Physical therapists' recognition of battered women in clinical settings.

Key Words: BAttering, Domestic violence, Physical therapy, Public health.

"Domestic violence," "battering," and "spousal abuse" are all terms referring to the victimization of a person by an intimate partner.[1,2] The National Crime Survey Project in 1980 estimated that the annual medical cost from domestic violence was approximately $44 million, not including the indirect costs of 175,000 days of missed work.[3] These estimates do not address the pain, despair, hopelessness, and self:blame that often result from abusive relationships.

Violence from a spouse or intimate partner is the leading cause of injury to women in the United States.[4] In a 1981 national survey of 2,143 married couples,26% of the couples reported at least one incident of abuse in the previous year.[5] A Harris poll of 1,793 women in Kentucky reported that 21% of married women and two thirds of separated or divorced women had been battered at least once.[6] Similar studies in Pennsylvania and Texas in 1983 reported incidences of 26% and 29%, respectively.[7,8] Domestic violence is not limited to married women. Walker,[9] in 1984, estimated that 50% of all women have been battered at some time by an intimate partner.

Men are not immune1e to domestic violence injuries.[10] Campbell and Humphreys[11] reported that approximately 2% to 5% of patients with injuries resulting from domestic violence are men. Because men are usually physically stronger than women, however, the injuries inflicted against women are frequently much more severe.[12]

Pregnant women are susceptible to being battered as well. The risk for abuse is higher for women during young adulthood, which coincides with their most active childbearing years.[13] McFarlane et al[14] report that 1 out of 6 (17%) of the 691 pregnant women they interviewed reported being subjected to violence during the current pregnancy. In studies of battered women, 42%[15,16] to 56%[17] reported being injured during pregnancy. Of 481 women who were admitted to an emergency department, battered women were three times more likely to be pregnant at the time of injury than women who were injured accidentally.[18]

Domestic violence has become a public health issue as well as a criminal justice matter.[19] In 1986, the Surgeon General recommended that identification of patients who are battered and knowledge of appropriate intervention strategies should be included in the training of all health care professionals.[19] Despite these recommendations, health care practitioners seldom recognize injuries resulting from domestic violence or inquire about domestic violence. Studies of emergency departments have shown that between 20% and 30% of women are admitted because of battering injuries.[1,20,21] Goldberg and Tomlanovich[10] found that 22% of male and female patients admitted to an emergency department identified themselves as battered in a self-administered questionnaire. Domestic violence, however, was documented in only 5% of the emergency department records.[10]) In a family practice residency training clinic, 22.7% of the women who completed questionnaires stated they were assaulted by their partners in the previous year. Only 6 out of the 394 participants recalled their physicians inquiring about physical abuse in their previous office visit.[20]

In other health care disciplines, education programs have been shown to increase detection of battered women.[22,23] In a retrospective study of female patients treated for trauma in an emergency department, a protocol designed to identify injuries from battering increased recognition of these women from 5.6% to 30%. Initially, each woman was asked how she had been injured. If the woman indicated she had been hit by someone or if she gave vague, evasive answers, the triage nurse asked a set of questions designed to help reveal the history of battering. In an 8-year follow-up study in the same emergency department, the identification rate dropped to 7.7%. The discontinuation of this protocol and the failure to monitor the staff's efficiency appeared to have contributed to this decline. As this example indicates, increased health care provider awareness can directly influence the detection of patients who are abused.[22]

Studies of whether physical therapists can recognize battered women have not been reported in our literature. Physical therapists play a critical role in prevention, treatment, and rehabilitation in health care. Consequently, our responsibility for addressing domestic violence could be critical for several reasons. We believe it is our profession's responsibility to identify battered women in cooperation with all health care professionals. According to Stark et al,[1] the majority of battered patients' medical visits involve nontrauma complaints at nonemergency sites. Thus, because many physical therapists treat patients in a nonemergency state, we are in an optimal position to recognize injuries resulting from battery. Even if a woman is receiving physical therapy for injuries not related to battering, physical therapists may have the professional responsibility to inquire, document, and refer the woman to the appropriate resources and counseling.

