Chapter 4

4.0 Introduction

This section includes a systematic way of presenting key findings as gathered from overall study from academic literature collected for completion of this research.

4.1 Findings and analysis 

Author and year	Key words	Study design	Results	Findings
Bitenc-Jasiejko, Konior & Lietz-Kijak (2020)	Lower back pain, Postural defects and “structural integration disorders”	Qualitative	About 25 to 83% of overall physiotherapists at a global scale have demonstrated a relapse of pain with 33% of overall cases inhibiting moderate pain index	This study has dealt with meta-analysis of diagnosis and treatment of LBP and other relevant back pains amongst physiotherapists. Furthermore. This studies comprehensive of a functional assessment of human “musculoskeletal system” along with proper discussion of “initial, systematic and cross-sectional control”
Borys et al. (2015)	Pain intensity, MSD, Depression and “healthcare utilisation”	Qualitative	Pain intensity of physiotherapists and other patients of musculoskeletal disorders were found to be at “ES -0.48” in general and “ES -0.22” due to anxiety	Use of a multimodal therapy has been proven successful in this study for treating LBP and MSD
Chou et al. (2018)	LBP, pain management, “chiropractic therapy”	Mixed method	Economic burden caused due to prevalence of occupational LBP was estimated at 110 billion Euros	There is a need of measuring proper intervention for successful use of CAM and Chiropractic therapies
Cruz et al. (2020)	Chymotrypsin, pain management, protease inhibitors	Qualitative	Almost 3.3 billion occupational injuries across world	Application of a “polyphasic approach” could be essential for coping up with this situation
De Sola et al. (2020)	Pain clinic, opioids, “non-malignant low back pain”	Mixed methods	Average “chronic pain or CP index” is at 28.9% in Europe	Limited information received by health-care professional is one of the major barriers to proper treatment of CP
Lochting et al. (2017)	PRO, LBP research, psychological distress and “pain catastrophizing”	Qualitative	Mean age for physiotherapists undergoing LBP was 38.3 years with 57.6% of female	Use of “Hopkins Symptoms Checklist (HSCL-25” could be useful”
Ngai Leung et al. (2021)	LBP, physiotherapy and RTW	Qualitative	Improvement through ODI was at 47.6 p	Use of a multidisciplinary program could increase patient muscular functions
Savia et al. (2017)	Healthcare costs, LBP treatment and PPI	Qualitative	3% of patients with LBP can afford self-management of pain	Launch of mobile application for determining “outpatient waiting”
Simula et al. (2020)	LBP framework, imaging, biopsychosocial factors	Qualitative	Over 90% of occupational pain are classified to be “non-specific” in nature	“Patient-Reported Outcomes measurements” is a widely used tool
Tanashyan et al. (2017)	RCT, rehabilitation, LBP	Qualitative	MRI scan of LBP physiotherapists show herniation of “L4-L5 5mm”	Physiotherapist working for more than 2 years have shown “Palpation of the metatarsophalangeal joints”
Vitola et al. (2018)	LBP management, behavioural therapy	Qualitative	More than 78.9% of physiotherapists face LBP after age of 45	Non-pharmaceutical treatments such as “acupuncture and spinal manipulation” along with psychotherapy is helpful
Wang et al. (2020)	Vibration therapy, LBP, WBV	Qualitative	Point prevalence ranged from 12 to 34%	A PICO system could be efficient in application of vibration therapy
Williams et al. (2017)	Musculoskeletal injuries, occupational actions, IPAT tool	Qualitative	Detection of anxiety and stress was accounted as a major reason at 82%	LBP and MSD are lesser among therapists having critical awareness and occupational ethics

Table 4.1: Findings and analysis 

(Source: Researcher) 

4.2 Summary 

The above table thereby justifies collocation of a range of academic and authentic sources with qualitative and mixed study design. These sources have contributed significantly towards determination of overall findings in context of physiotherapists’ LBP and occupational pain related issues. 

Chapter 5: Discussion 

5.0 Introduction 

The discussion chapter of this research study identifies a basic and significant element of entire literature that would further dictate framing of the conclusion chapter of this study. Furthermore, this chapter is highly based upon formation of themes based on objectives and research questions. Moreover, a thematic analysis within scope of a research have signified importance of research questions and objective fulfillment of study’s outcome in a systematic way. 

