Abstract
Objective
The aim of this study was to determine the prevalence of musculoskeletal pain and reported injuries for nurses and nursing aides.
Background
Nurses and nursing aides suffer from work-related pain and musculoskeletal disorders (MSDs). Although there have been a plethora of studies on MSDs, an overall understanding of the prevalence of MSDs and pain can lead to better prioritization of research needs with respect to the health care industry.
Method
A total of 132 articles on prevalence of MSD pain and injuries were included in the review. All articles were published in peer-reviewed English-speaking journals and subjected to a quality review.
Results
Reported prevalence of MSD pain for nurses and nursing aides was highest in the low back, followed by shoulders and neck. However, the majority of the studies have been concentrated on 12-month pain in the low back and predominantly in hospitals. Few researchers have investigated pain in the upper and lower extremities (less than 27% of the studies). Even fewer researchers have evaluated reported injuries or even subjective lost-time injuries (less than 15% of the studies).
Conclusion
MSD pain in the nursing profession has been widely investigated worldwide, with a major focus on low-back pain. Given new directions in health care, such as patients who live longer with more chronic diseases, bariatric patients, early mobility requirements, and those who want to be at home during sickness, higher prevalence levels may shift to different populations—home health care workers, long-term care workers, and physical therapists—as well as shift to different body regions, such as shoulders and upper extremities.
Keywords
Introduction
Musculoskeletal disorders (MSDs) plague the nursing profession (nurses and nursing aides). National injury costs in the United States for nurses and nursing aides (in 2013 U.S. dollars) have been estimated to be $1.6 billion, $344 million, $192 million, $65 million, and $134 million for low back, shoulder, knee, neck, and hand/wrist, respectively (Waehrer, Leigh, & Miller, 2005). The average MSD claim costs have been reported between $6,190 to $93,225 (Alamgir et al., 2008; Badii, Keen, & Yassi, 2006; Haglund, Kyle, & Finkelstein, 2010), and average low-back claim costs ranged from $2,270 to $14,235 (Black, Shah, Busch, Metcalfe, & Lim, 2011; Charney, Simmons, Lary, & Metz, 2006; Cohen-Mansfield, Culpepper, & Carter, 2006; Goldman, Jarrard, Kim, Loomis, & Atkins, 2000; Lipscomb, Schoenfisch, Myers, Pompeii, & Dement, 2012; Meyer & Muntaner, 1999; Park, Bushnell, Bailer, Collins, & Stayner, 2009; Stichler, Feiler, & Chase, 2012). Based on these cost figures, MSDs have placed a significant burden on the health care sector and specifically on the health care workers.
Understanding how MSDs impact workers, specifically nurses and nursing aides in this case, requires quantification of the prevalence of pain, reports of injuries and disability, and the understanding of the potential risk factors for these health outcomes. Ferguson and Marras (1997) developed a model for the progression of low-back disorders that can be the foundation for the progression of MSDs. The progression from stressor to disability has the following stages: (1) discomfort, (2) symptoms, (3) disorder (injury or illness), (4) incidence, (5) restricted days, (6) lost days, and (7) disability. In the current review, we utilized this progression to evaluate the different MSD outcomes for health care professionals. Further, the current review focused on the health outcomes and not the risk factors associated with MSD outcomes. Other researchers have conducted reviews of the studies investigating the risk factors (Bakker, Verhagen, van Trijffel, Lucas, & Koes, 2009; Buckle, 1987; Kuiper et al., 1999; Nelson & Baptiste, 2006). The authors of these reviews have identified patient-handling tasks to be associated with MSDs, specifically in the low back.
The objectives of the current review were to (a) determine the overall prevalence of MSD outcomes for nurses and nursing aides; (b) determine whether prevalence of MSDs vary by body region, occupational classification, and health care facility; and (c) identify the limitations of the understanding of MSD prevalence (e.g., where are the gaps). Based on the review, priorities will be identified to fill the gaps and lead to a better understanding of pain and suffering that nurses and nursing aides experience worldwide, specifically identifying body regions, outcomes (e.g., lifetime, yearly, monthly, current), and facilities that need to have more research initiated.