The purpose of our study was to answer the following questions in a cross-sectional survey:

1. Do physical therapists recognize battered women in outpatient clinical settings?

2. What is physical therapists, level of knowledge regarding domestic violence?

3. Do physical therapists believe there is a need for domestic violence education in the physical therapy profession?

For this study, we defined domestic violence as a one nonaccidental physically violent act inflicted by a female patient's spouse, partner, or ex-partner.

Method

Sample and Procedure

Twenty-five physical therapy facilities were contacted by telephone to determine whether they were willing to participate in the study. The 25 sites were selected from a list of northern California clinical affiliation sites for Samuel Merritt College and a Santa Clara County telephone directory. These facilities comprised 5 health maintenance organization (HMO) outpatient facilities and 20 private practices. Two hundred questionnaires were mailed or delivered to a convenient sample of physical therapists in January 1994. The size of the sample was selected predominantly due to budget constraints. A cover letter explained the purpose of the study and stated that all responses would be confidential. Physical therapists were asked to mail the completed questionnaire to the researchers in an accompanying self-addressed, stamped envelope within 1 week. There were no follow-up reminders for unreturned questionnaires.

Instrument

We developed a 13-item questionnaire based on an extensive literature review. The instrument was divided into three sections: physical therapists, demographic information, physical therapists, knowledge of battering symptoms, and whether therapists have recognized battered patients in the past. Demographic information included years of experience in physical therapy, gender, education, and sources of information related to domestic violence detection. We believe that this original survey instrument sampled adequate content based on our expertise. The second author (LSMcK) is a clinical specialist in adult mental health who specializes in the counseling of battered women and who also was a member of Surgeon General C Everett Koop's task force on violence and public health.[19] Feedback from a pilot study involving nine outpatient physical therapists at a large HMO helped refine the wording in the questionnaire.

Data Analysis

Data were coded and analyzed using descriptive statistics. Frequency distributions were examined for all responses in the questionnaire. The response rate for each question was computed in order to include partially completed questionnaires in the data analysis. Means also were computed.

Results

One hundred fifty-one physical therapists (76%) of those surveyed returned the questionnaire. Years of physical therapy experience ranged from 0.3 to 24 years, with an average of 11 years (SD=7.1) (n= 150). Of the 151 respondents, 121 (80%) were female and 30 (20%) were male. Academic degrees in physical therapy ranged from certificate to master's degrees.

Of 150 respondents, 43% had treated a female patient who they strongly suspected or confirmed was physically battered. The majority of these respondents (71%) had treated between one and five battered patients in the 12-month period preceding completion of the questionnaire.

Table 1 lists therapists, responses when they confirmed or suspected that a patient was battered. The most frequent response was to give the patient information regarding shelters or counseling (52%). One respondent alerted the police.

Table 1.
Therapists' Responses After They Identified a Patient Who Battered
(N=65)
                                          No. of
Therapists, Responses                     Responses    Percentage
Gave the woman information                34           52
regarding shelters or counseling
resources
Other                                     26           40
Told a supervisor or coordinator          21           32
Contacted her physician                   15           23
Documented/photographed her               13           20
injuries
Contacted social services                 11           17
Nothing, physical therapist did not        3            5
know what to do
Nothing, physical therapist felt it was    2            3
a private matter
Alerted the police                         1            2

Table 2 describes respondents, sources of information regarding identification, symptoms, and intervention for battered women. Only 8% of the respondents received information regarding domestic violence in physical therapy school. Books or magazines and television or movies were the two most commonly checked sources of information.

