HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Holder, N. L Articles by Shepard, K. F Search for Related Content PubMed PubMed Citation Articles by Holder, N. L Articles by Shepard, K. F

Cause, Prevalence, and Response to Occupational Musculoskeletal Injuries Reported by Physical Therapists and Physical Therapist Assistants

NL Holder, PT, is Staff Physical Therapist, Penn Therapy and Fitness at Westampton, 798 Woodlane Sq, Suite 11, Westampton, NJ 08060 (USA) (nholder{at}mail.med.upenn.edu).
HA Clark, PT, is Staff Physical Therapist, Lehigh Valley Hospital, Allentown, Pa
JM DiBlasio, P T, is Staff Physical Therapist, Vermont Sports Medicine Center, Rutland, Vt
CL Hughes, PT, is Staff Physical Therapist, Pinnacle Health System, Harrisburg, Pa
JW Scherpf, PT, is Staff Physical Therapist, VA Medical Center, Bay Pines, Fla
L Harding, PT, OCS, is Assistant Professor, Department of Physical Therapy, Temple University, Philadelphia, Pa
KF Shepard, PhD, PT, FAPTA, is Professor, Department of Physical Therapy, Temple University

Address all correspondence to Ms Holder

Submitted May 18, 1998; Accepted March 7, 1999

	Abstract

 
Background and Purpose. Physical therapists (PTs) and physical therapist assistants (PTAs) are susceptible to occupational musculoskeletal injuries. The purpose of this study was to examine the reported causes and prevalence of occupational musculoskeletal injuries to PTs and PTAs during a 2-year period. Subjects. A questionnaire was mailed to 500 PTs and 500 PTAs randomly selected from the American Physical Therapy Association 1996 active membership list. Six hundred sixty-seven questionnaires were returned, giving a response rate of 67%. Method. Based on a literature review and a pilot study, an occupational injury questionnaire was constructed and mailed. Self-reports of injuries were obtained. Results. Thirty-two percent of the PTs and 35% of the PTAs reported sustaining a musculoskeletal injury. The highest prevalence of injury was to the low back (62% of injured PTs and 56% of injured PTAs). The PTs reported the upper back and the wrist and hand as having the second highest prevalence (23%). The PTAs reported the upper back as having the second highest prevalence (28%). The PTs and PTAs reported making changes in their work habits of improved body mechanics, increased use of other personnel, and frequent change of work position. The majority of PTs and PTAs reported they did not limit patient contact time or area of practice after sustaining an injury. Conclusion and Discussion. Although PTs and PTAs are recognized to knowledgeable in prevention and treatment of musculoskeletal injuries, they are susceptible to sustaining occupational musculoskeletal injuries because of performing labor-intensive tasks.

Key Words: Musculoskeletal injury • Occupational injury • Physical therapy

	Introduction

Top Abstract Introduction Method Results Discussion Conclusions Appendix References

 
An occupational injury can be defined as an injury that results from a work-related event or from a single instantaneous exposure in the work environment leading to death, lost work time, medical treatment other than first aid, loss of consciousness, work restriction, or transfer to another job.¹ A Bureau of Labor Statistics investigation of occupational hazards in health care settings showed that injury rates among health care workers are high.¹ The injury rate among hospital workers, for example, has been estimated to be twice that of other service industries.² Activities involving patient contact are highly correlated with occupational injuries among health care workers.³ High levels of patient contact, as well as other variables in the health care environment that are thought to cause injuries, are common in the field of physical therapy.

The practice of physical therapy requires the performance of many labor-intensive tasks related to the delivery of patient care. Such activities include lifting, bending, twisting, reaching, performing manual therapy, and maintaining awkward positions for a prolonged period of time.⁴ Therefore, physical therapists (PTs) and physical therapist assistants (PTAs) are susceptible to musculoskeletal injuries.