Method
A comprehensive literature review was conducted to identify all published articles on the reported prevalence of MSDs in nurses and nursing aides. The review followed the critical procedures of Pluye and Hong (2014) and the Mixed Methods Appraisal Tool (MMAT). Each article was rated based on the criteria for qualitative and quantitative random designs, quantitative nonrandom designs, and mixed methods (Pluye et al., 2011). Any article that was scored less than 25% on quality was eliminated from the analyses but reported in the summary table. Although the majority of the studies concentrated on the prevalence of MSDs in nurses and nursing aides, there were several studies that included general health care professionals as the subject population without differentiating exact professional discipline.
Search Methods
A search for articles was completed over a 2-year period (September 2012 to September 2014), utilizing two search engines: Google Scholar and Thomson Reuters Web of Knowledge, which includes Medline, BIOSIS, Data Citation Index, Inspec, and Web of Science Core Collections. Combinations of words were entered into both search engines. The search words utilized in the search included nurses, nursing, nursing aides, long-term care facilities, hospitals, home healthcare, musculoskeletal disorders, low back, hand, wrist, knee, shoulder, neck, discomfort, injuries, and pain.
Inclusion/Exclusion Criteria
The following four inclusion criteria were used to select the articles to be included into this review: (a) full article study investigating the prevalence of pain or MSD injury in one of the targeted body regions for nurses and nursing aides, which included the following classifications: nurses, nursing aides, clinical nurse, assistant nurse, health care assistant, home care aide, practical nurse, and professional nurse; (b) published as a full-text article in an English-language peer-reviewed journal; (c) focus on health care setting, including hospitals, long-term care facilities, and home health care; (d) published prior to September 1, 2014. No exclusion criteria were based upon quality of the assessment, country of origin, or study design.
Results
In all, a total of 132 articles were included in the review. Table 1 provides a summary of the studies, including study population, study design, type of MSD outcome (e.g., pain assessment in lifetime, previous 12 months, previous 3 to 6 months, and current), reported MSD injuries (using company injury or compensation records), and lost-time injuries (subjectively reported) as well as the body region of pain/injury (e.g., low back, shoulder, neck, upper extremity, and lower extremity). Overall, most of the research into MSD pain and injuries for nurses and nursing aides utilized subjective surveys to take a snapshot of the health status (78%). A prospective design was utilized in only 19% of the studies, with 88% of these prospective studies utilizing a survey to assess MSD pain and injuries. Authors of four studies investigated previous injuries utilizing a retrospective design. Only two studies utilized a clinical evaluation to determine the presence of pain or injury. The majority of study authors (67%) investigated nurses (registered or licensed), and 24% of the study authors investigated nursing aides. Approximately 28% of the studies included populations with more general health care workers or a nondesignated nursing and nursing aide population. The bottom line is that authors of most studies have assessed pain and injuries utilizing a self-reported cross-sectional survey, which is good to understand pain frequency.
Summary of the Studies Included in Review, Including Study Population, Study Design, MMAT Criteria, Type of Pain and Injury Outcome, and Body Region
Note. MMAT = Mixed Methods Appraisal Tool; MSD = musculoskeletal disorder; RN = registered nurse; NA = nursing assistant; LPN = licensed practical nurse; LVN = licensed vocational nurse; PCA = patient care assistant; ATT = nurse attendant.
MMAT criteria is based on the checklist developed by Pluye and Hong (2014), which assesses quantitative studies with randomized designs (QUAN-R), quantitative studies with nonrandomized designs (QUAN-NR), quantitative descriptive study (QUAN-DE), qualitative studies (QUAL), and mixed methods (MM). Each study design had three or four criteria: all criteria satisfied = 100%, one criterion not fulfilled = 75% for four and 66% for three, two criteria not fulfilled = 50% for four and 33% for three, three criteria not fulfilled = 25% for four, and no criteria fulfilled = 0%. Shaded studies were eliminated from analysis based on less than 25% of criteria fulfilled.
The authors of the majority of studies investigated pain in the past 12 months (57%), followed by current pain (less than 7 days; 37%), lifetime pain (15%), and 3 to 6 months (10%). Authors of few studies investigated actual reported injuries (10%) or injuries with lost days (14%). When looking at the body regions, almost all of the researchers investigated pain in the low back (93%), with fewer researchers investigating MSD pain in the neck (47%) and shoulder (46%), upper extremity (27%), and lower (30%) extremities.
