By Lunne D. Maffeo, MSPT; Kimberly A. Vida, MSPT; Barbara F. Murray, MSPT; and Frankie Gilliam Harrison, DrPH, PT
The health care environment can be a hazardous place to work, despite the fact that the environment exists for the purpose of providing treatment to others who are ill or have been injured. The National Safety Council estimates that hospital workers are twice as likely as employees in other service industries to sustain work-related injuries.1 Among hospital workers, nurses have the highest incidence of job-related injuries.2 On-the-job injuries account for many incidents of lost work time for health care workers every year. Although many studies have examined work-related injuries among nursing personnel and health care workers in general, there is little current literature that addresses incidents of these injuries among physical therapists.3 Activities such as lifting and transferring patients are often cited as precipitating work-related injuries.3 These activities are performed routinely by nurses and physical therapists alike, especially in acute and long-term care facilities. There are few statistics available that disclose the nature and incidence of work-related injuries. However, those statistics that do exist suggest that hands-on patient activities place physical therapists at the greatest risk for injury.4 In the study by Holder et al, physical therapists and physical therapist assistants reported sustaining more occupational injuries to the low back than to any other anatomical area.5 The physical therapist respondents reported that the second most prevalent injury site was to the upper back and wrist/hand equally. Physical therapist assistant respondents in the same study reported the upper back as the second most prevalent site of injury. The incidence of injury to a specific anatomical area varied with the practice setting. The three most often reported activities performed at the time of injury were transferring a patient, lifting, and responding to an unanticipated or sudden movement by a patient.5 Our study replicated one conducted at the University of Iowa.6 These researchers found that the highest prevalence of work-related injuries among physical therapists was in the areas of the low back (45%), wrist/hand (29.6%), upper back (28.7%), and neck (24.7%). Bork et al also found that work setting, practice specialty, age of patient, and gender of therapist affected the prevalence of work-related injury. Physical therapists working in hospitals reported a higher prevalence of work-related injuries in every anatomical area except the wrists, hands, hips, and thighs. Female physical therapists had a higher prevalence of musculoskeletal symptoms in every anatomical area except the knees than did male counterparts. The activity most likely to contribute to work-related injuries was lifting or transferring dependent patients.6 A study conducted by Molumphy et al looked more specifically at the incidence of work-related low back pain (LBP) in physical therapists.7 Of the therapists surveyed, 29% reported having experienced work-related LBP. Molumphy et al found a negative correlation between the incidence of work-related LBP and number of years of experience, work setting, and age of the therapist; 64% of the physical therapists who reported work-related LBP were between the ages of 21 and 30 years, and more than half reported that initial episodes occurred during the first 4 years of practice. The two most common work settings in which physical therapists reported having sustained work-related LBP were acute care (46%) and rehabilitation (25%). The primary mechanism of injury was lifting with sudden maximal effort by 24% of respondents. An additional 24% of respondents indicated the injury mechanism was bending and twisting. Our study determined the incidence of work-related musculoskeletal injuries sustained by physical therapists currently licensed and practicing in Arizona in mid-1998. The purpose of our study was to identify causes of physical therapists’ work-related injuries and to increase the body of knowledge regarding these injuries. A total of 410 licensed Arizona physical therapists were randomly selected from the 1997 Arizona Physical Therapy Association Directory. Forty-six questionnaires were returned by the US Postal Service because of inadequate or incorrect addresses. The remaining 364 questionnaires were assumed to have reached the selected therapists. Each potential participant received a questionnaire and accompanying cover letter. Therapists were asked to return the questionnaire within 2 weeks. A second mailing took place approximately 3 weeks after the first. A