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Work-Related Musculoskeletal

Q) ~

Disorders and the Culture of Physical Therapy

BoneJ . ,1,.zc~Olllt

DECADE -AMERICA 2000-2010 -

, I I' I~'\ is n s/1n111<>1 <>/ t 111· /)Pr(ldr, t111 i11ten1ntin11fll. 111ult1diJr1 pl111n ri 111it1ntfr•e to 1111/rrn11t' hl'lllth-1rl11tl'd quality of lijl' j11r /JP(1/>lP. 111ith 11u1sru losileletal rli vnrrlrrt

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Background and Purpose. l\r1<.)\\1ledge. skills, relationships, and atlit11clcs

ur raring anll \vurki11g hard are a ll thougl1t to be valued by physical

L11erapisL'i. -rhis ;irticle explores how J>hysical therapists see cbernselvc.,,

in light of S<)lll<::' or these valttt"\, \\'hen L11ey CXpt:ricnce \\'Ork-related

111u.;culoskeleutl disorder (\i\'1-. ISDs). The article also explores the 'A'ays

in \vhich these v;.il11t'S n1ay co1npete " 'ith each other, and it sttggesL'> ho''' this n1ay cont1ib11t(· to the onset of'vVMSDs and t<> therapists' behavior

lilllcl\ving a V{JVlSD. Subjects and Methods. Eighteen tl1crapists '"hu had 111ad<.: a c;u·cer c hange after a \t\11vlSD participated in intervie\vs that

'"ere designed t<> gain insight into the attitudes ai1cl beliefs of therapist<. ,,·bo had hacl a \tV\ lSD. Results. Participants did not a nticipate v\'~lSDs,

and they typically believed their physical therap) k11u\vledge and ·kills

\vould t1avc jJrcvented V\'MSDs fro111 OCCltr1ing. l "hcy saw then1sclv<.:s as

kno,vledget:1hll' and caring cu1d inclicatecl that these characteristics \Vere

h igh.ly va.luecl b}' th c profe:.sio n . Their n eccl to rlcn1onstrate L11ese attributes sornclimes resulted in bcha,iors tht:1t con u;buted L<> the

rlt•ve l<lprnc11t or their \o\'MSD · and made then1 '''Or c after their onset.

Discussion and Conclusion. l "hc cult urJI vc1l ues of JJhysicaJ therapists

111ay make it dil'ficult for tl1c n1 to do their jobs iu a way that n1inimizes

Lht• risk or \i\lMSOs. The study idenlifie(I a potential Cl>nflict bet\\l("('ll

th e t hetaj)is1.; ' need t<l ( 1) dcn1onstrate their ability to \VOrk hard and

care for their patients and (2) appear k110\vlcdgcable and killed by rc1naining injury free . [Cron1ie JE. RobertSlHl \~ j . l3est ~10. v\'ork­

rclatcd inusculoskelctal disorders and the ctLlture or physical 1hcrapy.

Phys 'f 'her. 2002:82:459-472.l •

Key Words: C·ulture, l\1u!iculosllPletal inju1)'· PhyC!>ical therapy f1r<>}i•s.~ion.

J ea1i E Cro111ie, Val111a J Robertso11, Margaret 0 Best

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Physical Therapy . Volume 82 . Number 5 . Moy 2002 459

<Ill\ ph\''>ital Ll1c 1,1pi'L' t'\.l>t' I it·11ct· \\Orl..-1 elatt'd 11111'111lo-.l..1·l1·1.tl cli-;orclen. (\ ,-~1SI),) .'--; Ir1' l''' ig:1101-, 1n -;Ludie:. oJ ph\ sical Lhcrap1~ll> in E111 ope.'"' :--:u1 Ll1

. \.n1crica.' ·1 ·, a1 1d .\usU«tlia 2 u~ed clillt•rt·nt definitions to dc~cri l1<' \V~ISI), and repo11cd a \ilrtl'I\ ol prt•\·:1le11 ce:-. fr) t n111"r11ln~keletal dl-ir>rrl f· r, . !•01 t·x;1111plt' , i11vc-;Lig-a1ori. in ,, B111i ... 1i "' tlcl\' ur 2 I ~ pll\~il'a l 1 la·1~111i~1' I t·portt'd a l '.l-tll(llllii pt<'\'al<' lltt' nf /rn11 lir11ll /1((i11 (l.13P). \Vhith \\'<l'

defint•cl .1-. ",tn\' iatern1itte11t 11r toll:>l<1111 p.ti11 i11 an' ttrea ul LIH· b.u I.. fo1 th1e<· or 111lll'l' cl.\\, .. o l '.\K''"t:." . .\ life1i111e prt•\alt•11ce of LBP. ,,·hich ""'' dt•fi11ed as "pain beh>" 110 :111d the lo,,·e~t ribs ''hith 1<1,lt«l thr<.•c 01 111ort• da,, ... .

11f ~<)~ \\".I' IC'J><Jl*lt' cl ill ,I :-.111(1\ o( !)()() C:alifn1ni.111 1l1<·1api-;1,. 1 rn" nH1re rect'1ll \ 1111·rican "'ud) t>I' ,iJJ g'l~td11:1t CS Of,\ partirula1 pln'!.il'al lhl'I aJJ\ Jll ugte·llll. ~01 I.. et ,tl1 clt·fi11<'<l f .BP ,1~ 'joi>-rt·latt'l l ache . p:1i11 . di~r<1n1 1'ort.

:in ti so 011" n·ported 1111 annual prt.•\'i1 lcn1.t• ul' l5 °i . In an ,.\ll~Lralian 'llld\' o J 536 Lhctapi~ I ~ . C:1011iie l'f al:! d efined LBP .1-. "joli-1 C'latl·d ache. pain . etc" and rl'pt)rled .1 p1c.·,·a le11cc uf Ci'.!.5o/r,_ Tiu: re'>e:11tht'1' in hulh ol Lhc.•,t· 111ore rc<ent '> l11dit>:.1.'.! al") c..\..u11111<·d tht· <1111111al prt' \'. I· ll'nt.c of \\'t-- 1 ~1):.. i11 h111h :u1·a, 01lu·1 th.111 1hf' lo"· b.1tl... and 1h1•\' rt·portf'<l \.\~ISO-. in tht' llt'( k (~-1.7 '(, c1.11d

-17.f)l'l; fn1 Unrk et al 1 aud (~ 10111it· t' l ,11. ~ rc~pl'rti\l'lY ). .:.ll\111lclc.·1, ( I K.~1% a11d '.':!2 .9<'~,). 11pp('r hack ('.l8. / o/c. and 411 <'{,). \.\'l'i:<lS and hands ('.,?\)Ji'/(, and '..! J .811fi) . and knc.·<·s ( 1 0.~J'}t a nd 11 .~'.k ). ThC' 1\tL~ 1 ralian t1·s1·archPrs :tl :o:o repor1<·d atl .111n11al prc,·al1·11ct' ol tl111111h pain of :ti.Ii' 1 .

In ,1noth1:t rt.•c.e nl \lttd\' i11 the t · 11111·d State-. of 5 00 pli\'1oital tl1!'1 ,1pi:..1,, T-lold1·1 1·1 <ti • r1·p< n1ed .i lo\\·er pre\ · <1lt·11cc.· nf \\~I SO" (neck: ~).8<'(. uppL'r hacl..: 7.-1 %. \\'ri~L and h.1nt.I'>: 7. t <'c. and lo\' b.1t k: I !l.8' ~): ho\\l'\'(' I'. their rt·sull~ are no1 directly c:n1npurable because the\' defined tl1<·i1 \.\' t\'ISDs a<; occurring O\'l'r ,1 '.!-\'e,11 period ,111cl a:... a "jub-rL·J:tted 111llSCttlo~kc.·k·ial il tJlll) '·" f(1<· 111 ;~jo 1 il)' of lht·:...t· 1c·:...t·11r< lier~ .1grl'{' 011 011t· findin g-: th ey fuLilld Lhat

till' lirs l C'pisorle o l \•'{tvlSD l)( ( lll It'd witltin Lill' first rt'\\' vt:,u·o; ol pt.t<litt'~ 1 01 an1u1t){ \Ollll j.\'l'I tltt·rapii.ti.." '' Borl.. l't a l1 .111cl Schnlt·, and I l ai1~· nhsl'1'\ecl Lh.tt ph\sical

lii<·1.1pi'1'· l..1tn\\·ledgt· anrl c"pl'rti-.e did no l g-ranl 1 ht·111 i1nn111nit\ fron1 \\'~lSD~ .. \ltho11gh tlii!' irou' ;, 11111t·d. tht' li1c.·n1tu1e ollcrs 1111 l'xplanation lor the occurrenrt' ol this discr<'pancy hen,•ecn the rapi~L:>. kao"·le dg<.:' and 1·xpcrti.~e and Lile dot111nt' ll lt'cl prt·,·,1lt·11tc.• or \.\'J\I~[),,

Bui k ct al' ;u1cl 1'1o111111phy t'I al 1 rl'f1·rr<'d to inexperi­t•111·t· "'a possible contTihHting t:1c.Lor, ,,·hiclt is co11l-i~ tt· 111

'"ith tltl' g-e11t·r,d fi11di11 g 1111 tlit· tirnin~ of \i\'J\fSn nn.-.ct.

The i1npor1ance of' \\' t-.lSi)-; to the phYsical Lltcrap\' prufc~~ion \ \'as inclicaLt·tl I" ( 101111t· <'t .11.'..' 11ho rt·po1 rC'd that I in ti \11stralia11 1ht·1,1p"'' ,,orking in ;i U ;u·ea., of ph\''>it al 1herap~ praclic<· 1u.1d1· a< ,1ree1 tli<wgt· ht·< .111-.t· of \\ ~l~IJ .... 'fhe purpo't' or 0111 '-lll<h \\<I:... to in\'(''>ri){ale d1t• l'Xpcrit'll('('~ of' thi:... g-roup of therapists and lU t'"pl111 c is.,11es of irr1por1ance tu Lheni. This a11i clt· describe:-." qualitali\t: :-. llLrh i11 \vlii('h therapi.sts disc11<>sl'd 1ht·i 1 c:xp1·1·ieuccs 1vi1h \.\.tvlS l)s. \l\'e a t[c mpt to ide11Lil~·

a111111d1·s the therapi.sl'> lt t·lcl 11t,11 C\lllld ro111 1 ih1tll' tn tht'll U( lUITl~tl('l' a11d !'.('\('I ii\ . \'\'1· h<'li1•\'t' I ha! ph\'sir. LI lhl'I api~t ' \'it·,, tht·nhel\'t' ' :1-. he1ng kno,,·leclge,1ble. t:apa­hlt'. r:11 111g. ;u1d bard,,01 !...i11g. \\'l' explore ho" tht''<' t1.1it' 111,l\ LUllU·ibutt' lo the Ol< llrtt'lll'e nf \\' ~ l~D,, \'\'t· ,11,0 a11c111p1 Ln prn,idc -.onll' insighL<> into ho" · these t r.1it' nta\ conllicr. ai 11111es, leading to a dilen1111t1 1vht·n· ~l lhcl'aptsl i.s unable 10 cl1·111011s1rat1' :di ol tht'Sl' 1s:ii1s s i 1 n t rl 1 :i 11 1 · < 11 1 s Iv.

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The Culture of Physical Therapy \\\· l1c·li1·v1• 1ha1 unde.-...Landing the in1port.aut i:..sut·~ lor ph\ iC:ll Lht'rapbl.'> \\ iLl1 \\'~ISL):-. t t•quirei. !>0111C ::t\\<11 (' llt'SS

o l tlti: t·u111exl iu \rhic h th('\ \vor!.... ( :ant and I l igg~" t onfl•nd1·d that Lherc is a cuhure c;pecilic Lo Ll1e ph,-.ic.il thcrap" prolessiou. fhe\ c1..-.,t·11<·cl 1ha1 pnift·,,i(ln-. h:l\e a cli:..1inrt p1ol1·s,io1nd c11lt11rt'. a11d th<'\' desc1ibed pn1l t'~·

sio11al 'oc·iali1:1Lion as rhe prore~-. u l bein~ indurH'cl i1110 lh il> c1iltu1 e. The\· in1pliecl 1lta1 lht· <l\<'rl lt' <irni 11 g- i11 1he t'lll ric 11111111 i)\ otilv part of 1h<· prnc es-;. rh"'t student::. al!>u IH't·cl lo lt«1r11 the "hidden curri culun1. ·-.~1 1 "" 1 'fhe\· i11di­ca1ecl tha t n1an,· ol 1 he t 11t1raclcri-;tic' and \'ah11·-; con 1-. 111011 lo pll\·sical th~r:tJ)I'\' lict·11111t• increasinglv t'\ idt·nt

II:. ( 101111« l'T l'hll. C.radlhpC>n l l1 ·.1 l1 h ,,,1, .1 l'hll '111clt·111 111 1lt l' '>r hnu(, ul 1'(1\,111C ltl'1.1p1 .u1d (J1 r11p.1111111:tl I hl'ljfJ'· La T rn h« l 11iH·1,11\.

