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Motivations or drivers for the MSD Project: why did we embark on the study? 1999 ARC motion: “ Conference calls upon the CSP to investigate and raise awareness of the extent of strain injuries to the joints in the hand as experienced by physiotherapists. These injuries may be directly linked to the use of physiotherapy techniques and impacts on physiotherapists’ working lives as well as covering long term disability.” ‘ Physios often neglected in research’ from Beynon & Reilly (2002). CSP hopes to plug the gap in knowledge. Jean Cromie’s study: younger (under 30 years old) physios more at risk; 1-in-6 move specialty or leave the profession as a result of MSDs. Phenomenally high prevalence. CSP concerned if these figures replicated amongst CSP’s membership.
Questions based on the standardised Nordic questionnaire used to record work-related musculoskeletal symptoms in working populations. Questionnaire design also drew, with permission, on work of Cromie et al (2000) and West & Gardner (2001). Sample included physiotherapists, physiotherapy assistants & physiotherapy students far enough into their degree to have embarked on clinical placement. Also captured some retired members and members not currently practicing.
Snap shot of the demographic make-up of the respondents. Gender breakdown consistent with the membership of the CSP. Average age: 39.5 (Statistical Deviation = 12.07). Respondents between the ages of 31-40 formed the largest group (28.4%) Over half of the respondents supplying information about their work status (n=2,611) were working full-time (53.2%, 1,389), 36.6% (956) were part-time, 4.3% (113) were students, 3.0% (78) were retired and 2.9% (75) were non-practising at the time they completed the questionnaire. 73% (1,910) working in the NHS, 8.4% self-employed, 4.8% private healthcare, 4% private practice, 3.8% university setting. 33.7% general musculoskeletal outpatients, 11.3% elderly care, 8.2% paediatrics, 7.2% neuro (rehab), 6.5% orthopaedics 42.5% Senior I/Supt IV, 16.8% Senior II, 6.9% starter, 6.7% Supt III
Respondents were asked whether they had ever experienced “work-related musculoskeletal pain, discomfort, illness or injury” in their physiotherapy career to date; during the last 12 months and, if so, whether symptoms had persisted for more than 3 days; and also whether they had experienced symptoms within the last week. Prevalence calculated by dividing the number of respondents who reported an injury by the total number of respondents returning the survey questionnaire.
Three body areas with the highest prevalence. ‘ Worst’ refers to the respondents’ “most significant” or “most serious” injury. Respondents who indicated they had experienced musculoskeletal symptoms in any of ten body areas were asked to choose the one area of injury they considered the “most significant” - the worst - and answer subsequent questions about that injury. Of all injured respondents (n=1,796) 44.2% said the low back was their worst or most significant musculoskeletal injury.
Age is a significant finding. A greater number of respondents (58.5%) were aged 30 or under when their most serious work-related MSD occurred compared with 41.5% over 30 years of age. Statistically significant finding. Nearly a third of respondents reporting an injury first experienced symptoms within first 5 years after graduating. Some 12% were physiotherapy students at first onset of major injury. Most spinal problems occurred within first years of practice while lower limb problems appear later on. Little variation was found in average number of hours spent in direct patient contact across all injury types. Thumb injury the exception: the highest prevalence of thumb injury (49%) is seen in physios who spend more then 32 hours per week performing mob/manips.
The clinical settings with highest rates of injury - note this where the first onset of symptoms of the respondents’ most serious injury occurred . The extent of injury in general musculoskeletal outpatients was comparable to the proportion of respondents currently working in that specialty (31.2% injury rate compared to 33.7% working in the specialty ). For neuro rehab - highlighted in yellow - the injury rate of 13.6% was disproportionate to the number of respondents currently working in the specialty ( 7.2%) . Should be more concerned about neuro rehab. Elderly care: 12.1% of respondents reported first symptoms of their most significant injury occuring whilst working in elderly care. 11.3% of respondents currently work in elderly care.
