The lifetime prevalence of work-related thumb and wrist pain among physiotherapists in Bloemfontein

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1 ORIGINAL RESEARCH PEER REVIEWED Barnes R, 1 Colyn HJ, 2 Moolman C, 2 Roux Z, 2 Schabort DJ, 2 Yzel ME, 2 and Raubenheimer J, 3 1 Lecturer, Department of Physiotherapy, University of the Free State. 2 4th year Physiotherapy Students, University of the Free State. 3 Biostatistician, Department of Biostatistics, University of the Free State. Corresponding author: Mrs Roline Barnes, Department of Physiotherapy, Faculty of Health Sciences, University of the Free State, P O Box 339 (G30), Bloemfontein, South Africa Tel: +27 (0) BarnesRY@ ufs.ac.za The lifetime prevalence of work-related thumb and wrist pain among physiotherapists in Bloemfontein ABSTRACT International studies have shown that due to the physical nature of their work, physiotherapists are at risk for developing work-related musculoskeletal thumb and wrist pain. No relevant South Africa studies were identified. The aims of the study were to retrospectively investigate the lifetime prevalence of thumb and wrist pain among physiotherapists in Bloemfontein and determine the contributing risk factors. A descriptive study using a questionnaire was conducted, and 88 of the 102 physiotherapists in Bloemfontein participated. The lifetime prevalence of workrelated thumb and wrist pain was 62.5% (CI ). The main contributing risk factors were orthopaedic mobilisation/manipulations, soft tissue mobilisations and massage. Participants were convinced their work was influenced by their pain experienced and that their symptoms were exacerbated by clinical practice. Further research is needed on aspects of the job and work practices that contribute to injury to formulate preventative strategies. Key words: physiotherapists, work-related thumb and wrist pain, lifetime prevalence, risk factors INTRODUCTION The survivors are those who develop strategies for coping with the physical demands of the job and who continue to treat patients. 1 International research studies 1,2 suggest that musculoskeletal injuries among healthcare workers are Source: common and physiotherapists are no exception, despite their specialist knowledge of body mechanics and injury prevention. The World Health Organization (WHO) (1985) defined a work-related musculoskeletal disorder (WMSD) as one that arises when an individual is exposed to work activities and work conditions that signifi cantly contribute to its development or exacerbation, but which do not act as the sole determinant of causation. 3 Musculoskeletal disorders cover a wide variety of phenomena and experiences such as discomfort and pain. 3 WMSDs do not happen as a result of a single accident or injury that only last a short time, but develop gradually as a result of repeated trauma that lead to long lasting injuries to joints, muscles, ligaments, tendons, peripheral vessels or nerves. 3 Of all the structures in the hand, the thumb joints are the most vulnerable to biomechanical and work-related injuries in physiotherapists 2,4 due to manual therapy techniques that are a major source of upper limb musculoskeletal stress as well as techniques that repeatedly compress the thumb joint. 1,5,6 The application of many manual techniques, including mobilisation, manipulation and massage, requires practitioner-generated hand forces. Often these forces are transmitted specifi cally through the thumb to the patients. The thumb is used as a pseudo-weight-bearing-joint when force is transmitted through the thumb. The physiotherapist usually generates forces using her body weight, while the distal end of the 16

2 Table 1. A summary of surveys regarding the prevalence of work-related thumb and wrist injuries in physiotherapists Study details McMahon et al., Wajon and Ada, West and Gardener, Cromie et al., Holder et al., Bork et al., Number of physiotherapists in survey Prevalence of thumb or wrist pain Current 41% Lifetime 65% 83% 25% 33.6% 23% 29.6% Location of study Australia Australia Queensland, Victoria, United States United States Australia Australia of America of America Speciality All Manipulative All All All All surveyed therapy WMSDs do not happen as a result of a single accident or injury that only last a short time, but develop gradually as a result of repeated trauma... thumb is met by the resistance of the tissue being treated. The thumb is not designed for this function and may lead to repetitive strain injuries. 4 Work-related musculoskeletal pain in the thumb and wrist is becoming recognised as a widespread problem among physiotherapists. 1,2 The wrist and the hand is rated the second highest anatomical area of injury, following the lower back. 1,2,6,7 Table 1 summarises the prevalence of WRTWP in physio therapists identifi ed in six surveys. Thumb and wrist pain was a common complaint and physiotherapists are clearly susceptible to work-related musculoskeletal injuries. 4,3 The prevalence ranged between 23% and 83%. The large range could be attributed to the setting in which the physiotherapist is working. According to Bork et al. physiotherapists in outpatient facilities were more likely to have wrist and hand symptoms than were their hospital-based counterparts. 1 A study done by Australian researchers reported a 41% current prevalence of thumb and wrist problems and a lifetime prevalence of 65% in physiotherapists. 3 Lifetime prevalence is defi ned as the proportion of individuals in the population who have ever manifested the disease and who are alive on a given day, as opposed to the point prevalence and the period prevalence which measure the prevalence over a far shorter period of time. 9 Therefore fi gures for the lifetime prevalence will be higher than for the point or period prevalence as more cases will accumulate as time passes. No evidence of studies relating to physiotherapy work-related thumb and wrist pain in South Africa could be found and as a starting point in determining this prevalence, the aims of this research study were to retrospectively investigate the lifetime prevalence of workrelated thumb and wrist pain (WRTWP) among currently practicing and retired physiotherapists in Bloemfontein and to determine the contributing risk factors. 17

