
Bacharach et al., 2016		↓ applied hand force using the nylon tube, roller board, and roller tray compared with the cotton sheet and slide board versus sheet			↓ trunk moment using the nylon tube, roller board, and roller tray compared with the cotton sheet and slide board versus sheet
Bartnik & Rice, 2008		No difference in applied hand force between sheet and MaxiSlide and fabric slide sheets		↓ compression, lateral shear, and A-P shear for MaxiSlide and fabric slide sheets versus sheet
Blaauw et al., 2021			Mixed results with few consistent statistical trends between Strong Arm versus Hoyer Lift
Budarick et al., 2020		↓ hand forces (to none) when using turn assist compared to manual		↓ compression when using turn assist compared to manual	↓ shoulder moments when using turn assist compared to manual
Cheung et al., 2020			↓ one muscle (RES) for gait belt versus no belt, no difference in rest
Daynard et al., 2001		↓ applied hand force for friction reducing devices during boost in bed		↓ compression for friction reducing devices during boost in bed; ↓ compression for gait belt and even more with mechanical lift; few differences in cumulative compression and shear
Drew et al., 2015		↓ applied hand force for slide sheet and modified slide sheet versus sheet	↓ muscle activity for erector spinae for slide sheet and modified slide sheet versus sheet
Dutta et al., 2011				↓ external forces and moments at L5/S1 for ceiling lift versus floor lift
Dutta et al., 2012				↓ external forces and moments at L5/S1 for ceiling lift versus floor lift
Gagnon et al., 1986				↑ compression for gait belt versus no gait belt
Garg & Owen, 1992		↓ hand forces with walking belt versus manual		↓ compression with walking belts versus manual
Garg & Owen, 1994		↓ hand forces sling and gait and walking belts versus 2-person manual		↓ compression and A-P shear for sling and gait and walking belts versus 2-person manual
Garg et al., 1991a		↓ hand forces with gait and walking belts versus manual		↓ compression and A-P shear for sling and gait and walking belts versus 2-person manual
Garg et al., 1991b		↓ hand forces with gait and walking belts versus manual		↓ compression and A-P shear for sling and gait and walking belts versus 2-person manual
Grevelding & Bohannon, 2001		↓ hand forces with sliding tube and fabric tube versus manual
Hess et al., 2007		↓ hand force for slide versus scoot and pivot when transferring to wheelchair
Hodder et al., 2010			↓ muscle activity between trained (proper lifting techniques) versus untrained for trapezius, erector spinae and external oblique for repositioning and transfer to wheelchair
Howard et al., 2013			↓ muscle activity in Biceps, extensors, and erector spinae for ceiling lift versus manual, scoot, and modified scoot
Hwang et al., 2020			↓ muscle activity in all seven muscles for air-assisted device, slide board, draw sheet and frictionless sheet versus no device for turning towards and away tasks		↓ flexion moment for air-assisted device versus no device for turning towards and away tasks; ↑ extension moment for friction-reducing turning sheet versus no device for turning towards and away tasks
Hwang et al., 2019		↓ hand forces with slide board and air-assisted device versus draw sheet and frictionless sheet for lateral transfers	↓ muscle activity in all seven muscles for air-assisted device versus slide board, draw sheet and frictionless sheet for lateral transfers and repositioning		↓ shoulder moment for air-assisted device versus slide board, draw sheet and frictionless sheet for lateral transfers and repositioning
Iridiastadi et al., 2020				↓ compression force with floor lift as compared to manual ↑ small amount of shear force with floor lift as compared to manual
Jäger et al., 2013				↓ compression loads using proper lifting versus no training lifting repositioning in bed and transfer to chair; ↓ compression loads using slide aide versus proper lifting repositioning in bed and transfer to chair	↓ torsional and lateral moments using proper lifting versus no training lifting transfer to chair; ↓ torsional and lateral moments using slide aide versus proper lifting repositioning in bed and transfer to chair
Katsuhira et al., 2008	↓ vertical ground reaction force when wearing back belt versus no back belt during seated transfer				↓ sagittal and lateral trunk moment when wearing back belt versus no back belt during seated transfer
Keir & MacDonell, 2004			↓ muscle activity in all eight muscles ceiling lift versus floor lift and manual lifting; ↓ muscle activity in all eight muscles floor lift versus manual lifting for bed to wheel chair and wheelchair to bed
Koppelaar et al., 2011		↓ exerted forces for lift device versus no lift device for repositioning and transfer
Kothiyal & Yuen, 2004			↑ muscle activity for erector spinae for sling device versus manual
Kotowski et al., 2022			↓ muscle activity in the latissimus dorsi, rectus abdominus, and external oblique with air-assisted device versus draw sheet for repositioning and lateral transfers	↓ lateral shear and compression with air-assisted device versus slide board, dual friction sheets and draw sheet for repositioning; ↓ A-P shear, lateral shear and compression with air-assisted device versus slide board, friction reducing board, dual friction sheets and draw sheet for lateral transfers
Law et al., 2022	↓ external forces with sliding board as compared to manual	↓ hand forces with sliding board reduced as compared to manual
Lloyd & Baptiste, 2006		↓ hand force with air-assisted device, lateral transfer device, slide boards, and frictionless sheet set versus draw sheet for lateral transfer tasks		↓ compression and A-P shear with air-assisted device, lateral transfer device, and frictionless sheet set versus draw sheet for lateral transfer tasks	↓ shoulder, elbow, and torso moments with air-assisted device, slide boards, lateral transfer device, and frictionless sheet set versus draw sheet for lateral transfer tasks