5.1 Research Hypothesis     

Ha0 (Null Hypothesis): Occupational practices of physiotherapists do not lead to LBP and other musculoskeletal disorder

Ha1 (Alternative Hypothesis): Occupational practices of physiotherapists leads to LBP and other musculoskeletal disorder

Hb0 (Null Hypothesis): Occupational setting are the only cause for LBP in physiotherapists

Hb1 (Alternative Hypothesis): Occupational setting are not the only cause for LBP in physiotherapists 

5.2 Thematic analysis

Theme 1: Health issues faced by physiotherapists due to long working hours

Physical therapies as provided by a range of therapists is a collocation of a number of “rehabilitative health services” that often involve extensive pressure handling. Association with such consistent and highly physical strain involved job has made possible ways for physiotherapists to get accustomed to a number of musculoskeletal disorders. Through application of a number of “bivariate and multivariate analyses” differences between cause and symptoms of lower back pain and other associated musculoskeletal disorders have been considered (Çınar-Medeni, Elbasan & Duzgun, 2017). About 66.7% of overall LBP and neck pain events amongst physiotherapists occur from work related injuries while serving a range of patients with movement related disabilities (Tahir et al. 2020). 

Given the statistical dimensions as collected by a group of study, total number of estimated disabilities involved physiotherapists were are 355 within a single institute with about 51% male physiotherapists suffering from LBP and other relevant musculoskeletal disorders. This has been generally caused due to “manual medical lifts and patient lifting” of patients. This further accounted for an overall percentage of 56.8% (Lunde et al. 2019). Furthermore, it can be said that More than 88% of overall injuries have occurred due to prolonged working hours of physiotherapists in an awkward position in order to suffice through patient’s movement generation. More than 45% of women physiotherapists have been made accustomed to witness symptoms of medium to severe symptoms of LBP and other musculoskeletal disorders within 6 to 7 months or at most 1 year of their joining into the working sphere (Taulaniemi et al. 2020).

Furthermore, it has been noticed that physiotherapists who are accustomed to working premises within a “clinical setup” are 13% more at risk to get accustomed to LBP symptoms due to job demand. Other factors that have accompanied with working premieres and environment of healthcare conditions, factors such as “lifestyle and social living experiences’ ‘ also add up as a provocation element for persistent conditions of MSD disorders in physiotherapists (Vinstrup, 2019). Through an ultimate estimation of a number of causes, major ones were due to “massive weight lifting”, “repetition of similar tasks for a prolonged period”, “personal mental stress”, lack of employee diagnosis within physiotherapists. 

Factors such as “old age morbidity ratios” and “socio-demographic conditions” play a major role in determining severity of musculoskeletal disorders in physiotherapists. Due to working conditions of such therapists might cause “lack of spinal motion” that could be an entirely devastating role with “increased stress on back muscles” (Ekechukwu et al. 2020). Improper ways of handling patients with movement disabilities have also led to “muscle tension” at a specific area along with representative “fatigue, joint pain and strain as well as joint compression”. Furthermore, over 56.5% of physiotherapists have reported psychological stress to be a determinant factor of “lower back pain and other lumbar pains” (Maakip et al. 2020). Furthermore, it is important to mention that stress related symptoms of MSD and LBP are quite common in countries such as “South Africa, South Asian countries as well as Australia” (Bornhöft et al. 2019). This has further resulted in justification of “theory of stress” for relevant back pain which has been named as “Tension myositis syndrome or TMS”.

It is however, significant to mention that a number of “health care professionals” are similarly victims of such lower back and neck pain, owing to their job requirements. Furthermore, the job of physiotherapists to provide a number of “rehabilitative care” within a diverse range of highly disabling conditions is supposed to be the main reason for regressive health status of therapists. Other skills that require within job premises of “hands on” techniques are also reasons for such health severities. Techniques involving a number of “repetitive movements and prolonged standing and difficult postures” have caused further severities (Khan & Fasih, 2017).  Over 4 million physiotherapists globally have gotten accustomed to such problems since their occupational practice sessions. Maintenance of a severe and consistent “static and dynamic posture” could also lead towards regression of overall physical conditions of physiotherapists. 