A number of researchers^3,5–12 have investigated occupational injuries within health care settings (Tab. 1). The majority of these researchers have focused on nurses and nurses' aides. The results of these studies indicate that between 6% and 67% of health care workers studied in a variety of settings have experienced a work-related injury.^3,5–12

Scholey and Hair¹⁴ studied the incidence of back pain in the United Kingdom among PTs as compared with other occupations (control group). There were no differences between the 2 groups for lifetime prevalence, annual prevalence, annual incidence, and point prevalence for LBP.

Bork et al⁴ investigated the prevalence of work-related musculoskeletal disorders (WMD) during a 12-month period and factors that may be associated with these disorders among PTs. The 3 most common areas of injury reported by the 928 therapists who returned the survey instrument were the low back (45%), the wrist and hand (29.6%), and the upper back (28.7%). Lifting or transferring patients was identified as the factor most likely to be associated with the development of WMD. Treating a large number of patients in 1 day, working in awkward positions, working in the same position for long periods of time, and performing manual orthopedic techniques were also considered "major problems." Based on the literature, it appears that, although PTs have knowledge of and clinical expertise in musculoskeletal injuries, this does not grant them immunity from developing WMD.

Our study was designed to add information and increase our understanding of occupational musculoskeletal injuries beyond that of the previously published studies regarding PTs. In particular, in contrast to the study by Bork et al,⁴ we surveyed both PTs and PTAs and attempted to obtain information on responses to injury and how work habits or work settings were changed as a result of injury. The purpose of our study was to examine the causes, prevalence, and response to occupational musculoskeletal injuries reported by PTs and PTAs.

	Method

Top Abstract Introduction Method Results Discussion Conclusions Appendix References

 
Sample and Procedure

A total of 1,000 PTs and PTAs (500 each) were randomly selected from the 1996 American Physical Therapy Association (APTA) membership list representing members from all 50 states employed in a broad spectrum of practice settings. Although the equal numbers of PTs and PTAs selected do not reflect the ratio of PTs to PTAs in the Association, injury rates were not hypothesized to be related to APTA membership. A survey questionnaire was mailed to the PTs and PTAs selected from the membership list, and they were asked to complete the questionnaire if they had at least 2 years of experience in practice. Those with fewer than 2 years of clinical experience were encouraged to pass the questionnaire on to a PT or PTA colleague who met this qualification. A cover letter was mailed along with the questionnaire to explain the purpose of the study and to assure confidentiality. A self-addressed stamped envelope was provided to facilitate a high response rate. A reminder postcard was sent to all randomly selected PTs and PTAs 1 week after the initial mailing, and a second questionnaire was sent to those who had not responded 3 weeks after the initial mailing. The envelopes were number coded to facilitate follow-up on respondents and, upon return, were separated from the enclosed questionnaire and discarded.

Instrumentation

The survey instrument was a self-administered 2-page questionnaire composed of predominately closed-ended questions (Appendix). The demographics portion of the questionnaire was designed to obtain general information, including gender, age, weight, height, years of experience, setting and state in which employed, and hours of patient contact. The remainder of the questionnaire elicited information pertaining to job-related musculoskeletal injuries. Respondents who had been injured were asked about the type of injury incurred and the body part affected, the activity being performed at the time of injury, the work setting in which the injury occurred, and whether the injury was reported and a physician was consulted. They were also asked whether there was time lost from work as a result of the injury, what activities caused symptoms to recur, and whether the injury caused the respondent to alter his or her work habits, reduce patient contact hours, or change employment setting.

The initial questionnaire was developed based on a literature review and preliminary interviews with 15 practicing PTs and PTAs who met the sampling criteria. The questionnaire was then reviewed by a panel of 5 PTs and PTAs with 5 or more years of experience. Revisions were based on the recommendations made by the panel. We believe these revisions established face and content validity. A final version of the questionnaire was prepared prior to mailing in an effort to corroborate as well as expand on the work of Bork et al.⁴

To determine the reliability of the survey responses, we asked a small sample of convenience consisting of 7 PTs and 6 PTAs who had experienced occupational musculoskeletal injuries to complete the questionnaire. Two weeks later, they again completed the questionnaire. Test-retest percentage of agreement was calculated and found to average 98% (range=92%–100%). The areas of the questionnaire most susceptible to discrepancy were the demographics section (notably height and weight reports) and, in the recent injuries section regarding altered work habits as a result of the injury, responses to the question "What do you do differently?"