A summary of the prevalence for each body region as a function of outcome type is found in Figures 1 to 5. With the most data points, mean prevalence for low-back pain (Figure 1) was 65% for lifetime, 55% for previous year, 44% for previous 3 to 6 months, and 35% for current symptoms. Actual reported low-back injuries (MSDs reported in company injury reports) occurred in only 14% of nurses, and self-reported lost-day injuries occurred in 20%. Shoulder prevalence was slightly lower (Figure 2): lifetime at 54%, past year at 44%, past 3 to 6 months at 44%, current at 32%, reported MSDs at 24%, and subjective lost days at 12%. There were no data for lifetime prevalence for neck pain (Figure 3) and 42%, 48%, and 28% for past year, past 3 to 6 months, and current pain, respectively. The prevalence for reported neck injuries was 20% and for lost-day injuries was around 7%, although few studies went into these estimates. In Figure 4, the average prevalence of upper-extremity pain in past year and 3 to 6 months was 26% and 21%, respectively. Current upper-extremity pain prevalence was 15%. Again, authors of few studies investigated upper-extremity MSDs with a prevalence around 8%. No data have been reported for lifetime prevalence or lost-day injuries for upper-extremity pain outcomes. For the lower-extremity pain outcomes (Figure 5), mean past yearly prevalence was 36%, and the 3- to 6-month and current prevalence were 38% and 20%, respectively. Again, authors of few studies investigated the report injuries (6% of workers reporting MSDs) and lost-time injuries (8% on average). No data have been published for lifetime prevalence of lower-extremity pain.
Prevalence of low back pain as a function of pain outcome: lifetime, previous 12 months, current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.
Prevalence of shoulder pain as a function of pain outcome: lifetime, previous 12 months, current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.
Prevalence of neck pain as a function of pain outcome: lifetime, previous 12 months, current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.
Prevalence of upper-extremity pain as a function of pain outcome: lifetime, previous 12 months, current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.
Prevalence of lower-extremity pain as a function of pain outcome: lifetime, previous 12 months, current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.
The prevalence as a function of nursing category and health care facility is in Table 2. In general, the table of prevalence was sparse in many cells particularly with respect to lifetime pain and injuries (either reported or subjective lost time) as well as non-low-back pain outcomes in home health care and long-term care facilities. By far, low-back pain had the most cells filled with values. The prevalence for mixed populations (nurses, nursing aides, and other health care workers) tended to have higher prevalence of low-back pain than nurses or nursing aides by themselves. Hospitals had more studies investigating low-back pain than either long-term care or home health care facilities. Although the prevalence of low-back pain varied among the different facilities as well as nurses and nursing aides, the trends were not consistent. Authors of a large number of the studies investigated nurses who work at hospitals for low-back outcomes. For shoulder pain, the majority of cells were empty or had just a few studies. Nurses in hospitals were the most widely studied group for shoulder pain, with a mean prevalence of 44%. Home health care may be slightly more risky for shoulder pain (35%), but limited studies may undermine the estimates. Similar trends were found for the neck, upper-extremity, and lower-extremity pain outcomes—lack of evidence in many cells, some trending to higher levels in home health care, and not a lot of consistent trends.
Summary of the Mean Prevalence for Different Pain Outcomes as a Function of Health Facility and Health Care Worker (number of studies in parentheses)
Note. MSD = musculoskeletal disorder.
Discussion
Given the studies on the reported prevalence of MSDs in nurses and nursing aides, it was apparent that high levels of pain were experienced over the course of a year, with the highest levels in the lower back, shoulder, and neck areas. Although there is a critical mass of studies for these body regions and follow-up time frame, focusing on the yearly prevalence provides flawed representation of the pain and suffering for nurses as it does not capture the transient nature of pain. As our tracking systems and statistical procedures expand to handle big data, the capturing of instantaneous pain in these body regions may lead to a better understanding of the risk factors driving the injuries. One of the potential issues with nurses is that they have so many different risk factors they deal with on a given day, from interacting with sick patients to being on their feet for long periods to handling many materials (Poole Wilson, Davis, Kotowski, & Daraiseh, 2015). If one adds the mental and potential stress demands for a typical 12-hr shift, one has a complex set of risk factors that could all contribute to the pain suffered by the nurses.