Table 2.
Respondents, Sources of Information Regarding Domestic Violence
Identification, Intervention, and Symptoms (N = 150)
                                          No. of
Source of Information                     Responses    Percentage
Books/magazines                           114          76
Television/movies                         107          71
Personal experience (patients, family,     61          41
friends, respondent)
Health industry literature                 46          31
Other                                      19          13
In-service training                        13           9
Physical therapy school                    12           8
Physical therapist had not received any     9           6
information
Continuing education                        6           4

Less than half of the respondents (42%) correctly identified the head, neck, chest, and abdomen as the most common locations of injuries resulting from domestic violence (Tab. 3).

Table 3.
From Battering (N = 145)
Responses Regarding Where Therapists Expect to See Evidence of
Trauma
Question: If you were treating a
female patient you suspected
was physically battered by her
partner, where would you
expect to see evidence of                 No. of
trauma?                                   Responses     Percentage
Centrally: head, neck, chest,             61            42
abdomen[sup.a]
There is no pattern                       55            38
I do not know                             23            16
Peripherally: hands, forearms, feet,       6             4
calves
[sup.a]"Centrally" is the correct answer

When asked about identification of psychological reactions resulting from battering, 39% of the respondents identified all responses (Tab. 4). Respondents identified depression most frequently as a psychological symptom resulting from battering (83%).

Table 4.
Identification of Psychological Symptoms Resulting From Battering
(N = 151)

Question: What observations or
subjective complaints might
cause you to suspect the female           No. of
patient was battered?                     Responses     Percentage
Depression                                125           83
Jumpiness                                 119           79
Multiple vague complaints                 116           77
Insomnia                                   89           59
Headaches                                  83           55
Substance abuse                            83           55
Identified all responses[sup.a]            59           39
None                                        7            5

[sup.a]Correct answer. All of the response can be psychological
symptoms resulting from battering.

Although 74% of the respondents stated that pregnant and nonpregnant women were at equal risk for battering, 20% of the respondents identified pregnant women as being at greatest risk.

Five percent of the respondents routinely inqnired about patients, relationships with spouses or partners. Only 1% of the respondents routinely asked patients whether they were battered. The majority of the therapists (58%) never asked patients whether they were physically battered. Thirty-six percent of the respondents asked patients whether they were battered only when abuse was strongly suspected.

Eighty-six percent of the respondents (n=146) stated they would benefit from more instruction regarding domestic violence identification and intervention.

Discussion

This survey indicates that many physical therapists have recognized women who they strongly suspected or confirmed were battered. Physical therapists, rate of detection of battered patients in 1993 was very low. Thus, our results suggest that physical therapists rarely suspect abuse in their patients. Low suspicion of abuse has been found in many other health care disciplines.[10,13-22-25] Injuries resulting from domestic violence often are concealed by the victim, and if health care professionals fail to suspect abuse, the problem remains undetected.[24]

Low suspicion abuse may be related to physical therapists, lack of inquiry regarding domestic violence. These results were consistent with the findings of Hamberger et al,[20] who documented a very low incidence of physicians in family practice clinics asking about domestic violence. Institutional protocols designed to encourage staff to ask every patient whether she was battered have been shown to increase identification of these patients.[22,23] Because abuse can occur in recurring episodes rather than as isolated incidents, there is a need for therapists to constantly assess for battering.[19] Through early detection of domestic violence in health care, perhaps physical therapists can help decrease the length of time women wait before seeking help.

After identifying patients who therapists suspected or confirmed were battered, the therapists used different strategies. Twenty percent of the respondents who identified battered patients documented or photographed the patients' injuries. This step is important1t if medical records are subpoenaed for divorce or child-custody litigation. Fifty-two percent of the therapists gave the patients information regarding shelters or counseling. Counselors who are knowledgeable about the psychological and maladaptive effects of chronic battering can evaluate the woman's immediate safety, help her make decisions regarding her relationship, give legal advice, and develop a follow-up plan.[26]