Data Analysis

A cross-sectional design was used in an effort to determine what the PTs and PTAs thought were the causes and prevalence of their occupational musculoskeletal injuries. Prevalence rates for the 2-year period were calculated by dividing the number of PTs and PTAs who reported any injury by the total number of respondents. Prevalence was calculated by dividing the number of respondents with injuries of specific anatomical areas by only those reporting an injury. The same method was used to calculate prevalence rates for the activity being performed when injured, setting of injury occurrence, response to injury, exacerbation of symptoms, and changed work habits as a result of injury for PT and PTA respondents.

All questionnaires were analyzed using the Statistical Package for Social Sciences (SPSS version 4.1 for IBM) computer software program.^* Descriptive statistics were used to compare the demographics of the respondents in our survey with the demographics reported in APTA's 1996 Active & Affiliate Membership Profile Report.¹⁵ Nonrespondents were compared with respondents by job title and sex. The mean, standard deviation, and range were calculated for age, height, weight, years of experience, and hours per week in direct patient care of all respondents. Chi-square distributions were used to assess the statistical significance of observed differences among the subgroups by various work settings and personal characteristics. The Fisher exact 2-tail test, continuity correction, and likelihood ratio were used to determine the level of statistical significance.

	Results

Top Abstract Introduction Method Results Discussion Conclusions Appendix References

 
Demographics

Of the 1,000 survey instruments mailed, 667 were returned, producing a 67% response rate. Forty-four survey instruments were returned with inappropriate responses (eg, not meeting the criteria of having 2 years or more of experience) and had to be excluded from the study. Of the 623 usable survey instruments, 370 were completed by PTs and 253 were completed by PTAs.

The PTs and PTAs who responded were similar with respect to age, height, weight, and hours per week spent in direct patient care, but they were different in years of experience. Physical therapists had an average of 13 years of work experience, whereas PTAs had an average of 7 years of work experience. Additional descriptive and demographic information is presented in Tables 2 and 3. These findings indicate that our data were obtained from a subset that closely resembles the sex ratio according to APTA's 1996 Active & Affiliate Membership Profile Report.¹⁵

Four hundred fifteen (67%) of the remaining 623 respondents reported they had not sustained a musculoskeletal injury within the last 2 years. The remaining 208 respondents (33%) reported they had sustained such an injury. Thirty-two percent of all PT respondents and 35% of all PTA respondents reported sustaining a musculoskeletal injury.

Injuries to Anatomical Areas

The PT and PTA respondents reported the highest level of occupational injury in the low back (62% and 56%, respectively). The PTs reported the upper back and the wrist and hand equally as their second most prevalent site of injury (23%). The PTAs also reported the upper back as their second most prevalent site of injury (28%) (Fig. 1). The highest injury prevalence was seen in PTs and PTAs aged 21 to 30 years who worked between 41 and 50 hours per week. Years of experience had no effect on injury prevalence in PTs (²=8.13, P.087) or PTAs (²=0.75, P.94).

View larger version (54K): [in this window] [in a new window] Figure 1. Percentage of respondents who reported sustaining a musculoskeletal injury, missing work, and visiting a physician compared by anatomical area. Asterisk (*) indicates only those respondents reporting an injury (PTs=119, PTAs=88). PT=physical therapist, PTA=physical therapist assistant.

Injury Type

The most common type of injury reported by PT and PTA respondents was a muscle strain (69% and 78%, respectively). For PTs, ligament sprain (28%) and vertebral disk involvement (16%) followed muscle strain in order of reported prevalence. For PTAs, tendinitis (15%) and ligament sprains (14%) followed muscle strain in order of reported prevalence. The only statistically significant finding was that PTs had more (²=5.08, P.024) ligamentous sprains than PTAs had.

