Physical activity of physiotherapists in Germany: a cross-sectional study

Abstract

AimWe aimed to quantify the work-related physical activity of physiotherapists in Germany.Subjects and methodsWe included working physiotherapists aged between 18 and 65 years in Germany. We excluded physiotherapists working less than 20 h a week. We measured our primary outcome, work-related physical activity, by the average number of steps taken daily during work, standardized on an 8-h working day. We controlled the main outcome for potential confounders, such as working hours per week, age, weekday, and clinical setting (outpatient vs. inpatient), by multivariate linear regression analysis. We used R statistics for all statistical analyses.ResultsWe included 35 participants (7 outpatient and 28 inpatient), with a median age category of 20–29 years. Our participants had a mean work-related physical activity of 6614 steps (95% confidence interval, CI [6118; 7111]) per workday. Higher age, outpatient clinical setting, and working full time were associated with lower step count, but these associations were not statistically significant.Conclusions
The work-related physical activity of physiotherapists in Germany is comparable with results from other countries and can be regarded as ‘low’. Our result, however, might be affected by volunteer bias and gender effects. Further research should identify high-risk groups in the profession for cost-effective prevention.

Full text

ORIGINAL ARTICLE
Physical activity of physiotherapists in Germany: a cross-sectional
study
Bernhard Elsner
1,2
&Daniel Völker
1
&Mario Heinzmann
1
&Vera Rähmer
1
&Joachim Kugler
2
&Jan Mehrholz
2
Received: 16 January 2020 /Accepted: 8 March 2020
#The Author(s) 2020
Abstract
Aim We aimed to quantify the work-related physical activity of physiotherapists in Germany.
Subjects and methods We included working physiotherapists aged between 18 and 65 years in Germany. We excluded phys-
iotherapists working less than 20 h a week. We measured our primary outcome, work-related physical activity, by the average
number of steps taken daily during work, standardized on an 8-h working day. We controlled the main outcome for potential
confounders, such as working hours per week, age, weekday, and clinical setting (outpatient vs. inpatient), by multivariate linear
regression analysis. We used R statistics for all statistical analyses.
Results We included 35 participants (7 outpatient and 28 inpatient), with a median age category of 20–29 years. Our participants
had a mean work-related physical activity of 6614 steps (95% confidence interval, CI [6118; 7111]) per workday. Higher age,
outpatient clinical setting, and working full time were associated with lower step count, but these associations were not statis-
tically significant.
Conclusions The work-related physical activity of physiotherapists in Germany is comparable with results from other countries
and can be regarded as ‘low’. Our result, however, might be affected by volunteer bias and gender effects. Further research should
identify high-risk groups in the profession for cost-effective prevention.
Keywords Physiotherapy .Physical activity .Occupational health .Cross-sectional study
Introduction
Physical inactivity is one of the major risk factors for devel-
oping chronic, non-communicable diseases (Guthold et al.
2018; Martin et al. 2006). This risk factor can easily be
avoided by physical activity (Ekelund et al. 2016; Rütten
and Pfeifer 2016). In Germany, every second employee states
to work in the majority of the time in a sitting or standing
position (Finger et al. 2017). In the literature, work-related
physical activity is regarded as health promoting (Abu-Omar
and Rutten 2008; Samitz et al. 2011; Sofi et al. 2007), al-
though not to the same extent as leisure-time-related physical
activity (Sofi et al. 2007). Despite this, an overall increase of
work-related physical activity seems to be a suitable approach
in order to prevent non-communicable chronic diseases
(Goldgruber and Ahrens 2010; Wilke et al. 2012).
An essential approach for achieving higher amounts of
work-related physical activity is a workplace-related ap-
proach, which should consist of: (1) a concrete supply of pre-
ventive measures, (2) the redesign of work-related processes,
and (3) the creation of activity-promoting infrastructure at
work (Rütten and Pfeifer 2016).
The creation of activity-promoting infrastructure at work
can also be beneficial for medical personnel; for example, it
was shown that cardiologists only walked between 5000 and
6000 steps per working day (Abd et al. 2012), instead of the
recommended amount of 10,000 to 12,000 steps per day
(Rütten and Pfeifer 2016). In the German healthcare system,
there are approximately 197,000 physiotherapists
(Statistisches Bundesamt 2019). According to the World
Confederation of Physical Therapy (WCPT), physiotherapists
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s10389-020-01255-6) contains supplementary
material, which is available to authorized users.
*Bernhard Elsner
bernhard.elsner@tu-dresden.de
1
SRH University of Applied Health Sciences, Campus Gera,
Gera, Germany
2
Professorship of Public Health, Medical Faculty Carl Gustav Carus,
Dresden University of Technology, Fetscherstr. 74,
01307 Dresden, Germany
https://doi.org/10.1007/s10389-020-01255-6
/ Published online: 18 March 2020
Journal of Public Health: From Theory to Practice (2021) 29:1339–1342
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

