Journal of Back and Musculoskeletal Rehabilitation 29 (2016) 763–769 763

DOI 10.3233/BMR-160687
IOS Press

Prevalence causes and impact of work related

musculoskeletal disorders among physical
therapists
Qassim I. Muaidi and Alsayed Abdelhameed Shanb∗
Department of Physical Therapy, College of Applied Medical Sciences, University of Dammam, Dammam City,
KSA

Abstract.
BACKGROUND: Physical therapists are particularly vulnerable to work-related musculoskeletal disorders (WRMDs).
OBJECTIVE: To evaluate the prevalence, causes and impact of WRMDs among physical therapists in the Kingdom of Saudi
Arabia (KSA).
METHODS: A cross-sectional study of physical therapists using a valid and reliable questionnaire. A total of 690 completed
surveys were returned (response rate = 69%). The T-test and Pearson’s correlation were used to identify correlations between
variables and the incidence of WRMDs.
RESULTS: Working hours/week and WRMDs were significantly correlated (p = 0.005). Lower back (46.5%) and neck (26.6%)
pain were most commonly encountered. WRMDs were significantly correlated with altered work habits (p = 0.036) but not with
body mass index (p = 0.297). The prevalence of WRMDs among physical therapists was 47.7% with a significant difference
between full- and part-time practice (p = 0.023). Adjustable beds/plinths (20%) and splints (18%) were the most commonly used
assistive devices.
CONCLUSIONS: Physical therapists are especially vulnerable to WRMDs with a prevalence of 47.7%. WRMDs are impacted
by both work status and setting. Low back pain is the most common form of WRMDs (46.5%). Avoidance of poor work habits,
increased ergonomic awareness and application of safety measures are essential to prevent WRMDs.

Keywords: Prevalence work related disorders, physical therapy, safety strategies

1. Introduction ical therapists, pose an economic toll on society as a

Work-related musculoskeletal disorders (WRMDs)
are the most common cause of chronic pain and phys-
ical disability among contemporary workers [1]. WR-
MDs are described as the onset of pain during work
lasting for more than 3 days [2]. Health care pro-
fessionals, particularly those in direct contact with
patients are most vulnerable to WRMDs [3]. Physi-
cal therapists are highly susceptible to WRMDs [2,4]
which significantly impact on quality of life of phys-
∗ Corresponding author: Alsayed Abdelhameed Shanb, Depart-
ment of Physical Therapy, College of Applied Medical Sciences,
University of Dammam, Dammam City, KSA. Tel.: +966 55578
6349; Fax: +966 33330343; E-mail: aashanb@uod.edu.sa.
whole and may affect the quality of patient care [4–7].
Physical therapists usually perform a variety of manual
therapy techniques and various activities such as pa-
tient transfer, lifting heavy equipment and performing
repetitive tasks (i.e. bending, twisting and maintain-
ing awkward positions for prolonged periods) which
can result in and or aggravate symptoms of already
existing WRMDs [2–11]. Also physical therapists
use various strategies to avoid and reduce associated
work/environmental stresses and strains such as out-
sourcing strategies [9,12] which involve shifting all or
part of the workload to a colleague. Preventive strate-
gies involve altering handling techniques [13,14] and
application of reactive strategies in response to a per-
ceived risk of injury [15]. Although physical therapists