Activity Being Performed When Injured

Both PT and PTA respondents reported on activities they were performing at the time of injury. The 3 most prevalent activities were transferring a patient (PTs=30%, PTAs=36%), lifting (PTs=25%, PTAs=24%), and responding to an unanticipated or sudden movement by a patient (PTs=24%, PTAs=33%). Performing manual therapy was the fourth most prevalent activity for PTs at 21% (Tab. 4).

Seventy percent of the PT respondents and 68% of the PTA respondents who sustained a work-related musculoskeletal injury reported that their symptoms were exacerbated by clinical practice. Physical therapists reported that the top 4 activities that caused recurrence of symptoms were maintaining a position for a long period of time (36%), lifting (35%), transferring a patient (30%), and performing manual therapy (28%). The top 4 activities that caused recurrence of symptoms in PTAs were lifting (26%), maintaining a position for a long period of time (24%), transferring a patient (24%), and working in an awkward or cramped position (20%) (Tab. 5).

View larger version (69K): [in this window] [in a new window] Figure 2. Percentage of respondents who reported having a musculoskeletal occupational injury over a 2-year period. PT=physical therapist, PTA=physical therapist assistant.

	Discussion

Top Abstract Introduction Method Results Discussion Conclusions Appendix References

We found that a large number of PTs (57%) reported visiting a physician after a neck injury compared with injuries to other anatomical areas. In addition, a large number of PTAs (54%) missed at least a half day of work following a neck injury when compared with other injuries. We did not ask our subjects, but further investigation could be initiated to determine whether there were any radiating symptoms or neurological signs associated with this high response rate. In contrast to our study, Bork et al⁴ found that PTs who reported sustaining an injury to the low back were more likely to miss work.

The high prevalence of occupational musculoskeletal injury to the low back among PTs (62%) and PTAs (56%) in our study is similar to results found by other researchers investigating the prevalence of LBP among health care workers. Bork et al⁴ found a 12-month prevalence of LBP of 45%. Molumphy et al¹³ found the prevalence of job-related LBP to be 29% when they surveyed 344 PTs. In a study by Scholey and Hair,¹⁴ the prevalence of LBP in 243 PTs in Great Britain was found to be 38%. When compared with previous studies,^6,7,9,10 our results confirm that PTs and PTAs have one of the highest prevalence rates for back injury of those health care workers reporting injuries.

The anatomical location of the injury showed similar trends to those reported by Bork et al.⁴ As in the study by Bork et al⁴, the low back, the upper back, and the wrist and hand were the most frequently injured body parts among the PTs and PTAs in our study. Our reports of knee, ankle, and foot injuries, however, were substantially lower than those found by Bork et al.⁴ Again, we attribute this finding to the differences in the survey instruments used in the 2 studies. For example, PTs may experience an ache or discomfort in their feet, ankles, and knees from prolonged periods of standing or poor body mechanics, but this ache or discomfort may not be classified as a true injury from a single instantaneous event.

There are similarities between the findings of previous studies and our findings in regard to the activities that respondents were engaged in when injured on the job.^3,4,12,14 The most common activities found to cause occupational musculoskeletal injury were transferring patients, lifting, and responding to an unanticipated or sudden movement by a patient. Bork et al⁴ also found other problematic activities to be treating a large number of patients in 1 day, working in awkward or cramped positions, not enough rest breaks, and working in the same position for long periods.

Unlike previous research, we investigated the type of injury sustained by PTs and PTAs. Nelson and Olson³ found that sprains and strains were the most frequently reported injuries among all health care workers in a rural health facility. The most common type of injury reported in our study was a muscle strain. We also found that PTs reported having more ligament sprains than PTAs reported having. We asked the PTs and PTAs in our study what type of injury they experienced; we did not ask for a medical diagnosis. This approach may have led to reporting of self-diagnoses, which we believe could have led to questionable data regarding injury type.