total of 206 questionnaires were returned from both mailings. The self-administered questionnaire was adapted from a survey instrument used by Bork et al in their 1996 study. The modified instrument included three sections: demographics, symptom survey, and job injury. Of the 206 questionnaires completed and returned, 12 were eliminated from the sample because therapists had retired from the profession, were employed in management only, or were employed in a field other than physical therapy. Therefore, the total number of questionnaires utilized for data analysis was 194, yielding a 56.5% response rate. The age group most frequently represented was the 30-34 year old group, which comprised 22.7% of the respondents (n=194). Sixty-one females accounted for 31.4% of the sample, while 133 men accounted for 68.6%. The majority of respondents (39.2%) reported that they had been physical therapists for more than 15 years. A comparable percentage (38.1%) had been treating patients for more than 15 years. The majority (77.3%) of respondents had been working full time as physical therapists in the preceding 12 months. INJURIES BY ANATOMICAL AREA Seventy-one respondents (36.6%) reported sustaining work-related injuries in the previous 12 months. These injuries were to the wrist and hands (10.8%), low back (10.3%), elbows (4.6%), upper back (4.1%), neck or shoulders (2.6% each), knees (1.5%), and ankles or feet (0.52%). None of the respondents reported having sustained a work-related injury to the hips or thighs in the previous 12 months. Data regarding injuries by work setting appear in Table 1 (see page 36). The most common work setting in which respondents worked was outpatient private practice (n=53, 27.3%). This setting was followed by outpatient hospital (n=32, 16.5%), skilled nursing/extended care facility (n=29, 14.9%), acute care (n=18, 9.3%), and home health (n=17, 8.8%). Of the 20 low back injuries sustained by respondents in the current study, half occurred in outpatient hospital/private work settings. Similarly, 12 of the 21 wrist/hand injuries (57.1%) were sustained in outpatient work settings. MECHANISM OF INJURY The mechanism of injury most frequently described by respondents was lifting (30.5%), manual therapy (19.5%), bending (17.0%), and twisting (11.0%). Some injuries were sustained by more than one mechanism, such as simultaneously lifting and twisting. One respondent claimed to have simultaneously sustained injuries to the neck, upper back, shoulders, elbows, and wrists/hands while performing a manual therapy treatment. Another respondent reported a knee injury that was caused by excessive kneeling in an outpatient private practice. A summary of these results appears in Table 2. (see page 38). DISPOSITION FOLLOWING INJURY Of the 71 respondents who reported having sustained a work-related injury in the previous 12 months in any anatomical area, only five (7.0%) reported that they had been prevented from doing their day’s work as a result of the injury. To obtain care for work-related injuries, respondents reported seeking treatment from a colleague (n=31, 32.3%) or a physician (n=16, 16.7%). More than half reported treating themselves for their injuries. Therapists working in private practice outpatient settings reported a higher incidence of injuries in every anatomical area except the hips/thighs and ankles/feet. Therapists employed in either type of outpatient setting (hospital or private practice) sustained a similar number of injuries to the knees. Thirty-eight percent of outpatient physical therapists injured were employed by private practice settings and 17% were employed in hospitals. The high incidence of injuries in outpatient settings may be due to the fact that more surveys were returned by male therapists employed in this work setting. Slightly more therapists in the current study sustained injuries to the wrists/hands (10.8%) than to any other anatomical area. Respondents reported that 52.3% of these injuries were due to performing manual therapy techniques. Therapists who routinely perform manual therapy sustained more injuries to the wrists/hands than those that did not. A chi square analysis of this difference was significant (P = .0357). These findings are consistent with past studies on upper extremity repetitive stress injuries caused by manual therapy techniques.6 The results of our study appear to indicate that the incidence of work-related musculoskeletal-skeletal injuries is heavily influenced by the work setting in which a physical therapist practices. The highest prevalence rate for injuries occurred in outpatient private practice, outpatient hospital, and acute care, respectively. Therapists