Work-related musculoskeletal disorders among Jordanian physiotherapists: Prevalence and risk factors

Abstract

BACKGROUND:

Musculoskeletal complaints associated with work are common health problems among physiotherapists due to overload exposure and unsuitable postures.

OBJECTIVE:

To assess work-related musculoskeletal disorders (WMSDs) among Jordanian physiotherapists and investigate the factors that might increase the risk of having WMSDs among physiotherapists by using the ICF model as a guiding framework.

METHODS:

A cross-sectional study was conducted on 139 physiotherapists. Participants’ ages ranged from 23 to 61 years with 53.2% who identified as female. To assess WMSDs the Quick Exposure Check was used. Furthermore, depression, sleep, social support and job satisfaction were all assessed using Beck Depression Inventory, Pittsburgh Sleep Quality Index, Multidimensional Scale of Perceived Social Support, and Minnesota Satisfaction Questionnaire, respectively. Furthermore, age, gender, body mass index (BMI), educational level, smoking status and marital status were also collected from all participants.

RESULTS:

The results showed that the most common musculoskeletal complaints were as follows: 100% of the participants reported overload occurrence in the cervical spine, 97.9% in the lumbar spine, 96.5% in the shoulder joint, and 24.1% in the wrist joint. There was a significant negative correlation between total exposure and gender. Also, total exposure was significantly and positively correlated with BMI and the Minnesota Satisfaction Questionnaire (MSQ).

CONCLUSION:

This study suggests a need to increased knowledge of self-protection strategies among physiotherapists to reduce the occurrence of musculoskeletal disorders. Understanding the factors that might increase WMSDs is useful for future research, quality improvement, and educational programs to reduce the rates of WMSDs among physiotherapists.

Keywords

Risk factors musculoskeletal disorders injury physiotherapy Jordan

1 Introduction

Working in the physiotherapy field exposes therapists to the load of applying manual forces such as pushing, pulling, lifting, sustained demanding postures, static loading during treatment sessions, manual therapy techniques, and repetition [1, 2]. Therapists are exposed to unsuitable postures when working with their patients, which could lead to work-related musculoskeletal disorders (WMSDs) [2, 3]. These disorders are defined as musculoskeletal pain lasting more than three days experienced by the worker or the therapist due to their excessive workloads [1]. Also, These disorders are considered as damage to the musculoskeletal system, that is associated with the chronic pain and physical disorders occurring among physiotherapist [4]. The leading cause of these disorders is linked to performing demanding tasks. WMSDs are specifically common among physiotherapists (PTs) [5]. Based on a recent systematic review, the prevalence of WMSD is estimated to be between 53% and 91% among PTs who experienced WMSD symptoms at some point during their professional life [5].

Studies have demonstrated that work circumstances are linked to the development of WMSDs among PTs. Also, dealing with large number of patients during the day and working while injured is associated with WMSDs [1]. In addition to work circumstances, personal, psychosocial and environmental factors can play a role in increasing the prevalence of WMSDs among PTs. For example, some studies found a significant relationship between sleep quality and musculoskeletal disorders and concluded that improved sleep quality could decrease the occurrence of musculoskeletal disorders [6]. Furthermore, psychosocial issues, depression, and job satisfaction were found to play a key role in influencing WMSDs among PTs [7]. In fact, low job satisfaction was found as one of the risk factors that might increase the sickness absence among workers due to low back pain specifically [8]. Other important factors include social support and quality of life and the improvement of these factors was found to decrease the risk of WMSDs [9]. Based on the body part affected, some WMSDs are more common than others. For example, the lower back is the body part that is most frequently affected by WMSDs. Other body parts are less affected such as neck, thumbs, upper back and shoulders, while the lower extremities are not as common [5].

The occurrence of WMSDs is mainly investigated in the US, Canada and Australia, and they are rarely studied in the Middle East. No single study has examined the prevalence of WMSDs among Jordanian PTs and their possible associated risk factors. We believe that the work stress among physiotherapists is high. Physiotherapists working in Jordan are often prone to non-ergonomic positions due to the lack of adjustment possibilities of treatment beds, in addition to the major problem of understaffing. Furthermore, working long hours (of up to eight hours a day) without breaks, and large number of patients seen per therapist, are all factors that contribute significantly to the prevalence of WMSDs. Therefore, this study aimed to examine WMSDs among PTs in Jordan and investigate factors that may be correlated with WMSDs. Given the multifactorial nature of WMSDs, our hypothesis states that WMSDs among PTs is associated with environmental and work factors, affective factors such as depression, sleep quality and social support as well as with some personal characteristics, including age, gender, and BMI (body mass index). The aim of this study was to investigate the prevalence of WMSDs among PTs in Jordan. Additionally, risk factors (personal, environmental, and clinical characteristic) that might be associated with WMSDs severity among Jordanian physiotherapists were investigated.