1\11111 111111.1 . \ h 11 111.1, \11>!1 .di,1. d i 1ii1· l.11111 n l 1h1' ;.111<11. Aclcl1,.,, .111111n<·,pnnrlt·1HI'. It• ll1 C rr1111ie a 1 '><1111111 ol ()( ,·11pa11un.1I fltl'r:tp\ . L..1 l'n1h,·

l ' 11i \•t• r,i1\ , R1111rl o111,1, \ 'i1 l!>1 hl , :'.llHli \11 ,1 1.1lo;1U11111 1111"\!1l,1u11l>e.t'd11 .. 111)

l\IC > Ht'~I. I' I , \II'! I. is ~enior l:.rr;-1111111111,1 \ 1< 1011.111 \\'111 kLu\'<'I \u1 lio1111 . \ 'il 1111 1.1. \u~11.1li .t .

. \II a111l>u1' p r"' oded wnu11g. prnjt•1 I 111.111.1g1·1111·111, .1 11d 1 011,1th j ll•lll ( 1111 l11di11i.; I I'\ i"" nf u1.u1u'• 1i1 II lwt< 111· '11l1111i"lo11 01 C'rnmi1· p101 i1lc·d

111111 <'jll ll"'"11d1 d.1t..l <Ulll'<L1011. 'llh(l'lh .• 111(( tklll.tl 'uppnrt. Ur ( 111n1it• .111d \I, n .. ,1 l""'itlrd 11.11.1 .111.1h''' ll1 ( 1n1Uil' ,111<1 Dt Ruh,·11-1111

prn1iri<'d t.1nlt1i1·, "'1'1ip1nt'n1

I he >lll<h- Iv.IS .1pp10\t'd h\ Llot• F.11 ul l\ l tl11<' < Hlllllll lh'I . F.11111!1 11! H e.11lh ..,<It !Ill' I .1 I 1oh1· l llh'l'l',i l\'

'/'It 11 /1 II u /1• w111 11t!1111 iJ11•tl f11 ·r """"'' I . 200/J, r1111/ "''" 11111•/111'11 V111 •1•)1d>1'/ I 2. 21111 I

460 Cromie et al Physical Therapy Volume 82 . Number 5 . Moy 2002

in ~tude111' a.-. L.11.: 'ociali1ation pl'I iod pro~tt':..:..e)>. Cant ;1nd Hil{g' defined /Jrofe~\/01u1/ h1•llf1t11or as consisting uf learned v<1Jues and codes al beha\'io1 and .. occupational 1noral it". "1111· 1 • 1

"fht· action-; ul inexpe1 ie11tt•d 1Jli~sical lhl·rapist., <1r<'. Ri t·harcl-.u11!• < la i1 nt'cl. 'i trong-1) i11 f1 111·11c:l.'rl h) 1he \vorki11g t·n\ironn1c111 <ind the perl"ep1io11s of senior colleag\les. She pos1ulated lhat the 1\orkplat <' t tdture of ph\siral tht•rap1 dc1clop~ through <1 co11tinuo11:.. process ol pro­fl'l>Sio1u1I influence anrl interaction She also argued that phvl>ical 1.herapists 1vorking in a o;ucial group. :>1tclt :I\ a phvsiral thl·1<tp) dt·partn11•111. IH•l1;11·1· in a ""' that lOll­ll ih\11('<; (I) 1he ··shared u11dt>r-.1.111ding or\\ hc1t ii. go111g on."'•(lil?OI Sitt.: suggested thal lll('llllH·r~ or 111<· l{ro11p 11111 1lti11k si111i larl) and, hy the ir ac t ion~ and interactions. rt·i nf'nrt <' bt•ha11ors tJ1a1 are ncccptabll' lo the ~roup. "l'hese interac.:Lions and influcncl·s 1nav co11vey underly­ing c·xpt·c1atio11s and values that dete nnin<:> ho1v a tber­ap i ~t he haves in a gi1·cn 'iitua1 ion . Lnpn1>olo '\latl·d th\' ~an1e thi11g ruure su·v11gly, '>uggl'"'Li11g that thl' 111l'n1h1·1.., of 1101 k group-; o\c·1 tlr ··;1nl'1np1 10 i11lhtt'.llCc· incli,iclual-. 10 confonn to group expectations about ho'' 1 oil'., '>huuld be enac.:ted." 10'1., 11 >< 1

Richardson's" n1odel describing- L1 1c dcvclop1ncn1 ol a physical thcrap" 1vorkplac e t' 1tl1url· is based on t•d11ra­lio11a l atti1ritic:s leadi ng 10 knc11vleclgc ;tnd J>rac 1ica l '\kills, a11d c11:1hling tJ1erapists Lo develop trca unetll goals. Sl11· cuntc11tli.:d tJ1at 1he lit'\\'~ a11d c·:-.pc·ctatiOll'\ or 'ot'rlinr n1t•nthl'1., of the profession 111av acr ro influence the profe:.o;ione1I de1 elopment ol nc\1 II graduated ph1 sical L.11erapist:.. She argued tJ1at 1hi-; p1 oC<''" tlirou~h 11·hich tht· c1il111re of a ph,·sical therap\ \vorkplacc: is dc1·eh1pt>d is often unconscious.

II 11l c physical the r<ipy profe>;sion ha~ a culttu·e that i111l11encec; lhe behavior and \',tlllt'S nf' i~ lll<.: tnf>l'r'i .l:­

{;a111 alld HiggsM and 'Ricl 1:1rd11011 '> ~1 1 ~g-estecl. this raises thl· cp 1t·..,tion of 1vhcther the culture also influences the therapit.t'.' response Lo thei1 \·\ 'IYISL)11. 111 this arlicle. 1ve b1 iellv di~cus~ son1e of tht> cultural \'alue~ and an it udc;>' or lhl~ ph1-sical 1herapy prole~ .. ion tJ1a1 ha\·e been id1.'l1-tilicd in the literature. a11cl \\'t' -;ugg<'st ho\\' th1·~ 111<1\

influt'1H c• tilt· heha\'ior of phl'~iral therapist<; tO\\-ard 1hei1 o\\n \·\'}. fSf)c; and the \ l\' t\151111 of their colleague~.

T he idea lh<tl specific kno1vh.:dg-c is cen1ral ro physi cal thcrapi:..t practice has hec11 discussed bv a ntunber tJJ' rcscarChCr'i. 11 I ~ 1'bc f>ucJy ol' kt1t>1\11l•rlgc in lht.: physica l lht·rapy prorc~-,io11 i11cl11dcs bo1h kno"·ledge uf tJ1e con­tent Ot -.ubjet t !Tu'\ rt Cr or phv'iical t he1<1 P' au cl praclit a_I ki1011l1:dge of technique-, and .. kill,. on1e au1htll'> hl·licv<· th;11 ho1h t\T)t'S of k11011·lcdge arc: critical to the concept of expertise in ph\'sical therapist praclice. 11 Onl' of the areas in 1vhich physicti l the1~1pi sts ha1·e specilic

Physical Therapy _ Volume 82 Number 5 . Moy 2002

k110\1·lcdge is 1nu::.culo-.1-.t:lt.:t.1 I d iso1 de1 s a 11<l tJ 1cir 11at Ill l'. ca11~es. and 111a11agc1ne111 t-"1'1' 1

''-"'' Hces1011 and Si111on,• 1 a.o;st>1·1ed t11at therap1~t~ ' ~pecili.c k.t10\\·leclge ,h<Htld bl· LOtlfilstenl 1vi1h tltc·it Yalt1t·'>.

Pli \'~l('a l t lt 1·rapi~1s orten p1 .1ctiLt.: b.isccl un a belier in a :.p('Cific elioloF," ' <111cl. he1H 1-. ,, ra11~c· liir ill ne-~~ - 1'1 ( >titer pa1 t1dil{111s such <L~ the· N: 1 ~i 111oclt:I of in1pairn1enl also u11clcrpi11 1nttch of phl'-;ic;il thl'rapi.st practice; hn\1·e1·e1. c-1·c:11 \vhcn tJ1is occurs. \\l' to11tc.:nd that ph~">ica l 1lu·rtt­pi'>I'> look lcu attd trcat tht' ph,,iral 11npain11ent in order to 111i11imi1e dis:1bili11 and h.111dicap. 1·1ii., 111ea11-; Ultll

111,111\ tlterapisL' belie•\<.' i1 i' logi< ,ti to 1·'pl·c1 th<ll \\'}. I Si)~ l1tl\t' an idcntifi.1bh· rall'-l' and. tbt·refore. tha1 Vl'~ I Sl>s ca11 be pre\'entecl b\ dealing '"ith that c;11 1~t·. ' l'his 1nod<:I of phvsica l I ht'r:tpis1 practice is con~is te n t

1vi tli tl11· concept ofa " 1-i~ht" or ··proper" \var to perlorrn t:t~k'\ , \1•hich n1inimi1:e~ 1hc ri->k ol \i\' J\1SD'i. Fo1 lht• pu1 po'es of Lh.i1> a1 tit I\', thi' i' ('Ot1sidc.·r1·d t'llll'lt llt I of pJ1~·sicaJ th1•r;1pi'>t praclil'<'.

. .1 111:q11r

.\ 't·co11d 111ajo1 t·o11.,t11111 of ph1'i"al therap1 c:ultur1.· i~

the· idl'a 1ha1 ph,sical therapi-;ts are caring <:1u<l haid-11·orkin~. rhe\' place a high 1·aluc 011 hard \\'Ork l'i <lltd Oii

cai-ing and rcla1ion~h i P' 1vi th 1hci1 p:ll ien ts and col­l1·<1g11c·., . Thc·r~1pis1 ... :tlJo.o vah1<.· '-<'eing pal ien t.s as i11dil'id-11 a l ~ \\i th in a .~ocia l coutc>..t and 1·11tthli11g tli t· 11 1 to takt' tL·sponsil ii lily !'11r 111a11flgi11g tl1l.'i1 D\\ll condition.•H

In .1 tJ1eoret.ica l model of l':>.pt't li'il' in ph\sical thcrap}'. jcnsc11 i.llld colleagitt·~"' p1 npo.,t·d 1hat I of -1 defining ditn1·nsion.; 1va.s the auributC' nl caring and comn1iu11ent to patients. The\ con-.id<·tt•cl tlt;ll l)Jl(' or tJ11· th,11~1c1<:r­i:..tit 'i of cxp<'rl practic c ill I diff't·r1·11r specialt~ area~

(011ltopcclics. prdiatrir,, ge1 i.1Lri c~, .u1d neurology) "'<" 1h:11 it \\'a~ pat.ient--c:e11lt'rt'tl. 'fhcy h~· l ic1·l·d 1h i:o. i11 C' l11dc·cl a ~ 1 tc11 1g cn111n1il1111·11 1 In cloi11g \ Vh ;ll \Vas ht•st for the pill ic·I\ 1 and taking on <in .1cl\'(JC<ll'\ role '"h.en ner.essa rv. Expert therapists \\'ere rlt·sc1 ibcd as loving their 1vork a11d ha1'i1tg curnpassion a11d ron1n1itn1en1. Bees1on and Sin1t111 ... 1·1 also identified Lhi~ lugh value on pa1ietll­c1•nt1.' rl'd practice <l .. '- illl i1npot l<tlll lrallH' of ref"ert'llCl' in 1 hl· pi ac·1ic<' of 11e11rologi1 al rth<1hilir.1rio11.

'J'ht·1npists al~u value pre)\ i~in11 of c;11·e that inforn1~.

~upporL\, l't">j>l'ClS a11d t'llabk·'> !heir patienrs. :!H ( :urtis (.'t a l ~ 1 reported tha t th erapists shLl\vcd con1passiun <111d a 1vi ll ingncss ro he lp their patic 111s, parLit'ularl}' 1vl1 t·n a

pHtil' lll \\'<IS percc·ivl'd .I~ 1101 rt·~pon~i ble for Jiis nr fier l'oncliuon. It is unclear hn"' 1his en1phasis on L.u iug i~ exen1plitiecl \\llL·u L.111.· thc.·1apists tht'n1:..c:'ht·<; are th1·

. pat t\·111:>.

'l hi: lit1.·rature sho\\~ 1hat l-.1101\lcdgl'. skills. rclatinn­~hip~. and caiing are all 1·alucrl in phv-;ical ilierapist pr:ict ice. In 1 his ar1icle. \\'C' c-: pl ore ho1v phy~ical lUl'J-;,t-

Cromie et al d6 1

pi-;1-, sel' Lhe1nsef\'e-.. in light of sunH:' of the)>c '"<11ut·~. '"hen they experie11c·t· \i\'\1Sl)s. v\'e al~o t·xplore the \\"1Y'

in 1vliich 1hest: vah11;·~ n)ay compete 1vith each other and suggest not only ho1v u1i~ con1peti 1io11 1nav co11uibuH· LO

U1C onset or \iV~lSDs bul also ho11• ii conLrib11tes LO

thcr<tpiscs' beha1 ior al1cr a \·\'t\1SL) ha'> occun·ed.

