Work-related Musculoskeletal Disorders among Korean Physical Therapists

Work-related Musculoskeletal Disorders among Korean Physical Therapists J. Phys. Ther. Sci. 25: 55 59, 2013 Sin Ho Chung, MPH, PT 1), Jin Gang Her, PhD, PT 2), Taesung Ko, PhD, PT 3), Jooyeon Ko, PhD, PT 4), Heesoo Kim, MSc, OT 1), Ju Sang Lee, PhD, PT 5), Ji-Hae Woo, MPE, PT 1) 1) Department of Rehabilitation Therapy, Graduate School of Hallym University 2) Department of Rehabilitation Therapy, Faculty of Health Science, Hallym University: Okcheon-dong, Chuncheon-si, Gangwon-do 200-702, South Korea. TEL: +82 33-248-1421, E-mail: jghur7@empal.com 3) Department of Physical Therapy, Daewon University College 4) Department of Rehabilitation Medicine, CHA University 5) Department of Physical Therapy, Hallym College Abstract. [Purpose] This study sought to determine the prevalence of work-related musculoskeletal disorders (WRMDs) their associated work risk factors and the coping strategies used to reduce their risk among physical therapists in Korea. [Subjects] Korean physical therapists with at least 1 year of working experience. [Methods] A self-administered questionnaire was distributed to 234 physical therapists working in different hospitals, and 180 questionnaires were returned yielding a 7.9% response rate. Twenty-three of the returned questionnaires were excluded from the analysis because of incomplete data. [Results] The overall prevalence of WRMDs during the past 12 months was 92.4%. Female physical therapists reported a significantly higher prevalence of WRMDs than male physical therapists (p=0.028). The most injured body areas were the low back (53.5%) and shoulders (45.2%). Treating an excessive number of patients in 1 day (90.4%) and a lack of rest breaks (89.8%) were the most perceived work risk factors for WRMDs. The most commonly adopted coping strategies were modification of the therapist s or patients positions and use of a different part of the therapist s body to administer a manual technique (51.%). [Conclusion] WRMDs are significantly higher among physical therapists in Korea compared to many other countries. Education programmes on prevention and coping strategies for WRMDs are recommended for physical therapists in order to reduce the risk of further injury. Key words: Musculoskeletal disorder, Risk factor, Physical therapists (This article was submitted Aug. 31, 2012, and was accepted Sep. 28, 2012) INTRODUCTION Work-related musculoskeletal disorder (WRMD) is defined as damage to the musculoskeletal system resulting from work-related events 1), and it is one of the most general causes of chronic pain and physical disorders occurring among modern workers. WRMD results in loss of work time, restriction of tasks, or transfer to a different job, thereby affecting the quality of life of the patient 2 5). Previous research reported that the occurrence of WRMD was related to high biomechanical loading caused by inappropriate handling, 7). Silverstein et al. 8) observed that occupational risk factors such as repetitive movement, tasks of high intensity, and uncomfortable postures were associated with musculoskeletal disorders. Studies of industrial health workers report that physical therapists have a high prevalence of WRMD 5, 9, 10). The factors affecting this high WRMD prevalence include repetitive movements; continuous bending; lifting, and transferring dependent patients; unexpected, abrupt movements of the patient; manual therapy; limited working space; lack of personnel; age; and gender 9, 11). Performance of physical therapy is therefore associated with high risks of both acute and accumulated WRMD. The lifetime prevalence of WRMD for physical therapists was reported as 55% 11) in Australia, 8% 12) in the United Kingdom, and 85% 1) in Turkey. Treatment areas that triggered WRMD most were musculoskeletal outpatient care (31%), followed by neurological rehabilitation (14%), and elderly care (12%) 12). Glover et al. 12) noted that WRMD areas varied in physical therapists: low back (48%), neck (33%), upper back (23%), and thumb injuries (23%). The reason for the high prevalence of low back injury is that therapists who take care of patients have to repeat motions such as lifting and transferring, standing for a long time, and frequent twisting and bending 13). WRMD in physical therapists is associated with the therapist s age and clinical experience. For example, Campo et al. 14) observed that WRMD prevalence was higher in older physical therapists than in younger physical therapists. In contrast, most previous studies have reported that therapists experience symptoms before they reach 30 years of age, and the incidence rate within 5 years of graduation is