2 Materials and methods

A cross-sectional study was designed to investigate the prevalence of WMSDs among PTs in Jordan. This study also investigated the factors that might be associated with the WMSDs severity among Jordanian physiotherapists. Physiotherapists from different hospitals (public, private and military) in variant regions in Jordan (north, middle and southern parts) were recruited in this study. The sample size was determined based on similar studies conducted in different countries [22 , 33].

The criteria for inclusion were: 1) Working as a physiotherapist for a minimum of one year; and 2) A signed consent to participate in the study. Exclusion criteria were: 1) History of psychiatric disorders; 2) History of neurological conditions; 3) Spine surgeries; 4) Pregnancy; and 5) Having a major chronic disease or serious injury that may cause musculoskeletal pain.

The study used a survey method with the application of six questionnaires: Quick Exposure Check, Beck Depression Inventory, Pittsburgh Sleep Quality Index, Multidimensional Scale of Perceived Social Support, and Minnesota Satisfaction Questionnaire.

2.1 Outcome measures

2.1.1 Assessment of WMSDs: The Quick Exposure Check (QEC)

The Quick Exposure Check (QEC) is a self-reported questionnaire that is used to assess the exposure to the risks for WMSDs, and subsequently to provide a basis for ergonomic interventions in the workplace.

The QEC is known to be straightforward to use, applicable on a wide range of tasks, and the time needed to complete the assessment is estimated to be within 10 minutes [10]. The assessment of exposure focuses on the back, shoulders, upper limbs and neck, since WMSD are mostly reported in those regions [11]. The following aspects are assessed in the questions including the acting load; the maximum hand-lifted weight, the duration of work that involve lifting, the maximum force generated using one hand, the use of precise hand movements, the driving time per day, and the use of vibrating tools during work [11]. The scores are recorded on a scoring sheet to determine the scores for each body area. This tool allows for assessing the four main body areas (back and the cervical spine, shoulders, and upper limb) and covers a wide range of working activities. The score is classified according to four categories of risk exposure (low, moderate, high, and very high) and the exposure scores sheet must be used to determine the scores for each body area. Three domains (back, shoulder, and wrist) range from 10 to 56, while one domain (neck) ranges from 4 to 18, with a higher score indicating more exposure to the risks of WMSDs.

2.2 Other outcome measures

According to our hypothesis, three main domains included a range of factors that were selected for evaluation: affective, environmental, and personal factors. The affective factors included in this study are depression and sleep quality.

Depression was assessed using the Beck Depression Inventory II. The (BDI-II) is a measure that quantifies the intensity of depression by asking about 21 behavioural characteristics of depression. Scoring of BDI-II is calculated by summing the items’ results that can range between 0–63 with higher score indicating more intense depression [12]. The total score of BDI-II was categorized into 3 levels: 0–13 indicates no or minimal depression, 14–19 reflects mild depression, 20–28 indicates moderate depression, and 29–63 reflects severe level of depression [13]. The BDI-II has been translated and validated in Arabic language [14].

Sleep status was evaluated using the Pittsburgh Sleep Quality Index (PSQI) [15]. The PSQI is a well-validated and reliable measure of self-reported sleep quality which consists of 19 self-rated questions [15]. A recommended cut-score of 5 has been established for total PSQI, with scores≤5 indicating ‘good’ sleep and scores > 5 indicating ‘poor’ sleep. The PSQI has been translated and validated in Arabic language [16].

To assess the environmental factor, the Multidimensional Scale of Perceived Social Support (MSPSS) was used. The MSPSS is considered as one of the most used and validated outcome measures for social support [17 –19]. This measurement tool consists of 12 questions and has a three-factor structure assessing family, friends, and significant others [17]. Each item is rated on a 7-point Likert scale ranging from 1 = very strongly disagree to 7 = very strongly agree [18]. The MSPSS has been translated and validated in Arabic language [19]. The scoring is performed through summation across items according to the support source, then divide by 4. The scale score ranging from 1 to 2.9 indicates low support, a score from 3 to 5 indicates moderate support, and a score from 5.1 to 7 indicates high support [18].