Obviously, many researchers (Bakker et al., 2009; Buckle, 1987; Kuiper et al., 1999; Nelson & Baptiste, 2006) have shown a link between low-back pain in nurses and patient handling, which requires lifting and repositioning of heavy patients. Shoulder injuries and pain could potentially be related to the repositioning of the patient in the bed when the nurse leans over the bed and uses his or her upper body to slide a patient up in bed or turn the patient on his or her side; both are routine tasks performed by nurses (Poole Wilson et al., 2015). Although few study authors have investigated MSDs in upper and lower extremities, there are potentially many risk factors that may contribute to MSDs in the extremities, including standing and walking for long periods on hard surfaces or slips for the lower extremity and chart entry on electronic medical record devices and more-hand-intensive procedures to patient for upper extremity. However, the current review has focused on identifying the reported prevalence of adverse outcomes for nurses and cannot provide any direct insight into the underlying risk factors.
One take-home message from the current review is that studies are limited in the types of MSD outcomes and facilities. Table 2 has too many empty cells or cells with only a single study to draw conclusions of the prevalence of many of the MSD outcomes for anything but low-back pain in hospitals. The bottom line is that because of the primary focus on low-back pain for nurses, researchers may be neglecting many of the other injuries that the nursing profession faces, and with new procedures and devices, these risk factors are likely to continue to change and impact different body regions.
Another major conclusion drawn from the review was that few studies focused on more serious MSD outcomes, such as reported MSDs and lost-day cases. Although evaluating yearly pain is easier as one needs only a single survey, information about more serious cases is lost (Ferguson & Marras, 1997). Furthermore, the majority of the studies relied upon subjective assessments of pain (e.g., self-administered survey without clinical examination). The subjective nature of pain may be one underlying factor for the variability in prevalence of a specific pain outcome (as seen in Figures 1 to 5). Further, remembering episodes of pain over a long period (e.g., 12 months) can be highly subjective and person dependent, which may also contribute to the variability in prevalence across studies. The subjective nature of the pain assessments and long observation times make it difficult to identify the real casual factors for the injuries, especially in such a complex environment. Although patient handling is the big elephant in the room, many factors are likely to contribute to progression of MSDs in nurses.
Reported prevalence values may also be a function of when the study was conducted. By scanning Table 2, one sees that authors of few studies (fewer than 21 studies) investigated MSD prevalence before 1994, but there is a steady trend in more studies in the past two decades (culminating with 14 studies in the past 12 months). By having more studies in recent years, the prevalence estimates may be more accurate to the current MSD trends in health care. Health care is constantly changing, with new practices and policies that will directly impact MSDs. A perfect example is the no-lift policies that will likely reduce low-back injuries, but shoulder injuries may start to increase as a result of pushing force when moving the lift-assist devices. In the future, researchers will need to prove this theory of more diverse types of injuries. The bottom line is that the timing of the studies (date study collected) may have influenced the actual observed prevalence levels of the different MSD outcomes. Furthermore, these studies also represent the reported prevalence, which may not be a completely accurate estimate of the actual prevalence.
There were some major voids in the understanding of musculoskeletal pain in the nursing profession. First, studies were extremely limited in the investigation of home health care and long-term care facilities, with fewer than five studies in a given pain outcome category. With the likelihood of increased demands in long-term care and home health care facilities, it will be imperative to have a better understanding of MSDs and pain in these facilities. Home health care introduces another dimension of ergonomic risk, with each house representing a unique set of exposures. Home health care needs to be a high priority in both understanding ergonomic exposures and developing flexible interventions that are drastically different from the traditional hospital settings. Second, few researchers have investigated the upper- and lower-extremity pain for most of the pain outcome variables. As the demands, processes, and utilization of lift equipment change, the prevalence of the pain in body regions other than the low back may increase.
Finally, most studies have utilized subjective surveys to assess MSD pain, predominantly assessing yearly pain. As a result, the progression of MSDs from discomfort to disability has yet to be fully understood in the health care industry. Subjective assessments that have been predominantly conducted for 12-month retrospective periods are potentially biased, especially when determining association with exposures. In all, these voids indicate that there is a lot of work yet to be done in order to completely understand the exposures and resulting MSD outcomes in all types of health care facilities. Further, the bar will likely continue to change as health care evolves with different demographics (e.g., obesity and living longer) and processes.
