The occurrence of overload at work and musculoskeletal pain in young physiotherapists

1 Introduction

Musculoskeletal complaints associated with work are a common health problem in the industrialized world and a major cause of disability. An ergonomic approach aimed at reducing the burden of the musculoskeletal system requires a comprehensive assessment of all elements of the system of work and implementation of optimal solutions. Studies devoted to ergonomics are currently occupying an important place in scientific research [1–3]. A particularly important part of such research are investigations conducted in the field of occupational medicine [4, 5]. A professional group experiencing high overloading of the musculoskeletal system are physiotherapists. According to the literature, the work-related activities that most commonly lead to an injury in health professionals are lifting heavy equipment and patients, transferring patients, maintaining the same posture for a long period of time, manual therapy practices, responding to patients’ sudden movements, and repeated movements [6–10].

In Poland, there are about 50,000 physiotherapists and they constitute the third largest occupational group in the domestic health care [11]. Physiotherapists are exposed to overloading of the musculoskeletal system associated with non-ergonomic positions [12, 13]. According to Campoi et al., therapists who transferred patients 6 to 10 times per day had odds of moderate to severe low back pain and musculoskeletal disorders that were 2.4 times as high as for those who did not transfer patients [14]. Multiple repetitions of the same movement patterns lead to overload-related changes in the musculoskeletal system [15].

Overload changes among the professional group of physiotherapists most often occur in the spine, followed by those affecting the shoulder, knee and elbow joints. They are related to the kind of job positions (assumed while working with the patient), repeated activities and the type of the dysfunction of the patient [16]. Particularly difficult and demanding are patients in serious condition. Therapists using manual therapy perform a variety of techniques involving pressure, which significantly engage the interphalangeal and wrist joints [17]. According to scientific research, therapists dealing with bed-ridden patients, who have to be moved and who need to have their position changed, as well as manual therapists, belong to the group of health care workers most vulnerable to pain affecting the musculoskeletal system [18, 19]. Modern methods of neuromuscular re-education require operating with the entire body and using the force of hands to get the proper function of the patient. Therapeutic tables offer the possibility to adjust the height, but performing exercises on a mat on the floor forces the therapists to flex their trunks and adopt a kneeling or a sitting position [16].

2 Objective

The aim of this study was to assess the work-related loads experienced by physiotherapists and to conduct an analysis of the prevalence of the musculoskeletal system pain.

3 Methods

The study included 108 young physiotherapists, 69 women and 39 men, aged from 25 to 35 years (mean 27.12 ± 3.72 years). The body height of the examined subjects was within the range 150–192 cm (mean 171.9 ± 9.4). Their body weight ranged from 45 to 106 kg, with an average of 72.01 ± 14.07, and their BMI (body mass index) averaged 24.30 ± 3.68.

The criteria for inclusion in the study were working as a physiotherapist for a minimum of one year and a consent to participate in the study. The criteria for exclusion included working as a physiotherapist for less than one year and lack of a consent to take part in the study.

The study used a survey method with the application of two questionnaires: an author-elaborated one and the Quick Exposure Check (QEC). QEC determines the level of exposure to overload. It was designed by the Robens Centre for Health Ergonomics to enable a practical analysis of the risk factors for musculoskeletal disorders related to work [20]. The questions in the surveys concerned the working position of the respondents and the load affecting their musculoskeletal system. Questions covering the body position during work included an analysis of the setting of the lumbar and the cervical spine while working, as well as the working position of the shoulders, wrists and fingers. The questions related to the acting load included the following aspects: maximum hand-lifted weight (less than 5 kg, up to 10 kg, up to 20 kg, more than 20 kg), duration of work involving lifting (up to 2 hours, up to 4 hours, more than 4 hours), maximum force generated with one hand (up to 1 kg, up to 4 kg, more than 4 kg), the need for precise hand movements, driving time per day, the use of vibrating tools, subjective difficulties associated with the performed tasks, and levels of stress. The results obtained were summed up according to the attached key. The author-designed questionnaire concerned education, nature of work, overload and physical activity.

4 Results

Among the examined physiotherapists, 63 persons (58.3%) worked in an outpatient clinic, 24 persons (22.2%) had a private practice, and 22 (20.4%) worked in a hospital. The remaining study subjects reported other jobs or were employed in several places at the same time. The subjects worked in their profession for 6.25 ± 2.64 years on average. Their weekly hours of work amounted between 2 to to70 hours, an average of 31.73 ± 13.28. Women worked between 2 and 60 hours, on average 31.30 ± 10.39 and the men worked between 5 to 70 hours, on average obtained for men equaled 32.49 ± 17.33. As many as 58 persons reported higher education (53.7%), and 50 persons completed B.A. studies (46.3%).

Based on the Quick Exposure Check questionnaire, we found that 70 study subjects (64.8%) experienced pain in the lumbar spine, 60 (55.6%) felt pain in the cervical spine, and 34 (31.5%) reported pain in the wrist and finger joints during their occupational experience.