To assess the personal domain, factors included age, gender, body mass index (BMI), educational level, smoking status and marital status were also collected from all participants. Furthermore, job satisfaction was assessed using the Minnesota Satisfaction Questionnaire (MSQ) short-form. It consists of 20 items. The 20 items are presented in two factors including intrinsic and extrinsic satisfaction. Scores on these two factors in addition to a general satisfaction score were obtained. The 20 MSQ-short version items are rated on a 5-point Likert scale as the following (1 “very dissatisfied with this aspect of my job”, 2 “dissatisfied with this aspect of my job”, 3 “can’t decide if I’m satisfied or dissatisfied with this aspect of my job”, 4 “satisfied with this aspect of my job”, and 5 “very satisfied with this aspect of my job”). Item responses are summed to present a total score, with lower scores indicating low job satisfaction and higher scores indicating higher job satisfaction level [20].

Ethical approval was obtained from the Institutional Research Committee of Jordan University of Science and Technology (AA-20200060). After full explanation of the study and its procedures, all participants provided their informed consent prior to participation in the study.

2.3 Data analysis

Collected data was de-identified and entered to the Statistical Package for the Social Sciences (SPSS) version 25 for analysis. Data were checked for normality using the Shapiro–Wilk test (Statistical Package for the Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY, USA)). Additionally, data were checked for the presence of outliers. Descriptive statistics (mean, SD) and frequencies (proportions, percentage) have been used to analyse the demographic information and clinical characteristics. Also, correlation analyses were conducted to evaluate the association between QEC and other variables using Spearman’s coefficient.

3 Results

139 physiotherapists across the country completed the study. The mean age was (30.21) years (SD±6.59, range from 23 –61 years old). The sample was almost equally distributed based on gender with a female percentage of 52.2%. 24.1% of the participants were smokers. Most of the participants had an educational level of bachelor’s degree (83%), then diploma (5%), followed by graduate degree (10.6 %).

Table 1 represents the characteristics of the 139 participants of both genders who enrolled in this study (see Table 1).

Table 1
Characteristic of the participants

Variables

Age, mean ± SD (min-max) 30.21±(6.59) (23–61)

Gender, n (%)

Male 65 (46.7)

Female 74 (53.2)

Education, n (%)

Bachelor 117 (83)

Diploma 7 (5.0)

Post-graduate 15 (10.6)

BMI, mean ± SD (min-max) 25.61±(4.01) (15.24–37.55)

Work years, mean ± SD (min-max) 6.16±(6) (1–40)

Variables
Age, mean ± SD (min-max)	30.21±(6.59) (23–61)
Gender, n (%)
Male	65 (46.7)
Female	74 (53.2)
Education, n (%)
Bachelor	117 (83)
Diploma	7 (5.0)
Post-graduate	15 (10.6)
BMI, mean ± SD (min-max)	25.61±(4.01) (15.24–37.55)
Work years, mean ± SD (min-max)	6.16±(6) (1–40)

The distribution of the frequency and percent of occurrence for the different levels of exposure to overloading in the examined areas of the musculoskeletal system (back, cervical, upper extremity) demonstrated that the majority of the participants indicated a high level of overload occurrence on all areas (see Table 2).

Table 2

Levels of exposure to overloading

Exposure level	Back	Shoulder-arm	Wrist	Neck
Low	0%	0%	0%	0%
Moderate	%0	0%	3.5% (n = 5)	0%
High	0.7% (n = 1)	2.1% (n = 3)	70.9% (n = 100)	0%
Very high	97.9% (n = 138)	96.5% (n = 136)	24.1% (n = 34)	100% (n = 139)

n – number of participants, % - percentage of the exposure of overloading.

Table 3 shows the prevalence of occupational factors: vibration, driving, the difficulty of the performed work (workplace) and stress (see Table 3). Regarding the question about use of vibrating equipment and driving, the majority of the respondents marked a low-level overload occurrence.