5 J. Phys. Ther. Sci. Vol. 25, No. 1, 2013 Table 1. Demographic description of the study participants Respondents All (n=157) Male (52.9%) Female (47.1%) Age (yrs) Height (cm) Weight (kg) Years of Clinical Practice (yrs) 29.45 ± 4.14 (23~52) 30.98 ± 4.32 (25~52) 27.73 ± 3.17 (23~38) 18.54 ± 7.81 (154~187) 174.05 ± 5.30 (11~187) 12.3 ± 5.08 (154~178) 2.72 ± 12.35 (41~100) 71.24 ± 9.98 (52~100) 53.1 ±.28 (41~70) 5.21 ± 3.29 (2~20) 5.58 ± 5.39 (2~20) 4.80 ± 2.98 (2~1) Table 2. The frequencies of WRMDs by body part Neck Shoulder Elbow/ Forearm Wrist/ Hand Thumb Upper Back Low Back Hip/ Thigh n 45 71 11 53 12 25 84 14 35 10 % 28.7 45.2 7.0 33.8 7. 15.9 53.5 8.9 22.3.4 Knee Ankle/ Feet high 5, 9, 11, 12, 15). The suggested reason is that new physical therapists lack professional experience, knowledge, and techniques, and that they are rotationally dispatched to different places, thereby running a higher risk of injury 1, 1). More spinal symptoms related to WRMD have been found in female than in male therapists 9). WRMD results in shortened working time for 12% of therapists 1), a change in the working environment or loss of professionalism for 17% 9), and the need for rest breaks during working hours for 32% 12). Based on the above results, it is important to examine the work factors that may predispose therapists to WRMD and employ strategies to reduce the occurrence of WRMD. The aim of this study was to look at the WRMD prevalence among Korean physical therapists and to clarify the risk factors that develop into WRMD, thereby providing basic knowledge to preempt physical therapists musculoskeletal symptoms and to identify measures to reduce their risk of WRMD. SUBJECTS AND METHODS A questionnaire about the prevalence, work factors, and coping strategies of WRMD was distributed to Korean physical therapists working in different professional areas. The questionnaire was based on a previous study 15), and was translated and adapted to suit the working conditions of Korean physical therapists. The questionnaire consisted of two parts with 27 questions. The first part gathered demographic information from the respondents, year of graduation and working experiences, educational background, working type, working environment, working time, and major tasks. In the second part, respondents were asked to mark nine anatomical parts related to WRMD (neck, shoulder, elbow/forearm, wrist/hand, upper back, low back, hip/thigh, knee, and ankle/foot). This part also included questions about the degree of effects of onset and job risk factors of WRMD and the coping strategies and measures taken to reduce the risk of WRMD. The respondents were physical therapists with at least one year of working experience, excluding interns. Physical therapists with musculoskeletal problems resulting from unrelated causes were excluded for example, musculoskeletal problems occurring before working as a physical therapist, or arising from motorcycle accidents, sports injuries, or traumas. A total of 234 questionnaires were distributed and 180 questionnaires were collected, a participation rate of 7.92%. In total, 157 questionnaires (7.09%), excluding 23 incomplete questionnaires, were analyzed. The SPSS version 18 descriptive statistics package was used for data analysis and data were summarized as mean values, standard deviations, and percentages. The chi-square test was employed to determine associations between individual characteristics and WRMD incidence rates. When the expected frequency was smaller than 5, Fisher s exact test was applied. We chose a significance level of 0.05. RESULTS Among the 157 respondents, 83 (52.9%) were males and 74 (47.1%) were females. Their average age, height, weight, and years of working experience were 29.45±4.14 years, 18.54±7.81 cm, 2.72±12.35 kg, and 5.21±3.29 years, respectively. The number of regular workers and the number of secondary hospital workers was 151 (9.2%) and 123 (78.3%), respectively (Table 1). A total of 145 (92.4%) of the respondents experienced WRMD. The most common areas of disorder were the low back, 84 respondents (53.5%), and the shoulder, 71 respondents (45.2%), while the least common areas of disorder werewas the ankle, 10 respondents (.4%), and the elbow/

57 Table 3. Distribution of WRMDs by demographic characteristics WRMD n (%) No WRMD n (%) Age (yrs) Years of Clinical Practice (yrs) Gender * Employment Status Clinical Setting Ergonomic Training <30 30 <5 15 >1 Male Female Full Time Part Time Secondary Tertiary Yes No 85 (93.4) (.) 0 (90.9) (9.1) 95 (92.2) 8 (7.8) * indicates significant association at α = 0.05 4 (92.0) 4 (8.0) 4 (100) 0 (0.0) 73 (88.0) 10 (12.0) 72 (97.3) 2 (2.7) 139 (92.1) 12 (7.9) (100) 0 (0.0) 114 (92.7) 9 (7.3) 31 (91.2) 3 (8.8) 57 (90.5) (9.5) 88 (93.) (.4) Table 4. Job risk factors that may contribute to development of WRMDs Risks n % 1. Treating a large number of daily patients 142 90.4 2. Lack of rest breaks during the day 141 89.8 3. Repetition of the same tasks 13 8. 