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764 Q.I. Muaidi and A.A. Shanb / Musculoskeletal disorders among physical therapists
Demographic description of participated physical therapists
Gender Numbers % Marital status Numbers
Male 408 59.1 Married
Female 282 40.9 Single
Qualifications
Master 30.3% Full time
Doctoral Part time
Hours/week Mean ± SD Experience (Mean ± SD)
36.7 ± 8.10 10.16 ± 6.64
are commonly prone to WRMDs [9,10,15] the preva-
lence, causes and impact of WRMDs among physi-
cal therapists working in the Kingdom of Saudi Ara-
bia (KSA) have been largely unreported with the ex-
ception of two studies: one that directly evaluated the
incidence of musculoskeletal injuries among 162 ther-
apists in Rayed [8] and a second on 166 therapists in
Jeddah [10]. Therefore the aim of the present study
was to evaluate the prevalence, causes and impacts of
WRMDs among physical therapists in virtually all ar-
eas of the KSA. Outcomes concentrated on the im-
portance of preventive ergonomic training programs
and different safety measures for physical therapists
and related priorities before engaging in work to avoid
work/environmental risk factors, maintain the quality
of life of physical therapists and to deliver quality pa-
tient care. The specific objectives of the study were to:
(1) establish the prevalence of WRMDs among phys-
ical therapists working in the KSA; (2) identify asso-
ciations between the factors of sex, body mass index
(BMI), work experience, work status, work setting and
clinical placement areas with the incidence of WR-
MDs; (3) identify common risk factors for WRMDs
encountered by physical therapists in the work envi-
ronment; (4) determine the frequencies of various cop-
ing strategies employed by physical therapists to mini-
mize or eliminate exposure to work/environmental risk
factors for WRMDs.
2. Methods
2.1. Participants
A total of 690 physical therapists from various na-
tionalities working in various specialties in the KSA
participated in this study. Physical therapists with less
than one year in their current work settings or who
reported musculoskeletal pain as a result of previous
trauma were excluded from the study. All participants
read and signed a consent form approved by the ethical
Table 1
% Age Mean ± SD
520 75.4 Weight 71.41 ± 14.82
170 24.6 BMI 25.42 ± 4.91
Work status Work setting
545 79 Tertiary 63.8%
145 21 Secondary 36.2%
Common nationalities
Saudi Egyptian Jordan Others
27.9 35.6 11.6 24.9
review board of the University of Dammam and they
were advised that the collected data would be submit-
ted for publication.
2.2. Instrument
A self-administered questionnaire as a validated and
relatively inexpensive method to identify and evalu-
ate occupational risks was used to identify occupa-
tional health problems and risk factors of the study co-
hort [2,9,16,17]. The questionnaire consisted of two
sections and contained 27 questions. Section A of the
questionnaire included 16 questions to collect infor-
mation on the demographic characteristics of the re-
spondents, work experience, work setting and status,
and ergonomic training. Section B included 11 ques-
tions on the incidence of WRMDs, risk factors in the
work place, changes to working habits, coping strate-
gies and types of patients treated. Respondents were
asked whether they had experienced WRMDs, which
were defined as discomfort or pain due to work and
lasting more than 3 days in the last 12 months [2]. The
prevalence of WRMDs for each body region was cal-
culated by dividing the number of cases by the total
number of included therapists [18].
2.3. Procedure
A self-administered questionnaire was distributed
manually to 1000 physical therapists working in dif-
ferent areas of the KSA and each copy was accompa-
nied by a cover letter stating the purpose of the study
and assuring confidentiality. The purpose and content
of the questionnaire was explained to each participant
and a contact number was included to provide any fur-
ther explanations to potential participants. Each thera-
pist with more than 1 year of clinical experience was
asked to complete the questionnaire. Of the 1000 dis-
tributed questionnaires, only 690 were returned appro-
priately completed and included for analysis.
 Q.I. Muaidi and A.A. Shanb / Musculoskeletal disorders among physical therapists