Moreover, it has been found that factors relevant to “age, height and weight” have contributed towards accentuation of severities regarding LBP and MSD diseases. More than 73% of LBP and MSD have been witnessed to occur among physiotherapists having heights of more than 5 feet 6 inches. This is mainly relevant to greater stress amplified over the spinal cord due greater need of bending down to patients’ level (Roy et al. 2018). Furthermore, it is essential to mention that people with greater amounts of obesity and higher BMI weight are supposed to be more affected by the working conditions of physiotherapy than others. Similar cause of such conditions is due to inability of moving with lesser amount of flexibility. In addition, the overweight and lifestyle of obese people would be affecting physical conditions of a particular physiotherapists to a much larger extent few to exertion of excess body weight over the spine and other vertebrates.    

Theme 2: Ways to deal with LBP and other musculoskeletal disorders amongst physiotherapists

“Work related musculoskeletal disorder” or WRMD are one of the most significant conditions that are often faced by physiotherapists. Furthermore, it is important to know that WMSDs and injuries relevant to it are mostly concerned with development and “exacerbation of painful symptoms” that would allow for contributing to more severe health outcomes in therapists. This could be added up through consistent repetition of activities that lead towards “strain to the nervous system of the human body” along with “ligaments, muscles, tendons, joints and spinal discs’ ‘ (Maakip et al. 2020).  It is essential for the hospital and therapeutic institutions to look after physical stains caused upon their staff and practitioners with ample amount of focus upon “cumulative trauma disorders’ ‘ and development of a “overuse syndrome”. Furthermore, it is essential to consider that overexertion of just the upper limbs of the human body used for this profession could significantly add up to extremities caused in musculoskeletal situations. Maintenance of a standard within hospital and therapeutic institutions would thus be necessary and assertive of hospital’s recognising capacity of staff and healthcare professionals current state of being. 

Through formulation of a set of guidelines based upon “European Agency for Safety and Health at Work (EU-OSHA)” healthcare services could be amplified with an accentuated focus on health and wellbeing of physiotherapists. Increasing rates of MSD and LBP as well as other traces of lumbar pain have resulted in a rise of 12 million more hospitalisation cases of severe and chronic LBP in countries such as the UK and Australia. This has further added up to expenditure and the rise of economic costs up to 44.6 billion Euros to about 56.7 billion Euros (Khan & Fasih, 2017). Thus, identifying some basic and general number of risk factors are quite necessary in assuming a successful positive healthcare environment in countries such as the UK, Australia and South Africa. 

So, in order to focus upon reduction of statistics that would give rise to a number of ways in accommodating for a healthy lifestyle and postural ability of physiotherapists within working premises is a significant necessity. Furthermore, it is necessary that employers take consideration of a number of factors in avoiding greater risks of work-related hazards. Encouragement of an open discussion forum could be one of the greatest factors that would help in reduction of LBP causing factors in healthcare institutions would be through inclusion of a “minimal lifting approach” and accommodation of proper knowledge and training on accurate use of equipment facilities (Maakip et al. 2020). Adequate staffing would also be a major factor for identification of whether a number of physiotherapists would comply in companies with a good way of managing working hours along with appropriate detection and early diagnosis of MSD related symptoms. 

Regular re-evaluation on employers’ part would be exceptionally effective in measuring “content and frequency” of training courses. Especially through the constitution of a group of newly hired and young personnel for PT’s need to be strongly administered through feedback of training exercises (Maakip et al. 2020). Application of an “aggressive ergonomic evaluation” could be of high benefit for a particular healthcare firm in amplifying working conditions of its constituent physiotherapists. Based on guidelines of “NIOSH or National Institute for Occupational Safety and Health” application of spinal compression needs to be regulated within working activities of physiotherapists (Khan & Fasih, 2017). Furthermore, it is essential for a health institution to take care of ways in which high lifting techniques can be accommodated through proper training and setting up of lifting weight limits for staff working with alignment of their physical variability and conditions. 

It is important to mention that at present human society has not come up with any “targeted therapies for MSD” with a “supportive and symptoms based” treatment formula. However, in order to care for physiotherapists that have shown symptoms of MSD, a multidisciplinary setting of team could be highly efficient in considering prolonged effect of MSD over physiotherapists (Maakip et al. 2020). Consideration of a “broad spectrum” constituting a comprehensive approach could result in accentuation of high levels of neurological actions and improved metabolism in patients suffering from acute MSD and back pain (Khan & Fasih, 2017). Application of MRI could be highly beneficial for acknowledging the rate of “MSD variables and nonspecific symptoms’ ‘ within physiotherapists“. Alongside to this, hospitals might take consideration of withstanding early evaluation of MSD symptoms through “physical occupational interventions, speech therapy and maximising amount of mobility and communication”. 