Method Tht· t1i1n of Lhi" q11ali1.1Live "rud' '"a' to inYes1ig-att: tht' t•xpc·rienct" or a group or physical therapists h'ho 1nadl0 a caree1 change bcca11'iC of 1 heir WJ\.ISD. Qnalirarive 1neth­od'> all o\\·ed us to inves1igate the 1·ic1,"Poincs oi UH:

par1icipants ~md atten1p1 10 detc1mi11c 1hl· 111ea11ing that tho:.c 1vit.h the ''~ISO allach 10 the condition. Central 10 1hi~ approach i!' the helieft.ha1 each per-;011's cxperienc<' illu~1ratcs a clillere11t a'ipccl of tht• shart'd expcriencf· and Lltll )> a llo\\'S fot r111iltiplc realitie~ Lo coexist. no o ne of 1vhich can he <'"On!'liclerecl !hf' objecti\•e Lruth. ~:i The difl"ercnt meanings do noL con1pcle on 1 hl' basis uf Lruth; in tl'ad, each n1l'aning can be used to n1ake sense of t11e total cxpcricnce.:n

QualiLative me1hod-; 1·n1phasi1.<> 1he r-a tt~c of inlorn1an1~· l"Xpt·riences, in cli1di11g arypical expcri<"llll~S. C:onse­rp1c:n dy, 1ve believe rcli.1bili1v and \1tlidi1~ as they apply tu c.iu•111titatil't: n1cthodl> rann01 be used to judge ciualitau,·1: rt·l.carch. There i!!, ho\\'eYer, still a 11ccd to ensure the caliber and 1 n.1st"·ort.hiness of ciualit.a1iv1· r<·~t·arch. Kreh­iug:! 1 proposed scv<·r,11 -;n-ategies to e11<;11rc u1e calibe1 and u·11s1worthines~ of' ci1ralitative research: ( I) s<u11pling tn l'ns11re that a r~u1gc of experit:llCl'S is prest:n ted. (2)

Lransparency h' t lcarl) docun1enting rnethocls and pro­cl'd11rc·s, (3) cxamin.ttion and verification of the analysi~ b, other researchen. (peers). (4) exa1ni11aLiun of u1e analy!!is b\ u1c: panicipant.s (me1nber checking) . and (5) f)l'C''\t'ttlaLion of t11e data using rich de".;1 iptioni. 10 al11H\' the reader to judge 1hc 1ransf"cr<1biliL> of 11ic fincli.ngs. \i\'e usL·d 1hcsc sLrat(·gies in an t•ffort ro t>ll'\11re the cre<libilitv ul our '!tudy.

Interview Study L\e of inter,ie'''S ,,·ere u1e chosen n1cLhod because " '<' "'anted to undcrsta11d Lhc rneaning participants ac;signecl tu their experienc<'.S in rhe contex t ol their daily lives.:!~•

The purpose of"thc i111c: rvie1vs 1vas lo gain an 1111ders1a11cl­ing ol therapist~· CX(Jl'Cil·ttces 1vith \.\'111ISDs and \vh~ the\' " '1·rt· rnaking a rare(·r change. lntenic1,'S 1vere 1.011-

rh1<•tt·d he£1,·een Janu:u'\ and :\pril 1999 and la!>ted bcn,·een -15 ru1d 90 1ninutes. For Lheir convenience. the participants cho~e:: the inrervie'" setting. These included the.: p'1rticipant.s' ho111e or 1vorkplace. and 1ll c: univt·rsity.

Sampling. Rathe1 1han randomly sele( 1.i11g participant-; tor t11i.s srucly. '''t' u c<l a sampling p1ot·l·~., in 1vlrit.lt \\t' intcnLionalh sough1 participan1s "·ho ht1c1 1nade. or \Vere the proccs:. of n1aking. a career change in respon~c tu

462 . Cromie el ol

\\~ISO~. Thi~ 1vas clone so that info1-n1ation could bt· obtained fro111 111har \ve cu11sidert·d inforn1arjo11-1ich 1 herapisLs. TI1erapists \vho changed careers Jor othc1 reasons 1¥cre nnc intervicv.•ecl. Physica l Llit·rapisL'i 1\'hO n1ight provide 1 i('lt data 1vcrt· recr11i tcd tlu·ou~h the I t"Sl'archer'-. t1t'l\1111 k of colleague'l at ''°ork and tl11 uugh t hl· prof ession.11 as~ociaLion. b\ .i<l1 ct ti~i ng in a ph\ -.ical u1er.1py llt'\~~le1te1, a11cl h~ '''ord of rnouth. :\JI po1enti:il pttrticipanls \vho 1~·ere invir.ecl ro participate agreed 10 du 'iO. The inr erviciv ror1nar allo11•ccl the par1icipa111s I()

l'xpress their auir udc~ and expl•ri<·nr<·s. and the loo'ielr struc111rerl ~tlu·cl111<• of queSUOll'\ \Vas designed LO

<'llCOllrage participant~ lo introduce topic:, of particulat interl''iL if t11e\ '><> cle~irc:d.:1°• Tht• :\ppt>nclix contain~ tht: 01111ine of the i111ervie111 schedule.

ParlicipanLs 11·ert· assured uf con lidt·ntiality. and several steps " 'ere taken to ensure confiden tiality. Tltl· 11a111cs ol all participanL'i \verc changed in 1h1• 1ra11s<'"rip1.S. and tht­n.1u1cs or all plar<'' of 11·orf... l hanged 10 "X ... :· E.xact agl"'> arc 1101 giv~n . and. in the 11n1n1an· or participatll'>. the type of 11·ork done by 1herapi-.ts is dcscribt"d in general and vag11t• lcrms are u~ed rather than relerring 10 specific spcci;ll ry areas or practice. luf(>rrnauon tlta1 \Vas considerl'd as idcntifyit1g th<' par1icip;u1t ''':.ts Olli j tted.

Participants. Eightt'et1 phy<;ical U1l'I api'-t' parLicipatcd in the in1e1Yit·1v '111cl). '"'"'stopped rccn1i1ing ue111 par­ricipants at Lhi:-. point becau~e. in our opinion, the analysis ol 1ran~cripu. did not vic lrl ne::\v ctitl'gorics. Fifteen participan1~ 1v<'re 1von1cn and:~ \\'e·re 1ncn, rang­ing in agl' from their earlv 20s to rnore 1han 50 )t·ar, .. . \II had made a r r11Pl't 1ha11gP, defined <L'i: (I ) a change in the <.pl·c1alr~ arc..·a of pracLire (eg. orthopedic~ to 1¥onit·11 \ ht·alu1), (2) a chil11ge to a less phy~iralh cle1na11cli11g 1olt· 11·ith.i.t1 u1e:: speciall) area (eg. changing from a hands-on lrca11111.:11t roll· to leaching and research). (3) leaYing 1hc phvsical cherap~ profession to " 'ork in a11 alten1ativt' joh, or (-1) being 1111cn1pluvcd. r\ su111n1a1>' of part:icipan1s. i11cluding their 'itllcl~ "names.'" i<i pre'!entcd in u1e rabll'. All p:rrt.icipants i1•t>rc living in 1\11stralia at t11e 1irHe of 1hc..· intervie\vs. l\1•11 participar1ts haci 1raincd as therapisu. in ruttn tries 01her 11r:-111 A11scralia, and 2 others had unde1-t~1ken postf{racluale :audy at a univcrsiry nUL'Side 1\us1ra­lia. Ten parucipanL~ 1vere )Oungcr than '.~O vcars o.I age :ll Lhe ti1nc of tlu: i11iLi,1l onset of the \\'~ISO that resulted in a career change. Before injury thev \vorkccl in a 1·aril't\ of

areas. including pi-i1atc prac1icc-. pl·clia1rir~. ort.hopeclic-;, ncurol11g~· , an cl n· ha bil i 1ation and Ken era I hos pi liLI \\'Ork. Follo1ving the on~ct of their \.\'MSD, 2 participar11~ lt:f't the profes:.iun altogether, 1 \va1> s1udying full tirne. I had re1irecl, and the r<•1n;ii11ing 14 \vt"rt' employed as phvitical therapist.s in an alternate capacitY. TI1eir ne11 arl'<1'> ul practice included \\'On1cn ·s health . t•rgono1nics. occupa­tional reliabilitation , academia. and research.

Physical Therapy _ Volume 82 . Number 5 . Moy 2002

Table. Participant Summary

" Name" Injury

Denise Shoulder, neck

Jone Neck

Janet Thoracic spine, lumbar spine

Carol Low bock

Cathy Upper limb

Beth low bock

Emma low bock

Andrea low bock

Sharon Neck

Louise Thumb, knees

Liz Thumbs/hands

Peter Shoulder

Michael Upper limbs

Debby low bock

Kate low back initially, no\V upper limb

Jomes low bock

Ros Neck

Sue low back, thumbs

• 1\Dl .=nccivilics of dail) llviug.

Age (y) When Injury Occurred Cause of Injury/ Area of Work/ Current Situation

40s

20s

20s

20s

40s

30s

20s

20s

40s

40s

30s

30s

20s

20s

20s

20s

30s

20s

Unexpected movement by patient Left general work to go into desk-based work; now retired Struggles ta balance symptoms with ADL 0

Cumulative effect of heavy lifting Left aged care; no longer working os o physical therapist Hos chronic pain; manages symptoms by working Rexibly Potienl handling, patient fo ll Now consulting (some manual therapy) Manages symptoms, but cannot return lo previous area Heavy li fting 1n combination with heavy workload left general work, now desk based Balances symptoms as long as no clinical work Manual therapy, long hours, minimal variety in work Left manually Intensive area, now consulting Since changing career path, struggles lo manage symptoms Manually handling patients Now studying w ith o view to moving into desk-based position Symptoms well controlled as long as she does no clinical work Heavy manual handling of patients, patient foll Left genera l work; now in desk-based area Symptoms ore well controlled os long os she con manage her environment Static postural demands of monuol theropy Left manual therapy; now studying, but unable lo work Unable lo sit for longer than 30 min; driving, studying, AOL, and leisure activities ore all

problems Cumulative effect of flexed postures with sta tic holding Not currently working as o physical therapist Symptoms easily triggered Manually Intensive work; extensive use al hands to control abnormal movement Left manually intensive work; now works as a consultant Manages symptoms because of flexible work environment Cumulative effect of manually intensive work Now works in o desk-based role Symptoms under control as long cs she does not do rnonuol therapy Cumulative effect ol manual therapy Studying to move into desk-based role Hod surgery, symptoms related to certain manual techniques, so limiting their use enables him

lo control symptoms Monuolly Intensive work, long hours, lock of variety Studying to enoble o move to consulting Bolonce between symptoms and work easily upset, so he is careful regarding workload end

techniques; symptoms interfere with AOL and leisure activities Static postura l demands of manual therapy Moved into desk-based role Balance between work and symptoms easi ly upset Heavy manual handling of patients Mainly desk-based; some manual work low-back symptoms ore well controlled in new area of work; upper limb becoming o problem Heavy manual handling of patients; poor work environment Studying; now working as o consultant low bock pain worsening; manages by moving frequently Cumulative effect of manual therapy and associated postural demands Moving into more of o consulting role When she works, symptoms ore o problem; when she slops, she is fine; she cannot afford to

stop work Cumulative effect ol heavy manual handling; thumb symptoms related to specific manual

techniques Moved into desk-based area Symptoms under control as long as she ovoids lihing and manual therapy

Physical Therapy . Volume 82 . Number 5 . Moy 2002 Cromie el al . 463

Reporting of findings. The data arc presented using the ,,·01 cl~ of the participants. \rhich ;11 c.· considered i11 qualitative research to lie "lu\v-infl'rt•ncc· datt1." 1

" L''l tng the language of par1iripanu; in our opinion aJl01vs t ltt• reader to deternlinc Ute accura<.) of the a11al):-i)) <1t1cl the·

degree Lo " 'hiclt it applie.; 10 oth1·r o;i111,ttions. In thi' cit tic It•, direct q1101l·~ fro111 participant:- .ire follo1,ed h1 tht• parcicipant·s~t11<l1 11..i111calld u1e page 1111111beroftltl' u <1n!>cript on 1vhich the quote can be founcl.

Data Analysis Data analysis \\'(!!> c;arricd Olll iu a <,('rptenle or step_., dt·-.c-rih<'cl in the Figure.'.!7-:!'t Although the o;tep' atc· pre,ented sequential!), sou1e \\t'l'C:' 1c·1i:-itl'd during the an,tl)'>is to help < larif\ ;u1d intt'l1)tct the data. For c·x.1111 pl<:, , ,_., .1 t1e\1' category 11ras idcn t iliccl, prt'vio11s transc1·ipts 11•ere exan1incd to clctt'rtni11<; 1vhcther :i111 111ateriaJ n1igh1 rc:aso11abl~· be coded into Lhat ne11 ra1t·~o1-v.