Table 2
Prevalence of work-related pain in common body areas of physical therapists in KSA
Variables Frequency % Variables
Low back 321 46.5
Neck 183 26.5
Wrists 113 16.4
Thumbs 13.9 20.1
Shoulders 84 12.2
KSA: Kingdom of Saudi Arabia. %: Percentage of incidence.
2.4. Data analysis
Data were analyzed using SPSS (version 20.0)
statistical software for Windows (IBM-SPSS, Inc.,
Chicago, IL, USA). Pearson’s correlation analysis was
used to identify correlations between sexes, BMI, num-
ber of working hours/week, work experience, risk fac-
tors, commonly used protective strategies and WR-
MDs. The independent t-test was used to compare
means of work status, work setting, incidence of low
back pain, ergonomics between sexes and the preva-
lence of WRMDs. A summated index was used to cal-
culate correlations between risk factors, coping strate-
gies and WRMDs. A probability (p-value of < 0.05
was considered statistically significant.
3. Results
3.1. Patient characteristics and demographic data
Of 1000 distributed questionnaires, 690 were in-
cluded for analysis yielding a response rate of 69%
(59.1% of males and 40.9% of females). The study
population represented various nationalities: 27.9%
Saudi, 35.6% Egyptian, 11.6% Jordanian, and 24.9%
of other nationalities. A total of 30.3% of the partic-
ipants had post-graduate qualifications with a mean
working experience of 10.16 ± 6.64 years and a
mean number of working hours/week of 36.7 ± 8.12.
There was a significant correlation between working
hours/week and the prevalence of WRMDs (r = 0.12,
p-value = 0.005). Full-time workers reported a higher
prevalence of WRMDs than part-time workers (79.0%
vs. 21.0%) respectively t-value = 2.28 & p-value =
0.023). Regarding work settings the prevalence of WR-
MDs of those in tertiary practice (concerned with neu-
rological rehabilitation and elderly care) was signifi-
cantly higher than those in secondary practice (con-
cerned with preventive measures) (63.8% vs. 36.2%
respectively t-value = 2.19 & p-value = 0.029). The
mean values of body weight and BMI measurements
765
Frequency %
Knees 75 10.9
Elbows 72 10.2
Hips 55 8
Ankles and Feet 24 3.5
Upper back 20 2.9
of all participants were (71.4 ± 14.81, 25.4 ± 4.90)
kg/m2 respectively which were both within normal
ranges (Table 1) [19]. There was non-significant cor-
relation between the prevalence of WRMDs and BMI
(r = 0.04, p-value = 0.297).
3.2. Work-related pain in commonly affected body
parts
The overall prevalence of pain associated with
WRMDs in any part of the body of physical therapists
was 47.7% which was significantly higher in females
than in males (51.2% vs. 48.8%) respectively t-value
= 10.62 & p-value = 0.00). Onset of pain was gradual
in 67.5% of cases. The prevalence of WRMDs varied
with work experience (5–15 years vs. > 15 years). The
lower back and neck were the most commonly affected
body areas (46.5% and 26.6%) respectively. Low back
pain was significantly more prevalent in females than
males (51.8% vs. 48.2%) respectively; t-value = 2.26
& p-value = 0.024). The prevalence of work-related
pain in other body regions were as follows: thumbs
20.1%, wrists/hands 16.4%, shoulders 12.2%, knees
10.9% and elbows 10.2%. The patient may be affected
with more than one area at the same time (Table 2).
3.3. Commonly used equipment and strategies to
reduce body strain
The most commonly used equipment to reduce
body strain was adjustable beds/plinths (20%), splints
(18%), sliding boards, (8%), and patient lifting belts
(2.9%) (Table 2). The frequencies of the decision to
change treatment plan, change area of specialty and
leave the physical therapy field were (12%, 7.7%,
3.5%) respectively (Table 3). Relatively few physi-
cal therapists underwent ergonomic training or aware-
ness courses (9%) although the prevalence of WRMDs
among this group was significantly lower than those
who received no ergonomic training (t-value = 2.25
& p-value = 0.025). As physical therapists have di-
rect contact with patients during delivery of care. They
may be affected by infectious diseases such as fungal
infections (3.9%) bacterial infections (9.4%) asthmatic
bronchitis (7.0%) and skin dermatitis (6.0%).
766 Q.I. Muaidi and A.A. Shanb / Musculoskeletal disorders among physical therapists