Worldwide MSD Pain
Another interesting summary of the studies was how MSDs and corresponding pain impact nurses and nursing aides across the different regions of the world. For yearly prevalence, Australia/Philippines had the highest prevalence of low-back pain (71%), followed by Africa (64%) and the Middle East (58%). The rest of the regions (Europe, North America, South America, and Asia) had low-back prevalence between 51% and 57%. Yearly neck prevalence ranged between 37% (United States/Canada) to about 48% (Middle East, Asia, South America, and Europe). Shoulder pain was greatest in Asia (52%) and Europe (50%) and lowest in Africa (31%) and North America (35%). Upper- and lower-extremity pain was less than 30% in most regions, with the exception of the Middle East (45% for upper extremity and 52% for lower extremity). Overall, the North American region had the lowest prevalence rates, whereas the Middle East, Asia, and Australia/Philippines had the highest prevalence of yearly MSD pain across all body regions. Only one study has involved investigating pain for nursing in South America.
A slightly different picture of musculoskeletal pain was reported for current symptoms. The Africa region had the highest prevalence for low-back pain (63%), followed by the United States/Canada region (43%), Asia (32%), South America (34%), and Australia/Philippines (24%). Prevalence of neck pain was found to be lower than current low-back pain, with the highest levels in Africa (41% as reported in one study) and Europe (37%) and lowest in Asia (about 13%) and Australia/Philippines (about 20%). For current shoulder pain, Australia/Philippines (11%) had the lowest prevalence, whereas Europe (40%) and Africa (41%) were at the highest. The United States/Canada had a mean current prevalence of about 20%. Across the world, the number of studies on current upper and lower extremities was small, with most of them reporting below 15% to 20% for current pain. The only exception was one study in Africa (24% for upper extremity and 40% for lower extremity). For current pain, the general trend was that the lowest prevalence values were found in Australia/Philippines, whereas the highest values were in Africa. However, few studies have been performed in Africa.
Although the current review cannot provide insight into underlying reasons for the differences between world regions, one may provide conjecture about the underlying factors. The largest differences between regions were for low-back pain, whereby less developed countries had significantly higher prevalence levels. These regions also had the smallest number of studies, which may be reflective of some bias (e.g., overreporting in a few studies) or lack of infrastructure (e.g., limited use of lift-assist devices). Because the number of studies in a given region is liable to be directly related to the number of countries, the differences between developing and developed regions in low-back pain is likely due to better equipment and working environments. Future research with multinational investigators may shed more light into these differences. Many factors may contribute to the differences between world regions for the other body regions, with the most likely cause being different exposures during the treatment of patients. Another review of the actual exposures identified in different countries could provide valuable insight into what is driving the different prevalence levels.
Future Impact of MSD in Health Care
With an increase in the number of facilities adopting “no-lift” policies, prevalence rates may be trending down for nurses and nursing aides. As the effectiveness of these programs increases due to improvements in leadership, training, and accessibility of equipment, prevalence of MSDs, specifically low back, will likely continue to decrease in health care facilities. However, MSDs in the shoulders and upper extremity may actually increase as the physical demands change from lifting patients to pushing lifting-assist devices and other medical equipment. For this reason, future epidemiological studies on pain and injuries in nurses and nursing aides will need to focus on shoulders and upper extremities and go beyond the traditional focus on the low-back region.
Another major factor in future MSDs in health care could be the shift to early mobility whereby other health care providers besides nurses and nursing aides interact with the patient. Early mobility has increasingly become a responsibility of physical therapists (Perme & Chandrashekar, 2009). Physical therapists are required to handle patients with varying levels of physical function due to muscle atrophy, disease or infection, or drug-induced delirium (Perme & Chandrashekar, 2009). Physical therapists may be the worker population that is at most risk in the near future as this integration of patient mobility becomes commonplace in all health facilities. To date, authors of few studies (seven studies) have investigated the prevalence of MSDs for physical therapists. In these studies, the MSD pain in the previous 12 months was lower for physical therapists than nurses: low back-pain at 39% versus 55%, shoulder pain at 14% versus 44%, neck pain at 20% versus 42%, upper-extremity pain at 20% versus 26%, and lower-extremity pain at 6% versus 36%, respectively (Bork et al., 1996; Campo, Weiser, & Koenig, 2009; Campo, Weiser, Koenig, & Nordin, 2008; Cromie, Robertson, & Best, 2000; Holder et al., 1999; Molumphy, Unger, Jensen, & Lopopolo, 1985). Other studies have shown similar relative values for lifetime pain (Cromie et al., 2000; Salik & Özcan, 2004).