,\ J1·111b1·1 rhrrlung tt'ft·t~ to thc- proce ... ~ of 1 t•ttu11ing tht· 1natc: rial ro par1iripa111.s to 1·erif} tht' U<lll'il r-ipLion a11d the ilnaly'lis. f\1t'n1bc1 che::cking \Va:-. dont· n1•ice in our ~Luci\ (sLe::ps 2 anrl 8. Figure2>'1). Tht' i'irst check vt'riticd the ,1cct11<lC\' ot the rranscript aucl " '<!!> 111ad(' LO en .... url· thar panicipant.s had not 01niucd ai1\ i111por1a11t a-;pt•ct ul their experience. The ... econd 'itage ''"•'" included tu l'll'>lll'C that participa11L<. felt that Wt' t'l''>ltll'> f'('l>IC\l'nted their perspective c111 t.l1c caree1 t ltang<"

Results 'rhree n1ajor then1cs 11cre i<Lt:ntified I ro111 the da[a: 1he tt1lt11rc of ph\sical thl'rapY. loss. and future direction~. ·r11i' article deals ,,;tJ1 the lir;t of' thl''>l' tl1c111e": tltt· culture of' ph~·:.iral thc..·rap) . Participant<, in 1his '>tlld\ l'!-..pt c..·o;~ccl 2 111ajor bc..·lief~ inherent in 1>11' sical th1.· rap~ < ulun·c.-. The li1·<;1 belief 1vas 1ha1 pln~il'ttl 1ltt·1<1pist' art· k11111vh:dgeablc a11d rapahle. 'fhis ht: li<'f1va-; expres::.ed .1~

<111 cxpc..·ctatio11 that participants 1votlld nut expe::rie:: 11c.. e a \\'~lSD because t.lle\ kne\v the "riglll" ,,.a,· to perlnrtn tasks and coul<l executc 1hen1. If a p1 oblem did occu1. it \voulcl he n1inor and ~cll-co1Tecting. ,\ rC'h1c..u1nc..l· 10 1alk ahou1 \\'r.'ISDs i1 1hev OlltttTcd 11·a.-. a~~o( ia1ed '"it.11 1ha1 , l"X pe-rta liu n.

I ht> ~c>c..011cl belitd 111a~ t.11at UJl·rapis1' are caring and hat cl\\orlJng. Partit ipant., expressed thi., :ls teeling pre'­-.u1 c:cl to \\'ark \\'hen the" ,,·ere injllt t'cl. fhis belief 111:1nilested itsell as lccling of prc:~!.111 (' 10 gi\'t' rrec·e· dencc to tl1e nct·d)I ol tht· patient ovet t.hose of tltc plty~iral therapist. Participants alo;o dl·~<'ribcd fi:·t·li 11g pte~sure rron1 coUL·a1-,'1.1es a11d paticnrs in be cari ng and ltarch,orking, ('1t·n \\ht•n it could be dcLriinental to t.11t:ir 0\111 health.

464 Cromie et ol

Par tic:ipanL~· co1nn1t·tll'> " 'ere cnn<;t~ten1 11•it.11 the hte1a-111rt', ll'hich ori)$illatccl in otlter pop11latio11s or plt1')l lC 'al 1herapis1.s. Thi!> li11di11),{ suggest..; a 1vnrk cu lrure i11 pbvs­iral l11t•1i1 pv that \'alues kno1,1lc..·dgc . ~ki lls. and t·;11·­ing.1 LJ 7- 11' -r11c1api<;t!<. 0 belief, nla\ partly explain the \V:1\<; tlt,u 1he1· re)lponclt:d to and 1nan:1gecl their \\'M.SDs.

Knowledgeable and Capable

Preinjury. Phy~ica l therapists valut:' 1heiJ sp1.·ri,ili1ccl knO\\lledge .u1d \kill:.. 11 1 ~· Tltt• notion or lite "tight'' \\'a)

10 pt"rfurn1 Ut!>k' \\a:- central to 1 lte idea of the Lhen1pist ,,, k110\1°leclge,1hle ,ind capable. 'fo dt"finc a "1 i~ht" or "proper" ,,.a, itnplic: .. a knn,vn cau~e and that adopung the "1igh1" prac1ic:e enables the prac tiLionet Lo a'oid \vhat is kno\Vll to be harn1f'111. \ ·\'t· c1 n1te 11d th111 this a.ssun1p1ion cau1101 he justified. TIH·rc· are, ror cx<u11ple, '>C\·c:ral difTt•rl'tll ... rhool~ of lhnughl about Cl>I"rCt'l liJti11g lt•ch11iqt1e'>.·io 1101\'t'\'t't', Lhe idea of a "tight" 01 ~proper"

'' <l\'. '>pecific.:alh k1H1\\ 11 Lo ph,itiral therapists. is s11g­J{l''ted in tlte ph\o;ical ther<lp\ litcra111re. For cxa1nplc" J\lil'J7~je\,·ski and Kun1ai'~ and ~lolun1phl' <'I al' ~ug­

gested thal the rea.,011 younger 1herapis1s bad a highc..•t prc·valencc of I.BP \vas L11at they did not 11st· •· pro1Jc·r" patient h;u1dling teclu1iques .. \ltltouglt inexpe1ie11cc..· n1;\\ 11•ell be a la< 101 in the on,et of l.BP. tbe ·1alt:111ent

"'"' i111plit:' that tht·r<· '''as a ri~hl '''" fut t.l1csc thcn1pi't' to hand IL' patient~ and t.llat it 1vas not 11~crl. This bt:liet in a "riRbt" '"a~. exprc..·sscd h) pa1 titipants as a 1neaus of preventing v\"f',.ISl)s. ihmores die ergu1101nic rl;ata 1lt;11 ~uggcs[ chat 1h1.· job needs Lo r ltatt ){<' 1~11ltPr than t.l1t' ,,·urker. { 1

The therap~L' in our stuc..h belil'\t·d 1ha1 k1101vledf{e and expt>rien<.l· had ,t p1 l' \t'lltivc bcneli1. Heth obscr•erl that ,(1<· .. ,,,a, ah1·a)' vcn ca1·eful" and had "111anagcd for 1'0

tn:1ny f8J years" and 1houg-l1L site could ''krcp going \1•ith \1•hat [she I '<l hcc:n doing, \\'hich 1vas being carel ul, 1naking ~lire I -;he I kept [bL'r Jselr re<L'>onably lit, attcl ... not cloiJ1g ,Ul\'Lhing sill) .. lBt·tlt: p -t). St11bb'> et a( 1'.!

rautiout'<I ag,1i11't 11-.ing- 1hjs ; t' .1 su~te){' tu p1e\etlt \\'I\ ISO:-. con1 n1en ling that in tri nsit ,dh unsafe \Vork !'a11-not be tu.icle sal'c by training {itnpr<l\'ing kno1vled~c

about the job) .

So111e participa11ts cxpc<.tl'd L11at tht·v 1vcn1lcl not hecnntl' 111jur~·d hPrr1111P tht·~ 11·t·1l· phv'>ical tht·tapists. l 'he1 di'­<ll~~t·d other nrc11pational group' ,1s being '\ll'iceptihlt· 10 hack \\'i\ISD .... hut '"" t.l1c111sel\'l~s fl'- '0111chc>1v dillt-rt"nt. \1•ith <lifft-·rt•n1 t·,p<·ct;ttions apph~ng. For instan cc:

You got preLL\' tired, h111 you kt1011•, vou could n1anagc j11~l about <111\'thing. ~o. vou 1calh ... thought uur:-.c-; 111igh1 get problcn1~ lifting. but vo11 didn't tltittl- \1111 11·ould .... (.Jane: p I 0)

Physical Therapy Volume 82 Number 5 Moy 2002

l. Interviews tape recorded and transcribed in their entirety by the researcher (JC).

2. Member check l: Transcripts returned to participants to check for accuracy and to add any comments. 28

3. Transcripts coded by placing a word(s) adjacent to text, capturing the meani11g of eacl1 passage. 29 Some passages had more than one code to describe the data.

4. The codes were grouped together under beadings \¥ith similar or related meanings and designated as categories. This reduced the number of groupings. 27

5. These categories were peer checked by co-researchers independently coding a sample of transcripts.

6. Similar categories were grouped together as thematic categories. At this stage, the researcher identified relationships and interactions among the categories.

7. Quotes illustrating the thematic categories were organized into separate files, and all data were accounted for in this way. Each file contained quotes from the participants that illustrate the relevant theme.

8. Member check 2: The thematic categories were synthesized into a narrative summary, to reflect the experiences and interpret the meaning of the experiences of participants. This was returned to participants for member checking, and their responses were recorded. 28

Participants indicated parts of the summary wit11 which they strongly agreed or disagreed. Participants concurred with my interpretation of t11e data and reported they felt their experiences had been accurately represented. For example, Jane said:

Thank you for the opportunity to comment on your study. My overall reaction was one of overwl1elming agreement.... I appreciate being part of the study because even at this late stage it has helped relieve me of tl1e perhaps ridiculous feeling of being the "only one" to be injured.

9. Further analysis condensed the thematic categories into 3 major themes. This study presents one of these major themes.

Figure. Analysis of interview data.

Physical Therapy . Volume 82 . Number 5 . Moy 2002 Cromie el al . 465

l can' t recall any or n1y colleagues having hurl lht'ir back. ·rhe \\·ardsmen ofLc11 hurl Lheir back. Bul u~ phvsio~ [ phy ·ical 1 herapists] pride oursel\'es on not having hurl our backs .... Thal \\'a:. a \'ery sLrong fee ling .... IL '!> just 0 11t- of those a ltitudes )'O IL

pick up. a~ the junior. That vou can do iL better. you can do i l correctJv. IL ,,·;1s .. . there ,,·as a cor-

• reel ''"'', and the nurses got 1heir backs burl, the· physius didn'L, you knO\\' what l rn ean? (Jan('i: pp 5. 10)

I \Vas cc1 lainly a\vare that it \Vas a high-risk siLuaLio11. B11i l ft• l1. " 1'111 a physiotherapist, I kno\v ho'" to deal '"ith it. I kuo\v \\'hat the risks are. and l kno"' ho"' Lo 1ninin1i1c the risks." (Beili: p 12)

fh e in[erviews indicated tJ1a1 participants believed that \:\' f\1SDs could be prevented as Jong as the' had the "right" t<:chnique or perforn1ecl in the "con·ect" \\'a\.

Tl1e culture [is] ... it doesn't n1atLer '"hat size vou '

arc, it doesn't maLte.r \vhethcr vou'rc n1ale or fernale, it's the techniciue, Lhe \\•ay . ... If you\·l' got thl' techniqu<.' right . .. and you·re using yo111 body cor­rectly. it's not going lo put s1rain on yo11. (Debby: p 7)

Dcbb) 111cnlioned that her larger (male) colleague~ gave .. absolute!) no considerat.ion for the fact that you \Vere 1nuch sn1aller, ~u1d obvioush \\leaker than the b lokes

•

[men] in the course." She described the ·•culn1re" as "\'el) much 'vou can <lo anything ... don'1 giYe me the excuse that you' re a sn1all female'" (Debby: p 8). 111e nt·t en·ect of thi'l kind of comment \\laS Lo underl·s1imate 1he difficuJtv LhaL people \\liLh diffcrC'nt body types n1ay have 1\'itl1 aspects of 1nanual therapy, and it ma} ha,·e given therapists the impression that if tJ1ey had difficult\' in pe1forming a technique, they v.•ere doing ic incorrectly. The underlying assun1ption behind such co101ncnts i~

that the problem is \Vith tbe therapist rather than the technique.

This belief in the ·'rigb1" \ \la)' as a pr0Lec1ive 1nechanisn1 led participants Lo feel that they would remain t11Li11-jured, c\'cn ,.,,hen the} acki10,vledged Ll1aL there 1ver<' circ111ni.lances in \Vhich the "right'' 1vay '"01ild not be an effective preventive su·aregy for o tl1er ·1vorkers. J anel said:

I fcl"l that if I can manage all the circumstances, I can get Ll1rough 'vithou1 hurling myself. lf I h ave hurt 1uysclf, I haven't done sotnething quite right. B111 1\ lien 1 relate I.bat to ... \\IOrkcrs, I can sec that there are -;etups. thaL no 111atter ho"' ,,•eU they do il. because the, 're doing it so much and so often, .. . the}·'re goin g to be i1tjured .... Bui 1 think for myself. I like LO

tl1ink I've got rite 'iituation under control. (j anc1: p 12)

466 . Cromie el ol

Not only does tltis be lief in a right 1vay as a prt:vcnLivc stratc~ give 1ht·rapists a t~ilse sense ul' security, it has moralic;tic OYertones that assign blatne if a \t\TNISD occurs.

I f you do rite thing Lhc right way, )'OU \\IOn ' 1 get injured. l th ink 1.ha t" ::-. probabh, \Vhat I thought .... '011 that 1'1n older and "ri er, I kno1v )Ou're r\·d11ci11g )Ollr ri~ks of iriju~, but I think b::ick in st11cl en t days and early practice davs you 'd think you 're doing it the right 1va1•. nothing \Vill happen. I t'<; not as sin1ple a.s tha1. . .. 'i·uujust think ~as long as I'm a good girl and do it 1he right 1vay, J'll be all rig-ht." (Jane: rr 10-11 )

Jane highlighted a n1orali~1ic aspect of the concep1 of a "tight" \1ay \villi her use of the phrase "as long as I'm a good ~irl and do it the righ1 1vay" (J ane: p l l ). The logical extension or this idea chat there is a r ight and \\Tong " ·av to perform task'> is the idea that if Lhe thcrapi~t expe1;ence a \,V~1SD they must have done som('tlting \vrong. This \va~ expressed by .J anet (p 11 ). 1vho '"a" unable to \\'Ork out \Vhat ·he had done wrong bur .. kne\\· .. it \\'a$ her "faull" because she had the injury.