3 Figure 1. Timing of the initial episode of work-related wrist and thumb symptoms amongst physiotherapists (n=54) METHODOLOGY A descriptive study was used. The WHO defi nition mentioned earlier 3 was the operational definition of WRTWP, and the questionnaire from Barnes et al. and David was adapted for the study. 10,11 The study population of 102 included all qualified and currently practicing physiotherapists as well as two retired physiotherapists in Bloemfontein. Ethics clearance was granted by the Research Division, University of the Free State (Reference number: REC ). Data collection A pilot study was conducted on two physiotherapy lecturers at a local tertiary institution to enhance the face and content validity of the questionnaire. The data of the pilot study questionnaires were included in the fi nal outcome of the study, as no changes were made to the questionnaires. The questionnaire was hand delivered to the 102 physiotherapists who formed the sampling frame, and SMS messages and telephonic reminders were subsequently sent. This resulted in a return of 86 completed questionnaires, giving a fi nal sample size of 88 and a response rate of 84.6%. Statistical analysis Statistical analysis was done by the Department of Biostatistics at the University of the Free State, using the 95% confi dence interval, percentiles, means and percentages. The statistical level of signifi cance was set at p <0.05 for tests of association. Table 2. Frequency of work-related and non-work-related thumb and/or wrist pain Wrist and/or thumb pain (WTP) Frequency n (%) Symptoms aggravated by physiotherapy work (n) Work-related wrist and/or thumb pain only 55 (62.5) 51 Work-related wrist and/or thumb pain and wrist and/or thumb pain from non-work factors 17 (19.3) Wrist and/or thumb pain from non-work factors only 6 (6.8) 1 No WTP 10 (11.4) Total 88 (100) 52 Table 3. Physiotherapeutic techniques associated with work-related thumb and wrist symptoms Technique Number of participants Percentage 95% CI Orthopaedic manipulation % 69.7% ; 89.8% Percussions % 10.2% ; 30.3% Shake and vibrate 3 5.5% 1.90% ; 14.9% Massage % 34.7% ; 60.2% Soft tissue mobilisation % 52.3% ; 76.6% Other 4 18

4 Table 4. Factors contributing to work-related injuries or discomfort in the thumb and wrist joints Statement Agree Disagree The repeated execution of the same task 98.1% 1.9% The treatment of many patients on a daily basis 95.9% 4.1% Exceeding physical limitations 80.4% 19.6% Execution of orthopaedic mobilisation/manipulative techniques 78.0% 22.0% Working in the same position for long periods 73.9% 26.1% Working in uncomfortable positions 72.9% 27.1% Not enough rest periods during the day 70.2% 29.8% Working with a current injury 48.9% 51.1% Insufficient knowledge in prevention of injuries 37.8% 62.2%... the thumb joints are the most vulnerable to biomechanical and work-related injuries in physiotherapists... RESULTS Of the 88 participants, 73 and 15 were female and male respectively. Their ages ranged between 23 and 70 years, with the median being 31 years. The median number of years that respondents had been practicing physiotherapy was 8 years. The mean number of years of practice was WRTWP was experienced by 62.5% (n=55) at some time since they had started studying and/or working as physiotherapists. The 95% confi dence interval (CI) for the lifetime prevalence of WRTWP among physiotherapists in Bloemfontein was 52.1% 71.9%. Table 2 shows the distribution of those with WRTWP, thumb and wrist pain not due to work (e.g. sports injuries) and both work and non- WRTWP. Overall, 51 (58%) of the whole sample reported that they had experienced thumb and wrist pain as a result of either their work as physiotherapists or from external causes, and that their work as physiotherapists had exacerbated the pain. Regarding pain location, of the 68 who answered the question, 38 (55.9%) experienced thumb pain in either their left or right hand, or bilaterally; 34 (38.6%) experienced wrist pain in either their left or right hand, or bilaterally; and 12 (13.6%) experienced both wrist and thumb pain. A mean value of 4.2 was given for the pain experienced by respondents, using the visual analogue scale of Pain influenced their work as a physiotherapist in 26 or 49% (n = 53), whilst 43 or 79.6% (n = 54) indicated that clinical work exacerbated their pain. Figure 1 presenting the timing of the initial episode of work-related thumb and wrist symptoms, shows that over 42 or 77.8% of the respondents who experienced pain had already experienced pain in their thumb and/or wrist within fi ve years of completing their studies. This means that 47.7% of the whole sample had experienced pain before the fi ve year mark. No signifi cant associations were identifi ed between age, gender and years in practice and the development of WRTWP (age t = -1.87, df = 55.2, p = 0.07; gender Chi- square = 1.93, df = 1, p = 0.16; and years in practice t = -1.43, df = 58.9, p = 0.16). Table 3 shows the physiotherapy techniques that the respondents felt caused their pain and symptoms. It is evident that orthopaedic manipulation and soft tissue mobilisation were by far the most likely techniques to result in pain. Table 4 lists the factors indicated by the respondents contributing to their work-related injuries or discomfort in the thumb and wrist joint. It is evident that most felt that high repetition and a high volume of daily treatments were likely to result in injury, and that relatively few respondents felt that 19