Analyzing the distribution of the frequency of occurrence for the different levels of exposure to overloading in the examined areas, it was found that the majority of the respondents indicated a high level of overload occurrence in all four areas: lumbar spine, the shoulder, the wrist and cervical spine. On the other hand, in the question about the level of prevalence of overload associated with transportation to the patient, the use of vibrating equipment and stress, the majority of the respondents marked a low level. The levels of exposure to overload affecting the analyzed parts of the musculoskeletal system are shown in Table 1. Table 2 presents the prevalence of different levels of exposure to occupational factors: the use of equipment generating vibration, difficulty of the performed work and stress.

While analyzing the relationship between the level of exposure to overloading and the sex of physiotherapists, no statistically significant dependences were noted.

An analysis of the influence of BMI on the level of exposure to overload was carried out. For this purpose, the subjects were divided into two groups: those with normal BMI (18.5 to 24.9 kg/m²) and people who are overweight (25 to 29.9 kg/m²). A significant relationship was observed between the presence of excess weight and the level of exposure to overload, associated with transportation to the patients (p = 0.021) (Table 3). In the group of overweight people, there were more persons in whom exposure to overload connected with driving a car was higher.

Statistically significant positive correlations were noted between the number of years worked in the profession, and the level of exposure to overloading the shoulder and the level of exposure to vibration.

It was also found that the number of years worked in the profession correlated negatively with the level of exposure to stress. The relationship between musculoskeletal pain, and the number of years of professional experience and the number of hours of work per week was found. It has been reported statistically significant positive correlations between the number of years worked in the profession and the level of exposure to the overloading in the area of the arm. The number of hours of work per week correlated positively with the level of exposure for all areas of the body analyzed. Tables 4 and 5 show the Spearman’s correlation coefficient ρ between the level of exposure to overloading, and the number of years worked in the profession and the number of hours of work per week.

In order to analyze the relationships between the type of work and the level of exposure to overload, individuals who performed only one type of work were distinguished among the respondents. The subjects were divided into two groups: those dealing with physiotherapy (exercises with the patient) and persons involved in physical therapy (working with devices). There were noted statistically significant correlations between the type of work and the level of exposure in the area of the cervical spine, the level of exposure associated with vibrations and difficulties of the performed work. In the group of people who were engaged in physiotherapy, a higher level of exposure in the area of the cervical spine and a higher level of exposure associated with the difficulties of the performed work were observed. The details are shown in Table 6.

In this study, the largest percentage of respondents (37%) were persons who reported the frequency of undertaken physical activity equaling to once a week. As many as 33% of the respondents declared active exercises practiced more than 3 times a week. There was no statistically significant correlation between the frequency of physical activity undertaken and the level of exposure to overload.

5 Discussion

In the work performed by physiotherapists, incorrect work habits lead to musculoskeletal pain [7, 22]. Musculoskeletal disorders depend on the nature of the performed professional activities, their repeatability and duration [23, 24].

Nowotny et al., in a study on 47 physiotherapists aged 25–55 years working in three different working positions, observed that the position of the spine in all cases deviated from the fully ergonomic setting. Taking into account ergonomics, the least favorable activity were exercises performed in low positions - on one’s knees and on the mat. Each position burdened the lumbar spine the most, and the least the thoracic spine. The authors found that the therapists working with patients using PNF (proprioceptive neuromuscular facilitation) assumed working positions with a variety of settings of the cervical spine, and the movement of the lumbar spine was often repeated [25].

Nowotny-Czupryna observed that professional activities of physiotherapists working with children applying the NDT-Bobath method (neurodevelopmental therapy) were characterized by monotony of the movements of the cervical spine, and in the lumbar area, the bending position was the prevailing one [15]. Research conducted by Cromie et al. on 824 physiotherapists showed that more than 80% of the respondents experienced musculoskeletal pain in at least one area of the body within one year. Almost half of the respondents (48%) suffered from pain in the lumbar spine, and 12.2% experienced pain of the cervical spine [7]. In our study, 65% of the respondents pointed to the problems affecting the lumbar spine, 55.6% experienced pain of the cervical spine, and 26% suffered from the pain located in the shoulder. Most of the respondents assessed the level of exposure to overloading as high in all analyzed areas of the body. The cause was tilting the torso during work and repeating similar movement patterns in non-ergonomic positions. This is confirmed by Truszczyńska et al., in whose study it was established that the cause of job-related backaches is hard physical work, routine tasks with external load, and repetition of rotation and flexion movements [26]. Similar results were obtained by Cromie et al. The persons who were exposed more to the pain of the lumbar spine and the wrist joints were those who worked more hours per day [7].

Low back pain was the most common work-related musculoskeletal disorder among the examined physiotherapists [27, 28]. In the United States, the prevalence of low back pain among physiotherapists ranged from 45% to 62% [29]. Mierzejewski and Kumar found the prevalence of low back pain in Canada to amount to 49%, while Shehab et al. reported a 70% prevalence of low back pain in Kuwait [30, 31]. According to Cromie et al., the percentage of physiotherapists (out of 928 examined) with symptoms observed in wrists and hands was 29.6%, in upper back - 28.7%, and in low back - 45% [7]. Musculosceletal disorders concern the general population and manufacturing workers. Gerr et al. informed in their prospective epidemiologic study of 386 manufacturing workers that they obtained the following resuls: hand/arm disorders = 19/100 person-year (PY), neck/shoulder disorders = 14/100 PY [32].