'\~' lten l hurl 1ny IO\\I back, \Valking Lh at guy. I felt rd done it \\Tong, but r co11ld11'L for the life of me 1vork out 1vhr. Bui I .. ull had the injury, so I kne"' Lh a1 it 1\'as n1~ h111lt. (.Jan<·t: p 11 )

The belier in a "right'' '""n. ;.111d the subsequent assun1p­tion of" rongcloing (,,;Lb its associated moralistic over­roncs) if \\~ISDs occur. ma~ be a reason for I.be parlic­ipanL~ · reluc tance 10 discusi; che issue.

And it's almo-;t ii '!Omt.'thing doe go '''rang, I 've done son1ething ''Tong. so therefore it is a bit of a failure-1ypr lhing. (Liz: p 11)

For phvsical tht·1;ipi ts co discuss \'\l~lSDs '"'as apparcntl~·

to aclrnit that the' failed to live up to Lhe standard required of a phvsical therapisL. Debby spoke of pressure to be "strong and able 10 do everytltl11g . .. in ord(•r to pass . . . vou have to be able to do everything vour-elf. .. . I go1 tha1 son of,'ih<' [sic] ,,·hen I \"US a student."

(Debby: p fi)

Not onh· did therapist!> l!CC themselves as unlikely co experience inju~ because of their kno,vledgc, Lhey perccivccl rhernselves as being fit a nd able, botl1 as a by-product ol ~1ouL11 , but <.i lso because the 1vork itself had tnadc 1 he111 ph\'sirally able. 1·rus con11nenc by J anet cxcn1plifie tl1c expectation, ex pre ·scd by I.be partici­pants, Lhat tlic) \11011lci not experience \o\l.f\.lSDs:

You cio a lot of phvsical \Vork. You kno,v, I '"as very strong fron1 ha1 ing done it. And I suppose I just

Physical Therapy . Volume 82 . Number 5 . Moy 2002

assun1t:d Ll1at I could <lo it. ... But certainly vo11 h'ere • •

ah~-avs Lifting them (patients) arounrl. yo11 \\'reslle \Vi th thco1 on the floor, you know ... it \Vas verv hard . . physic.al \Vork. I 1nean, I had big shoulders o n me lheo, and big 1nuscle . And you 1vere young. Sn, yeah. vou considered voursc·lf invincible. Don 't kno\1' vou're , , going Lo h11rL yourself. Certai11lr \Vo11lcln '1 do it no1v. (Janet: p 4)

So1nc partjcipan Ls fe lt. that their you t.h and fi tncss 1~·01.dd afl:ord them a degree of protection lro1n \-\1\itS[)s (Andrea: pp 5-6 Carol: p 11; .Ja111es: p 2: ~lichael : p 3; Debby: p n; .Janet: p 4; .Ja.nc: p I 0). 1\-lirhacl and l)cbhy e'lrpressed 1.his as a feeling th.al they \Vere '"invincible.~

I n1ean, i1'sa clifllc11ll age group [20s] , because you clo think that you're invincible when you're not injured. I ~·as prohably as guilty of that as an yone .. .. I think it's one of those things, 1vhcn you're 21. and rou really feel invin<.;bte ... . (tvtichael: pp 3. 9)

I \Vas ;1 h it foolhardr 1vhen r \\1as youngt"r, ancl ... thought I was a bit infa llible. you kno,v. a hit invinci­ble really . ... (Dehb)r: p 6)

\Nork-relaled a1uscluoskel e tal disorders 111ere not only <;('en as in1prubablc, buL a lso a~ undesirable. J\ s ( :arul ~aid. physical therapis1.~ '\ vere rne:1111 tn be Iii ... you \veren't n1eanl to be injured'' (C.:arol: p 4).

AlLl101 1~h 1nan1 participan ts in 1hi~ '\Ludy helie-vt'd Lh<t l their kno,vledge \YOulcl help prevent inju1-y, f\ndrea cautioned that:

The \Vay the \Vhole system's slrucrured, you 've got lo sec pat.ie111 af1 er pa ti en t after patit•n 1 ;.ift Pr pa 1.ien 1.

.1\ .nd vou can ' r baye a bit of a break. ,

She fe lt this rnade ii dirllcull f'or individual tlte1<1pis~ '' ' act to avoid vV?vISDs. She added:

)'ou 1nigl11 have a ll the knovo1ledg<' of ho\v your hack ~ttu·es, but .. . having no con u·ol o\·er y<)Llr en,~ron­n1cnl is a huge tactor. (Andrea: pp l f>, 18).

La additiou 1.0 the participants' expeciation that th e)'

\.vouJd not experience WNISDs because of Ll1e i.r special­ized kn o\vlcdg-c. non-physical therapists also had this expectation. Beth 1vas a\vare of tl1e percept.ion of o th ers: "They' re going. 'You 're u1c experL in LiJLing.'" aod heca11se sht· acrep Led Lhat.. <;hl· tell "it \Vas Ill)' responsi­bili ty, and if' something [\vent] \vroug, I 'd got oo one to hlan1e." ThtL<;, 1vhen 1he injury occun·ecl , she described fee ling Lhat '·1 sholl ld havt' kno'''n .. . ()I' T ::;ho11ld have m.ini1nized the r.isks further ... .'' (Beth: p 12) . She idcJJLiJiecl that ii \va~ her "fau lt that I she] got rhis injury"

Physical Therapy . Volume 82 . Number 5 Moy 2002

(BeLh: p i ·1 ). 1\ndrea encountered a si n1ila r a tLiu1de frntn o l hers. saying. "\'ou shoulrl have kno1.vn. \ 'ou' re a physio Lphvsical therapist} , vou should kn.O•v '"hat's bad for your back." (1\.ndrca: p 18).

lniury. Follo\\ring 1.he onset of a \•'{NISD, participants S<'t'lnt·d Lo r(;' ly o n 1heir kncHvledgl' to !.('lf-rna 11ag(" their inj1Jry. Rather than seek fornl~tl rreatn1ent. pa.rtici1)ants te nded to self-treat (Peter: p 4; Carol: p l; Sue: p 3; Cathy: p 4: Debbv: p 4: Liz: p 3; Kate: p 3; .Jane: p 7). This is possibly a n indic:arion of 1he be lief tha1 the v\'tl~SD \V<IS

111inor and or litLie long-tenn in1portance.

It's nol as if recenLly there's been a treatment that's been Ltclpful. There b.aso't been. I a1anagt' it 1vitb l''ENS l transcuta11 eous clc..·ctrical nt·rve s1i1n 11la rjonj and just mv 0 \¥11 self-help ren1edies. (K.."lte: p 3 l

[ n ever, I never 1vcnt Lu a doctor. I never Look any 1nerucat.ions such as pain relief or anti-spMm ... , ;1ny form of an t.i-inll;un n1aL01-ics, or anv for111 o l' 1nuscle ,

r(' laxants, a nd I never tnok iinll' off . ... T \Vasn't going ro trust a physio [physical therapis1.l .... I se lf-Lrea1 ed .... (Sue: p 3)

·rreatn1enl-\Vise. I really didn ' t do n1uch. 1 had a litLle bit or physio I physical the rapy I, for a short period or rin1e .... Other 1.han 1hat , I j11s1 used 1ny 0\1111 kno\vl­edge, J guess .... Most or the t.i111e, I sell~treat. (j a111es: p 3)

Betb meot.ioned she managed her symptoms by g-etting informal trcatmcnL frorn a colleah'l.lt: <tnd by self-. 111anag1ng.

Tr T rarnl· hon1e <t11d I 1hongl11 , 'Oh, 1ny hack'-; a hit sore today.' I \Va.~ sharing a house \\ith a p1ivate practice physio [physical therapist], so T'cl leap up on the dining roo tn 1.ahle and he'd ~rive 1ne a fe1¥ 1nobei. [sic] if I said my back ,..,.a..~ really sore. So that sor1 of 1hing . .. . l really deal r \Vith it by doing exercise. Or l'd. vou kno\v, lie do,vn on r.he floor and \\lat.ch te lly

• • [sicl. I'd think, "Oh. no, n1r back's a bil sore to si1 1onight." (Ileth: p 6)

-rhe purpose of 1 his inforrnal 1.vay of 111anaging their W~1Sl) appeared tc> be so that the participants cotlld con1.i11ue caring for their patients. a culturally desirable occupalion . 1 ~.H1 T he ass11n1prion rh a1 they cou ld look after Ll1en1selves n1ay rel1ec1 the participants' possible heli<·f 1h ~11 they \Vere scll~a\1•are and knrnvledgcable enough lO 01anage their vV~ISDs themselves. Allerna­tively, par1jcipants rr1ay have underest.in.1ated the severity or their v\'t11£SD!1 and Lht• llt'Cd LO have 1.ltern ron11ally rnana~ed by a health care professional. /\ possib le con­sequen~ce of n1anaging \·'.'NlSDs in this \vay is that. th.era-

Cromie el al . 467

pis ts 111ay receive less-1 han-opt i1na I l rea In 1e;·111 .lnd 111a11-agen1en 1 ol the ir c..·n11di1ion. Thi' i" an i..:suc lur f11rtltc.:1 in' cs1 igat ion.

Postiniury. Dl·:-.pilc tlit' expect.-ition that a \Vl\ISD 11'oulcl 11<>l occur. participant!> did expe1 il'llCl' \\1'1SI)., . \fter tht'

on ct nf .1 \\ ~lSD. pat ticipanl'- lt'll<il'd to de11~ iLS se\ t>t · itv. i · ht:v assu111cd their inju1' '''nu.lei hC' 111ino1 :incl selJ.-corrccting. ;\s jane put ii. "I'll he 1 igh1 i11 a d:t) or 11vo" ( p 4). This ex pl't laLio11 c1111 Id perhap'l be anot ltt>t l'Xpres ... iu11 of' th<· 'l'll'l' nf in\in<·ibilit\ 111entioned l',1r­lier. Bt· th rt·f11sed 10 "e\'en con~ider th.11 it 11oul<l he a long-tenn problelll. Or I hat r :;he I \\•nu Id 11(.ll be able l!J

co11 ti11 uc prattici Ill{ a~ a clinical phvsio l pl l\·sical I I HT.I·

pis11:· (p 10)

I n.·111c111bc..·r n1y n101her saying, ·o.\J \\'<'II. l ' hat'-: i1 1ht·11. Yo11'll h:l\·c..· 10 do son1t•thi11g t•l.,t•." f l -.aidl. '"\\l1at ,u·e )OU t,tlking ahnul~ Of COlll"l>C I'll be fine.~ .-\nd "' a 101 ol tht' 1i1ne I \\'as just likc l~ic I. '"!'\o. 110, 110. 11 '11 hi: fine . 1'1n not going 10 be one nl thn.'e people 1vho's got a long-te1·111 back proble111 01 1vhc 1

need~ ~111 gerv. I'1n '11re ii lju-;1 do thc'it' l''\l'l'ri-;t·-;. ,111<1 ha,·e a bit of ph\'ilO aud ha\ '(' a hit ol a break, 1' 11 ht· fine 10 go back <lKai11 ... (Bl·lh: p 10)

·rh(' rt·h1c1anct· to accept bein).{ i1u11rcd i., ... in1ilar to 1h.n rle..,crihed b\ ~le.Ke\ ill and l\lnr').frlll ·1·1 in rhe1r '>tudy of tl1t· 1:·xpe1ie11<'l'' of physicians \\irh :in illness. ·1 hey rc1,orH· cl 1ha1 their participants \vere relurt;1n1 10 idc·111if: illness in 1hcmselve-.. Si.111ilarh. <:athy dc·..;c·rihf'd "1g11oriug all 1lt1· siRns" (p :~). The rea<;on 'lhe g;ne fur 1hi., '""'' 1ha1 'he "loved I hl'r I ~vork . .-\ncl l hat '"''~ "1111e1hi11~ 1 ha L ''a~ nul going lo go" (p ·-1) . ,\, ( ::l rol p111 it. "I didn't \\-dill rn adn1i1 1hal r \\'aS [a~J inj11red i.L'> I \\'as" (p I).

·rhe practice ol conlinc1ing ro 1vork, even 1huugh thl·i1 svn1ptu1n:-. ~11ggcstl'd thac thev sho11 ld perhap' chang-t· their b1.·lt;l\ior. \\'<'IS u~cd h~ -;01111· panicipant'i as a '' 'l\ ol precendin~ that !ht· i1tjur' ""~ 1101 a.; iu1po1 t.1n1 <1;. it realh ,,.;i ... -1hat is. ,1-;" ron11 ol denial . l -hi1' '"a' C:ath\ \ . c-xpt'ri<'IH '" when ~he clecirled lhfll she "\vasn 'L ~oing 10 1 elate" h<•t S\ 111pto111s 10 her \\ork. bcca11sl:' she "ln,·<·d" hl·t \Vot k. <:;he artrih111.ed her svn1ptu111s to '"ll'nni-;'' a11d "a Int of things. rec1 eationaJ tl1111g ... :· She to1111d that ..,h,· "cuuldn '1 play golf' b111 "\vas 1101 gning to givt· up I h1·1 l 1\'ork" (p 4). ~i1nilarh. Ros u·iecl "u111ptel'll t\1i11Ks" ht· fc1r<!

"ht· got 10 I he <;tage \\'hl'fl' she kill'\\ o;ht· h.1d to "alter het hf'c" and h,u\ to ,1dc\11·~., ht·r '""' k (p '.\).