5 Source: their injuries resulted from insuffi cient knowledge in injury prevention. Education or advice regarding the protection of thumb and wrist joints was received by 36 (65.5%) of the respondents received before the onset of their WRTWP. DISCUSSION OF RESULTS The study identifi ed a 62.5% lifetime prevalence of workrelated thumb and/or wrist pain at some time during their working life in the physiotherapists investigated from Bloemfontein. This is very similar to the fi ndings of McMahon et al. 6 who documented a lifetime prevalence of 65% in their Australian study (CIs were not reported). Other international studies have reported prevalences of 23% 8 and 29.6% 1 (USA) and 41% 6 (Australia), but these were prevalences measured over shorter periods and it is not unexpected that their fi gures were lower than in this study. A large proportion of the respondents had found that working as physiotherapists exacerbated their thumb and wrist symptoms (70.8%). Women (83%) were better represented than men (17.1%) in the study as physiotherapy has been seen as a predominantly female occupation in South Africa. A similar study conducted by Adegoke 12 indicated that men (63.5%) were better represented that females (36.5%) due to the fact that physiotherapy as profession in Nigeria is more male dominated whilst in Europe and America it is more female dominated. The demographics in South Africa should change in future, due to the selection processes and due to marketing strategies to attract more male students to the profession. The median number of years the respondents have been practicing as a physiotherapist was 8 years, indicating that the participants in this study were experienced physiotherapists. Physiotherapists appear to be particularly likely to develop WRTWP within the fi rst fi ve years after qualifying. In this study, 47.7% experienced pain before the fi ve year mark, compared with 47% and 46% in West and Gardner s 7 and Adegoke s 12 studies respectively. Therefore it could be assumed that an increase in the workload after graduation might have contributed to the prevalence of work-related injuries due to overuse of the thumb and wrist joints during physiotherapy practice. Age, gender and years of practice were not identifi ed as risk factors for developing WRTWP. This fi nding concurred with the study by McMahon et al. 6 Cromie et al. 2 however found that younger physiotherapists reported signifi cantly more thumb pain than older physiotherapists. It also differs from Adegoke et al. 12 who reported a signifi cantly higher 20