Table 3
Frequency of the used equipment or decision taking to reduce body strain
Variables Frequency % Variables Frequency %
Adjustable bed/plinth 138 20 Change treatment plan 83 12
Sliding board 55 8 Change area of specialty 53 7.7
Patient lifting belt 20 2.9 Change from Neurology rehabilitation
Splint 124 18 Change to Orthopedic
Others 20 2.9 Left job of PT 24 3.5
Non-of the above 333 49.2
Ergonomic training 62 9

Table 4
Job risk factors contributing to work-related discomfort (%)
Risk factors Irrelev. Min Sig. Mod Sig. Maj Sig.
Performing the same task over and over. 3.6 21.9 34.3 40.1
Treating a large number of patients. 1.0 30.3 28.7 40.0
Not enough rest breaks during the day. 3.8 51.9 25.7 18.7
Performing manual orthopedic techniques. 7.5 23.2 39.7 29.6
Working in awkward or cramped positions. 2.2 25.5 26.4 45.9
Working in the same position for long periods. 2.2 10.0 44.3 43.5
Bending or twisting your back in an awkward way. 2.6 36.1 18.7 42.6
Reaching or working away from your body. 25.8 18.4 31.7 24.1
Unanticipated sudden movement or falls by patient. 8.0 50.0 24.8 17.2
Assisting patient during gait activities. 3.3 24.3 30.4 41.9
Lifting or transferring dependent patients. 0 51.2 48.8 0
Working with confused or agitated patients. 8.0 50.0 27.1 14.9
Carrying, lifting or moving heavy materials 8.0 50.0 24.8 17.2
Working at or near your physical limits. 25.9 20.6 19.4 34.1
Continuing to work when injured or hurt. 10.7 16.7 51.9 20.7
Work scheduling (over time, shifts, workday). 29 23.6 16.1 31.3
Inadequate training in injury prevention. 31.2 30.0 19.1 19.7
Irrlev: Irrelevant; Min Sig: Minimum significant; Mod Sig: Moderate significant; Maj Sig: Major
significant.

3.4. Job risk factors and work-related discomfort
The most commonly associated environmental/job
risk factors with physical therapy are clarified in Ta-
ble 4. The prevalence of WRMDs was significantly
correlated with the type of treatment (r = 0.052 &
p-value = 0.017). Patient responses were scored on
a 4-point scale (1 to 4) as irrelevant, minorly signifi-
cant, moderately significant or majorly significant. The
mean score of all participants was (47.0 ± 8.8) points
of a total possible score of 68 with minimal and maxi-
mal values of 26 and 67 points respectively (Table 4).
3.5. Commonly used strategies and altered work
habits to reduce body strain
Application of altered work habits and commonly
used strategies to reduce the frequency of body strain
is clarified in Table 5. Patient responses were scored
on a 3-point scale (1 to 3) of almost never, sometimes
and almost always. The mean score of all participants
was (21.5 ± 1.79) of a possible score of 36 points, with
minimal and maximal scores of 19 and 27 points re-
spectively. There were significant correlations between
WRMDs and the use of altered work habits and com-
mon strategies to reduce the frequency of body strain
(r = 0.08, p-value = 0.036 Table 5).
4. Discussion
4.1. Characteristics of participating physical
therapists
Musculoskeletal problems are common among
health care workers particularly those who engage in
direct contact with patients [3,20]. The response rate of
physical therapists was 69.0% which is consistent with
that in similar study by Glover et al. (74%) [1]. But it
was higher than in other studies by Salik and Ozcan
(59%) [7], Alrowayeh et al. (63%) [17] and West and
Gardner (53%) [2]. This comparatively high response
suggests that the participating physical therapists felt
that the topic of this study was important to their pro-
 Q.I. Muaidi and A.A. Shanb / Musculoskeletal disorders among physical therapists 767

Table 5
Frequency of altered work habits and used strategies to reduce body strain (%)
Altered work habits and applied strategies Always Sometimes Never
I get someone else to help to handle a heavy patient. 20.7 43.5 35.8
I modify patient or therapists position. 62 29.9 8.1
I use different parts of body to administer a manual technique. 35.9 58.7 5.4
I warm up and stretch before performing manual techniques. 11.7 56.5 31.7
I use electrotherapy instead of manual techniques to avoid stress. 7.7 68.8 23.5
I pause regularly so i can stretch and change my posture. 19.7 64.5 15.8
I adjust plinth or bed height before treating a patient. 44.9 52.9 2.2
I select techniques that will not provoke my discomfort. 31.2 67 1.9
I stop a treatment if it cause or aggravate my discomfort. 17.1 65.7 17.1

