Journal of Integrative Medicine 16 (2018) 84–89

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Journal of Integrative Medicine

journal homepage: www.jcimjournal.com/jim
www.journals.elsevier.com/journal-of-integrative-medicine

Review

Occupational hand injuries: a current review of the prevalence and

proposed prevention strategies for physical therapists and similar
healthcare professionals
Giles Gyer ⇑, Jimmy Michael, James Inklebarger
The London College of Osteopathic Medicine, 8-10 Boston Place, London NW1 6QH, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Hand injury is the second most common work-related musculoskeletal injury among physical therapists
Received 21 October 2017 (PTs) and other manual therapy professionals such as osteopaths, physiotherapists, chiropractors,
Accepted 4 January 2018 acupuncturists and massage therapists. However, the nature and extent of this problem have not been
Available online 6 February 2018
fully explored yet. Therefore, the objective of this study was to review the existing literature published
on the prevalence, risk factors, consequences, and prevention of hand injuries among PTs and similar
Keywords: healthcare professionals. The lifetime prevalence of hand injuries was about 15%–46%, and the annual
Occupational injuries
prevalence was reported as 5%–30%. Thumb injuries were found to be the most prevalent of all injuries,
Public health
Physical therapists
accounting more than 50% of all hand-related problems. The most significant risk factors for job-related
Occupational therapists hand injuries were performing manual therapy techniques, repetitive workloads, treating many patients
Complementary therapies per day, continued work while injured or hurt, weakness of the thumb muscles, thumb hypermobility,
and instability at the thumb joints. PTs reported modifying treatment technique, taking time off on sick
leave, seeking intervention, shifting the specialty area, and decreasing patient contact hours as the major
consequences of these injuries. The authors recommend that PTs should develop specific preventive
strategies and put more emphasis on the use of aids and equipment to reduce the risk of an unnecessary
injury.

Please cite this article as: Gyer G, Michael J, Inklebarger J. Occupational hand injuries: a current review of
the prevalence and proposed prevention strategies for physical therapists and similar healthcare profes-
sionals. J Integr Med. 2018; 16(2): 84–89.
Ó 2018 Shanghai Changhai Hospital. Published by Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
2. Prevalence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
3. Risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
3.1. Work-related activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
3.2. Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
3.3. Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
3.4. BMI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
3.5. Work settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
4. Consequences of injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
5. Prevention strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
5.1. Outsourcing strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
5.2. Workplace strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
5.3. Personal strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

⇑ Corresponding author.
E-mail address: info@osteon.co.uk (G. Gyer).

https://doi.org/10.1016/j.joim.2018.02.003
2095-4964/Ó 2018 Shanghai Changhai Hospital. Published by Elsevier B.V. All rights reserved.
 G. Gyer et al. / Journal of Integrative Medicine 16 (2018) 84–89 85

5.4. Reactive strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Competing interests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