.-\lthouglt tltc literall11t· doct1111e1H~ 1hc f"<Lt'lll of\i\'l\!Sl)., in pll\ .,ical tlu·rapi~t~. 1 -7 indi\'idual Lherapi-.t:-. did 1101 t·xpect to <'Xperit"ucc 'v\' ivlSDs. The cul1111,tl conrex1 ol ph,·sical therapy \Vhei r parti< ip:inl" believed 1hat ''dui11g IL right" ,,·a~ <111 c..·fft·cLive prc-vcnti\e 'tra1t·g-.. a11d llH· t''>Pl't tat ion that 1he\' ,,·ould not t''-j>l'I i1·11re \i\"~l~L).,

468 Cromie el ol

illl'fllll 1ha1 so111<· participants \\'ere st1rprised hv 1heir 0\\11 injuries ( jane: p IO;J;utcl: p 5). "It never o<.rurrecl LO n1l' 1hat it could ro1npro1nio;e 111~· back'" (.\11d1t·<t: p Ii).

J <tnt·l dc;<;cribed he1 i1~j11ry a~ a "shoe k" because a~

"phv:-.ioo; I ph\.,il'al ther.1pi'>1 ... ] l"•ej pridt· ourselvel> on not ha\ i11~ h11r1 011r bad.. .... " She ''"IS shocked .. th:it it "rdS

'0 .,P\'l"te. :·\ sbol k Lha1 i1 did11 ' t jusr s11clcle11lv get bl'tter. i\.nd I had 10 give up [field] hockey. 'J'hal 1vas a hig shock." (Janet: r 5).

fhis l'X!JCCLLll i1111 i<i not u 11 iq Lil' to ph\ "ira l 1 lu' 1~ 1 pis ts: 01 hc1 gro11ps ol \Vorkers exprl·ss si1nil:-11 cxpt'Clatiuns.'1·1.3!;

The txpectation <·xpres:o.t·d b\ ihe p<u-Licipants that 1hev " 'otdcl not experil·nce \\"~1 ' L)l! \\'tlS co11~is11·11t "·ith the pre,~1iling- a~sumption tha1 pln·siral 1herapis1. arc "strong and l ()()<ff fll to be able to pcrf'un11 l hci1 duticl.."·11>11··1•1o1 Particip::tnt'i' ~urpi-isc ancl .,liork ;11 the t'Xlcnt and severif\ ol tbeit \ ·\' l\ISDs is pt'rhaps ine,•itablc. ii the: underl~·i11g profc.,-;ional c11ltural hl'liclS .ti'<' that p!Jy..,iral lher;1pis1<; :-ire 1-nn\vledgeablt· ,111CI capahk• a nd , tht·rt·lo1 e. do not get i.uju1t·cl and. if injtll\ occurs. it 11·ill he 01inur and 't'll-{otTecli11g.

In :tddi1ion ro ll11.· LLLti1.1 1clc or "f'll hl· r-ight" (jaue: p '1) and lhe prelt·r(·11ct• for -;ell-111~u1agi11g. pttrLicipa11l~ did 1101 -.pt·al.. of 1.heir \'\' l\'1 Do;; 10 others (Sill': pp 7-H;.Jan1e : p 1:1; Pt·ter: p 7: Bl·t11: p 16; .Jant·: p I~) . . .\s .Jane put it. "1hetC:'\jus1 nu f't1tlll'C' in r1a lking aboutJ it. There'sjnst 110 pl't,<111al g"ains to be 111ade" (p 12). Ro:. fe lt 1111able to cli!.< 11~-; her \\~I D \\'ith tollcague., because "1' 111 the one:- ''ho':-. got 1hr prohlL•m'" (p 10). Sht· "Pokt· of feeling "alo11e" (p 15) in he1 t·xpcrir11t(' and '"isolntecl" (pp l l . 15).

\\lH' ll I read \our article i11 1he ... ne\\·sletter, l 1ho11ght, "Oh ( :0<1, 1'111 not tht: nnlv one." 1\ncl 1 n1ean, I !..no\, f'111 not tht· nnlv one. b111 10 see acll1t1llv

• it i11 print. ... I just t11ought. "l 11111'\1 cor11ac1 that ''n1n,1n ~traiRhUl11'ay.~ !:>u1ne1i111es yo11 feel like 'ou'rc in a sinkiug !-!hip. like you uri• tbe nn l) one. :\11d .. . "I've got 10 l'hange 1ny joh" ;u1cl ... "v\ll1r?" and .. . ... , he-re must bt· nt11ero; 0111 thC're. ,,·here are the\t" .. . )'011 '011 nf' ft:t·I \ 'l'l\ i-;ol<Hed. (Ro': p l--1)

Participants did nut \\1<1111 tlteir peers 10 vie\v the n1 as LLnahll· Lo rnanagc· their ir~j11ry (Dcbbv: p G; Janf': p 12: Sue: p 10). :.\t the Lime t11a1 l3ct11 i1u111t:ci ht·r~ell. -;he '"knc\v no one " '110 h.a<l a hat k i11,j11ry" and reiler1ed that i1 she had "knov;11 a11otht·r ph,·<;io ['vi1h a !>Utular i11j1111]. ii '""uld have 1nacle it ea iet f'or 111e." B('rause 'ihe kne1,· or 110 Ollt' e\;;e \\ho had had ii ~in1iJar e>..perience. she fch "tlti~ lta,11'1happt·11ecl10 anvonc else. and. the1erort'. T'cl berle1 g1·1 111\'St'll back a~ quicklv as I can. because evt'1\011e el~e i coping" (pp l l, f3 ).

Physical Theropy Volume 82 Number 5 Moy 2002

Tht:s(' i:on11nenLS inclicaLc Lll<n panicipants belie\'ed 1he prohlt·111 of \i\TMSD;. i11 ph}"ic;ll Lhcrap) 1Va!i a 11 individua l one;>. The sratistic that J in 6 thl· rapistJ. confrnnt the iss11t" uf rnaking a career chang-e because of their \·\':'vlSDs'.! indicai('s that the experience is 1101 unique. 1t is surp1·is­ing. thereinre. that rhese rherapi:-:ts "'f're 1111a\\'arc nf 01hers1vlio ll<1d faced or \\'ere l~1cing .,i111i lar siuration.5. :-\ 1 111~ ... ihlf' l'(:<tSOll rc1r this \V<l!i tl1Pi1 rt'liH't<llll '(' I ll cli~C' llSI>

Lhei1 \o\'~1SL)s.

1 had a lot of difficult\' ~vorkin~. ;111d 1nosL pt·oph· arouud 1ne didn't kno\1' tha1I 11•as h:-tving dil'fi111lry ...

it \\':.JS so1n<: tl1ing 1 was very gnucl aL hiding ... [I I didn't 1e ll anybody, IH1t gc111·ra ll~, I I dicll 1101 1nak(· a big cleaJ of' i l. J SI l}Jpose ... C\'ell U l had LO \Vt'<l I 11 I}'

TENS f1111itl , T'cl ke~:p it hidcleu .... (.Jaut·: p 12)

Participants. ii seems. did. not speak about their \rVl\llSD~ because the\ f'cl t it 1n igh t con1pron1 isc Lhcir currcn L and future e 1nplo,·n1ent. Sharo11 said:

... I fell . ... "()f{, J'n1 ·1 l , and ... un l11t· ~a·ap heap hasic;1llv .... " I 1nea n , 1.vhv \\loulcl lltt-\' 1ak1· 01 1 ~01111·-. , . boch that '''as perhaps a liahiliry? (p l~ )

This '''as 1101 0111~ an issue for participants 1vhn ;o,nu~h1 e1nplovn1en1 rron1 orhers. ir \Vas also idenri lied as ;:i

potential problc111 by Peter, a sell-e1nployecl private prar 1i1 in nt"r. *

I 11L·ve1 spoJ..e al>o111 it. ... II' you' re ... n11111i11g a c li nic .... if V<lll do .~tari 10 <'01nplai11 . or if people

start to relaLe things to your ph\'si<:al s1.atu!t. LhaL tnay afrct l 1hc clinic as " 'ell. (p 7)

Tltis reason for noL Lalkin){ about \\1Vl.SOs niay bl' \\•ell f'<lllllcl{:d; t11erapist1-> art· ill risk or bt·ing discri111i11alt•d .1~ains1 if 1hey :u·e kl1n1.vn Lo hav<· a (pote11tially) dis­.1hLi11g i11jury:~ 1 • or cfuability.:17 The ne~ati,·<· re poJJses t·liritt·cl \\'lil'll tltt· sulti l·ct is brouglt1 up 1'01 cli:-.c1 1ssio11 n1:l\' provide a disincent..ive for therapisL"> 10 disc11ss \o\1 M Sl)s. ~t<

Hardworking and Caring 111 uur opi11io11 , the secund n1;tjor a~pect ol the culture of' pl11·siral 1h1· rap), "'liirh 1vas idt0 ntilicd i11 1111• i11t(•1'\'i<'\l'S. slio\\'ecl parLicipants' percep1io111\ n l then11\elvt'S :is cR1i11g­

aud harch\lorkjnl'{. 'fhese percep 1 io11~ \\lere son1eti1nes aL odds \\0id1 lhl' de"irablc l.r<lil. or being knn\1'ledg-t·ahlt::. because pai·Licipants did Lh ing;s rhar 1he\ kne1v n1ighr he: harntl'ul Lu t.hcn1sclvcs in Lhe interests oJ l•\lorking hard and c;iring ror 1l1< ·ir patic11ts. Partiripants' l'Oll111H'111" il111s1 r<lted ho\\' tl1ey placed t11e nl·eds llf t11eir patients ;1Jic~arl or lli eil' O\\' ll <llld hO\\' tJ1t:ir lJelia1-ior \\l<IS iullu-

Physical Therapy . Volume 82 . Number 5 . Moy 2002

enred h1 tJ1eir p<:·rceptinn of Lhen1seh·cs as caring and I nu ch,,orJ..i 11g.

Sue obser,·ed the tende11r.~· of putting her p<Hients' needs ahead uf Iler 011111. She ide11tilicd pbysic;rl tlJerap~' u·aiu­in~ :1s in~tillill)!; i11 tht"rapists a sensf' of ··re'>ponsibility LO paLienLs" Lo Lue extt•11L t11aL:

(h1r pain i-. n111ch. 111111 Ji lc·ss tltan their pa in . :\11cl 1ve carry on regardlc::.s .... You've got 10 pul Lh~· bra1·e face on. \'nu'vc 1-{ol 10 1vork long hour~. yott.\' t: g«1L 10

hf' Lhis pc1fccr liulc giver. (p 11)

1' Jti'\ St'llSC' of' " 1 c~po11.;;i)) iJity'' ~ll(' spoke or is ~in1ilar lO ;t

"sense of dutv" expre.,~ed hy phy"icia11s:1:•q•co-1•1i and is perhaps UCll ,llrp1 i-;iJlj{ in the ligJi1 or Lile high Valt1t: tJ1aL phvsical ll1c·n1pisL" pla<'<' 011 cari ng-. 1 1 ' ~

Sue and En1n1a both spoke of needing to be seen b1· their pee1·s as 1vo1 ki1tg lrard a11d 111aki 11g" sig 11 ilirant contri­bution. Sue idenrified herself as the "typical physio l pb)";ical 111crapisLJ. k(·en tll please. ket•11 Lu do 1ny job 1.vcll,'' a 11cl !-.lit· co11111H·1111•d 1hat slit· 1101 0111\· 1va1111:cl tn ''giye 1.he1n t11e best Lha1 I roulrl" h111 aL"o d id IJllt wanr

"collt"agttt:s lo 'iee Llt<tl [ 1va:- doing a11vLlu11g- less tban the bcs1 that r could" (p 10) . En1111a ('Choerl thi:; ;nvareness of

Lhe perception of peers ::ind the need to ·:just haYe to ... " 'ork rcalh· hard'' to t11c extent t11at she lound it dilliculL

' to cv~·n t<' ll other" Lhat -;lie 1vas taking ri1ne off on a rt"giLlar basis (p 14). 1\s :-i11e put it. ·'\~'e have this e rhos 1huL 1vc· 11avt· 111 1vork ha1 cl a 11d t"Xl1a11sL oursel\'es basically" (p 2}. The par1 icipa11 1~· 11 eed 1n \\1ork h:-ircl

;u1d deliver high-<1ualiLy ser'\ice tu 1heir pa1ie11ts (Sue: p I 0: E111n1a: µ ~) \1'<l1> cunsisLcnt 1vith Jacobson 's d c­scripLio11 ot pliysic;1I t it<"ra pi.l\ts ;.JS "ind 11s11·in1 1s an cl l 1archvorking." 17 11' 1 H!••

~

Tlit· p:1nicipa111s· "e11se- of' rt·-.po11sibilitv 10 lh<·ir patients and tl1e Lrails or caring- <1 11<1111or\..ing hard \VAS expre<;sed by ronLinuing- to u·c;11 11!1·i1 pa1it>nts l'\'c··11 11 he 11 tlrey the1nst' lve:- 1verc 1111\.vell.

l tL,;;ecJ Lo just go into t111.: back ul the roon1 and du 1uv excrcis<·s, and 1he11 g-o hack and St't' a fe"' 1nore palienL<;. You knn11' ... n11tl1ing -;topped Dle b-rJru 1vorki11g. I \\'a'> ahh· 1c1just sLiJJ 1vorJ.. .... ((;aL11y: p "I}

Liz ob:-.erved that ''id<:ally. you prohahl) wo1dd havt· nnt 1vorkcd on those day~ \Vhen \ ·OU • .• did have pain. and you knl'\V rha1 vnu \Vere ... perhaps. 1naki1114 ii. \\'Orsc." I loh'e\•er, she con1n1entcd that '\vhen vou ·re ... self-

' cnt ployC'cl, yo11 tCtHl Lo just <lo ii. ·rhcrc·'-; nu one al that shon ~orl o l nolire· that yo11 can call in ... (p 6). Thii; i.n1plies Lhal :.he 1nay have 1vanted 10 rake time nlf to n1a11agl' lit>r o1,•11 ('011eli1io11, h11t ht•cau~e the needs of her

Cromie et al . 469

pat.ienl~ \vcrc clccn1ed co be n1orc impor1<1111 Lh;i11 l11·r O\\'T1. sh(· continued \vorki.ng.