explicitly cover the areas prevention and health promotion
and, amongst others, it is their core responsibility to motivate
people to participate in physical activity (WCPT 2017).
However, until now, it is unclear how active physiotherapists
in Germany are and if there is actually a need for primary
prevention in the physiotherapy profession.
The primary aim of our study was to quantify the work-
related physical activity in physiotherapists in Germany.
Materials and methods
This explorative study was a cross-sectional study and was
conducted in January 2018. It involved a convenience sample
among physiotherapists in Berlin and Gera. Inclusion criteria
were: (1) working clinically in an outpatient or inpatient set-
ting and (2) working more than 20 h per week. Exclusion
criteria was working less than 20 h per week.
Our primary outcome was the mean number of steps
walked per workday (continuous). We recorded the data on
five consecutive days with a pedometer (Omron Walking
Style IV, Omron, Kyoto, Japan), standardized on an 8-h work-
ing day. We choosepedometers because these are valid assess-
ments to estimate physical activity and the measurement on
five consecutive days is reliable (Kang et al. 2009a; Tudor-
Locke et al. 2002).
Our primary outcome, work-related physical activity, was
analyzed by a multivariate linear regression model, controlled
for working hours per week, age, weekday, and setting (out-
patient vs. inpatient) (Bolker et al. 2009). The predictive per-
formance of the model was estimated by cross validation (k=
2) and R
2
. In case of multicollinearity, the corresponding var-
iable was excluded from analysis (James et al. 2013). All
statistical analyses have been conducted with the software R
statistics (R Core Team 2012). The level of significance αwas
set to 0.05.
Results
Overall, 35 physiotherapists participated in the study. Their
characteristics can be found in Table 1.
Primary outcome
The mean number of steps walked during an 8-h working day
was 6614 (95% confidence interval, CI [6118; 7111]). A
boxplot of the distribution of the number of steps walked over
the age of the participants can be found in Fig. 1.
The number of steps walked during an 8-h working day
depending on the setting (outpatient vs. inpatient) can be
found in Fig. 2. The number of steps (mean (standard devia-
tion, SD)) walked in an outpatient setting was 6393 (2195)
and in an inpatient setting, it was 6670 (1242). There was no
statistically significant difference between the two settings
(mean difference, MD = 277 steps; t=−0.32044, p=0.76,
95% CI [−2316; 1763].
The number of steps walked per 8-h working day (mean
(SD)) varied slightly between weekdays: Monday 6157
(1697), Tuesday 5827 (1768), Wednesday 6570 (1971),
Thursday 6364 (1665), and for Friday 5801 (1771). A boxplot
over the distributions can be found in Fig. 3.
The analysis of the dependent variable (number of steps
walked during an 8-h working day) by multivariate linear
regression (n= 34) with the prediction variables age, working
time (hours per week), and professional setting (outpatient vs.
inpatient) yielded no statistically significant difference
(adjusted R
2
in the test data = 0.09; Table 2). The independent
variable weekday was removed from the model due to
multicollinearity.
Table 1 Characteristics
of the participants No. (%)
Age (years)
17–19 1 (3)
20–29 20 (57)
30–39 9 (26)
40–49 4 (11)
50–59 1 (3)
60–67 0
Setting
Outpatient 7 (20)
Inpatient 28 (80)
Working time
Full-time (40 h/week) 29 (83)
Part-time (<40 h/week) 6 (17)
17−20 20−29 30−39 40−49 50−59
5000 7000 9000
Boxplot of steps walked by age
A
g
e cate
g
ory in years
Number of steps during an 8−hour working day
Fig. 1 Number of steps walked during a standardized 8-h working day by
age category (n=35)
1340 J Public Health (Berl.): From Theory to Practice (2021) 29:1339–1342
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Discussion
Our results suggest that physiotherapists in Germany walk
about (mean (SD)) 6500 (1600) steps on a representative 8-h
working day. Although the differences were not statistically
significant, the number of steps walked seems to be decreased
with higher age and increased in physiotherapists working in
an inpatient clinic compared to an outpatient setting.
The results of this study are in line with Abd et al. (2012), who
showed that cardiologists and cardiac surgeons achieved a sim-
ilar level of physical activity of 5000 to 6000 steps per day (Abd
et al. 2012). According to the pedometer index of Tudor-Locke
and Bassett (2004), the work-related physical activity of physio-
therapists in Germany should be classified as ‘low active’
(Tudor-Locke and Bassett 2004). In a multicenter cross-
sectional survey, which measured work-related physical activity
among American physiotherapists by accelerometers, there were
similar results in this regard (Brewer et al. 2016). However, the
recommended optimum of physical activity by guidelines was