Physical therapists practicing in rehabilitation settings and PTAs practicing in hospital settings at the time of injury reported more low back injuries than their colleagues in other practice settings reported. Physical therapists and PTAs are more likely to perform patient transfers and lifts (activities commonly found to be a mechanism of low back injury) in the settings where patients are more dependent. Practice setting proved to be a relevant factor for PTs sustaining wrist or hand injuries when compared with other setting or injury profiles. Thirty-eight percent of PTs in SNFs and 32% of PTs in outpatient settings reported experiencing a wrist or injury. We expected to find a high prevalence rate for wrist and injuries in outpatient facilities, where there may be a higher likelihood of manual therapy techniques being performed. Bork et al⁴ found that PTs who regularly performed manual therapy were 3.5 times more likely to sustain a wrist or hand work-related injury than PTs who did not routinely perform manual therapy. We are unsure as to the reason for the high prevalence of wrist and hand injuries in SNFs.

A high percentage of PTs (70%) and PTAs (68%) who reported sustaining work-related musculoskeletal injuries also reported having their symptoms exacerbated by clinical practice. The top 3 activities that caused recurrence of symptoms for both PTs and PTAs were maintaining a position for a long period of time, lifting, and transferring a patient. A high percentage of PTs also reported that performing manual therapy caused symptoms to recur.

In our study, a large percentage of PTs (79%) and PTAs (81%) reported that they altered their work habits as a result of their injury. These figures indicate that the respondents felt that a change in work habits was required in order to decrease the risk of another injury. These figures also demonstrate that a large percentage of respondents believed they had some control over the recurrence of their injury. The work habits most commonly changed were body mechanics, increased use of other personnel, and changing work position frequently. A very small percentage of respondents (PTs=4%, PTAs=2%) increased their administrative time and decreased patient contact time. Poor body mechanics often results in some insult to the back. Because a high percentage of PTs (62%) and PTAs (56%) reported a low back injury, it was not surprising to see a change in body mechanics as the most cited area of improvement. The vast majority of PTs and PTAs surveyed did not limit their patient contact time, limit their area of practice, or consider changing jobs due to their injury or risk of another injury. This finding demonstrates their tendency to work through injuries without disrupting their daily routine or career.

In our opinion, future research should be directed toward determining the efficacy of intervention programs that might be used to decrease the incidence of work-related musculoskeletal injuries for PTs and PTAs. To determine whether job-related injuries differ among clinical specialty areas, further research is needed. Another idea for future studies is to take a closer look at the relationship of injuries sustained by manual therapists.

	Conclusions

Top Abstract Introduction Method Results Discussion Conclusions Appendix References

 
The prevalence of work-related musculoskeletal injuries reported by PT and PTA respondents was highest in the low back and the upper back. The most common type of injury reported by both PT and PTA respondents was a muscle strain. The 3 most prevalent activities performed at the time of the injury were transferring a patient, responding to an unanticipated or sudden movement by a patient, and lifting. Seventy percent of the PT respondents and 68% of the PTA respondents who reported sustaining a work-related musculoskeletal injury also reported that their symptoms were exacerbated by clinical practice. They reported that the top 3 activities that caused recurrence of symptoms were maintaining a position for a long period of time, lifting, and transferring patients. For PTs, performing manual therapy was also highly reported. Most of the PTs and PTAs who reported sustaining an injury admitted to altering their work habits as a result of the injury. The most cited area of change was improvement in body mechanics.

Labor-intensive tasks appear to make PTs and PTAs susceptible to occupational musculoskeletal injuries. Because our findings indicate that few PTs and PTAs change their level of patient contact of change jobs due to injury, occupational injury preventions programs should be developed to limit PTs' and PTAs' susceptibility to work-related injuries.

	Appendix

Top Abstract Introduction Method Results Discussion Conclusions Appendix References

 

View larger version (113K): [in this window] [in a new window] Appendix. Occupational Injuries in Physical Therapy Survey Questionnairea

	Footnotes

 
Concept and research design were provided by Holder, Clark, DiBlasio, Hughes, Scherpf, Harding, and Shepard; writing, by Holder, DiBlasio, Hughes, Scherpf, and Shepard; data collection, by Holder, DiBlasio, Hughes, and Scherpf, with collection tool construction by Shepard; data analysis, by Holder, Hughes, and Shepard; project management, by Shepard; fund procurement, by Hughes; clerical/secretarial support, by Holder; and consultation (including review of manuscript prior to submission), by Holder and Hughes.

