Qualitative thematic analysis revealed that the osteopaths in this study were able to articulate clearly the various facets of their experience of having sustained a WRMI. The findings further suggest that the experience of a WRMI was, for these osteopaths, a challenge that prompted resilience and adaptation. Participants offered advice for injury prevention grounded in their experience both as a practising osteopath and from their own personal experience. We have first presented the demographic profile of the participants followed by the key themes that explore the participants’ experiences of WRMI. Quotes from the interviews are included to clarify and support our interpretation.
Of the 13 osteopaths interviewed, four were female and nine were male. Their ages ranged from 26 to 58 years. The number of years in osteopathic practice ranged from two to 38 years, with an average of 10.5 years. There was no consistency about the time in practice before sustaining an injury: three participants were injured during their first two years of practice, five had been in practice between five and 10 years before sustaining their injury, four had been in practice more than 10 years, and one participant had been in practice more than 20 years before injury.
Two-thirds of the participants reported sustaining more than one injury, with three reporting three or more individual WRMIs. These participants were encouraged in the interview to discuss the injury they perceived as the most serious and/or as having the most significant effect on work and their life in general.
Qualitative findings from thematic analysis
The qualitative thematic analysis produced four main themes: theme two has two subthemes that describe risk factors and risk modification used by participants. The four main themes are:
Injury prevention in osteopathy education
Theme 1: Perseverance
This theme exemplifies the participants’ resilience and their motivation to recognise and manage the impact of a WRMI on the different aspects of their life. The following provides a picture of the participants’ experiences of initial concern and subsequent drive to maintain, to some extent at least, the status quo of clinical practice.
The majority of participants clearly expressed their determination to continue working whilst injured, regardless of the limitations posed by their WRMI. Although they voiced concern that they might not be able to continue working in the same manner as before the WRMI, they explained that they needed to make changes that permitted them to continue to provide patient care and ensure the viability of their business.
I didn’t know what to do for a while—I just wondered how I was going to keep on going. I was quite [worried] and I realised that I had to do something different. I had to change the way I was doing things. (Participant No. 13).
There was, however, a tendency for some participants to just ‘push through’. When asked how they managed their injury at work, a few said they continued working despite their injuries and pain. “I’m the type of person that just pushes through things … using painkillers” (Participant No. 6). Many participants conveyed a high level of commitment to their work and to their patients’ health and wellbeing, often putting the patients’ health before their own. Taking time off work due to injury was not a popular option. For those who did take time off, they did so only when suffering considerable pain or disability.
Theme 2: Inevitable change
Work as an osteopath is demanding both physically and mentally due to the physical nature of the work and the entrusted responsibilities of patient care. This theme explores the participants’ experiences of the various risk factors inherent in clinical practice, the changes injury had on their practice and life and the changes they implemented to modify risk and manage WRMI. Participants discussed numerous factors that they thought contributed to their injury as well as the risk modification strategies that they instigated. There are two subthemes within this theme, (1) ergonomic and biomechanical factors: risk and risk modification, related to practitioner and equipment, and (2) psychosocial factors: risk and risk modification.
Ergonomics and biomechanical factors: Risk and risk modification
Faulty practitioner ergonomics and posture was mentioned by participants with many believing it played a significant role in their injuries. Poor technique selection and execution, cumulative effects of repeated loading of joints and soft tissues and overuse were also identified by participants as risk factors. Responses varied between those who were recent graduates and those who had studied many years ago when ergonomics in practice had not been emphasised by their educational institution. There was also differences between the experiences of male and female participants.
For example, several of the male osteopaths had treated patients considerably larger than themselves and suggested that larger patients often sought treatment from a male practitioner. They believed their injury had resulted from the poor ergonomic positioning and extreme stretching of their own body, required to accommodate the patient’s size. Participant No. 13 explained that providing treatment for a “bigger patient, resulted in tension restriction around the diaphragm area”.
Participants also mentioned the effects of poor ergonomics in previous employment, as a risk factor to injury. They suggested that the accumulation of poor technique usage over time had either led to or compounded their injury. One participant (Participant No. 3) highlighted poor technique as a massage therapist prior to becoming an osteopath as a major contributing factor that ‘certainly had an effect’ on their current injury.
The following quotes highlight the influence of a previous work situation on injury.
I was a chartered accountant before, sitting down all day and studying all night. I would say neck stiffness, particularly around the cervicothoracic junction, definitely contributed to my injury. (Participant No. 7).
[The injury was] originally just an overuse one; I was doing massage as a uni student. It was more like a tendonitis, like a flexor tendonitis through my elbow and wrist and a bit of carpel tunnel. [Participant No. 12].
Numerous strategies were highlighted with awareness to posture as a primary preventative measure for WRMIs. For example, Participant No. 6 suggested injury prevention for her is “all about posture and how I’m actually standing and leaning over people”, and participant No. 2 explained: “I use self-postural awareness… a full-length mirror, so I can correct my posture whilst working”. Others discussed pre-empting overuse injuries by decreasing the number of repetitive or posturally demanding techniques in clinical practice.