Only one respondent had reported abuse to the police. California law requires that any health care practitioner employed in a health facility, clinic, or physician's office must immediately make a phone report to the law-enforcement agency when partner abuse is suspected or confirmed.[27] The American Journal of Public Health reports that "[a]t least one other state (Kentucky) requires the reporting of adult domestic violence, and several other states have laws mandating that health care providers report injuries resulting from criminal acts including assaults."[28(p460)] The low rate of reporting domestic violence to authorities in our study could be due to existing documentation of the abuse, the therapists, lack of knowledge of the California law, or the therapists, belief that reporting the violence would be countertherapeutic or ineffective.[24]

The results of this survey indicate that very few (8%) of the physical therapists surveyed had received instruction about domestic violence during physical therapy school. This percentage is substantially lower than what has been reported by other health care professionals. In a survey of 1,516 professionals, including dental hygienists, dentists, physicians, nurses, psychologists, and social workers, 40% of the respondents recalled receiving some educational instruction in spouse abuse during their professional training programs.[24] Physical therapy professional education may be far from achieving the Surgeon General's recommendation that all relevant professional schools include education about domestic violence by the year 2000.[19] In addition, physical therapists in our survey felt that they would benefit from additional instruction in domestic violence identification and intervention.

Possibly due to this lack of education about domestic violence in physical therapy schools, the respondents were more likely to rely on informal sources of information such as books, magazines, television, movies, and personal experience for information about battering. Their reliance on these sources of information may have contributed to the finding that few of the therapists identified that physical injuries caused by battering are more likely to occur in a central pattern (ie, head, neck, chest, abdomen). Injuries to these areas are easily hidden by clothing or the woman's hair, and without formal identification strategies, therapists are likely to fail to identify battered patients.[29] Few therapists were able to identify depression, multiple vague complaints, headaches, insomnia, jumpiness, and substance abuse as psychological symptoms of battering. Many times these psychological symptoms emerge after the first incident of abuse.[30]

The majority of the physical therapists surveyed reported that pregnant and nonpregnant women are at equal risk for battering. Past research has indicated that pregnant women are at approximately the same risk for being battered as nonpregnant women.[13:31] Women who are already involved in an abusive relationship, however, may be at risk for more frequent and more severe battering during pregnancy.[15, 18] Thus, physical therapists should assess pregnant patients as well as nonpregnant patients for battering. Physical therapists ale having an increased role in obstetrics-gynecology in health care and should be aware of the possibility of abuse in this patient population.

Several limitations should be noted when interpreting the results of this research. The pilot questionnaire was developed specifically for our study and has no established reliability or validity. Because the survey instrument was very brief, results cannot be interpreted as a test of therapists, complete knowledge of domestic violence. The instrument was developed with the assistance of one expert in domestic violence and may not be all-inclusive. Also, the physical pattern of injuries from battering was determined through research in emergency departments. Future research studying the incidence and types of injuries of battered women and men seeking physical therapy would strengthen the content validity of our knowledge questions. The therapists were asked to retrospectively recall information regarding past patients. This study was conducted in one geographic area and may not represent regional variations in physical therapy practices. Future studies with a random national sampling technique would help generalization of the results. Finally, we were unable to use inferential statistics because of the small sample of physical therapists. Future studies relating the demographic information (eg, gender, years of experience, academic degrees) to the types of the responses on the questionnaire would help strengthen interpretations of the data. Domestic violence research also should include male as well as female patients.

Despite these limitations, we hope this survey will promote future physical therapy research in domestic violence. Other research topics dealing with domestic violence could include the development and efficacy of physical therapy domestic violence detection protocols and educational programs. Additional research surveying physical therapy schools would help determine whether education about domestic violence is being included in physical therapy curricula in response to the Surgeon General's recommendations.

Conclusion

The results of this survey indicate that many physical therapists have treated battered patients at some time in their careers. The number of battered patients recognized in the past 12 months, however, was very low. Low detection of battered patients could be due to physical therapists, lack of domestic violence education in physical therapy schools, reluctance to ask patients whether they were abused, or beliefs that domestic violence is an uncommon occurrence in their patients, lives. We hope this report will prompt future physical therapy research in domestic violence and improve the quality of care of battered patients.