Theme 3: Recommendations for resolving these issues 

Prolonged symptoms of MSD could cause heavy impact upon conditions of physiotherapists regarding their “muscles, bones, and joints”. MSDs have been noted to be of various kinds including “tendinitis, carpal tunnel syndrome, Osteoarthritis, rheumatoid arthritis RA and fibromyalgia or even bone fracture” (Vinstrup, 2019). It is confident damage to physical and bone structures of specific action related diseases that could deteriorate basic lumbar spinal conditions of a human being. Early diagnosis is one of the most significantly effective ways of taking care of easy symptoms and facilitating improvement of “long term outlook” on MSD conditions. Diagnostic signs of MSD could be accumulated through provision of regular and timely check-ups and provision of a “physical examination system” (Maakip et al. 2020). Symptoms such as “muscle weakness and atrophy” could be diagnosed with imaging tests. Provision of such imaging tests such as “X rays and MRI scans” with proper examination of “bones and soft tissue structures” (Vinstrup, 2019).

Awareness system within working premises of physiotherapists would be another important factor that needs to be taken care of, by parent institutions under which physiotherapists function. Furthermore, it is important to know that through application of moderate exercises, one would be able to encapsulate improvements within initial conditions of physiotherapists (Maakip et al. 2020). Furthermore, the healthcare firm could also provide for “over-the-counter medication provision” to its therapists such as “ibuprofen and acetaminophen” in order to avoid occasional existence of pain. Both “physical and occupational therapy” would be highly recommended” in this section (Vinstrup, 2019). Through application of such therapies within hospital premises, other staff would also be able to identify common causes and problems of MSDs. Such therapies could in turn help in reduction of “pain or discomfort along with maintenance of strength or particular range of motion”.

Maintenance of a healthy and effective lifestyle would be another necessary component that needed to be taken care of by hospitals and intrinsic members. Furthermore, several therapeutic conditions have been administered in recent years in order to manage issues relevant to musculoskeletal and other vertebral conditions. Use of regenerative medicines could be yet another significant step at countering scope of modifying acute MSDs onto a chronic one (Khan & Fasih, 2017). Furthermore, through regenerative medicines growth factors could be stopped along with alignment of “mesenchymal cell therapy” used for augmented healing of MSD and lower back pains. Hospital staff should be well acquainted with physiotherapeutic medications and testing facilities that could be amplified for determination of pain index in physiotherapists. (Vinstrup, 2019). Identification of “weight bearing cause” could suffice for accentuation of better healthcare premises for physiotherapists to work within. All of such findings could be later amplified and used for generation of historical indicators for a patient’s physical state.

Through use of a “computerised gait analysis system” a particular hospital would be able to quantify the number of ways in which localisation of pain could be administered. Furthermore, severity of “soft tissue structures and bones” could be administered through application of “radiography, MRI or CT scans and even nuclear imaging techniques” (Maakip et al. 2020). Furthermore, being a part of the hospital arena, it would be useful for physiotherapists to get a check-up done immediately through either conventional scans and imaging techniques and in severe cases even “synovial fluid analysis” could also be accommodated for development of a “prognosis based on earlier diagnosis”. This would in turn help physiotherapists to help in administration of “restricted or modified activities’‘ with immobilisation of “acute and chronic injured structures” (Khan & Fasih, 2017). Apart from these kinds of therapeutic and detection-based disorders of MSD and lower back pain in physiotherapists would be through application of NSAIDs and even “corticosteroid administration” for severe cases. Furthermore, hospitals might provide for a chance of ‘physical therapies, or extracorporeal shock wave therapy” and in certain cases even surgical repairs for curing staffs moderate to severe MSD por other kinds of WRMD within hospital premises.               