1. Introduction industry education. These policies and programs provide health

care workers with standard procedures to move patients and cli-
Occupational injuries affect professionals from almost every ents in a way that does not cause strain or injury. However, since
industry. Workers in the healthcare and social-assistance sectors, the severity and extent of these injuries among PTs are not fully
however, are injured more often than any other group, with 5.2 explored yet, the best practice guidelines may not yet be sufficient.
cases per 100 full-time workers [1]. These injuries can severely Therefore, the aim of this paper is twofold. The first purpose is to
damage various body parts, including the hands, head, eyes, neck, review the literature relating to the prevalence, risk factors, and
shoulder, spine and feet. A full review of all the body parts affected consequences of hand injuries among PTs and similar healthcare
by occupational injuries is beyond the scope of this paper. The professionals. The second purpose is to describe preventive strate-
focus of this review is occupational hand injuries among healthcare gies that could be used by PTs to reduce the risks of developing
workers as a result of using professional manipulation and similar hand injuries.
techniques on patients.
Work-related hand injuries are the most frequent bodily trauma
that professionals from various industries sustain at work [2–4]. 2. Prevalence
These injuries can be disabling and have an enormous impact on
the overall quality of life, as they often lead to serious social and The prevalence of hand injuries among PTs and similar health-
economic consequences for not just workers but also their families care providers varies between studies (Table 1). In general, the
[5,6]. In prior studies, it has been reported that these injuries lead estimated lifetime prevalence of wrist and hand injuries is approx-
to work restriction, prolonged sick time, changing of work settings, imately 15%–46% [12,14–17], and the 12-month prevalence is
and even a career shift [7–10]. reported to be between 5% and 30% [12,14,18–22]. The differences
Hand injuries are common among healthcare workers involved from study to study, however, could be due to the considerable
in direct patient handling activities. In general, nursing assistants, variations in the designs and methodologies of these studies. The
physical therapists (PTs), and similar healthcare professionals are variations also exist in the way occupational hand injury is defined
more prone to these injuries [11,12]. According to the Bureau of in these papers. For example, some studies considered thumb
Labour Statistics [1], nursing professionals are at the highest risk injury as a part of hand injury, while others described them sepa-
of work-related nonfatal musculoskeletal injuries. On the other rately. Hence, some authors have found hand injury as the second
hand, PTs are at moderately high risk of nonfatal musculoskeletal most common work-related injury [7,9,16,18], whereas others
disorders, hand injuries being one of these significant health reported it as less frequent than low back, neck, shoulder, and
problems [2,7]. PTs and their assistants are at greater risk for these upper-back injuries [12,19,22,27].
injuries due to their physically demanding job duties and labour- The prevalence of hand injuries is high among chiropractors. A
intensive tasks. The practice involves prolonged constrained survey conducted by Holm and Rose [23] reported that wrist/hand/
postures, patient transfers and lifting, repetitive tasks, application finger injury was one of the three most serious injuries sustained
of high-velocity forces, and bending/twisting postures during by doctors of chiropractic in their overall career. In fact, the authors
certain manoeuvres [12,13]. found injuries to the hand, wrist, and fingers (42.9%) to have the
Existing studies on PTs have identified the job tasks that might highest prevalence, followed by shoulder (25.8%), and low back
lead to hand injuries. Some organisations are already addressing (24.6%). Similar findings were reported by two earlier studies on
this issue with institutional policies and programs as well as work-related injuries of chiropractors [28,29], although Homack

Table 1
Prevalence of hand injuries among PTs and similar professionals.

Study Population Subjects (n) Body part Prevalence (%) (profession, duration)
Holder et al. [7] PTs and PTAs 623 Wrist and hand 23.0 (PTs, 2-year); 15.0 (PTAs, 2-year)
Campo et al. [9] PTs 882 Wrist and hand 5.3 (1-year)
Glover et al. [12] PTs, PTAs, and PT students 2688 Thumb 23.0 (lifetime); 17.8 (1-year)
Wrist/hand 17.0 (lifetime); 12.5 (1-year)
West et al. [14] PTs 217 Hand 25.0 (lifetime); 14.0 (1-year)
Rugelj et al. [15] PTs 133 Wrist/hand 15.0 (lifetime)
Salik et al. [16] PTs 120 Wrist/hand 18.0 (lifetime)
Rozenfeld et al. [17] PTs 112 Wrist and thumb 46.2 (lifetime)
Bork et al. [18] PTs 928 Wrist/hand 29.6 (1-year)
Cromie et al. [19] PTs 536 Thumb 33.6 (1-year)
Wrist/hand 21.8 (1-year)
Adegoke et al. [20] PTs 126 Thumb 11.1 (1-year)
Wrist/hand 20.6 (1-year)
Darragh et al. [21] OTs and PTs 3297 Hand 21.0 (OTs, 1-year); 20.0 (PTs, 1-year)
Alrowayeh et al. [22] PTs 212 Wrist/hand 11.0 (1-year)
Holm et al. [23] Chiropractors 1000 Wrist/hand/finger 42.9 (lifetime)
Wajon et al. [24] PTs 155 Thumb 83.0 (1-year)
McMahon et al. [25] PTs 961 Thumb 65.0 (lifetime)
Jenkins et al. [26] PTs 395 Thumb 65.3 (lifetime)