Although the prevalence of job-related low back pain is relatively high for physiotherapists, it is even higher in other occupations. Gerr et al. reported the prevalence of back pain in 51% of office workers and in 75% of construction workers [33]. On the other hand, the authors’ study group did not embrace the whole population of physiotherapists, but only the young ones aged from 25 to 35 years. Since the occurrence of musculoskeletal disorders increases with age, most probably their incidence would have been much higher if the study group had included older subjects.

Physiotherapists in their education programs learn about working place ergonomics, but despite having this knowledge they suffer from musculoskeletal pain.

The elements of physiotherapy practice which have been suggested as risk factors include: treatments which demand repetitive movements or continuous bending, lifting/transferring dependent patients, responding to unanticipated or sudden movements made by patients, performing manual therapy, restricted workplace conditions, understaffing, age and sex [7, 28].

Pain at the base of the thumbs is a common problem, especially in physical therapists practicing spinal mobilization [34]. Pain in the wrists and hands is common, with the annual prevalence of 29.6%, in the general physical therapy population, second only to low back pain (45%) [29]. Similarly to Salik and Özcan, while analyzing the different body parts injured, the authors of this study found the highest frequency of injuries in the lower back, followed by the hand-wrist (18.2%), shoulder (14.4%) and neck (11.8%) location [27].

Another risk factor for musculoskeletal pain related to the work mentioned in the literature is the lack of adequate physical activity and taking up forms of active resting. In the population of physiotherapists studied by Lisiński and Samborski, the percentage of people who reported pain in the lumbar spine and did not manifest any physical activity amounted to 60%. There were only 30 persons (23%) who practiced sport 1-2 times per month. Physical inactivity can have big impact on the occurrence of musculoskeletal pain. However, in our study, no statistically significant correlation was found between the frequency of physical activity and the level of exposure to overload [21].

In this study, there was no significant relationship observed between gender and the level of exposure to overload, but a limitation of this analysis is the fact that the number of male respondents was 39, and the group of women was much more numerous (69 respondents). This trend reflects the proportions in the population of physiotherapists, in which women are the majority. However, in the three areas of the body including the lumbar spine, shoulder joint and wrist joint, by far a greater number of women - as compared to men - referred to the level of exposure to overload as high. In addition to this, the analysis of the literature indicated that women are more prone to develop musculoskeletal overload [23]. This is confirmed by Adegoke et al., who showed a greater risk of musculoskeletal disorders in women [35]. A study by Hesham et al. also conducted among physiotherapists, demonstrated that the incidence of overloading the lumbar spine was associated with gender, and the majority of the women surveyed experienced pain in the lumbar spine. The authors explain this predisposition with finer physique characteristic for women [29].

In our study, it was demonstrated that the number of years worked in the profession correlated negatively with the level of exposure associated with stress. It can be assumed that seniority has impact on the level of stress - the longer it is, the lower the level of stress. Experienced physiotherapists have gained knowledge on how to deal with psychologically demanding situations they meet in their work. In addition to this, a positive correlation was noted between the number of hours of work per week, and the level of exposure to wrist joint overload.

Alrowayeh et al. reported over five times more frequent incidence of pain in the lumbar spine in a group of physiotherapists aged 20–40 years, compared to people over the age of forty [24]. This is also confirmed by other authors [36, 37].

The high prevalence of lower back complaints among younger physiotherapists could be associated with the lack of professional experience, knowledge and skills [27].

Physiotherapists are a professional group which has the fundamental knowledge of ergonomics and biomechanics. In Poland, even though physiotherapists have such knowledge, they are not able to use it in their work due to the lack of specially adapted equipment (chairs, couches, massage tables) or consulting rooms. In these conditions, the job of a physiotherapist often involves working in a hospital ward where they have to deal with lifting and moving patients and performing active-passive exercises, often in non-ergonomic positions due to the lack of adjustment possibilities of hospital beds. The second option is working with patients in private physiotherapy clinics where the biggest problem is related to too many working hours during the day and too many patients per one therapist. Another possibility is working in the patient’s home. This form of therapy is becoming increasingly popular in Poland, however, a patient’s room is never adapted for the work of a physiotherapist and requires them to work hard in non-ergonomic positions. All these factors cause frequent occurrence of musculoskeletal disorders.

In conclusion, it may be stated that spine overload in physiotherapists belongs to rather common pain-related disorders affecting the musculoskeletal system. What is alarming is the fact that in our study the pain was reported by a group of young physiotherapists, and this phenomenon has also been observed by other investigators [6, 21]. Therefore, the recommendations include deeper consideration of safe patient-handling and movement policies applicable in the profession of physiotherapists [38].

6 Conclusions

Musculoskeletal pain associated with the work of physiotherapists occurs already in young people. The lumbar section of the spine is particularly exposed to it.

Conflict of interest

None to declare.