Theme 4: Responsibilities of healthcare institutions in coping up with such health anomalies 

Hospitals need to be well aware of working conditions that lead towards decreasing efficiency of physiotherapists because of a musculoskeletal syndrome. Repetitive labour could be effectively reduced by the hospital authority to take care of a “less labour-intensive working condition”. Application of robots could be an essential step in undermining efficiency in jobs that involve higher manual handling of weights at large scale therapeutic institutions. Individual risk factors need to be identified with proper care of physiotherapists’ health conditions such as “individual BMIs and presence of co-morbidities” (Taulaniemi et al. 2020). 

Based on guidelines of OSHA and NIOSH working regulations should be compliant with corporate social responsibility in taking utmost significance to workers’ occupational health and safety. Inadequacy on “injury prevention” training needs to take into considerations by administrative officials within a therapeutic institution.  Furthermore, such health care centres need to be assertive of systems that would take a judgemental step of reducing psychological stress factors leading to severity of MSD based working conditions (Taulaniemi et al. 2020). Factors such as “low working content, time pressure and high perceived working load, perceived amount of stress and psychological stresses” are certain indicators of causing severity in lower back pain and other lumbar spine pains.     

In order to avoid more than 5.5 billion Euros of total economic cost spent behind provision of financial concession to staff suffering from MSD and lower back pain could be avoided through initial adoption of intervention measures. Through utilisation of “administrative time dealing” and training of injury prevention as well as early rehabilitation, hospitals and therapeutic institutions could avoid scope of future anomalies in physiotherapists. Application of a risk assessment in this regard would be able to retain at least 65% of overall normalcy into physiotherapists physical health status (Taulaniemi et al. 2020).  

Through undermining employer’s responsibilities about ways in which employee communication could be enhanced, prevention measures could be applicable. Application of an “adequate staffing measure” would be equally suitable for taking control of a “re-evaluation of staff’s physical and historical records” along with their ergonomic evaluation. Training of “body mechanics” accompanied with “back care training” would be necessary for implementation of a highly saturated and structured prevention program (Taulaniemi et al. 2020). Consideration of a number of feasible measures along with provision of an integral training system within physiotherapists about ways to handle excess weight and asking for help would in turn reduce scope of such physical trauma.  

Application of a “custom training system” with safe use of proper equipment, training for sustained posture management and controlling “caseload variations” need to be considered. Activities that could be made an integral part of such training would be application of a “cognitive behavioural theory” along with training regarding “patient centred goal setting, graded exposure and gradual systematic progression” (Taulaniemi et al. 2020). Application of “promoted micro breaks” would also be an essential element of increasing entire operational productivity.  

5.3 Hypothesis justification 

Based on the above discussion hence it can be said that various occupational factors have been witnessed to be primary cause of degrading MSD conditions. Thus, hypothesis Ha1 (Alternative Hypothesis) is justified. On the other hand, it has been said that not just occupational settings however other factors such as mental health and stress could also lead up to regressive state of lower back pain and other MSD diseases. Thus, Hb1 (Alternative Hypothesis) has been proven right through this discussion.

5.4 Summary 

Hence, based upon the above discussion major issues of musculoskeletal disorders have been notified along with identification of processes that could help in successful countering of such conditions among physiotherapists. This section has thereby significantly contributed towards identification of major themes of the entire study based upon research questions and provide ultimate justification for two research hypotheses.  

Chapter 6

6.0 Introduction 

This section is based primarily upon factual information collocated within the systematic literature and accompanies a number of conclusive statements that would help in further research in concerned subject matter. The conclusion section is a summation of major study outcomes that has shaped the entire basis of study’s validity and contextuality. Through studying this chapter, one would be able to justify key objectives that have been drafted at the preliminary section of this study. Verification of aim and objectives of the entire study has been carried out in this section significantly.  

6.1 Summary of review findings 

Through systematic review of this study and entirety of entire subject matter could be significantly established. Based on the amount of literature this study has dealt with, it can be found that musculoskeletal disorders among physiotherapists could be due to the major amount of “physical efforts” that physiotherapists constantly put through their occupational jobs. This has made physiotherapists to be more susceptible to a wide number of lumbar spinal defects and chronic disability in certain cases. Prevalence rates as obtained from studying a number of academic literatures has portrayed that more than 66% of cases belong from the UK and 61% from USA, while the rest 98% cases are from Australia and 91.3% of cases are from Nigeria. Another significant reason that has been associated for degradation of such physical ailments among therapists round world is due to increasing prevalence of job pressure and need for administering maximum number of “manual effort” for treating their patients. Risk factors that have been studied are majorly witnessed to be due to continuous exertion of force, “continuous bending, patient transfer, sudden unanticipated movements and lack of physiotherapeutic assistance for themselves”.