Marras et al., 2009				↓ A-P shear, lateral shear and compression with ceiling lift versus floor lift for patient transfer in room
McGill & Kavcic, 2005		↓ hand force with friction reducing covered board versus bed sheet during pushing and pulling lateral transfer	↓ extensor muscles with friction reducing covered board versus bed sheet during pushing and pulling lateral transfer	↓ A-P shear with friction reducing covered board versus bed sheet during pushing and pulling lateral transfer
Muona et al., 2022	↓ ground reaction forces with slide film as compared to regular sheet
Nelson et al., 2003			↓ muscle activity in shoulder and erector spinae with ceiling mounted lift, friction reducing device and stretcher that converts to a chair versus manual for transfer tasks	↓ compression force with ceiling mounted lift, friction reducing device, and stretcher that converts to a chair versus manual for transfer tasks	↓ shoulder and low back moments with ceiling mounted lift, friction reducing device and stretcher that converts to a chair versus manual for transfer tasks
Nevala & Tamminen-Peter, 2004			↓ muscle activity in erector spinae and trapezius with electrically adjustable shower trolley versus traditional shower trolley for shower tasks
Nussbaum & Torres, 2001				↓ compression and A-P shear for training in proper lifting versus none	↓ low back moment for training in proper lifting versus none
Potvin, 2017		No difference hand force between gait belt and no gait belt		No difference compression and shear between gait belt and no gait belt	No difference hip and knee moment between gait belt and no gait belt
Rice et al., 2009		↓ hand force with ceiling lift versus floor lift and stand-up lift for pushing and pulling of lifts
Riccoboni et al., 2021				↓ compression with motorless assisted device versus manual handling with 1 and 2 people during sitting and standing of person	↓ low back moment with motorless assisted device versus manual handling with 1 and 2 people during sitting and standing of person
Santaguida et al., 2005				↓ A-P shear and compression with ceiling lift versus floor lift for bed to wheelchair transfers
Schibye et al., 2003				↓ compression for training in proper lifting versus none for repositioning, elevate to seated position, bed to standing, and reposition in wheelchair; ↓ A-P shear for training in proper lifting versus none for turning, repositioning, elevate to seated position, and bed to standing	↓ trunk moment for training in proper lifting versus none for repositioning, elevate to seated position, bed to standing, and reposition in wheelchair
Silvia et al., 2002				↓ compression for Barton System versus 2-person draw sheet in lateral transfers; ↓ compression for Barton System and mechanical lift versus 1-person hug in bed to chair transfer; ↓ compression for Barton System versus 2-person and 1-person hug and 2-person draw sheet in chair to bed transfer; ↓ compression for Barton System versus 2-person (hug and 1-person hug and 2-person draw sheet in repositioning
Tang et al., 2018		↓ applied hand force for walking belt versus gait belt when transferring patient for males and females		↓ compression and A-P shear at L5/S1 for walking belt versus gait belt when transferring patient for males and females; ↓ compression at L4/L5 for walking belt versus gait belt when transferring patient for males and females; ↓ A-P shear at L4/L5 for gait belt versus walking belt when transferring patient for males and females	↓ elbow, shoulder, and trunk moment for walking belt versus gait belt when transferring patient for males and females
Theou et al., 2011			↓ number and duration of EMG bursts with slider system versus traditional bed sheet
Ulin et al., 1997				↓ compression for mechanical assist device (screw-activated, hydraulic, and electric) versus manual (pivot, slide board, and gait belt) for patient transfers	↓ shoulder moment for mechanical assist device (screw-activated, hydraulic, and electric) versus manual (pivot, slide board, and gait belt) for patient transfers
Vinstrup, et al., 2020			↓ muscle activity in erector spinae with ceiling lifts and intelligent beds versus manual, draw sheet, sliding sheet, and sliding boards during patient transfers
Waters et al., 2012		↓ hand forces with ceiling lift versus floor lift for patient transfers with larger differences for carpet		↓ compression with ceiling lift versus floor lift for patient transfers with larger differences for carpet
Wiggermann, 2016		↓ hand forces with turn assist versus manual turning and lateral repositioning of patient in bed		↓ compression and A-P shear with turn assist versus manual turning and lateral repositioning of patient in bed	No difference in shoulder moment for turn assist versus manual turning and lateral repositioning of patient in bed
Wiggermann et al., 2021		↓ hand forces with air-assisted device and friction reducing sheets versus draw sheet and glide sheet during repositioning; ↓ hand forces with air-assisted device and friction reducing sheets versus draw sheet during lateral transfer; ↓ hand forces with turn assisted device versus manual during turning	↓ muscle activity in brachialis with air-assisted device and friction reducing sheets versus draw sheet and glide sheet during repositioning	↓ compression with air-assisted device versus draw sheet, friction reducing sheets, and glide sheet during repositioning; ↓ compression with air-assisted device and friction reducing sheets versus draw sheet during lateral transfer
Zhuang et al., 1999		↓ hand force when placing sling and using ceiling lift versus manual with gait belt when positioning for transfer; ↑ hand force for trunk when stand-up lift and sliding board versus manual with gait belt when positioning for transfer		↓ compression when placing sling and using ceiling lift versus manual with gait belt when positioning for transfer

ORCID iD

Kermit G. Davis https://orcid.org/0000-0001-8080-8138