This slide gives an indication of serious injury by clinical setting. Three-quarters (75.5%) of respondents whose major musculoskeletal injury had been to the thumbs first experienced thumb pain in the general musculoskeletal outpatients setting. Almost half of all respondents whose major musculoskeletal injury had been to the hand or wrist first experienced this injury whilst working in general musculoskeletal outpatients. Etc
For respondents reporting their most significant musculoskeletal injury to be the low back almost 18% said the injury occurred whilst working in neuro rehab. Similar proportion of elbow/forearm injuries (as the most serious injury) occurred whilst working in neuro rehab. Counts very different - just a handful of elbow/forearm injuries compared to low back (over 100) but similar proportion of worst injury. Slide gives a flavour of severity of injury by specialty.
Respondents who reported musculoskeletal injury were asked to consider 18 ‘job risk factors’ and to indicate, on a 4 point scale, how each factor had contributed to their most significant injury. Adding together the responses indicating factors to be of ‘moderate’ or ‘major’ influence the top 6 job risk factors were: Performing the same task over & over 73% Working in the same position for long periods 67% Treating a large number of patients in one day 67% Bending or twisting back in an awkward way 56% Lifting or transferring dependent patients 56% Continuing to work when injured or hurt 52% Others of interest: performing manual therapy techniques 49% Too few rest breaks 41% sudden patient fall 39% Lack of staff 35% By contrast, the factor considered to be the least contributive to injury was inadequate training in injury prevention . Only 210 out of 1,515 responses - 14% - viewed inadequate training as being a problem.
The first three figures in the right column (in yellow) suggest under-reporting of MSDs. Not an accurate reflection of the problem. Tip-of-the-iceberg. Encourage reporting of injuries otherwise MSDs remain an “invisible” problem. Over 40% of respondents had not had a risk assessment in their current post.
To gain an insight into how injured CSP members respond to musculoskeletal injury in the workplace respondents were asked to rate 13 strategies using a scale of 1-4 (1 indicated the strategy was ‘irrelevant’, 4 indicated the strategy was ‘almost always’ utilised). The top three are shown. 86% of injured CSP members almost always adjust the plinth or bed height - this is after sustaining an injury, not before. Message appears to be that taking some remedial action is better than taking none at all.
Our study confirms the high incidence of MSDs in physiotherapists In our study, 48.4% reported low back problems. 44.2% said the low back was their most significant injury. This is a similar finding to Cromie et al (2000) and West & Garder (2001) for the most significant area of injury (48% and 41% respectively). Younger physiotherapists and newly qualified graduates appear in most need of intervention services aimed at reducing injury rates. Relatively few injured physiotherapists leave the profession. This could point to ‘survivor bias’ where CSP members who are injured early in their career find effective ways of managing their symptoms to avoid serious re-injury. They learn to adapt.
Almost a third (32%) of musculoskeletal problems first became apparent to the injured physiotherapist within the first five years of practice. This is consistent with findings from other studies. Most physiotherapists who sustained an injury did not consider inadequate training in injury prevention to be a factor in their injury. How do we explain this apparent ‘Information Rich, Practice Poor’ finding? Younger physiotherapists are more at risk. Perhaps age and initial onset of injury - ie within first few years of practice - point to the existence of a vulnerable period where the principles of physiotherapy learned as a student are not implemented safely in practice? Should we look elsewhere - for example, into issues of professional socialisation and how physiotherapists are inducted into the world of work? Are CSP members ‘Inducted into Illness?’ If so, what can be done? One school of thought is that if work is unsafe, no amount of training can correct the situation. Physiotherapy is undoubtedly a high risk occupation for MSDs in the health sector. So is Musculoskeletal Damage an inevitable legacy of physiotherapy? Our view (CSP Employment Relations & Union Services) is that a solution-based approach to the problem of work-related musculoskeletal damage in physiotherapy should not be beyond the CSP. This could include practical interventions focusing on risk assessment, regular awareness raising of the dangers, perhaps more supervision in the early years and the sharing of information on effective preventive strategies and good practice. It is only by addressing the totality of the individual approaches of CSP members to their work, the behaviours and attitudes that collectively make up the culture of physiotherapy, the structures that dictate how work is organised and the commitment and political will of employers and government to invest in effective interventions that the high levels of musculoskeletal injury within the profession can begin to be tackled systematically.