PTs: physical therapists; PTAs: physical therapy assistants; OTs: occupational therapists.
86 G. Gyer et al. / Journal of Integrative Medicine 16 (2018) 84–89

[29] did not actually combine the wrist, hand, and finger percent- repetition of the same task as the most significant risk factor that
ages in his study. In a more recent study by Ndetan et al. [30], it contributed to their injuries. Cromie et al. [19] found that manual
was reported that hand/wrist injuries were the second most preva- techniques that frequently increased the risk for wrist and hand
lent musculoskeletal injuries among chiropractic students, pre- problems among PTs were joint mobilisation, soft tissue work,
ceded by neck/shoulder. and passive range of motion testing. Of the three techniques, how-
The thumb has special functions (e.g., opposition, retroposition, ever, soft tissue work was identified as the greatest risk factor for
palmar abduction, and radial abduction) and accounts for up to repetitive stress injuries. The odds of developing hand/wrist inju-
50% of overall hand use [31]. It is also the most frequently injured ries in PTs who routinely performed soft tissue techniques were
part of the hand, accounting more than half of all hand-related 13.61 times higher than those who did not perform these
injuries among PTs [14]. This is not surprising given that many techniques.
manual therapy techniques utilise this digit more often than other Significant job-related risk factors associated with thumb prob-
digits. In addition, studies on PTs that described thumb and hand lems include manual and manipulative techniques, trigger point
injuries separately reported higher incidence of injuries to the therapy, massage therapy, repetitive workload, treating many
thumb than wrist/hand. Cromie et al. [19] found that the annual patients per day, thumb hypermobility, and an inability to stabilise
prevalences of injuries to the thumb and wrist/hand were 33.6% the thumb joints while performing physiotherapy [14,19,25,33–
and 21.8%, respectively. In a later study, Glover et al. [12]. also 35]. In the literature, however, performing manual therapy
described similar findings. The authors reported that the lifetime techniques has been identified as a significant risk factor for the
prevalence of thumb injuries was 23.0% whereas the prevalence development of thumb injuries among PTs. In a study about Irish
of wrist/hand injuries was 17.0%. PTs, it was found that 56% of the participants developed thumb
The prevalence of thumb injuries in PTs and similar profession- pain as a result of manual orthopaedic work [33]. Similar findings
als varies widely from study to study (Table 1). Direct comparison were reported by Bork et al. [18], Cromie et al. [19], McMahon et al.
of the findings of these studies is extremely challenging. This is [25], Caragianis [34] and Regla and James [36]. All these studies
because of the variations in the study designs and methodologies suggested manual orthopaedic techniques, mobilisation/manipula-
and the differences in the definition of thumb injury. For example, tion, and massage as the leading risk factors for thumb problems.
Glover et al. [12] conducted their survey on a randomly selected Snodgrass et al. [35] reported that 100% of the participating PTs
sample, while the survey sampling of Rozenfeld et al. [17] was attributed their thumb injuries to manual techniques, particularly
non-random. In general, the lifetime prevalence of thumb injuries posterior to anterior spinal mobilisation and soft tissue massage. In
is around 23.0%–65.0%, [12,25,26] and the 1-year prevalence addition, Wajon and Ada [24] found that 83.0% of PTs who per-
ranges between 11.0% and 83.0% [12,17,19,20,24]. formed spinal manipulative therapy, unilateral and central pos-
teroanterior glides in particular, sustained a thumb problem.
Thumb hypermobility, weakness of the thumb flexors, exten-
3. Risk factors
sors or abductors, and instability at the thumb joints have been
reported as potential risk factors for thumb pain and discomfort
PTs and similar healthcare professionals perform a wide variety
among PTs. Snodgrass et al. [35] found that PTs in the thumb pain
of work-related activities, and many of these job tasks lead to occu-
group had increased mobility at the thumb carpometacarpal joint
pational hand injuries. Box 1 illustrates some of the potential job-
compared to those in the non-pain group. The authors also stated
related factors that contribute to the development of wrist/hand/
that the weakness of the thumb muscles, instability at the thumb
thumb injury. Other risk factors that are frequently described in
joints, and hand-position during application of manual techniques
the literature include age, gender, body mass index (BMI), and
are correlated with thumb problems in PTs. In a later study, similar
the type of clinical setting.
findings were reported by Australian physiotherapists [25]. Wajon
et al. [37] suggested that thumb alignment while performing pos-
teroanterior pressures has an association with job-related thumb
• Performing the same task repeatedly
pain. Wajon and their colleagues also reported that PTs who were
• Performing manual therapy techniques
less likely to report thumb pain were the ones able to keep their
• Treating a large number of patients per day
metacarpophalangeal and interphalangeal joints in extension. Fur-
• Not enough rest breaks during the day
• Intensive thumb use
thermore, in a recent study, it was found that massage therapists
• Continuing to work while injured or hurt
with thumb pain had a significantly decreased extensor and flexor
• Working in the same position for long periods
muscle strength than those without thumb pain and control sub-
• Working in awkward or cramped conditions
jects, respectively [38]. Taken together, these studies suggest that
• Lifting or transferring patients
there may be a correlation between thumb pain and application
• Working at or near physical limits
of manual techniques. However, such correlation may not indicate
• Reaching or working away from the body
a causal relationship. This is because the incidences of job-related
• Inadequate training to prevent injury
thumb pain mentioned above were often associated with a
decreased strength and stability of the thumb.