Table 3

Prevalence of occupational factors

Exposure level	Driving	Vibration	Work place	Stress
Low	98.6% (n = 139)	98.6% (n = 139)	27% (n = 38)	0%
Moderate	%0	0%	54.6% (n = 77)	7.1% (n = 10)
High	0%	0%	14.9% (n = 21)	43.3% (n = 61)
Very high	0%	0%	2.1% (n = 3)	48.2% (n = 68)

n – number of participants, % - percentage of the exposure of overloading.

Descriptive statistics for affective factors are presented in Table 4, showing the mean and SD for each item. Additionally, Table 4 presents the correlation between those outcome measures and the total exposure level. Total exposure levels were measured using the following formula:

Table 4

Descriptive statistics for affective measure and results of correlation analysis between total exposure level and body structure, personal, and environmental domains (n = 139)

Total exposure	Mean (SD)	Spearmans’ rho	P-value
BDI	4.88 (8.36)	–0.158	0.063
PSQI	2.62 (5.76)	0.023	0.786
MSQ	71.56 (10.77)	0.187	0.028*
BMI	25.61±(4.01)	0.211	0.013*
Gender	––	–0.367	<0.001**
Working hours	6.16±(6)	0.014	0.872
MSPSS	5.48(1.1)	–0.43	0.619

BDI: Beck Depression Inventory, PSQI: Pittsburgh Sleep Quality Index, MSQ: Minnesota Satisfaction Questionnaire, BMI: Body Mass Index, MSPSS: Multidimensional Scale of Perceived Social Support. **Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed).

$E = X / X_{\max} 100 %$

E is the total exposure level, X is the total score of exposure for (back + shoulder/arm + wrist/hand + neck), and X_max is the total maximum of score summation [21].

None of the affective outcome measures presented any significant correlation with total exposure (see Table 4). Descriptive statistics of the personal domain are also presented in Table 4. The table presents the correlation between those outcome measures and the total exposure level. As noticed, there was a significant negative correlation between total exposure and gender. Also, there was a significant positive correlation between the total exposure and the Minnesota Satisfaction Questionnaire (MSQ). In addition, there was significant positive correlation between BMI and total exposure. Whereas, there were no significant correlations between age, number of working years and total exposure level. Table 4 also demonstrates descriptive statistics of the environmental domain. The table shows that there was no significant correlation between MSPSS scores and exposure level (see Table 4).

4 Discussion

This study was conducted to examine WMSDs among Jordanian physiotherapists and investigate the factors that might increase the risk of having WMSDs among physiotherapists. The results showed that the most common musculoskeletal complaints were as follows: 100% of the participants reported overload occurrence in the cervical spine, 97.9% in the lumbar spine, 96.5% in the shoulder joint, and 24.1% in the wrist joint. There was a significant negative correlation between total exposure level and gender. Also, total exposure level was significantly and positively correlated with BMI and the Minnesota Satisfaction Questionnaire (MSQ).

The finding showed that physiotherapists demonstrated a high level of overload occurrence in the cervical spine at 98.6% and lumbar spine at 97.9%. This is confirmed by Truszczyńska et al., as (65%) of the respondents suffered from loading and pain in the lumbar spine, and 55.6% experienced pain of the cervical spine in Poland. This increase in the level of exposure and pain were due hard physical work, routine tasks with high load, and repetition of rotation and sudden movements [22]. Low back pain was the most common work-related musculoskeletal disorder among physiotherapists in the United States, Canada and Kuwait, and the prevalence of low back pain among PTs was 45% to 62%,49%,70% respectively [23 –25].

Everyday PTs working in hospitals or clinics are subjected to work overloading, dealing with demanding repetitive movements or continuous bending, lifting and moving patients, performing active and passive exercises, performing manual therapy, in addition to being in restricted workplace conditions. All these conditions influence the prevalence of musculoskeletal disorders [1 , 5].

Although the prevalence of work-related low back pain and cervical pain are relatively high for physiotherapists in Jordan, therapists are not able to take proper precautions or measures for their safety during therapy sessions. Even though PTs learn in their educational programs about how to conduct the session with the least possible risk, they still suffer from pain due to the lack of specially adapted equipment (for example couches, chairs, and massage tables). As reported in the literature, PTs who work with clients (adults or children) who apply Proprioceptive Neuromuscular Facilitation (PNF), manual exercises, and neurodevelopmental therapy (NDT-Bobath) have reported recurrently bending positions and frequency of movements [26, 27].

