Impact of Work-Related Pain on Physical Therapists and Occupational Therapists

Professional ideals.

The participants aspired to a professional ideal that included dedication, self-sacrifice, compassion, and clinical expertise. This professional perspective influenced their behaviors with regard to work-related pain: They all continued to care for their patients while in pain, some minimized or did not report their pain, and others engaged in self-diagnosis and treatment of symptoms (or accessed colleagues to do the same). Most of the participants did not miss any work time because of their symptoms and continued to perform activities that exacerbated these symptoms. Most emphasized that they did not take time off because of their work-related pain unless “I can’t get out of bed.” Several indicated that going to work helped them feel better “because you are helping someone else feel better.” Two aspects of the professional culture, professional identity and responsibility, help explain these behaviors.

A professional identity that combined a self-image of strength, athleticism, and independence with expertise in musculoskeletal health emerged. This identity made it difficult for the participants to reconcile their pain and change their work practices to improve their comfort. One therapist commented, “I felt that, I have to be like superwoman.” Another explained that working as a therapist requires her to be “thin and athletic.”

Expertise in the diagnosis and treatment of their own musculoskeletal disorders contributed to this identity, and the therapists reported that their knowledge helped them decide whether their symptoms were significant or not: … we usually know what's going on with ourselves. So we say, “No, it's OK, it's safe for us to keep going,” or … we’re able to self-diagnose or diagnose each other and we know that it’ll get better.

They reported that this knowledge differentiated them from other professionals: I think that different professions have different mindsets … different priorities that they will set, and I think as therapists, we know what the pain is and if it's anything to be worried about, so we will just continue to keep working, where other professions, … they may not realize that there's something that you can do for it and still be able to do your job.

Experiencing work-related pain challenged their professional identity and affected their self-identity: … it almost changes your identity because it seems like people who get into physical therapy are athletic … you come from this elite kind of place where you’re very competitive and you’re athletic and you really just want to keep going through things. It changes your self-image of who you are.

They felt pressure to hide the pain, not report it, and work despite the pain. The participants blamed themselves for the pain that they experienced: That's what we were taught. Use good body mechanics and you’re fine. So you almost pretend, “I don’t want to be looking like a bad therapist and say this hurts, so I’ll just do it and endure it, because maybe I’m not using good body mechanics.”

The participants described a strong sense of professional responsibility to patients and coworkers. Commitment to coworkers and the resultant guilt at burdening them encouraged participants to continue to work regardless of pain severity. Several identified staffing shortages, in particular, as contributing to the burden: I actually feel guilty not going into work as to what therapist am I inconveniencing. Who has to take over my patients?

The participants felt responsibility toward their patients (eg, “I have never said, ‘No, I will not take that patient,’ because this is my job.”) and were reluctant to let their symptoms interfere with patient care (eg, “I knew I hurt myself, but I was doing an eval, and I had to do the eval—you don’t just not do it—and I sat on the floor … in a lot of discomfort….”).

They emphasized the caring nature of the profession and possessed both a desire and a sense of duty to care for others: You are the one that's supposed to help heal, you know what I mean, you’re the one that's taking care of the ones that are really hurting.

They found patient treatment and progress to be rewarding, and these goals motivated them to continue to work, even when they were experiencing pain: Because I enjoy what I do, and I enjoy working with the people that I work with, it's almost like you want to be there. You want to see that patient get out of bed, you want to see that person walk because you’ve been investing all your time, and your patient's, for this [moment].

The participants also experienced professional pressure to continue to work, and taking time off affected how they were perceived by their peers: I also think it's perceived, perhaps by your staff or other people you work with, if you are not putting in that 100% that you’re not a good therapist.

They discussed asking others for help during activities that placed them at risk of further pain or injury. However, they were divided on whether this practice was acceptable. Many participants said that asking others for help was acceptable: I’ve let go of having to transfer that 200-pound person by myself or kind of feeling like I don’t have to ask for help.

However, some participants either were unable to obtain help or thought that it took too much time to wait for help: I will admit, sometimes I don’t, because you’re waiting for 15 to 20 minutes before someone comes and helps you.

Work habits.

Work-related pain affected the participants’ daily work habits despite the dedication and responsibility cited above. They adapted their work to compensate for their discomfort, making changes in how they organized their days and modifying the ways in which they performed treatment activities. They expressed concern about the effects of their pain on the quality of patient care and engaged in a process of reflection on their ability to provide effective patient care.

The participants had enough professional autonomy to be able to make changes in their daily work processes. One common adaptation was altering the daily work schedule. They used strategies such as inserting supervisory tasks in between clinical visits, reorganizing appointments so that patients requiring more challenging treatment activities could be seen in the morning, scheduling appointments when several therapists were available to help with moving and treating patients, and arranging cotreatment sessions with occupational therapists and physical therapists: … I literally structure my day, especially if I’m having a bad day; I’ll structure my harder patients in the morning because I know that by the end of the day, I’m just not going to be there physically.