J"n1 a <>olc prac1itioner n1y<;c)f. and there·~ certninl~

n1uch n1ore pressure on you 10 he Lhcrl'. ' rhere 's no one t.herc if you're ill. You [have to] go iu ,,.hf'n vou ·rt• ill. . .\.nd I mean l\·c had Lii11cs " 'hen ... I \ ·e gon<' in and created n1y prh·atc patic11ts. And beC\,·een patient.s, I've Jai n dovvn on the bed and ahnosl gone 10 sleep ... because rhere' no one 1.hc:rt• to take up th e load .. o I th.ink you pusu vouri,l·l f a bit rnore. . . . u I think ... [that] you can be a bit n1ore vulnerable a.i," solo prartilioncr. ( L)ebby: p 12)

There ''"!. nu expectation that 1.herapi<1t.~ \\'Ottld \\'Orl.. hard not only because they cared abou t 1ht·ir patients, but a lso because tltcy were paid 10 do so. Andrea t.old or feeling prcssLLrcd 10 \vork beca11se th<ll was ,,1ha1 ,,-;1-, l'XpecLt•d-trea1ing parients e\e11 t.ho11gh 1.ht· had s,mp-1om" her-.clf.

T had \\'<1Ne hack pain t.han \vhar 1 his pat.ienc did ... . T can't bclie,·e I did it. I do11 't knO\\' " 'hv I did it. l l '''a' just ... the pressure. That ''':l.~ '"hat I '";L-; expectt·d tn do, hcca11se I \vas at \\'Ork. That '"as '''lin1 I 1vas getting paid for. ( p ~()).

1'ficliat·I identified long hour~ as a11 expectation ol the job, \\1hich he call~ "ridic1tlous."

I thin l- clefinitelv the long days .. .. Tuesday \Vas probahlv a bit ridiculous really .... Olten. I'd hl' going just harnrncr aucl tong, eigh1 o'<lock in 11le morning through to Ii.nish with rn) last patient. get tJ1e1n out or Lhe dour at. ahout 9:30 [P~l ] \\ith about If) 1ninutt:~. half an hour for lunch. So it ''"'~ just ... too ll11l("ll. .. . (p 3)

Carol spoke of being reluccant to challenge 1he prl·,·ail­ing expectations because of be1 inexperience as a phr'i­icaJ therapi..-;t. he said:

'l' ou \Vere confronted 1,·itJ1 this diJcmrna. that the hospital procedurl· -.aid .... But that " 'as "'hat \\'t\S

expl'clt·ci. so }OU didn't cha llenge it. ... It \\ias a hit confronting ... 10 get to your first job and ha\'c a dillerent set of rult·s. And '"e 1vere only liri,t year' 11111. e\-CP.'body else had done this .... Tht• cult urc '''as ) ou did a~ ~·ou 1vere tuld. o you dicln'1 rock lthe] boat. (pp 8-9)

I nl·xperience as ,,·ell a.., \van ting to please colleagues ancl cmploye~ led sonH: participant.s co act in accord 1vi1h pat.ienti.' (or relatives'} expectat.iuns. l\1irhael h<id an upper-li1nb injury and giving a 1nassage increased his discontlort. H o 1v(•\"l' r . he responded to his patit·11L,·

470 . Cromie el ol

expeLLaLions (k:spil<' hi~ aw'1reness tha r lh e u·cau1H' n1 1\'as not like ly to he effective. 1\s ht· pu t it:

Everyone likes being 111assaged. So I Liiink I g-01

.s ucked into 1 he habit of probably (giving rnassagesJ

... e\'e11 [to] the- pai.i1•11t,, '"ho ... I kue,,· [\1•ercn'tl real!\ going 10 ... [~el helpeclJ tha1 niuch [bv the 1nas~t1ge]. I 'd still do it . .iust heca1t!'>t" T kne\v L11at JitJ \1•as somet,.hing tha t preuy n1nch everyone likes when lhev gt· t trt·;ucd . So l did a hell uf a 101 of n1as~age. (p 3)

Conflict between being knowledgeable and capable and being coring and hardworking. Par1icipants· report:. of \\Orking \\'hen Li1e\ ''ere injured and the expectation~ of e1nplovt•rs, COll<:agues. and paticnL'i illustrate a con nict thal c1111ld a rise bel\veen 1 hc:rapists' krtO\vledge ol wuaL 1vas best in tcr111s of caring for t.heir 0\\111 health and lht• need 10 de1non'>tr"ate their hard\vorki11g and caring nature.

1-\lLhough they \\'1'1-c· ofte11 noL overtl)' l'Xprcsscd. t hesc 2 '\t'lil of belief~-or therapist~"' kno\\•lcdgeable and capa­ble ,incl of t.ht>rupi-;L'\ a.-. raring and hard\vorking-are pervasive t' no 11gh to fnn11 part of Lil<' c11lr11rc ol the phvsica I therapv profession. \.Vi 1.h in 1 he prolessiou. 1.hese beliel gi,·e rii.e 10 a prcs'>urt· to conlunn. The li1t·1a111re suppo1 Is the exi'itt•nce of a \VOrki11g 111lu1re '''ilhin the physica I 1 he ra P>' profession , \vh ich deli nes behavior acceptabk· to 1111· group, ;111d an under'it.anding- of the role!» and rcspon~ihilities of the n1e1nbcr-. or the profes­~io11.11-'1 i ; Our studv supporl!» 1he 1101.ion ol prevalc-111 expecuujons ancl belief:~ 1vithin Lile physicnl 1hera py prol<·ssion. It provides C\citlcncc Lhat thC''\t' ex1)ecl.ations and beliets inlluence a1t.i1ud1·-; abouL. and resp<111i.c' to. \\'~lSD'\ \\'hl'n 111<')' occur.

Th e.~e c1dtwd.l be liefs ro1 Ill a prevailing expectatio11 Lhat tber.ipil>ll> \\111 acl in \\'ays that demonsl1<1Lc high lcvC'l~ of skiJI .111<1 kno,,·lcdge as \\'ell a hard \\'ork and caring. 'fh.is expectation , as n1a11i.fested hr 1hc therapists i.n this ~t11dy, is cong1 ucn t \\' i 1 h Richarcl~nn 's" assen ion Lha1 phv.,ical thcrapi•as. by their action~. rt·in.forcl' hl·ha\'iors that are acceptable to Lht· gro11p. If ~enior 111cn1ber of t.hc: prof es!. ion holtl 1 li is expect.al ion and th LI!. exert prcss11 re. inexpt·ril·ncecl 1herapisL~ 111t1v \vc·ll fee l obliged lo act in a \\'a\' that de111on:-.Lralt'il the desirable \'ctlues.

Jn 0 11r opinion , inexperienced or unck·rconfiden l 1.her­apists 111ay find 1.ht:n1selvt·s in a no-\vin situa1io11. lf 1he)' fail Lo put the· 11<·t-cls of their patients first. t.he) 111<1\ he seen as 11ncari ng or I~·· If t.hc:v do pt 11 1 he need~ oft heir pa1ients fir t a11cl ~uhseq11c11 1ly expe1ience an injury. they rua · hC' pt·rcci\'eci as incom petent. 1"his siLuatiun could explain \\'h) rhe participant.-. in thi' scudy repor1ecl beha,ior that den1onstn1led their care :u1d ltard \\'Ori-

Physical Therapy Volume 82 . Number 5 Moy 2002

l.O\vard their patients. but v\'hich came a t a personal he<Ll lh COSI.

Haring a high level or kno\vledge (Uld skill is \•alued bv the pruft::ssion 1 19 and one uf t ht' \V<l)'1' of den·10111>U<1Li11g this is to ren1ain uninjured. This interpretation ma\ help explaiu t11c observed reluctance of physical lherapists to talk to ot11crs about their \i\TNISI1~. Caring for the patient is also high.ly valucd. 1 ~' and our data suggest rhat this can son1c tin1es Lake prccccle11ce over caring f'or 011eself' as a therapist.

ParLicipanLS in our studv appeared to cxen1plif~· huw lhe culn1rally rlcsirable traits of being knowledgeable. capa­ble, and caring and of \vorking hard have the potential to Ctlnllict. This 1vas particularly clear \l'hen tht· par1jci­pa11ts kne'v Lhat \Vha1 they were doing \Vas potentially ha11ni.ng Lhen1, but they did it ::u1}'\\·ay.

Limitations and Further Research Our lindjngs are specific to the 18 therapisrs '"'h o participated in the interviev,rs. ·rhe inLen'ie"'s \Vere car­ried out in ;\ustralia. and che findings 1nay nor be applicable to other population of physical therapists. Therapists in olher cou 11 Lrics are opera ti 11g 1vi th i 11 t liei r O\\'D broader culture and rn">' have differing \'a lues and experiences ru, a result. l-lo 1vever, our extensive use of parrjci pan ts· \Vords enables tl1e reader t.o in fer ti te applicability of the findings to their O\vn situatio n . Participants' expe1;enccs provide u1sight UltO aspects of the physical L!Jcrapy professiu11 and its cuhurc that nla) i.nfl uence t11e developrr1en t of. and responses tc1.

vVMSD~. Neverilieless. furilier researcl1 to dete111tine ilie applicahilit)' of the-se findings in other pop1ila1ions is needed.

Our data raise several other issues for f11rther in\'es1iga­tion. Further research is needed ro investigate the cur­rent ·u·ategics used by therapist.s 1.0 preven L their O\Vll

injuiies. A possible reason thai the ··,;gh1" \Vay has been i.neffecLive in preventing \l\TMSDs may simph· be Lhat lhe "right" ~Va) h;1.s not yet been idenLifi ed. The Occupa­tional Safety and H ealth Adn1inistra1ion identifies the need for a number of interventions in n1ar1aging e rgo­non1ic risk.:1\1 These include hazard identificaLiuu and reporting, job hazard analysis and control, training. n1anagernent of vVMS:Ds, and prograi11 evallLation. lt 1vould seen1 prudent fnr the physical therapy profession to identif), a.~sess, and control aspects of LherapisL'' jobs that increase the risk of vV~'1SDs. Further research is necessar\ to identifv particularh tiskr aspects of physical therapv '''ork, and chis research is li kely to indicate that specific tasks 1uay need to be changed. This is an

i1nportan1 first st<·p in Lii(' process of 1nini1nizing the incidence of \tVMSDs an1oog therapists.

Physical Therapy . Volume 82 . Number 5 . Moy 2002

These findings also have irnplications for the reaching ol bcg.i n ni ng practitioners. It is approp1iate for the physica 1 1hert1py profe ·sio11 to considt'r the belie(~ and values it is conveyiug Lo its ne\,1est 1nen1bers a11d to ensure noL on Ir that they ttre socialiLcd into caring for their patients, bur also that they a re taught the import<mce of caring for I heir 0'\111 bodies.

References I Bork BE. C.<Jnk TM. Rost'r:ranct? JC. ~· 1 al. \Vork-rela1ed 111usculo.skel-,

t'ta l clir.urrl~·rs ;in1ong plty~i<.ll 1h,,r.ipisr. ... Pit)"' 17wr. l!l96:7fi:82i-8'.\!1.

2 Cro11'1ic .JE. R11beru;on \(j . Bt:$l !\1(). \·\lork-rchllcd n1u•culuskclc1al rlisordt· 1~ 1n physical Llt erapisL~: prevalence. se1•erit1. risks, and rcsp<>ll~~. Phy,1 flier. 2000:80:336-351 .

3 ~licr1.ejc11,...ki M, Ku1nar <;, Prevali-11r<- nr low back pain an1,.ng phvsical 1herapis1.« in Ed11HJn1011, Can aria. /Jisabil Rl'habil. 1997: 19: 309-3 Ji .

4 ~lolurnph) M, Unger B, .J1;:11scu GiVl, Lopopolo RB Incidence o l 11'<Jrk-rclat..-d 1 .. w balk pai11 i11 phy'i"'' 11icn1pis1.•. l'lt)'s '/'/1ri . 1985:fif1: ·H!2- ·18ti.