Box 1. Job risk factors contributing to wrist/hand/thumb injury.

3.2. Age
3.1. Work-related activities
The age of PTs may have an effect on the prevalence of hand
The risk factors that contribute to the development of wrist/ injuries. It has been reported in a number of studies that younger
hand injuries in PTs and similar professionals include a variety of PTs are more prone to wrist/hand/thumb problems than older
work activities (Box 1). Of these, performing manual therapy tech- PTs [12,14,16,19,22]. In an earlier study, Holder et al. [7] also
niques, treating a large number of patients per day, and frequent reported similar findings. The authors found that PTs and physical
repetition of the same techniques or task have been found to be therapy assistants (PTAs) of the 21–30-year age group had a high
the three most significant job-related risk factors [7,12–14,17–19, prevalence of work-related musculoskeletal problems. In contrast,
32]. Rozenfeld et al. [17] reported that 85% of PTs identified other studies have reported that they found no statistical
 G. Gyer et al. / Journal of Integrative Medicine 16 (2018) 84–89 87

correlation between age and increasing prevalence of wrist/hand/ a result of hand/wrist injury [12,16,34]. For example, West and
thumb pain [9,24,25]. Gardner [14] found that 91% of the hand-injured PTs changed their
techniques, 55% used splints, braces, or other orthoses, and 45%
3.3. Gender sought treatment by medical doctors. Caragianis [34] reported that
42.5% of the affected therapists altered their work hours or tech-
The effect of gender as a potential risk factor for wrist/hand/ niques due to injury, and nearly 66% undertook treatment. In rela-
thumb injuries of PTs has been controversial. While some studies tion to thumb pain/discomfort, Wajon and Ada [24] found that 74%
found a higher prevalence of wrist/hand injuries among female of the therapists modified their physiotherapy techniques to allevi-
PTs than their male colleagues [12,18,22,27], other studies did ate symptoms, 29% used splints or taping, and 25% decreased their
not find any significant differences between the prevalence of patient contact hours. In an earlier study, Regla and James [36] also
wrist/hand problems and the gender of PTs [16,17,21]. In PTs with reported similar findings. Furthermore, McMahon et al. [25] docu-
thumb problems, however, Glover et al. [12] reported that the mented that 19% of the respondents altered their work settings
prevalence of injuries was similar between male and female. In because of thumb injury.
contrast, two studies reported a significantly higher incidence of The number of PTs leaving the physiotherapy or similar profes-
thumb injuries among male PTs [19,25]. The authors of these stud- sions as a result of wrist/hand injury is extremely low. Cromie et al.
ies argued that this might be due to the fact that male PTs often [19] found that only 3.2% of PTs left the profession due to work-
performed more manual therapy techniques than female PTs. Nev- related musculoskeletal injury. This trend has been reflected in
ertheless, some studies also found no correlation between gender earlier and later studies. In a study of Australian PTs, it was
and thumb pain/discomfort [17,29,34,35]. reported that out of 117 respondents, only 3 left the profession
and 1 retired early because of health reasons [14]. Another study
noted that only 1% of the PTs took early retirement or left the pro-
3.4. BMI
fession because of an occupational injury [12]. Two more studies
also indicated similar findings. In one study, it was found that 4%
Because having a low BMI is disadvantageous for handling and
of the respondents made a career change due to thumb problems
treating large patients, it has been thought to be a contributing fac-
[25], and the other study reported that out of 882 PTs, only
tor for hand injuries of PTs. Snodgrass et al. [35] found that a low
1 (0.1%) physiotherapist with a wrist/hand problem left the profes-
BMI of PTs was associated with an increased prevalence of thumb
sion [9]. Except for these two papers, however, none of the above
injury. Two later studies have also reported similar findings
studies directly linked hand injuries with leaving the profession;
[17,22]. However, evidence to support this claim is still limited,
the estimations were primarily based on musculoskeletal injuries.
as no other study has so far reported BMI as a potential risk factor
Therefore, the actual consequence of wrist/hand problems in
for hand/wrist injuries among PTs.
relation to career change among PTs is still unknown.