fession. The participants in this study represented var-
ious nationalities with the majority from Egypt, which
may be due to the attitudes of Egyptian physical ther-
apists who find the work environment in the KSA to
be favorable followed by Saudi Arabia which may be
due to the increased need of physical therapist as a re-
sult of increasing rates of traffic accidents resulting in
severe injuries. About one-third (30.3%) of the study
participants had a masters and doctoral degrees. The
majority of participants were foreigner nationals work-
ing in various rehabilitative centers that usually do not
require postgraduate qualifications as a prerequisite. In
addition most participants (79%) were primary clin-
icians or practitioners employed on a full-time basis
similar to that reported by Adegoke et al. who found
that 96.5% of Nigerian physical therapists were full
time and only a quarter had postgraduate training [16].
In the current study there were more male than fe-
male physical therapists reflecting the population from
which our sample was drawn which was in accordance
with a report by Alrowayeh et al. in Kuwait [17] but
in contrast with results of other studies [1,2,7,20]. This
result may be attributed to the differences between
western societies and the KSA where greater number
of working physical therapists are male and the sex dis-
tribution in our study was largely representative of the
population of physical therapists working in the KSA.
4.2. Prevalence and characteristic of WRMDs
The prevalence of WRMDs was significantly higher
among female than male physical therapists which was
consistent with other related studies [1,7,20]. It has
been suggested that the higher prevalence of WRMDs
among female physical therapists may be related to
a lower BMI that puts them at a disadvantage during
delivery of patient care [20] in contrast to the report
by Salik and Ozcan who found a higher prevalence of
WRMDs among males than females [7]. However this
finding may be attributed to the greater use of manual
techniques among male physical therapists than their
female counterparts [7]. In the current study there was
no correlation between the incidence of WRMDs and
BMI. Sex is a potential risk factor for WRMDs, as fe-
male therapists tend to have a smaller body build [20].
In our study female participants had a lower mean BMI
than males (24.3 vs. 26.1) kg/m2 respectively which
poses a disadvantage when handling and treating larger
patients and may be a contributing factor for the higher
incidence of WRMDs among females [21]. The preva-
lence of WRMDs among junior therapists within the
first 5 years of physical therapy was higher than for
those with more experience (consultant) which was
consistent with previous reports [1,2,7,20]. This find-
ing may be attributed to less knowledge lower skill
levels and lack of professional experience in recently
qualified physical therapists [17] in addition to the
healthy worker effect which refers to the lower fre-
quency of illnesses among older workers than younger
workers [18]. An increase in the number of work-
ing hours/week and number of treated patients from
6 to 8/day were correlated to an increased incidence
of WRMDs among physical therapists in the KSA to
47.6% in at least one anatomical area. This rate of WR-
MDs was still lower than that reported by Adegoke et
al. in Nigeria (91.3%) [16] Grooten et al. in Sweden
(53.5%) [18] and Salik and Ozcan in Turkey (65%) [7].
This lower rate may be explained by differences in the
delivery of patient care [18] while it was greater than
reported in the United Kingdom (37.2%) by Glover
et al. it may be attributed to the greater use of man-
ual techniques and higher number of treated patients
in tertiary care [1,5,20]. Physical therapists working
in tertiary care reported a higher prevalence of WR-
MDs than those working in preventive care despite
their advanced knowledge of injury prevention strate-
gies [20,22] indicating that it is very important to in-
crease the awareness of physical therapists in different
work settings particularly those working in rehabilita-
tive centers [7].
768 Q.I. Muaidi and A.A. Shanb / Musculoskeletal disorders among physical therapists
4.3. Body areas most commonly affected by WRMDs
Among physical therapists in the KSA the lower
back and neck were most commonly associated with
pain from WRMDs (46.5% and 26.6%) respectively
which was in accordance with the reports by Nordin et
al., (51.7% & 46.5%) respectively [22] and West and
Gardner, (35% and 24%) respectively in Queensland
and Australia [2]. Reports of low back pain was sig-
nificantly higher among females than males (p-value
< 0.05) which was supported with the results of Ade-
gok et al., who reported a higher prevalence of low
back pain among female therapists [16] which may be
caused by differences in body build and physiological