4. Working in inappropriate postures 128 81.5 5. Lifting or transferring dependent patients 12 80.3. Bending or twisting the back in an awkward way 122 77.7 7. Continuous working in an injured state 122 77.7 8. Working in the same position for long periods (standing, bending over, sitting, etc) 115 73.2 9. Performing manual orthopaedic techniques 113 72.0 10. Unanticipated sudden movement or falls by patient 105.9 11. Working at or near your physical limits 101 4.3 12. Carrying, lifting or moving heavy materials or equipment 101 4.3 13. Working with confused or agitated patients 98 2.4 14. Work scheduling (overtime, irregular shifts, length of workday) 98 2.4 15. Assisting patient during gait activities 9 1.1 1. Reaching or working away from the body 88 5.1 17. Inappropriate training in injury prevention 7 42.7 forearm, 11 respondents (7.0%) (Table 2). The frequency of WRMD was only associated with gender (p=0.028); it showed no relation to age (p=0.51), clinical experience (p<0.999), work type (p=0.723), working environment (p=0.723), or education (p=0.54) (Table 3). One hundred twenty respondents (80.5%) experienced WRMD within 5 years after graduation. The onset of WRMD was gradual in 123 respondents (82.0%) and abrupt in 27 respondents (18.0%) (data not shown). A total of 59 respondents (37.8%) changed patient treatment due to WRMD, 142 respondents (91.0%) changed their expertise area, and 82 (52.2%) were considering job transfer (data not shown). Those with WRMD were asked about 17 occupational elements used in prior studies 15, 17, 18). A four-level Likert scale (1: irrelevant, 4: significant meaning) was used to determine the significance of occupational elements in WRMD occurrence. The response to each occupational element was divided into insignificance (1 and 2) and significance (3 and 4). The significance of each occupational element was presented as a percentage among the entire respondent population. A total of 1 occupational elements had scores over 50%. The most significant occupational element was an excessive number of daily patients (142 respondents, 90.4%) and a lack of rest breaks (141 respondents, 89.8%). The least significant occupational element was inappropriate training (7 respondents, 42.7%) and reaching or working distance from the body (88 respondents, 5.1%)(Table 4). The more generally applied strategies for preventing WRMD were modification of the therapist s or patients postures, 81 respondents (51.%), and using parts other than the therapist s hands to apply manual treatment, 81 (51.%). The least applied strategies were electrical therapy instead of manual therapy in order to reduce the risk of injury, 9 respondents (5.7%), stopping therapy when discomfort was experienced, and stretching exercises and postural change during regular rest breaks, 11 respondents (7.0%) (Table 5). DISCUSSION The purpose of this study was to provide basic information for preventing musculoskeletal symptoms and to identify measures that could reduce the incidence of WRMD

58 J. Phys. Ther. Sci. Vol. 25, No. 1, 2013 Table 5. Coping strategies of the respondents for reducing the risk for development of WRMDs Strategies n % 1. I modify patient s position/my position 81 51. 2. I use other body part in order to apply manual treatment 81 51. 3. I adjust plinth/bed height prior to the treatment of a patient 74 47.1 4. I select techniques that will not cause or aggravate discomfort 48 30. 5. I warm up and stretch before performing manual techniques 22 14.0. I get someone else to help me handle a heavy patient 21 13.4 7. I pause regularly so I can stretch and change posture 11 7.0 8. I stop a treatment if it causes or aggravates my discomfort 11 7.0 9. I use electrical therapy instead of manual therapy to avoid stressing an injury 9 5.7 by examining the WRMD prevalence and risk factors for WRMD among Korean physical therapists. The collection rate of the questionnaires distributed in the present study was high, at 75.8%, compared to those reported in previous studies: 52.% in West and Gardner 11), 58.1% in Adegoke et al. 15), 58.5% in Salik and Ozcan 1), 3.4% in Alrowayeh et al. 19), 4.5% in Grooten et al. 20), 8. 5% in Cromie et al. 9), 9% in Molumphy et al. 1), 7% in Campo et al. 14), 73% in Glover et al. 12), 77.1% in Nordin et al. 21), and 80.0% in Bork et al. 10). Studies of WRMD prevalence in physical therapists in different countries indicate a prevalence of 47.% in Kuwait 19), 53.5% in Sweden 20), 57.5 1% in the United States 10,14), 7.5% in the United Kingdom 12), 71.% in Malaysia 21), 85.0% in Turkey 1), 54.8 91% in Australia 9,11), and 91.3% in Nigeria 15). The causes of WRMD included lack of personnel, bad working environments, and lack of equipment to reduce the burden on the body. In the present study, the high WRMD prevalence rate in Korean physical therapists, 93%, arose from treating excessive numbers of daily patients because of a shortage of therapists, and a lack of rest breaks to reduce the burden to the body. In the present study, WRMD prevalence was 88% in male physical therapists and 97% in female physical therapists, similar to the rates reported by Adegoke et al. 15) of 8% in male physical therapists and 100% in female physical therapists. The higher rate for females was because women are physically weaker than men increasing their risk of injury when lifting and transferring patients. On the other hand, Cromie et al. 9) noted that the