3.5. Work settings

5. Prevention strategies
PTs and similar healthcare professionals practice in a wide
range of clinical settings, and the physical workloads differ A number of studies have suggested preventive strategies for
depending on the area of specialty [39]. Hence, the prevalence of PTs and similar health professionals to cope with the work-
hand/wrist problems among PTs varies across various work set- related wrist/hand/thumb injuries [7,13,16,17,21,34,40,41]. None
tings. In general, outpatient therapists are reported to be more of these papers, however, demonstrated a statistical association
prone to hand/wrist/thumb problems than those working in other between the strategies and injury prevalence.
settings. In a study of PTs and PTAs, it was found that 38% of PTs Based on the implications described in the literature
working in nursing homes and 32% of PTs in outpatient clinics sus- [16,17,19,40,42], we suggest that hand-injured PTs could adopt
tained a wrist/hand injury; in contrast, only 13% of PTs in hospitals the following four types of preventive strategies to avoid re-injury.
and 0% in home-based care had a similar problem [7]. It has also
been reported that PTs working in outpatient settings, especially 5.1. Outsourcing strategies
private practitioners, had a higher prevalence of wrist/thumb inju-
ries than others [9,12,16,19,25,36]. Another major area of specialty These strategies were first proposed by Cromie et al. [19]. The
that is often associated with hand/wrist problems is rehabilitation authors suggested that PTs could shift all or part of their physical
in the hospital or clinic setting [16,22]. workload to another person as self-protective behaviours. For
example, they can obtain help in lifting/transferring patients using
PTAs.
4. Consequences of injury

The most common consequence of hand/thumb injury among 5.2. Workplace strategies
PTs has been ‘‘modifying treatment techniques.” Studies reported
the percentages of technique changes to be about 42%–91% These strategies include minimal lift and/or no manual lift
[12,14,19,33,34]. Another major consequence of hand injuries in approach, ergonomic design of the work-station, use of aids and
PTs is ‘‘taking time off on sick leave.” However, the rates of sick equipment (e.g., mechanical lift devices, height-adjustable plinths
leave due to injury vary widely from study to study, and the or beds, thumb splints, and mobilisation wedges), frequent train-
responses range from 1.6% to 27.0% [7,9,12,14,22]. The variations ing or workshops on proper patient handling, and more rest breaks
in findings can be attributed to the methodological differences in the work schedule.
among studies, dissimilarities in study population, varying clinical
settings, and/or different geographic locations. 5.3. Personal strategies
In addition, many PTs stated that they chose to seek medical
treatment, minimise patient contact hours, increase use of These strategies include use of proper body mechanics, modify-
mechanical aids, modify work schedule, alter their specialty area, ing practice technique, performing warm-up exercises and muscle
change the type of patients treated, and take more rest breaks as relaxation techniques, strengthening thumb muscles, using the
88 G. Gyer et al. / Journal of Integrative Medicine 16 (2018) 84–89

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