Some participants attributed their injuries to a lack of physical fitness and strength. This was, for some, a “vicious circle” where injury caused weakness and weakness caused injury. They related how this played out in other areas of their lives besides work, such as driving, engaging in sport and fitness training and even getting out of bed in the morning. Participant No. 12 lamented that they were unable to do strength training since a WRMI and Participant No. 7 said, “I actually had to stop that [judo and jujitsu] a few years ago because I just couldn’t do the gripping anymore”.
Two female participants felt they had returned to work too soon after childbirth when their fitness and strength were reduced. Participant No. 4 explained that ‘not being as physically active and fatigue from a lack of sleep’ had led to her injury, and Participant 11 succinctly described that her return to clinical practice after childbirth was “too much too quickly, without any match fitness for treating”. This participant went on to explain that her early return from maternity leave meant she “didn't have as much core strength and was over recruiting my upper body”. Another female participant proposed that hormones related to menstruation increased the risk of injury.
Participants also discussed equipment that was not ergonomically appropriate for carrying out certain techniques. Using the correct treatment bench is important for osteopaths, and several study participants suggested that using a bench that was either too wide, too narrow or not height-adjustable was a major factor in the development of their injury. Participant No. 9, for example, recounted how as a beginner practitioner he did not have an adjustable-height bench. He believed that this was a major contributing factor to his injury because it necessitated “bending over benches in an awkward position”. Participant No. 6 suggested the width of her bench had contributed to her injury, stating, “it is a little too wide”. Many discussed how addressing treatment table height and width, determining a safe technique selection for each patient and requesting patients to move themselves during techniques had been critical to recovery and to prevention of further injury.
In addition to discussing the ergonomics of equipment and posture, there were specific techniques that some participants felt were dangerous due to the high compressive forces required for their execution. This included high-velocity low-amplitude (HVLA) techniques and myofascial work requiring sustained or repetitive force, such as rib-raising and cross-fibre massage. Although many practitioners considered soft tissue techniques an integral part of their diagnosis and treatment practices, they believed the repeated and sustained pressure of these techniques contributed to their injury. Repetitive strain and overuse were reported as common occurrences, not only in the wrists and hands but also in other parts of the body if a participant used the same technique frequently.
The HVLA techniques that participants identified as causative of injury were seated thoracic spine HVLA, lumbar spine HVLA and a supine thoracic spine HVLA known as a ‘cuddle’. Participant No. 6 described her experience of using HVLA to be “quite vigorous and compressive” and said she was “weaning” patients off this technique type.
Almost half of the participants identified the HVLA technique commonly called a “cuddle,” in which the practitioner uses an epigastric contact on the supine patient’s elbows , as the injurious technique. Although Participant No. 13 identified the ‘cuddle’ as their favourite spinal technique, he also said, “I usually regret it later”. Others also commented on this technique.
I [sometimes] damaged my sternum when I used a cuddle technique. I would yelp, and patients would look at me and see I had gone white, and ask me if I was OK and if I needed to sit down. (Participant No. 9).
I have a mid-thoracic injury that I think is from doing cuddles. It’s not overuse but compression and flexion/ extension of the thoracic spine from doing that thrust. (Participant No. 8).
Most participants said that techniques that caused injury needed to be either adapted or not used at all. This often involved modifying factors associated with ergonomic and biomechanical risks and reducing the frequency with which they were used.
I cut back work, restricted treatments to one cuddle per patient and applied it with far less force. (Participant No. 8).
You are going to be susceptible to injury, and you just need to think it through biomechanically and, yeah, work out ways to minimise it. (Participant No. 13).
Participant No. 1 also made the suggestion that “if you do acquire an injury, stop immediately and act early” and Participant No. 10 suggested, “it’s not worth the long-term costs of putting up with pain when you treat”. However, in contrast to these views, Participant No. 5 believed that injury was inevitable with certain techniques and one had to be ‘willing to pay the ultimate price, which is probably a chronic overuse injury’.
For the most part, the participants were certain of both the cause and the factors that had led to—and in some cases continued to aggravate—their injury. This finding is not surprising because osteopaths spend a great deal of their work time discussing and diagnosing the injuries of others. However, there were examples of participants who struggled to understand and manage their injury.
It [the injury] would go away and then come back— Go away after I had a sleep and then come back again when I worked or did too much—and then go away again. Then it just stayed and got worse and then I also injured my left [wrist], because I was overusing my left hand. I was like okay! I had five months off work and used my income protection and that’s when I really started to investigate it. I went to the sports physician and he thought it was carpal tunnel. So, I had a cortisone injection and then I saw a hand specialist and he then thought it wasn’t carpal tunnel. He sent me to the neurologist. The neurologist did nerve conduction studies and MRI’ed my neck and didn’t find anything, (Participant No. 3).