Many therapists adapted by avoiding certain activities or altering treatment plans because of their symptoms. Typically, these measures were taken to reduce exertion associated with transfers, gait training, and manual therapy. One therapist stated: … sometimes you find yourself using, doing other things with them so you don’t have to transfer them.

Another explained: I’ll just do one trigger point, tell them to “breathe through it and then go stretch yourself.” I won’t stretch it manually, I’ll just have them do it themselves.

Others changed the ways in which they performed tasks while in pain by modifying the technique or the environment: It [pain] has made me more of a cautious therapist. And I don’t think I work with the children as physically as I used to. I rely a lot more on the equipment in the gym now; if I know that they’re a hard transfer from sit to stand, then I put them on the mat and then I just elevate the mat instead of picking them up myself, so then they can do it themselves.

Some therapists asked patients to do more than they normally would have. This practice was perceived as beneficial for the patients as well as themselves: I have a patient right now … and he walks like a turtle. I told him today that “my back is really hurting, you have to take bigger steps, and you have to help yourself more …”; he speeds up, so it helps him out….

Most participants expressed deep concern about maintaining the quality of care of patients and asserted that their care was not compromised. They engaged in a process of reflection to assess whether working in pain or adapting their work affected the quality of patient care. Many indicated that they would stop practicing if they could not provide valuable and skilled treatment. One participant stated: I really try and assess whether I am being effective with them or not.

Some participants, however, provided examples of situations in which quality of care might have been affected by their symptoms: I have one home care case, and I complain about it, and I only have one, and I shouldn’t even be complaining. But I don’t want to go there; I want to go, like my heart's there, but it's a child with CP [cerebral palsy] who's now 3 years old and he's huge, and he has no trunk control, nothing, and I want to be there, but by the time I get there, I feel like I’m not being beneficial towards him. I hate to admit it, but my 4 to 6 (pm) patients might be getting gypped.

The effectiveness and necessity of using manual therapy (which increased pain) were debated at length. Therapists working in outpatient settings, in particular, varied in the amount of manual therapy they provided and whether they thought it was necessary. While discussing the use of exercise-based interventions instead of manual therapy, several participants asserted that patients expect hands-on manual treatment and that this expectation influences treatment decisions: I have people, colleagues that I work with, that they don’t really do a lot of manual therapy, and it shows up in their kind of work and patients are not satisfied.

Interactions between therapists and patients were influenced by the therapists’ symptoms. The participants thought that at times they had worse pain than their patients: You ever have a patient complain to you and just look at them and think, “If you only knew.”?

Some therapists expressed irritation and decreased patience with their patients: Like when someone comes in to me and says, “Oh, I have tightness in my upper trap,” I mean honestly, my first reaction, the bubble says, “Suck it up.”

Patients also noticed therapists’ discomfort. One therapist explained: I had my (cervical) collar on; the patient's like, “You’re gonna help me? Get me a new therapist—I’ll take that guy.”

The participants reported no specific incidents in which the safety of patients was compromised but expressed concern that it could be. In particular, they worried about their symptoms affecting their ability to transfer or move a patient safely: I’m always afraid that … I’m going to drop somebody; it's all of a sudden going to happen and I’m going to drop someone.

They also were concerned for their own safety, and that concern interfered with clinical decision making (eg, “… the fear of hurting yourself more isn’t letting you do what you have to do.”).

These daily changes in the work process and concerns regarding the quality of work reflected the less immediately obvious effects of pain on therapy services. The process of the work changed, but the visible output remained the same (ie, patients were still seen and cared for). Productivity, perhaps the most obvious measure of decreased work output, did not emerge as a primary theme. Most, although not all, of the participants stated that they did not reduce their patient case loads and continued to treat everyone who was assigned to them.

Life outside of work.

In addition to work-related effects of pain, the participants described many ways in which their symptoms affected them outside of work. The participants performed all or most job-related duties but endured significant consequences in their personal lives. Many returned home at the end of the work day or weekend too fatigued or in too much pain to participate in other types of activities. One therapist noted: I never took naps in my life before. I’m just so physically exhausted; you know, pain makes you tired, it really does.

In addition, they identified multiple psychosocial consequences of pain, including depression, sadness, anxiety, frustration, and resentment (eg, “It [pain] makes me grumpy … complaining all the time.”). Activity limitations were pervasive and included decreased participation in leisure activities, activities of daily living, instrumental activities of daily living, and social activities.

Some participants changed the ways in which they performed leisure activities, others changed the types of activities, and some no longer engaged in activities that were important to them: I haven’t been backpacking in I don’t know how long because the idea of having a 40-pound backpack, you know, I can’t do it. So those kinds of activities that bring me so much joy, I’m not able to do….