not achieved: the mean (SD) number of steps walked during
work in an outpatient setting was 3195 (1333) steps and in inpa-
tient setting, it was 4475 (1465) (Brewer et al. 2016). Our results
showed that physiotherapists in Germany walk more steps during
work than their colleagues in the United States and that working
in an inpatient setting was associated with a higher level of phys-
ical activity. The latter could be explained by different work
organization procedures in inpatient settings (e.g., working on a
single hospital ward vs. working among different wards), which
could have resulted in longer distances to be walked in order to
see a patient. There are also indications that longer working time
was associated with a lower step count. This could be explained
by a possibly higher compression of work in the schedule of part-
time workers, thus resulting in a higher relative physical activity.
The results show that physiotherapists in Germany are suit-
able candidates for individualized health promotion programs by
promoting physical activity (Ziesche and Köppel 2017), which
should: (1) be implemented after assessing the employees’de-
mands, (2) be close to the workplace, (3) have a responsible key
person, and (4) have a marketing platform (Wollesen et al. 2017).
A limitation of this cross-sectional study is that volunteer
bias may have occurred and rather physically active therapists
voluntarily participated in the study, which may overestimate
the real amount of work-related physical activity in physio-
therapists in Germany. Essential covariates like the age of the
participants, clinical setting, and weekday have been con-
trolled and taken into account in the analysis. It should also
be taken into account that only the surveillance of physical
activity with pedometers can raise the physical activity by up
to 2000 steps per day, which may also result in an overestima-
tion of physical activity (Kang et al. 2009b).
One could also argue that the analysis did not control for
gender effects. In the published literature, it was shown that
women in general have a lower mean work-related physical
activity than men (Finger et al. 2017). Since this might rather
be a self-selection effect between different professions, we
discarded this analysis.
Another limitation is the small sample size of this study, so
future studies should recruit more participants, control for
gender-specific effects, and include other professional settings
Table 2 Analysis of the predictors age, clinical setting, and working
time on the primary outcome, work-related physical activity (numbers of
steps walked during an 8-h working day). Multivariate linear model with
cross-validation applied on the test data (n=34).Adjusted R
2
= 0.09
βcoefficient Standard error t-Value p-Value
(Intercept) 9926.6 1775 5.592 <0.0001
Age −120.06 521.23 −0.230 0.82
Setting 107.28 783.89 0.137 0.89
Working time −81.82 40.11 −2.040 0.06
Outpatient Inpatient
5000 7000 9000
Boxplot of steps walked by clinical setting
Clinical settin
g
Number of steps during an 8−hour working day
Fig. 2 Number of steps walked during a standardized 8-h working day by
clinical setting (n=35)
Mon Tue Wed Thur Fri
2000 4000 6000 8000
Boxplot of steps walked by weekday
Weekday
Number of steps during an 8−hour working day
Fig. 3 Number of steps walked during a standardized 8-h working day by
weekday (n=35)
1341J Public Health (Berl.): From Theory to Practice (2021) 29:1339–1342
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of physiotherapists (like working in schools/universities), as
well as physiotherapists working over weekends.
Conclusion
The work-related physical activity of physiotherapists in
Germany can be regarded as ‘low active’and is comparable
to those of physiotherapists and other medical professions in
other industrialized countries.
Contributions of authors Conceptualization: Author 2, Author 3, Author
4, Author 1; Methodology: Author 1; Formal analysis and investigation:
Author 1; Writing - original draft preparation: Author 1; Writing - review
and editing: Author 6, Author 5; Funding acquisition: Author 1, Author 2,
Author 3, Author 4; Supervision: Author 5, Author 6.
Funding Information Open Access funding provided by Projekt DEAL. We
would like to thank the Anschubfinanzierung of the SRH University of
Applied Health Sciences for supporting the acquisition of the pedometers.
Compliance with ethical standards
Informed consent was obtained from all individual participants included in
the study. The approval of the local ethics committee was given (1422-0515).
All testing was ethically harmless and the measures used are internationally
certified and are standard outcome measures for physical activity. The eval-
uation was carried out in accordance with the 2013 Helsinki Declaration.
Conflict of interest The authors declare that they have no conflict of interest.
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