Musculoskeletal system problems connected to occupational conditions are common among health care workers. The costs of these are substantial, both in terms of money and in terms of work time lost [1, 7, 9, 17, 18]. Research has shown that musculoskeletal problems are particularly common in health care workers who are in direct contact with patients [1, 7, 8, 17, 18]. Physiotherapists have a high prevalence of WRMDs [1, 7, 8, 15].
The results from studies on WRMDs in physiotherapists have generally been similar, though some have differed according to country. Such variations are linked to level of development, the status of the profession of physiotherapy in a given country, psychosocial, and epidemiological factors [2, 5, 8, 11, 13, 14]. In Turkey the law bars physiotherapists from providing primary care; each patient must be referred. Considering the differences in physiotherapy practice among countries and regions, we felt it would be valuable to investigate the prevalence and features of WRMDs in a group of Turkish physiotherapists working in various capacities, and to compare to findings in other countries.
In this study, we collected demographic and WRMD data from 120 physiotherapists in Izmir, Turkey, and analyzed rates of injury, risk factors, injury types and sites, and post-injury management. We asked to complete the self-administered questionnaire if they had more than 2 years of experience in practice. Thus, response rate of questionnaire was low (58.5 %) in our study. The survey answers revealed that 85% of the respondents had experienced WRMDs. Cromie  reported that younger physiotherapists have a higher prevalence of musculoskeletal problems related to occupational conditions. Rugelj  investigated low-back pain in physiotherapists, and found an incidence of 66% in subjects between the ages of 20 and 40 years . In line with this, a study of Australian physiotherapy students by Nyland  revealed that the 20- to 21-year age group had the highest frequency of low-back pain. The average age of the physiotherapists in our study was 30.4 years. This mean age corresponds with other findings in the literature, and confirms that physiotherapists tend to experience WRMDs at young age. Such injuries in younger physiotherapists may be associated with lack of professional experience, and the lower knowledge and skill levels people tend to have in the early years of this career.
Concerning sites of musculoskeletal injury during professional activities, the highest incidence is in the low-back region. Biomechanical studies have shown that physical loading factors, such as body flexion, rotation and weight loading, play a role in this . In a study that covered 25% of all physiotherapists working in Australia (824 total studied), Cromie  found that the rate of work-related low-back pain was 48%. Other authors have revealed various rates of this problem in physiotherapists: Bork  45%, Holder  62%, Molumphy  29%, Scholey and Hair  38%, Mierzejewski  49.2%, Rugelj  73.7%, and Nyland  69%. Our survey of Turkish physiotherapists revealed a 25.5% incidence of low-back pain. Interestingly, this figure is lower than most other rates reported in the literature. In our study, when we categorized physiotherapists according to practice setting, low-back pain was the most common WRMD in all subgroups.
Studies of WRMDs in health care of professionals have identified the lower back as the most commonly involved area of the body, followed by neck and upper extremities [3, 13, 19–21]. Investigations of physiotherapists have revealed similar results. Bork  and Holder and et al.  listed the regions most commonly involved musculoskeletal injuries as the lower back, hand-wrist, and neck, respectively among physiotherapists. On analyzing the different body parts injured in our subjects, we found the highest frequency of injuries in the lower back, followed by the hand-wrist (18.2%), shoulder (14.4%) and neck (11.8%).
According to the literature the work-related activities that most commonly lead to injury in health professionals are lifting heavy equipment and patients, transferring patient, maintaining the same posture for a long period, manual therapy practices, responding to patients' sudden movements, and repeated movements [1, 8, 17, 18, 22–24]. Bork  identified the main causes of WRMDs in physiotherapists as staying in the same position for along time and continuing to work when tired; Molumphy  emphasized lifting and leaning downwards with sudden maximal effort; and West  highlighted maintaining the same posture for along time, manual therapy, repeated movements, and increased work load. In our survey, the main causes of WRMDs were patient transfer, repeated movements, lifting heavy equipment, patients and working when too physically tired.
Holder et al.  identified three activities that aggravate the symptoms of former WRMDs in physiotherapists and assistant physiotherapists as staying in the same position for a long period, lifting and patient transfer. In our study, the respondents to our questionnaire noted lifting, staying in the same position for a long time, patient transfers, and repeated movements.
In Turkey, most physiotherapists work in general hospitals. In these facilities, the daily treated patient number is too high, and this number far exceeds the number of physiotherapists on staff. In addition, the majority of patients in these hospitals are seriously ill .
People who suffer injuries on the job may be treated with medication, rest and exercise. Physiotherapists have fundamental knowledge about ergonomics and biomechanics, and using this knowledge may vary depending on professional knowledge and skills. In Turkey, physiotherapists are trained in ergonomic working principles at the undergraduate level. However, in many working environments the equipment used (treatment table, chair, etc.) is not ergonomic, and consequently the physiotherapist cannot follow ergonomic principles while doing his or her job.
A study conducted by Cromie  in 2002 examined whether physiotherapists use their own knowledge to prevent WRMDs. The author found that this was true for most of the physiotherapists investigated. In our survey, of the physiotherapists who had suffered WRMDs, 27.6% said they used their professional knowledge and 26% said they used rest to manage the injury.
Previous research has shown that physiotherapists who have suffered a WRMD tend to change their professional attitudes to avoid additional injuries. Holder et al.  found that 79% of physiotherapists and 81% of assistant physiotherapists who had suffered injuries on the job changed their professional attitudes to avoid other WRMDs. It has been reported that the most common strategies used by physiotherapists to avoid WRMDs are correction of body mechanics, and frequent postural changes. The respondents to our questionnaire said that, after suffering a WRMD, they paid more attention to correcting body mechanics, avoided lifting heavy equipment or patients, changed position frequently, and got other personnel to help them with tasks that involved lifting.
Mierzejewski  reported that 13.7% of physiotherapists in Edmonton, gave up their career after suffering work-related low-back pain, and that 35.3% continued to work after this problem. Cromie  found that 17.7% of physiotherapists changed their field of practice in connection with WRMDs. Of the respondents in our Turkish survey who had suffered WRMDs, 67% did not change their field of practice after the injury, 82% did not restrict their time with patients, and 64% said they would not consider changing their field or department of practice due to their WRMD. This means that 33% did change field of practice after a WRMD, which is 1.9 times the rate of those who changed field in Cromie's study. As noted above, most physiotherapists in Turkey work in general hospitals, and it is not usually possible for such physiotherapists to change their field of work.
Some professions have very high WRMD prevalence, and this has led to more intensive research in recent years. These types of injury have major consequences for society, workers, employers, and the insurance sector due to loss of labor force, long-term disability and delay in returning to work, decreased productivity, and psychological effects on employees. Therefore, minimizing and preventing WRMDs has significant potential social and economic benefits. It is important to invest in studies aimed at reducing these types of injuries in physiotherapists.
Our study has three main limitations. A physiotherapist's working time in a day is not long, but he or she treats a very large number of patients during this time. Our survey would have been more informative if we collected data for the number of daily treated patients. We also did not inquire about the physiotherapists' activity levels. This would have been valuable information, as sports and recreational activity may affect WRMD frequency. Another limitation of our study was comparing various areas of practice and techniques used by physiotherapists and investigating their relationship to WRMDs.