Some participants reported that vacations required special planning. Travel was a distinct consideration for some, who worried about an increase in symptoms while flying or driving. Others considered the effect of vacation activities on their pain and whether they would be able to return to work after the vacation. A few reported that they did not change their leisure activities and often experienced pain as a result.

Work-related pain affected activities of daily living and instrumental activities of daily living, including rest and sleep, health management, home management, child rearing, decisions about whether to have children, and community mobility, in several ways. Health management was mentioned by almost all participants in all groups. In particular, eating, exercise, and weight gain were prominent topics: Sometimes if you’re in that much pain, you’re going to limit what you’re doing for your workout, cause you’re already doing your workout at work, and when you’re in pain, you’re like, “I’m not doing any more.”

Although most therapists limited exercise because of pain, 2 participants remarked that they exercised more: … last night I got out of work, I forced myself on a Friday to work out for an hour 15 minutes because it makes me feel better.

The participants asserted that pain affected their appetite and ability to control their weight. In fact, most reported weight gain since the onset of their work-related pain and attributed it to a reduction in physical exercise and a change in eating habits. Several therapists reported craving carbohydrates and other “comfort foods” as a way to cope with their physical and emotional symptoms. This behavior conflicted with their self-image of athleticism: I’ve put on a lot of weight. I’ve put on, I think, 15 to 25 pounds this year because I haven’t been able to do what I want to do.

Home management activities were affected by work-related pain. Participants were limited in their ability to cook, clean, and participate in home maintenance and, in some cases, relied on their partners to take over: I agree. It's like, “OK, you want dinner, I’m not cooking it.” I can’t stand, and it's even if I do make dinner, like the kitchen's a disaster because I can’t stand to wash the dishes because that just puts me over the edge, that static standing.

Only 2 participants mentioned their children. In each case, pain affected their interactions with them: Sometimes like at the end of the day if I’m working early mornings or an afternoon and I come home, he’ll always want to jump and wrestle … but sometimes I can’t.

Some of the participants without children worried about managing the demands of child care with pain: We don’t have kids yet, but sometimes it's kind of sad to think [about] having a major headache, or not being able to run with them, or not being able to be as patient.

Most participants experienced limited engagement in social lives. To some, this was most evident in their interpersonal communication with significant others: You don’t want to talk to anybody. You talk to the people at work, and then you don’t want to talk to anyone at home, cause you’re upset that you’re in pain, and you’re tired. You’ve been able to accomplish all these major goals in your life, and then it's just too much to go out to dinner and you feel bad. I feel really bad for my [partner] sometimes.

Others reported significant limitations in social activities: … for me, when it comes to do something fun, if it is not a mandatory thing I’m less apt to do it.

Career plans.

Work-related pain affected long-term planning by the participants. Reflections on the future included fear and anxiety about the ability to continue this career, planning for a different career, and planning for a different direction within the profession of occupational therapy or physical therapy.

Most participants were satisfied with their jobs, enjoyed working with patients, and found their work rewarding. One major concern, however, was longevity. Most participants doubted their ability to work in a clinical capacity for much longer and expressed fear and anxiety about their professional future. Often, the anxiety represented fear of the future and their ability to continue to practice (eg, “… I’m 33 years old and I’m thinking, ‘Oh, God, am I going to last?’ …”).

They described frustration with their pain, and some felt resentment or anger toward patients, whom they perceived placed them at risk: I’m holding her up, so I was concerned that she could end up on the floor and I could end my career, and I was resentful…. I was mad. I was mad at her.

Some were actively considering leaving the profession: I told you I’m out…. In like 2 years, I’m out … something completely different. I don’t know if OT [occupational therapy] is for me in terms of the work that I’m doing because I’m 30 and I’m not sure if I’m already having these issues, what's going to happen, so it's been really, really challenging.

Others were planning on staying in the profession in different capacities: I’ve gone back to the doctoral program. So if the day comes that I can’t be manually treating patients, then I’ll have some options to still be within the field and maybe in the education realm instead of the clinical end of it.

Among participants who experienced anxiety about their professional careers, some questioned their career choice, others expressed concern about making a career change, and many had fears about their future: I’ll admit there are some days when I go home, my body hurts, and I don’t understand why I chose this profession. So that's the honest truth. When you’re in that much pain, you’re like, “Why am I doing this to myself?” I worry about what's the next step. Do I cut back my hours more and more?

Despite the levels of work-related pain noted by the participants, almost all of them thought that work was rewarding. They were satisfied with their jobs and valued the caring aspect of their work. Most participants enjoyed contact with patients and reported that caring for patients improved their mood and sometimes their symptoms: You go to work and you love your patients. This is what makes you feel good. You know? I like going to work.

Many were concerned about having to do something else and did not want to leave the profession, but acknowledged the physical demands of the work: I love what I do, I really enjoy it, and I want to continue it. I don’t see myself doing anything else, but yeah, you need to be strong.