Based upon the table of findings it can be clearly noticeable that a number of intervention measures could be adopted by healthcare industries in order to take care of occupational hazards relevant to LBP and WRMD. These could range from a number of separate multi-disciplinary programs such as “patient outcome recorded measurements” and “chiropractic therapy” and many more. However, it is important to note that in order to gain an intervention measure functional within a particular occupational environment, objectifying key measures and infrastructures required for painting out deliberate provision of satisfactory healthcare support to therapists. 

More than 84.4% of UK’s therapists are subjected to denial of proper healthcare acknowledgements that further lead towards getting subjected to severe and chronic LBP syndromes. About 44.4% of therapists do not get proper provision of work-related training in Nigeria that accounts for more than 3 million physiotherapists suffering from a lifetime spinal anomalies and constant pain. One of the air concerns that has been identified in this context is that 48% of physiotherapists undergoing such ailments belonged from the age group 26 to 31 years. 

Concerns over MSDs due to occupational setting is as valid as concerns for implementation of adequate health care policies. For instance, application of “Quality, innovation, productivity and Prevention” or QIPP has been one of the major initiatives taken by British healthcare system for endorsing   

6.2 Linking with objectives 

Objective 1: To understand the health issues among physiotherapists

 Based on the above discussion and a number of analyses it has been clearly evident that prolongation of a career as a physiotherapist, deeply affects the health conditions of these health professionals. Furthermore, it has been found that factors relevant to Lower Back Pain and other musculoskeletal disorders amongst physiotherapists have also been caused due to riding mental stress and occupational pressure and strict working conditions. 60% of overall physiotherapists in their entire lifetime have one way or other faced grave anomalies regarding back related injuries. 

Objective 2: To explore the causes and effects of neck and back pain in the physiotherapy profession 

Furthermore, in this study, a number of primary literatures have shown evidential proof on relevance of age and working conditions in worsening MSD related conditions of physiotherapists. Through application of such literature, this study has significantly fulfilled its second objective and has confounded factors associated with “neck and back pain”. It has been found that factors such as “age, phase course, BMI and even psychometric elements” add up to regression of such physical ailment related conditions.  

Objective 3:  To come up with recommendations to resolve the issues 

Through study of a vast number of literatures, this study has come up with a number of intervention measures on both employee and employer’s part. This has enabled the fulfillment of study’s third objective. This study has significantly added on notifying benefits of following “OSHA guidelines”, ““Benchmarking Controlled Trial (BCT) design”, physiotherapists training and various sorts of activity promotion techniques in order to acknowledge graveness of the situation and allow for a better occupational standard for physiotherapists at hospital. 

6.3 Recommendations and findings 

The work-related musculoskeletal disease can vary through different factors such as age, sex, timer pressure and marital status. As a mitigation plan, it can be said that time of workplace spending needs to be reduced in a workplace. In UK, 83.3% of the employees used to face low back pain. Thus, it is identified that healthy activities such as physiotherapy, exercise need to be increased in order to manage this disease. Maintenance of following recommendations would thereby be necessary in this context.

• Carrying out occupational “Nordic Musculoskeletal survey” for physiotherapists in hospitals  
• Following of OSHA guidelines 
• Provision of treatment through “acupuncture, spinal manipulation, and psychotherapy”
• Provide long-leave on case of severities in situation  
• Consideration of “behaviour therapy, pharmaceutical and non-pharmaceutical treatments” 

6.4 Summary 

This entire section sums up key contents of entire research and adds relevance to set objectives of the study. Furthermore, through inclusion of a number of recommendations this section serves as a conclusive one for the entire research work. from the analysis it is understood that more than 57.4% of overall hospital and therapeutic training centres have lagged such infrastructural requirements along with improper and inadequate requirements for trained staff and appropriate knowledge of working conditions. Thus, this study has significantly contributed towards satisfying above objectives to its fullest. In doing so this study has significantly dealt with a number of literatures informing about health issues of physiotherapists. 

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