‘ THE MSD PROJECT’ <ul><li>Annual Representative Conference (ARC) motion 1999 </li></ul><ul><li>MSDs widely considered a problem in health </li></ul><ul><li>Wealth of info on nurses but ‘physiotherapists often neglected in research’ </li></ul><ul><li>Cromie et al (2000) 91% lifetime prevalence in Australian physical therapists </li></ul><ul><li>Ramifications for CSP members (health & safety) & Government policy (retention) </li></ul>
METHOD <ul><li>Self administered questionnaire </li></ul><ul><li>Randomly selected 10% sample of CSP members </li></ul><ul><li>3,661 questionnaires distributed (summer 2003) </li></ul><ul><li>2,688 returned </li></ul><ul><li>73.4% response </li></ul>
DEMOGRAPHICS <ul><li>89.4% female, 10.6% male </li></ul><ul><li>average age: 39.5 (range 20-80) </li></ul><ul><li>53.2% full-time, 36.6% part-time </li></ul><ul><li>73% working in NHS (60.7% in hospitals) </li></ul><ul><li>33.7% in Gen Musculoskeletal Outpatients </li></ul><ul><li>42.5% Senior I/Super IV grade </li></ul>
PREVALENCE <ul><li>Body Area Career Annual Worst </li></ul><ul><li>Low back 48.4% 37.2% 44.2% </li></ul><ul><li>Neck 33.0% 25.7% 13.6% </li></ul><ul><li>Upper back 23.4% 18.4% 12.0% </li></ul><ul><li>Thumbs 23.3% 17.8% 10.2% </li></ul><ul><li>Shoulders 19.5% 14.8% 6.4% </li></ul><ul><li>Wrists/hands 16.7% 12.5% 6.8% </li></ul><ul><li>Whole Body 67.5% 58.0% n/a </li></ul>
Most Significant Injury <ul><li>Spinal 69.8%, Upper limb 24.8% </li></ul><ul><li>58.5% under age 30 at initial onset </li></ul><ul><li>32% within 5 years of graduating </li></ul><ul><li>Little variation in average number of hours spent in direct patient contact </li></ul><ul><li>Except thumb injury - 49% over 32 hours per week performing manipulations </li></ul>
ELDERLY CARE <ul><li>Hips/thighs 25.0% </li></ul><ul><li>Knees 22.6% </li></ul><ul><li>Ankles/feet 20.0% </li></ul><ul><li>Low back 14.4% </li></ul><ul><li>Upper back 13.4% </li></ul>
Job Risk Factors <ul><li>Performing the same task over and over </li></ul><ul><li>Working in the same position for long periods </li></ul><ul><li>Treating a large number of patients in one day </li></ul><ul><li>Bending or twisting back in an awkward way </li></ul><ul><li>Lifting or transferring dependent patients </li></ul><ul><li>Continuing to work when injured or hurt </li></ul><ul><li>Inadequate training in injury prevention </li></ul>
Consequences of injury <ul><li>Sought physio treatment informally from a colleague (61%) </li></ul><ul><li>Modified physio techniques (59%) </li></ul><ul><li>Consulted a doctor/GP (39%) </li></ul><ul><li>Took sick leave (32%) </li></ul><ul><li>Reported injury to manager (16%) </li></ul><ul><li>Occupational health (12%) </li></ul><ul><li>Filled in accident form (10%) </li></ul><ul><li>Decreased patient contact hours (9.4%) </li></ul>
Preventive strategies <ul><li>Adjust plinth/bed height: 85.8% </li></ul><ul><li>Modify my/patient’s position: 79.1% </li></ul><ul><li>Help handling heavy patient: 65.5% </li></ul><ul><li>The vast majority of preventive strategies adopted were deemed to be at least moderately effective </li></ul>
Summary <ul><li>High incidence of MSDs in CSP members: career prevalence 67.5% </li></ul><ul><li>48.4% low back problems </li></ul><ul><li>Younger physiotherapists & newly qualified graduates most at risk </li></ul><ul><li>1-in-16 move within or leave the profession because of MSDs </li></ul><ul><li>43.9% no risk assessment in current post </li></ul>
Conclusions <ul><li>Information rich, practice poor? </li></ul><ul><li>Inducted into illness? </li></ul><ul><li>Musculoskeletal damage - the legacy of physiotherapy? </li></ul>