changes accompanied by pregnancy and childbirth. In
our view these findings may also be mainly due to asso-
ciated mechanical workloads and stresses as there were
only slight differences between the sexes. Body parts
with a prevalence of work-related pain > 12.2% in-
cluded the thumbs, wrists/hands, shoulders, knees and
elbows. These results were supported by those of pre-
vious studies [7,17] but lower than those of other stud-
ies [1,3,16,24] indicating that high rates of associated
pain may result from repeated application of work-
related therapeutic tasks such as lifting, transferring
and manual techniques. In addition these studies sup-
ported our findings of a greater incidence of WRMDs
in response to physical therapists performing the same
task over and over (40.1%) treating a large number of
patients in one day (40.0%) working in awkward or
cramped positions (45.9%) working in the same po-
sition for extended periods (43.5%) awkward bending
or twisting of the back (42.6%) assisting patients dur-
ing gait activities (41.9%) working at or near physi-
cal limitations (34.1%) and applying orthopedic tech-
niques (29.6%) in addition to moderate use of assistive
equipment.
Relatively few (9%) physical therapists received er-
gonomic and safety training for pain prevention in the
current study and as expected there was a significant
correlation between such training and the prevalence
of WRMDs. So training in ergonomic and safety mea-
sures should be recommended as a prerequisite to join-
ing a physical therapy practice. This result is supported
by Holder et al., 1999, Salik and Ozcan 2004, Bud-
dhadev and Kotecha 2012 [3,7,25]. They reported that
physical therapists paid more attention to correction of
body mechanics, avoidance of lifting heavy equipment
or patients and frequently changes in position. Phys-
ical therapists have fundamental knowledge about er-
gonomics and biomechanics. Although their use may
vary depending on professional knowledge and skill
levels as only 12% of the study participants made treat-
ment decisions to reduce physical work strain. Physi-
cal therapists can sometimes modify patient treatment
regimens although such deviations may not be permit-
ted in many workplaces and they may face administra-
tive restrictions from the physicians who are ultimately
responsible for physical therapy treatment plans. This
puts a greater strain on the therapist than if one is al-
lowed to alter the treatment plan. In fact Salik and Oz-
can [7] stated that efforts were underway to enact le-
gal amendments that will permit a doctor to direct a
patient to a physical therapist who will actually create
the physical therapy program. In the current study rel-
atively few (7.7%) Saudi physical therapists reported
leaving their profession or changing their area of prac-
tice/specialty which may be a result of the reasonable
income and under-representation of physical therapists
in the KSA. Thereby encouraging physical therapist
to remain in the profession. This finding was consis-
tent with those of other studies that reported that few
physical therapists actually change their areas of prac-
tice [1,2,7,26]. Some physical therapists may continue
in certain specialty areas in spite of discomfort while
others may leave to pursue ambitions in other fields.
There was a significant correlation between com-
monly used coping strategies and the incidence of
WRMDs. Application of these strategies in our study
were reasonable but physical therapists could be fur-
ther encouraged to increase the use of beneficial strate-
gies especially the availability of recent technology
and various mechanical facilities. The most commonly
adopted strategies were modification of position and
selection of techniques that will neither aggravate nor
provoke physical discomfort. These findings were in
accordance with a report by Glover et al., who found
that handling heavy patients can aggravate or provoke
physical discomfort of therapists [1].
5. Conclusion
Physical therapists working in the KSA are espe-
cially prone to WRMDs with a prevalence of 48.6%
with low back pain (46.5%) being the most common
as a result of repeated mechanical load and manual
techniques. The physical therapists participating in this
study recommended changing work habits, applica-
tion of preventive strategies, and implementation of
ergonomic and safety measures to ensure continuous
physical health and maintain quality of life for both
physical therapists and patients.
 Q.I. Muaidi and A.A. Shanb / Musculoskeletal disorders among physical therapists
Acknowledgements
The authors are grateful to all participated physical
therapists for their patients and valuable co-operation.
They thank also Dr Enas F. Youssef for her valuable
assistance in managing and collecting data.
Conflict of interest
None to report.
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