Acknowledgments

We thank the woman who inspired this study. We also thank our many friends and family who provided feedback and encouragement.

TJ Clark, PT, was a student in the Master of Physical Therapy Program, Samuel Merritt College, 370 Hawthorne Ave, Oakland, CA 94609, when this conducted in partial fulfillment of the requirements for her master's degree. Address correspondence to Ms Clark at 156 Marvin Ave. Los Altos, CA 94022 (USA).

L Smith McKenna, DNSc, is Assistant Professor of Nursing, Samuel Merritt College, and Clinical Nurse Specialist, Adult Mental Health, in private practice in Lafayette, CA 94549.

MJ Jewell, PhD, PT, is Associate Professor and Chairperson, Department of Physical Therapy, Samuel Merritt College.

This study was approved by the Summit Medical Center Review Board.

This article was submitted September 23, 1994, and was accepted August 21, 1995.

References

[1] Stark K, Flitcraft A, Zuckerman D, et al. Wife Abuse in the Medical Setting: An Introduction for Health Personnel. Rockville, Md: National Clearinghouse on Domestic Violence (Children, Youth, and Families Administration); 1981. Monograph No. 7. [2] Rosenberg ML, Stark E, Zahn MA. Interperson violence: homicide and spouse abuse. In: Last JM, ed. Maxcy-Rosenau Public Health and Preventive Medicine. 12th ed. East Norwalk, Conn: Appleton-Century-Crofts; 1986: 1399-1426. [3] National Crime Surveys: National Sample, 1973-1979. Ann Arbor, Mich: Inter-University Consortium for Political and Social Research; 1981. [4] Centers for Disease Control and Prevention. Family and other intimate assaults. MMWR 1990;39:525-529. [5] Straus MA, Gelles RJ. Behind Closed Doors: Violence in the American Family. New York, NY: Anchor Books; 1981. [6] Schulman MA. Survey of Spousal Violence Against Women in Kentucky: Harris Study No. 792701. Washington, DC: Lewis Harris Associates; 1979. [7] Szinovacz ME. Using couple data as a methodological tool: the case of marital violence. Journal of Marriage and the Family. 1983;45:633-644. [8] Teske RHC, Parker JC. Spouse Abuse in Texas: A Study of Women's Attitudes and Experiences. Huntsville, Tex: Criminal Justice Center, Sam Houston State University; 1983. [9] Walker LE. The Battered Woman. New York, NY: Praeger Publishers; 1984. [10] Goldberg WG, Tomlanovich MC. Domestic violence victims in the emergency department: new findings. JAMA. 1984;251:3259-3264. [11] Campbell JC, Humphreys JC. Nursing Care of Victims of Family Violence. East Norwalk, Conn: Appleton-Lange; 1984. [12] Family Violence: A Workshop Manual for Clergy and Other Service Providers. Rockville, Md: National Clearinghouse on Domestic Violence (Children, Youth, and Families Administration); 1981. Monograph No. 2. [13] Gelles RJ. Violence and pregnancy: Are pregnant women at greater risk of abuse? Journal of Marriage and the Family. 1988;50:841-847. [14] McFarlane JM, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy: severity and frequency of injuries and associated entry into prenatal care. JAMA. 1992;267:3176-3178. [15] Stacey W, Schupe A. The Family Secret. Boston, Mass: Boston Press; 1983. [16] Fagen J, Stewart D, Hanson K. Violent men or violent husbands. In: Finklehor D, Gelles R, Hotaling G, Straus M, eds. The Dark Side of Families. Beverly Hills, Calif: Sage Publishing; 1983:49-67. [17] Bowker LH. Beating Wife Beating. Lexington, Mass: Lexington Books; 1983. [18] Stark E, Flitcraft A, Frazier W. Medicine and patriarchal violence: the social construction of a "private" event. Int J Health Serv. 1979;9:461-493. [19] Surgeon General's Workshop on Violence and Public Health Report. Washington, DC: US Department of Health and Human Services; 1986. [20] Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med. 1992;24:283-287. [21] Bowker LH, Maurer L. The medical treatment of battered wives. Women Health. 1987;12:25-43. [22] McLeer SV, Anwar RAH, Herman S, Maquiling K. Education is not enough: a systems failure in protecting battered women. Ann Emerg Mfd. 1989;18:651-653. [23] Tilden VP, Shepherd P. Increasing the rate of identification of battered women in an emergency department: use of a nursing protocol. Res Nur Heallh. 1987;10:209-215. [24] Tilden VP, Schmidt TA, Limandri Bl, et al. Factors that influence clinicians' assessment and management of family violence. Am J Public Health. 1994;84:628-633. [25] Appleton W. The battered woman syndrome. Ann Emerg Med. 1980;9: 84-91. [26] McLeer SV, Anwar RAH. The role of the emergency physician in the prevention of domestic violence. Ann Emerg Med. 1987; 16: 1155-1161. [27] Cal Ch 992 (AB 1652). Spousal and Domestic Violence Reporting Laws. 1993. [28] 9211 (PP): domestic violence. AmJ Public Health. 1993;83:458- 463. [29] Sheridan D, Belknap L, Engel B, et al. Guidelines for the Treatment of Battered Women Victims in Emergency Room .Settings. Chicago, 111: Chicago Hospitals Council; 1985. [30] Hammers M. Domestic violence facing the epidemic. Nurseweek. 1993;61: 6-8. [31] Helton AS, McFarlane J, Anderson ET. Battered and pregnant: a prevalence study. Am J Public Health. 1987:77:1337-1339.