Psychosocial factors: Risk and risk modification
Psychosocial factors can both contribute to and be the result of a WRMI . Most of the osteopaths in this study were aware of the influence of psychological stress and the pressure of overwork on the risk of physical injury. Several participants discussed how they were more likely to be injured late on a workday when fatigued, especially when seeing a large number of patients. For example, Participant No. 1 acquired their injury when they were ‘seeing 60 to 80 patients a week’. It was suggested by Participant No. 6 that the reason her injury was worsening over time was due to “increased fatigue with the greater number of years in practice”.
For many, a WRMI meant reducing the time they spent in clinical practice. Some participants said they reduced their overall hours worked each week; others said they decreased the number of hours worked each day. This reduction in time spent in clinical practice resulted in a decrease in the number of patients seen. For some, a period off work was required.
Since the diagnosis, I have reduced patients from 20 down to 14 patients a day and more breaks. I’m now doing three or four consultations and have a 30-min break. (Participant No. 7).
Most participants spoke of the pervasive and detrimental influence of injury on their general health and wellbeing. Several participants discussed the frustration and distress they felt because the effects of WRMI forced them to abandon the sports and other activities that were central to their well-being. This included interacting and connecting with family and friends and involvement in activities such as yoga, martial arts, gym work, and sports such as swimming and rock climbing. Participant No. 13 said, “it generally decreases my ability to interact at home and enjoy life generally,” whereas Participant No. 9 explained how the injury impacted his social life, stating, “I was unable to connect with friends at the time”. Participant No. 1 explained the flow-on effects of injury:
The biggest impact is not being able to participate in sports, and for that reason I have lost a lot of general fitness and tone and have put on about 15 kg over the past two years.
Another important area influenced by injury was sleep. For example, “It affects my sleep; I wake up with mid-thoracic tightness at night” (Participant No 8). Others spoke of a complex set of impacts on their general health and energy levels. Participant No. 13 explained, “I get a bit of tension around the diaphragm, and it can be associated with a tension headache, lack of energy and lack of ability to concentrate.”
Theme 3: Seeking help
The third theme relates to participants’ experiences when seeking help from others and initiating self-help strategies to manage and rehabilitate from the injury. Help was sought in a variety of areas, including occupational therapy, pain specialist management including injections and medication for pain and inflammation, acupuncture, manual and exercise therapy (chiropractic, massage, osteopathy, physiotherapy), counselling and stress management, and attention to rest and nutrition. Two participants employed hand splinting in the form of strapping/bracing as an intervention to manage pain and as a preventative measure against further injury.
Some participants discussed a broader range of coping strategies that they used to navigate the psychological issues and stress associated with their injury. These included practising meditation or mindfulness; seeking regular de-briefing and support from counsellors and psychologists; establishing strong work–life boundaries; and having healthy habits and routines with regard to nutrition, exercise and sleep.
Theme 4: Injury prevention education in osteopathy
Most participants discussed the need for formal injury prevention training in pre-registration and continuing education courses for osteopaths. They suggested modules that focused specifically on the ergonomics of safe clinical practice, including biomechanics of force delivery and its effects through the practitioner’s body, effective and safe posture, and the use of whole body rather than strength. New graduates or those returning to practice after a long break need to build up a patient load slowly, be realistic about what can be achieved with each patient, and become informed of and take steps to reduce the risk of injury in clinical practice.
Course content directed towards protecting osteopaths over decades of work…some specific physical health regimes about strengthening and stretching exercises set out for osteopaths that address the sort of injuries that we are likely to have. (Participant No. 9).
Exercise physiology and exercise prescription courses were considered essential knowledge for graduating and practicing osteopaths. It was pointed out by several participants that in their opinion osteopathy is slow to engage with exercise as a primary treatment modality. They suggested in-depth knowledge of exercise physiology and experiential training in exercise therapy would equip osteopaths with the skills to design exercise rehabilitation programs for patients, reducing the hands-on manual therapy demands of osteopathic consultations. Such knowledge and skill would also benefit the practitioner to assess their own exercise and strengthening needs. It was acknowledged however that some osteopaths possess advanced exercise therapy skill, usually gained outside their osteopathic education.
Traditionally our profession has not been good at applying non-manual therapy approaches, maybe [we are] less strong in our exercise advice and rehabilitation approaches. (Participant No. 4).
When osteopathy was developed, people moved [were active]. And that‘s why [Dr] Still treated trauma, not inertia. That‘s really no longer the case. It‘s taking the profession a really long time to come to grips with what the exercise literature is actually saying. It’s a difficult space because the consumers are really honing in on movement and as a profession, we are not really skilled up, at all, to really offer any meaningful clinical integration of movement and exercise into osteopathic practice (Participant No. 5).