prevalence of WRMD was higher for female physical therapists because they used mobilization and manipulation techniques more. The low back is the body part with the highest WRMD prevalence, having been reported as 2% by Salik and Ozcan 1), 28.8% by Molumphy et al. 1), 32.0% by Alrowayeh et al. 19), 35% by West and Gardner 11), 45.0% by Bork et al. 10), 44% by Glover et al. 12), 51.7% by Nordin et al. 21), 5.5% by Grooten et al. 20), 2.5% by Cromie et al. 9), and 9.8% by Adegoke et al. 15) Shehab et al. 22) observed that lifetime WRMD prevalence rate was 70% among physical therapists with low back pain patients, because physical therapists handled their patients using inappropriate body mechanics and wrong techniques. Nordin et al. 21) observed that physical therapists using manual treatments experienced more stress in the spine than in the hands because they applied manual treatments in the standing position over a long time. In the present study, the low back (53.5%) was the area physical therapists complained most about among the areas of pain. This was followed by shoulder pain (45.2%), which may occur when applying force while holding a patient or performing repetitive work or holding or reaching hands. Low back and shoulder pain are considered to be associated with the treatment patterns of physical therapists who work in a bent position and with repetitive upper extremity motions. Work factors of WRMD, as noted by Bork et al. 10), included lifting or transferring dependent patients (25.7%), excessive numbers of daily patients (19.0%), and holding the same position for a long time or an inappropriate position (18.4%). West and Gardner 11) noted holding the same position for a long time (57.7%) and continuous working in a damaged state (50.8%). Cromie et al. 9) reported lifting patients (53.8%), repetitive tasks (52.3%), lifting or transferring (43.%) dependent patients, excessive numbers of daily patients (41.4%), and holding the same posture for a long time (41.5%). Glover et al. 12) noted repetition of the same work (73%), the same position for a long time (7%), and the excessive number of daily patients (7%); and Adegoke et al. 15) observed excessive numbers of daily patients (83.5%), the same posture for a long time (71.3%), lifting or transferring dependent patients (7.8%), and performance of manual treatments (7.8%), and inappropriate postures (4.%). In the present study, work factors of WRMD were excessive numbers of daily patients (90.4%), lack of rest breaks (89.8%), repetition of the same tasks (8.%), inappropriate posture (81.5%), and lifting or transferring dependent patients (80.3%), results which are similar to those of previous reports. What is interesting is that the lack of rest breaks was the second most significant risk factor. We consider the reason for this is increased tension in Korean physical therapists, and heightening of muscle fatigue, due to the excessive numbers of daily patients and lack of rest breaks. As strategies for reducing WRMD, Salik and Ozcan 1) noted the use of improved body mechanics (20.5%), avoidance of lifting (1.4%), and changing working position frequently (13.7%). Glover et al. 12) observed adjusting the plinth/bed height (8%), modifying the position of the therapist or

59 patient (79%), and assistance when handling heavy patients (%). Adegoke et al. 15) reported modifying the position of the therapist or patient (4.3%), selecting a treatment method that would not cause or aggravate discomfort (47.0%), and adjusting the plinth/bed height prior to the treatment of a patient (39.1%). Strategies employed by Korean physical therapists included modifying their position or the position of their patient (51.%), using other body parts in order to apply manual treatment (51.%), and adjusting the plinth/ bed height prior to the treatment of a patient (47.1%), similar to previously reported strategies. Bork et al. 10) asserted that physical therapists who applied manual treatment had a WRMD risk that was 3.5 times higher than that of those who did not, while Robertson and Spurritt 23) noted that those with moderate to severe symptoms used electrical therapy as a protective behavior. Korean physical therapists widely use manual therapy techniques, but electrical treatment is used the least (5.7%), despite high WRMD rates. This is because Korean physical therapists have a high sense of responsibility for their patients, and they expect manual therapy to have better results than electrical treatment; therefore, they conduct manual therapy using other body parts as protective behaviors rather than using electrical therapy. The prevalence of WRMD was higher among physical therapists in Korea than in other countries. The most common body parts affected were the low back and the shoulder. The WRMD prevalence was higher in females than in males. The most important work factors of WRMD were excessive numbers of daily patients, insufficient rest breaks, and repetitive performance of the same tasks. 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