Invited Commentary

The authors of this article are to be commended for undertaking a project that is relevatn not only to the treatment of individual women but also to health care policy and the education of physical therapists. The epidemiological statistics on battery are alarming. Battery is the most common cause of injury to women. Three to four million women per year are battered by their partners.[1] Approximately one third of emergency department visits by women are due to battery.[2] Thirty-five percent of long-term disability in women is attributed to battery (Joanne Tolin, Director, Maryland Alliance Against Domestic Violence; personal communication; October 11, 1995). Pregnant women may be even more vulnerable. Estimates of women who are battered while pregnant range from 25% to 45%, and abuse is a leading cause of infant mortality.[2] Given these statistics, the likelihood that therapists are treating women for injuries sustained by battery is great. As this study indicates, however, few therapists are aware of the injury pattern that may indicate battery, and few have had training or education in this area. Fewer still routinely question female patients about abuse or battery as a possible etiology to their injuries. These findings clearly indicate that physical therapists lack knowledge about this issue.

Although the findings suggest a general lack of information about the issue of domestic violence toward women, two findings are particularly alarming and need to be addressed.

A Lack of Suspicion

First, the therapists in this study rarely suspected abuse in their patients. As indicated by the authors, this finding is consistent with other disciplines prior to the initiation of educational programs and use of protocols that require questioning patients about abuse. Therapists must become aware of the clinical signs that may indicate abuse. Indicates that typically would be seen in physical therapy include central pattern of trauma (head, neck, chest, abdomen), a change in appointment pattern, vague or nonspecific complaints, depression, and migraine headaches. Therapists also must become sensitive to the deterrents to identification. Tilden[3] discusses deterrents that stem from factors related to the victim and the health care professionals. Women who are battered often demonstrate hostage behavior, depression, embarrassment, and fear of reprisals. In addition, because of lack of options (eg, housing, child care, financial dependency), women often remain in abusive relationships.