5 Holder NL, Clark li.~. Ui.lilasio J!\'l, ct al. Cause. prevalence. and re;;poasc lo ocrupationaJ 111tisculoskclctal i11jurics rcponC'd b)' phy:sical thcrapisi.s and ph\sical 1J1cr:.tpis1 ;i~sis1.an1s. l'h\•s '/'l11:r. tY'J\):79:642-652.

6 Scltolcy ~1. Hair t'vl. Back pain in physiolhcrapisc.s invol\•ccl 111 back rare t·cl 11 ca1ion. Etg()l1rn11ir..~. 1989:32: 179-190.

7 1~111Dunrn ]\VC. Low b;ick disabiliL~ ..imuug self-;:111ploycu cle111is1.S. veterinarians. phvsiciau.s and physical thcrapisl.S in Lhc Netherlands. Actn ()1thnf1 Scnnd Suppl. 1995;'.'!6:1:3-()<J.

8 Can1 R. Higgs .J Professional sociali1.ation. In: Higgs J. Edwarcls H. eds. Edul't1ting B!!f!i1'111ing Prllcl1tim1er.1. Oxford. England: Ilu1ten11or1.h Hcint.:n.1a1tn; l!J!J!J:46-5 I .

9 Richardson B. Professional deve lnp111en1, 2: professional knowledge and >ilu:t lt•J it'an1ing i11 the workplace. l'li.~.~iollll'rnfi:i · 19!l9:8!i:467-474

10 Lop11pulv RB. DC\cloptucnl uf the Prufcs.siu1111J Rule Beli.1.1~ .. r~ Su1vcv (PROBES) . Ph vs Th1·r. 200 l:8 1:1317-1327.

11 Richardson B. l'rofc~sional cducaLlon aJ1d professional pr..i.riicc today: do 1hey n1a1chr Ph)'Si()th1.,.,,/J)" 1992:78:2~~26.

12 Pr<tll j"\•\I. Tt11;.1J·<l;. .t plillosnph) uf physioll1c1<tp)- Ph,1•illlhrrt1/I)· I Y89:75: 114-120.

13 Beesccin S. Simons H.. Phvsioth<"rapy prai:ticc: prac.:lilio ners· pt·r­~µcr li vcs. Pliysiatilen1f1y 17uo1;. a11d Practue. 1996; 12:231-2112.

14 J<'nS<"fl G~f. C.wy('r .J. Hack L~f. Sh<-pil.rd KF. Ex/wrtisr in l'hy"ir,,/ ·n11!r11f11• /'ractu;,?. Boston. Mass: B11ucnvor1h-Hcinc111ann: 19Y9:294.

15 Guide to Phvsical Thcrapis i Practicl'. Ph\'S Ther. 2001:81 :9-74'1.

16 Roberts P. fbcort•ticaJ n1odcls ot phvs1othcrapy. Pl~1·sio1herapv. lY94·: 80: :361-366.

17 j.ttt)hsoll "BF. Rnlt--n10Llt•I t •o 11t:t·p1~ hcf111'<' a11d ..i.f1er 1.ile run-n<1I prolcssionaJ socialization pcri1)d. Phys Th1•1: 1980;60: 188-1911.

18 Raz P.Jensen C~•l. \.\laltcr.J. Ora.kt.: Li\·!. Pt·r-.pcctivcs 011 gentler ;u1d profc~>lonal is!.l1e. ai:nuu~ ltin:tle pl1»sicotl 1.hcr:1.pbLS. P/i.~J Tht'f. I 991 : 71 :530-[1'10.

t9Jr11srn GM. Gwycr .J. Shepard Kr. Hack L\<l. Expen practice in physical 1 ht'ntp} . l'hy< Th,•r. 2000:HO:~!i-!1\1 .

Cromie el al . 471

20 O"'\«il i\11•. l'.1li>.1uo l~I . \V1•stc1111 SI .. Rt.>la11011,h1p 111 th• · rap 1 ~L' ;11dtudc·s. Li1ilcl1t·11 s ruotu1 ability. and pa1r11ii11g '11 "" i11 111111licr,· p1·1Trpti1111 nl tht·1,1pi'L~ hc•li.tnor' d111111g t:arh· i11tent·11tio11. /'/i\1 //in 2ft!ll:XI 1112-1-121

21 <.u1u_• h.i\, Dil\i~ C\'I. Tn111hll· 1 h. P.ipoulirli' l)J,. E.1rl) faniih 1·xp1·1 i«1H<'' and helping IH·haviors of ph,,ical 1l1c1ap1s1,. 1''1\'' T/i,•1. J•19•'i:/r, JO!llt-1100,

22 Shrp.utl hF. le""'" (. \f. '>d1u1oll 1\I, .-1 .ti .\h..-1nilll\c- .tpprn.u )i,., 10 1C">Carch 111 ph\Sit.11 1ht 1.11J\: pu,JU\J\lll and phe1111n11"1111l11gy l'/1,1 1 ·1111•1 . JYQ)\:7'.tRR-10 1

2~ [t dt...,11111 ( . \\'illi.u11' \( I>. S1..1i111nn-Rng•·r• \\' P<t11C·nc.> aud pro· lC'<,1onab' 11111h·r-;tantl111g' nt the 'au,,., of c h11111i1 [Mill bl.u11t. n·,p1111,1hilal\ .11111 id1·11UI\ protection \or Sn ,,lrd. 1!1117. l fo:li99-70'J

2·1 Krcfu11µ I . Rigor in <j11.lli1.11iv<' n·M~:i 1 ( h: J lit· <L~>•"'''"''nl ol u ll>twor· d1111c'"· .. 1111/01·r11p 7111·1 J9'11: -F>:2 1~ -222

25 ~11nirhtt·ll11 \ . \r<JJll R, [1111t'w1·1l I· \11"'1.aurlt'r I /11 drj1tlt f11lrn•1n1• 111;r: Pn 110 / 1h·1, li•rh 11111111·•. I 11a/ys1<. ~ 1 l'lbou n1t'. \ "i 1 11111.1. ·\11s11.1la.1. L"t1g111:111 c:1 ... ~11i1 ... : lllCJ'i·~f17

26 Po\\<'ll R.\. ">i11,a.:k 11~1 F1K 11~ gr11111i-. ! 111 j Q.11111 H1.,,/lli C:n1r

1490;8: 1!111 ·,n 1

27 Jt· rhl"ll t.J\1 <.l1mli1.11"' 1nr1hod~ 111 pla1s1cal lhl'rap1 rc<<'an h .• 1 I 01 111 ol <I i ~• 1pli11ccl l nrp 1 i ry /'hJ.• T/11'1. I 1lHH:fi!-l :·1!12-500.

28 l.incol11 Y\. \.uha f(~. \ '1H1111tli11u /111111if\ '11•whun P.irk. C:a lif· "·')('' 1'11hliC"a11011' Inc: I 9iC1: 11 h

29 Huh1-rn1an \:.l. ~lilcs ~lit l):ua 1n.:111.Jg1·111 ... 111 an<l a11ah~i\ n1c1hurh. 111: Dt·111i 11 NJ{. Lluc11l11 YS, ,.,!<,. lla111/lm11h oj Qu11/it11t1v1: Ue5f(1rrh.

:'\rwbtlr\ Pai I.. Calil: !:i.u.(c: l111hlir:11in11' I 11t"' I fl!l·I: l2H- I H

30 (.arg \ \\hat has" l''I''' f t ll tr.u11illjt \\Ori.cf"' in "1t>lll't 1" lif1i11i; It« l1uiqu•·' In: :.t.Ul.l' \\'~. 1-\,11"''"''1.' \\ , ~11111.h II. .. rarholsk1 1., rrJ, 7 h1! l 'ruttl't.ltn~< 11/ thr /11tn1111/1m111/ t :i-g.1111111111' IHon11l1m1 I I 'm /ti Cml}i•11•1111•: Th,, t:1Jtu11u1111r1 n/ 1\1111111ril llht11 \\'<11't1\\', Pnlaud· la, lor & F1.1111 h ,

Hlfl'.l;X'l-111

31 (.randjt ·.111 F Filli11J!. tllr Ta•k tu tltl' \/n11. +th t•d. London, cnKl.n1rl r.I\ lor & I· 1.incis: 1988::lti'.l

32 'irubb, 111\, liur:kk· I'\\ . 1 ludson !\IP. Riv1·r~ PIVI. Back p~u11 111 rhl' 1111hi11 g p1 nf,..,,iou. 2: 1·1! ,·n j, en.-.,, 11f 11 ai n ing /· rs;111wm1r5. I !Jx:~:\!6: ifi7-i7!J.

33 ,\lc:K<·,·111 C. :-.. ruri,r.-111 1\1 ·\.110111alt1t 1 ~ p:111c11ts· rhc t'XJll'ri<'n"·' nl d11c101"\ \\'i lh .111 il l n.-~'>. S11r111!11K) nfffr11/rh il'lld 11/nrn 1!)!!7; 19:1:\44-h(\7.

34 Reirlj, F.1 •• 111 C'., l.tl\\\ I:.. 1'1lgrimd$!C of p.1in; tht' dint·~' cxpcnc:ntt!> ot won1t'n "11h 1 e1}eliu11n -11.uu iu1un anrl 1h,· 'earrh for crt>dilaila1'. \ 11r '\ti 11/nl. I Ci!l I ::~2:1)0 1 - t;J 2

35 S.1\'1'1"\ LK. \Vtiod<'n J\.I. The r.-la1ivt• 111 llt1<·ncc ol li l c t:vt•nts n11rl h.b~le' 1111 l\OI l.-rchu1•d in111ries: 'nnlt· A1t'>lnLlia11 t•l'idc:nc(· /-/11mr111 Ud(l/1n111 I !Ill l:·l i:~R:~!\O:">

:J6 (,.Han· (", TI1on1'on ll Expcncntc> ol phvs1ot11erap1<L< \\ith phi, .. 1u1l di:«1hlli 111·:-. Ph! 1ioth1'1f//(\' I '191 :77: :'7· 1 -:~78.

37 Fr<'tll h c;, \"i,11all\ i111p.1irt·d phv,iHthl'1 .1pi<L' thri1 'tn1~,.cl1· t11r arcep1.111c1· .anrl •un1\ .11. /11 f11lnlt/\ n 111/ \ tH·utv. 199.>: I 0;:~-1 'l

38 ( n>TIH<' I~. Robcn~on \'.) . l~es1 /\IC). ()c<upauuual in111rics in PT., , f'h_n "/~1rr 20fJO;H!l::"12!1-:"1:\ll

39 l:.r[!llllfllllll• frrq11ritl~\ ·\\kfd Q11e1tiri111 Iii. \\ 'a~ hinitton DC.: Or,.11p.1· uonal ~fef\ and I l e .. hla \dn111115u-;.1uu11: :!000.

472 Cromie el al

Appendix. lnlerv1ew Prompls

Initial Schedule of Questions This schedule is inlended as o guide only, lo ensure lhe inlerviewer covers o il relevonl ospecls of lhe work-related musculoskeletol disorder. The nature of qualitative research means thot as new doto emerge, different ospec1s of lhe inrerview may 111creose or decrease in emphasis and new areas rnoy be investigated. It 1s expected that areas orher than those covered in lhis guide may be included in lhe Interviews.

Personal / Demographic Information Age Sex

Work History Years of practice os a physical therapist, oreos of proclice Current or more recenl practice Other relevanl 1 n formo lion • Tell me oboul your work history ond how injury fil 1n10 lhol

Causes • How dad injury occur? Whal caused it? Did i i occur in the course of

your normal w ork? Were there unusuol circumstances surrounding lhe 1n1ury lhot moy hove affected 1he nature or exlenl of the Injury?

• What contributed to ii? • Whor exacerbated 11? • Whal ospecl of the causal foclor wos important 111 the onset of the

Injury? For example, if lifting was the cause, wos ii lhe excessive weigh t? The frequency of lhe lifling? The ampli tude? The posture in which II occurred?

• Was there o poinl ol which you recognized thol You were al risk of in1ury? You would hove lo change your area of procllce or leave oho­

gelher2 • Do you hove any o lher comments about the causes of your in1ury2

Management • How did you manage your Injury? • Were there any skills or ottribules I hat you hod acquired as o physical

1heropi st lor student) lhal helped you manage your injury belier than 1f you had come from a d ilferenl professional background?

• Whal would you hove done dlffe1ently w1lh the benefil of hindsight? • Did you hove lreotmenl for your symptoms? • Do you hove any other comments aboul your injury or the way in

which ii was managed?

Resolution • How much experience hod you hod as a physical therapist when you

mode the decision lo change area of practice? • How did you choose on ohernolive2 Wos your prior experience an

advontoge? How?

• Did your !raining give you any advantages in choosing whal oreo to go inlo or changing?

• Were lhere any skills or attribute~ thor you hod acquired as a physical 1herop1sl lor studenl) that helped you change lhe area in which you practice?

• Do you anlicipole lhal you will moke o ther career changes because o f injury? Do you expecl lhol you will ever proc1ice lri lhe original oreo thol you left because of injury?

• Do you have ony lang~erm lim11ohons becouse of your injury2 • Are there any things you con 1h1nk of that would have mode rhe

tronsillon (both choosing and changing) easier? Do you hove any o ther comments?

Physical Therapy . Volume 82 . Number 5 . Moy 2002