Limitations of Current Review
Although the review has provided potentially valuable insight into the prevalence of MSDs in nurses and nursing aides, several potential limitations need to be discussed. First, the review was for the most part inclusive of all the articles that evaluated prevalence of MSDs. We did use the MMAT (Pluye & Hong, 2014) to rate the quality of the articles, with the lowest-quality articles being eliminated from the review. Second, only articles published in English were included. This criterion may have resulted in some estimates being neglected in non-English-speaking countries. Third, the review concentrates on the health outcome and neglects the underlying risk factors. A complete understanding of the impact of MSDs on the nursing profession will require quantification of risk factors, which other reviews have done (Bakker et al., 2009; Buckle, 1987; Kuiper et al., 1999; Nelson & Baptiste, 2006). The current review complements these previous reviews by highlighting who is at risk of MSD injuries and pain and specifically for nurses and nursing aides. Finally, the current review concentrated on prevalence and not actual incidence rates. Obviously, injury rate would take into account the number of nurses or nursing aides who were exposed to MSD risk factors. However, studies on incidence rates were more infrequent than those on prevalence (29 vs. 88, respectively), making it difficult to draw inferences with respect to health outcomes, especially when one starts to break prevalence rates down to the different types and body regions. Given these potential limitations, the review was robust in its inclusion criteria, which allowed for the identification of missing data for the English literature as a whole.
Conclusion
Although MSD pain in the nursing profession appears to have been broadly investigated worldwide, there were several major voids in the literature. First, the majority of authors investigated MSD pain in nurses and nursing aides in hospitals. Few researchers have investigated MSD pain for nurses and nursing aides in home health care and long-term care facilities (fewer than five studies in a given pain outcome category). Second, few authors have investigated the upper- and lower-extremity regions for most of the MSD pain outcome variables. With changes in demands and expected increased usage of lift-assist devices and other safe patient-handling equipment, it will be imperative to understand the pain and injuries in the extremities. Finally, most studies have utilized subjective surveys to assess MSD pain, predominantly in the previous year. Better clinical diagnoses will improve the understanding of MSD pain. Given many environmental and social changes in the health care industry, including living longer with more chronic diseases, bariatric patients, early mobility, and wanting to be at home during sickness, higher prevalence levels may shift to different populations—home health care and long-term care nurses—as well as in different body regions, such as shoulders and upper extremity. Future research will be needed to track these potential shifts in pain, away from a focus on low-back pain for nurses in hospitals.
Key Points
Authors of a majority of the studies investigated musculoskeletal disorder (MSD) pain in nurses and nursing aides in hospitals, whereas few studies have settings in home health care and long-term care facilities.
Authors of few studies have investigated the upper- and lower-extremity regions for most of the MSD pain outcome variables.
Most studies have utilized subjective surveys to assess MSD pain, predominantly in the previous year.
Footnotes
Acknowledgements
Partial funding was provided by Hill-Rom, Inc., to conduct this literature review and provide a solid foundation for researchers investigating musculoskeletal disorders in health care.
Kermit G. Davis is an associate professor at the University of Cincinnati in the College of Medicine, Department of Environmental Health, where he also directs the Low Back Biomechanics and Workplace Stress Laboratory. He received his PhD in occupational ergonomics from The Ohio State University, College of Engineering, Department of Industrial and Systems Engineering. He is a certified professional ergonomist.
Susan E. Kotowski is an assistant professor at the University of Cincinnati in the College of Allied Health Sciences. She is also director of the Gait and Movement Analysis Lab. She received her PhD in occupational ergonomics and safety from the University of Cincinnati, College of Medicine. She is also a certified professional ergonomist.