In addition to a lack of knowledge about violence, health care professionals often feel discouraged by their unsuccessful attempts to help a woman who seems to reject this assistance by staying in an abusive relationship. Therapists also may feel reluctant to offer assistance becuase of the complex nature of battery, believing that it is social or a legal problem rather than a health care problem. Our role as therapists is limited; however, in providing direct services to women who are battered, we are responsible for attempting to identify causes of an injury and in turn helping the women, our patients, gain access to necessary services.

Many health care professionals, men more so than women, also believe many of the myths associated with battery. Some may assume that "women like it" or that comestic violence is an accepted part of a particular culture. Others may assume that "she asked for it" or that the victim provokes the abuse, placing blame on the victim ("rational cause").[3]

Identifying women who are battered requires training in all factors related to battering. Training must focus ont only on the physical signs and symptoms that may indicate an injury is related to battering but also on sensitivity training to explore and change attitudes related to women who are battered. In addition, the theoretical frameworks that are used to explain the origins of domestic violence should be explored. These frameworks guide how the health care professional views his or her role in the identification and care of women who are abused.[2]

Noel and Yam[2] described three frameworks: medical, sociological, and feminist. The medical framework focuses on the injuries, and treatment is prescribed relative to the injuries seen. External factors such as stress, employment status, and poor conflict-management skills are the focus in the sociological framework. Power inequity is central to the cause of violence toward women according to the feminist framework.[4] The feminist framework emphasizes providing support to the women and diminishing the blame, and explores social factors that promote an environment of abuse and male dominance. Additional perspectives that may influence how health care professionals view their role include family systems theory and ecological theory.

Learning From the Lay Media

The second disturbing finding of the study by Clark et al is that most of the therapists received information about domestic violence from the lay media. The education of a health care professional should not be left up to the lay media. In 1985, the Surgeon General recommended that all health care professions should include a component on domestic violence in their education programs by the year 2000.[5] This recommendation was reiterated in 1990 in Healthy People 2000: National Health Promotion and Disease Prevention Objectives.[6] Over the last 10 years, many professional organizations, including the American Medical Association,[7] the American Nurses Association,[8] the American College of Obstetricians and Gynecologists,[7] and the Centers for Disease Control and Prevention,[9] have produced position statements against physical violence, specifically against women. In addition, many professional organizations and advocacy groups have produced training programs that are incorporated into professional education programs, in-service training, and continuing education (Joanne Tolin; personal communication; October 11, 1995). It is time for physical therapists to design appropriate guidelines and protocols specifically for therapists. Professional preparation programs must include specific training in the identification of physical abuse in women and how to discuss the issue in a therapeutic manner with the women.

Once again, I commend the authors of this article for providing the profession with the information needed to initiate awareness, education, and training programs on domestic violence, specifically the battering of women. Therapists, lack of knowledge as shown by this study, coupled with the incidence of injury due to battery, should impel us all to action.

Toby Long, PhD, P7, Assistant Professor Department of Physical Therapy University of Maryland Baltimore, MD 21201

References

[1] Wilson JS. Guidelines for the care of abused women: the least we can do. Home Healthcare Nurse. 1994;12:47-53. [2] Noel NL, Yam M. Domestic violence: the pregnant battered woman. Women 's Health. 1992;27:871-884. [3] Tilden VP. Response of the health care delivery system to battered women Issues in Mental Health Nursing 1989;10:309-320. [4] Kurz D. Social science perspectives on wife abuse: current debates and future directions. Gender. Soc. 1989;3:489-503. [5] Surgeon General's Workshop on Violence in Public Health: Source Book. Atlanta. Ga: Centers for Disease Control and Prevention; 1985. [6] American Public Health Association. Summary of Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington. DC: US Government Printing Office; 1990. [7] Council on Scientific Affairs, American Medical Association. Violence against women . JAMA. 1992;267:3184-3189. [8] American Nurses Association. Position Statement of Physical Violent Against Women. Am Nurst. 1992;24(4):8. [9] Centers for Disease Control and Prevention. Family and other intimate assaults. MMWR 1990;39:525-529.