in outpatient facilities sustained more wrist/hand injuries than their hospital-based counterparts, since 12 of the 21 reported wrist/hand injuries occurred in the former setting. This finding is related to the considerable amount of manual therapy performed in this treatment setting and possibly to the large percentage of male respondents. The high incidence rate, apparently from routine performance of wrist and hand activities, may be due to the hands-on nature of the orthopedic setting. In this particular setting, it is common to see an increased use of soft-tissue/joint mobilization on a repetitive basis. Because this is a skilled procedure, the physical therapist, not the physical therapy assistant, is usually the provider that must perform this service. This may account for the high incidence of repetitive strain injuries and overuse conditions sustained by therapists who frequently perform these daily activities. Of the 21 wrist/hand injuries reported, 11 respondents (52.3%) cited manual therapy activities as the mechanism of injury. These findings suggest that manual therapy techniques are a major source of upper limb musculoskeletal-skeletal stress, as documented by the Bork study. In comparison, the study conducted by Bork et al determined that the most common mechanisms of injury were lifting or transferring dependent patients, catching patients during falls, and lifting heavy equipment. The most common mechanism of injury in Molumphy’s study was said to be lifting with sudden maximal effort by 24% of the respondents. An additional 24% said the injury mechanism most implicated was bending and twisting. Although we found that a moderate number of physical therapists (36.6%) experienced work-related, musculoskeletal-skeletal injuries, very few (2.6%) missed work due to these conditions. Of the five respondents that did miss work, three sustained injuries to the low back and two to the wrists/hands. The percentage of physical therapists in the current study who sought treatment from a physician for their injury was also very low (16.7%). Seven of these injuries were to the low back and five were to the wrists/hands. Since a large percentage of respondents sought treatment from a colleague or treated their own injury, a visit to a physician or the need for absence from work was most likely not warranted. There is also the possibility that these same therapists continued to work in an injured state. One limitation of our study was the failure to use a stratified, random sampling technique. This resulted in a somewhat skewed respondent pool. Because respondents were predominately male, their responses may have been more representative of therapists working in outpatient private practice settings.8 The decidedly male cohort of respondents may also have contributed to the small percentage of individuals who were prevented from doing their day’s work. Nevertheless, our findings shed light on the types and mechanisms of musculoskeletal injuries of Arizona physical therapists in a variety of employment settings. Lynne D. Maffeo, MSPT, and Kimberly A. Vida, MSPT, are part-time pediatric home health physical therapists at REM Arizona Rehabilitation, Phoenix. Vida is also a part-time staff physical therapist for Glendale Union High School District, Glendale, Ariz. Barbara F. Murry, MSPT, received her master of science, physical therapy degree at the Arizona School of Health Sciences, Kirksville College of Medicine, and Frankie Gilliam Harrison, DrPH, PT, is an associate professor in the Physical Therapy Program at the Arizona School of Health Sciences, Kirksville College of Osteopathic Medicine. REFERENCES 1. Stellman JM. Safety in the healthcare industry. Occupational Health Nursing. 1982;10:17-21. 2. Lewy R. Prevention strategies in hospital occupational medicine. J Occup Med. 1981;23:109-111. 3. Harber P, Billet E, Gutowski M, et al. Occupational low-back pain in hospital nurses. J Occup Med. 1985;27:518-524. 4. Fosnaught M. Injuries on the job: PTs at risk. PT Mag Phys Ther. 1999;7:34-40. 5. Holder NL, Clark HA, DiBlasio JM, et al. Cause, prevalence, and response to occupational musculoskeletal-skeletal injuries reported by physical therapists and physical therapist assistants. Phys Ther. 1999;79:642-652. 6. Bork BE, Cook TM, Rosecrance JC, et al. Work-related musculoskeletal-skeletal disorders among physical therapists. Phys Ther. 1996;76:827-835. 7. Molumphy M, Unger B, Jensen GM, Lopopolo RB. Incidence of work-related low back pain in physical therapists. Phys Ther. 1985;65:482-486. 8. 1996 Active & Affiliate Membership Profile Report. Alexandria, Va: American Physical Therapy Association; 1996.