Ms Holder, Ms Clark, Mr DiBlasio, Ms Hughes, and Mr Scherpf were students in the Master of Physical Therapy Program at Temple University at the time this study was conducted in partial fulfillment of their degree requirements.

This study was approved by the Institutional Review Board of Temple University.

^* SPSS Inc, 444 N Michigan Ave, Chicago, IL 60611.

	References

Top Abstract Introduction Method Results Discussion Conclusions Appendix References

 

1. Occupational Injuries and Illnesses in the United States by Industry, 1992. Washington, DC: US Department of Labor, Bureau of Labor Statistics;1992 .
2. Stellman JM. Safety in the health care industry. Occup Health Nurs.1982; 30:17–21.[Medline]
3. Nelson ML, Olson DK. Health care worker incidents reported in a rural health care facility: a descriptive study. AAOHN J.1996; 44:115–122.[Medline]
4. Bork BE, Cook TM, Rosecrance JH, et al. Work-related musculoskeletal disorders among physical therapists. Phys Ther.1996; 76:827–835.[Abstract/Free Full Text]
5. Wilkinson WE, Salazar MK, Uhl JE, et al. Occupational injuries: a study of health care workers at a northwestern health science center and teaching hospital. AAOHN J.1992; 40:287–293.[Medline]
6. Myers A, Jensen RC, Nestor D, et al. Low back injuries among home health aides compare with hospital nursing aides. Home Health Services Quarterly.1993; 14:149–155.
7. Smith WA, White MC. Home health care: occupational health issues. AAOHN J.1993; 41:180–184.[Medline]
8. Schwartz RJ, Benson L, Jacobs LM. The prevalence of occupational injuries in EMTs in New England. Prehospital and Disaster Medicine.1993; 8:45–50.
9. Stubbs DA, Buckle PW, Hudson MP, et al. Back pain in the nursing profession, I: epidemiology and pilot methodology. Ergonomics.1983; 26:755–765.[Medline]
10. Harber P, Billet E, Gutowski M, et al. Occupational low-back pain in hospital nurses. J Occup Med.1985; 27:518–524.[ISI][Medline]
11. Vasiliadou A, Karvountzis GG, Soumilas A, et al. Occupational low-back pain in nursing staff in a Greek hospital. J Adv Nurs.1995; 21:125–130.[ISI][Medline]
12. Arad D, Ryan MD. The incidence and prevalence in nurses of low back pain: a definitive survey exposes the hazards. Aust Nurses J.1986; 16:44–48.[Medline]
13. Molumphy M, Unger B, Jensen GM, Lopopolo RB. Incidence of work-related low back pain in physical therapists. Phys Ther.1985; 65:482–486.[Abstract/Free Full Text]
14. Scholey M, Hair M. Back pain in physiotherapists involved in back care education. Ergonomics.1989; 32:179–190.[Medline]
15. 1996 Active & Affiliate Membership Profile Report. Alexandria, Va: American Physical Therapy Association,1996 .

This article has been cited by other articles:

				J. E Cromie, V. J Robertson, and M. O Best Physical Therapists Who Claimed Workers' Compensation: A Qualitative Study Physical Therapy, December 1, 2003; 83(12): 1080 - 1089. [Abstract] [Full Text] [PDF]

				J. E Cromie, V. J Robertson, and M. O Best Work-Related Musculoskeletal Disorders and the Culture of Physical Therapy Physical Therapy, May 1, 2002; 82(5): 459 - 472. [Abstract] [Full Text] [PDF]

				J. E Cromie, V. J Robertson, and M. O Best Occupational Injuries in PTs Physical Therapy, May 1, 2000; 80(5): 529 - 530. [Full Text]

This Article Abstract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Holder, N. L Articles by Shepard, K. F Search for Related Content PubMed PubMed Citation Articles by Holder, N. L Articles by Shepard, K. F