6 prevalence of WRMDs among female physiotherapists, which supports the fi ndings of Bork et al. 1 and Glover et al. (as cited by Adegoke). 12 Cromie et al. 2 however reported a higher prevalence of WRMDs among male physiotherapists and attributed their fi ndings to a greater usage of mobilisation techniques by male physiotherapists. Therefore, there is still controversy whether gender and years in practice are associated with the development of WRTWP. It is notable that for almost half (49.1%) of the respondents with WRTWP, the pain value was enough to infl u- ence their work as physiotherapists. Furthermore, 79.6% indicated that their symptoms were exacerbated by doing clinical work. Although 65.5% of the respondents received education or advice regarding the protection of thumb and wrist joints, it could be assumed that it is the physical nature manipulations, mobilisations and massage in the concept of repeated executions of the same tasks. 6 This was followed by treatment of many patients on a daily basis (95.9%), exceeding physical limitations (80.4%), the execution of orthopaedic mobilisation/manipulative techniques (78%), working in the same position for long periods (73.9%) and working in an uncomfortable position (72.9%). Working with a current injury was considered to be a least contributing risk factor (48.9%), whilst only 37.8% responded that in sufficient knowledge in prevention of injuries was a major contributing risk factor in the development of their work-related thumb and wrist symptoms. These values compare to a prior study by West and Gardener 6 in which respondents with hand injuries chose using manual therapy techniques e.g. mobilisations, manipulations and massage (82%), repetition (77%) and treating an excessive number of patients a day (73%) as their three most important risk factors. WRTWP was experienced by 62.5%... at some time since they had started studying and/or working as physiotherapists. of the work that predisposes to injury and not a lack of education or advice regarding protection. Physiotherapists have specialist knowledge of body mechanics and injury prevention, which should help them to avoid injuries. The possibility of poor adherence of principles taught could, however, not be excluded. Participants indicated more than one type of physiotherapy technique that elicited their pain. Across all speciality areas the task showing a highly signifi cant relationship with to WRTWP was orthopaedic mobilisations/manipulations (81.8% [95% CI 69.7% %], Chi-square=40.45, p<0.01), although soft tissue mobilisations (65.5% [95% CI 52.3% %], Chi-square=9.55, p<0.05) also appeared signifi cant, and massage (47.3% [95% CI 34.7% %], Chi-square=0.29), while not signifi cant, also seemed to be associated with an increase risk of WRTWP. Only thirteen participants indicated that chest physiotherapy (e.g. percussion, shake and vibrate) caused their work-related pain. McMahon et al. 6 reported similar fi ndings for soft tissue (70%) and mobilisation (75%). Regarding the factors which they perceived had contributed to their work-related injuries or discomfort, seven were selected by more than 50% of those with WRTWP. A major risk factor for the largest number of injured physiotherapists (98.1%) was repeated execution of the same tasks. It is assumed the physiotherapy population would include 21

7 Limitations of the study The possible limitations of the study are that it relied on recall of events that could have occurred long ago as a lifetime prevalence was investigated, so that there may be problems of accuracy. It was also only conducted in one city and the sample was predominantly female, which means that the results may not be generalisable to South African physiotherapists as a whole. CONCLUSIONS AND RECOMMENDATIONS According to Snodgrass et al. 7 work-related musculoskeletal pain in the thumb and wrist is becoming recognised as a widespread problem for physiotherapists. This study has indicated that WRTWP is a common problem for Bloemfontein physiotherapists. The lifetime prevalence was 62.5%. In addition, many of those with the problem reported that it had influenced their work as physiotherapists and that symptoms in 79.6% were exacerbated by doing clinical work. In view of the ongoing controversy, further research is needed to investigate whether age, gender and years in practice are associated with the prevalence of symptoms in Bloemfontein. A shorter period prevalence should also be determined. The most commonly reported risk factors were orthopaedic mobilisation/manipulative techniques, soft tissue mobilisation and massage. As has been demonstrated by this research and that of Cromie et al. 2 a knowledge of ergonomics, injury and treatment does not appear to offer the physiotherapist immunity from injury. The results of the study suggest that the physical nature of the job is most likely to predispose to work-related injuries rather than a lack of education or advice regarding the protection of thumb and wrist joints. Research is needed to further investigate aspects of the job and work practices that contribute to injury with the longterm goal to formulate preventative strategies that can be implemented by physiotherapists regarding the protection of their thumb and wrist joints. Research into possible modifi cation of work practices would be worthwhile. The South African Society of Physiotherapy should be utilised as a voice to inform physiotherapists about the results of the study and to create awareness amongst physiotherapists regarding work-related thumb and wrist pain. LESSONS LEARNED 1. Work-related musculoskeletal pain in the wrist and thumb appears to be a widespread problem for physiotherapists who regularly apply manual techniques. 2. Orthopaedic mobilisations/manipulations, soft tissue mobilisations and massage were regarded as being particularly associated with work-related thumb and wrist symptoms. 3. A risk analysis is required to determine whether physiotherapy techniques can be modifi ed to prevent injury. 4. The potential for work-related thumb and or wrist problems as well as possible management strategies should be discussed with undergraduates. REFERENCES 1. Bork BE, Cook TM, Rosecrance JC, Engelhardt KA, Thomason MJ, Wauford IJ and Worley RK. Work-related musculoskeletal disorders among physical therapists. Physical Therapy. 1996; 78(8): Cromie JE, Robertson VJ and Best MO. Work-related musculoskeletal disorders in physical therapists: Prevalence, severity, risks and responses. Physical Therapy. 2000; 80(4): Akobundu U. Work-related musculoskeletal disorders: causes and prevention. National Workshop for Newly Appointed Magistrates, October Nigeria. Accessed 18 September Available at: php?option=com_docman&task=doc_view&gid=1588&itemid= Snodgrass SJ and Rivett DA. Thumb pain in physiotherapists: Potential risk factors and proposed prevention strategies. 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