This study showed that sleep quality and depression were not significantly associated with the total score of level of exposure to overloading in all areas of the body. This study demonstrated that there was no statistically significant association with depression (p = 0.06), yet as noticed it was approaching significance. This statistical finding might be due to the relatively small sample size. Future studies with larger sample size are required to confirm this finding. Contrary to our results, multiple systematic reviews have found that physiological, psychological, and emotional distress were significantly associated with a higher prevalence of WMSDs [28, 29].

It is important to note that one study in Jordan by Almhdawi et al., assessed WMSDs and their related predictors among Jordanian nurses using the Nordic Musculoskeletal Questionnaire (NMQ) and Depression Anxiety Stress Scale (DASS21) [30]. They reported that depression, stress and anxiety were significant predictors for lower quadrant WMSDs [30]. However, only one recent study showed that increased workload alongside other variables (such as gender and sleep quality, and ergonomics) were significant predictors of upper quadrant WMSDs.

The results of our study showed no significant correlation between sleep quality and exposure level to overloading. Our findings were not in agreement with other studies that reported a statistically significant relationship between sleep quality and musculoskeletal disorders [6]. Again, such a discrepancy might be due to the different outcome measures used in different studies or due to the sample size.

In agreement with previous studies [4, 5] this study demonstrates that females have a higher prevalence of WMSDs compared to males. That may be due to differences in skeletal muscle mass and body sizes between genders. Even though males spent longer hours working from a standing position, they suffered less from WMSDs than females [5, 31]. Such a finding in our study was relatively similar to other cross-sectional studies conducted in Nigeria and Malaysia where their results showed a significantly higher prevalence of WMSDs in females [31, 32]. Also, a Polish study showed a significant relationship observed between gender and the level of exposure to overload, although this study had a sample size of females twice the size of males [22]. However, one study in Kuwait showed that the frequency of WMSDs was not gender-related [33].

Regarding job satisfaction, our study showed that there is a positive relationship between overall exposure to overload and job satisfaction. Previous studies showed the same results by reporting that a low level of job satisfaction was associated with WMSDs prevalence [29, 34]. To our knowledge, there are only a few studies that examined job satisfaction and its association with musculoskeletal disorders. This association might be explained by the fact that therapists who have high job satisfaction receive higher monthly salaries, but in return they work extra hours, and this high effort and overload increases the problems related to the musculoskeletal system.

The findings of this study reported no correlation between the level of exposure of overloading and the duration of experience of PTs. Previous studies have reported that professionals with musculoskeletal complaints were younger and had less years of experience and that WMSDs have occurred more often in the younger age groups between 20 and 40 years [33, 35]. Possibly this discrepancy can be explained by the mean working years in this study (6.16 years). Also, there are no differences between old and new employees in the number of daily sessions in Jordan. In addition, all therapists work in the same position for long periods, working in static postures and continuing to work while injured due to restricted number of vacation days. Furthermore, physiotherapists in Jordan prefer to use manual therapy frequently with patients as they believe in its usefulness compared to other treatment methods.

The present study revealed that the presence of WMSDs is positively correlated with body mass index. A recent systematic review of risk factors associated with work-related musculoskeletal disorders also found that the development of disorders was correlated with a higher BMI [29]. Also, our findings are similar to findings from another study conducted in Malaysia, where significant differences were observed between therapists who had WMSDs and those who did not in therapists with a BMI higher than 25% [31]. Contrary to these results, among Nigerian PTs, results showed that the prevalence of WMSDs was negatively correlated with BMI [32]. Also, in Kuwait, PTs complaining of WMSDs showed that BMI was not significantly associated with WMSDs [33].

In addition, the results of this study showed that social support had no correlation with the level of exposure to overloading. To our knowledge, there are no previous studies that showed the association between social support and WMSDs among PTs. One study among nurses reported that social support was a protective factor of WMSDs in nurses [36]. Another study showed no relation among workers in general between WMSDs and social support [37]. Although our findings indicated that PTs reported good social support in Jordan, no statistical significance with physical disorders was demonstrated. This might be explained by the methodological differences between this study and previous studies, such as the use of different outcome measures and statistical analysis methods. Also, the differences in the studied groups are an important factor explaining the differences between our results and the results of previous studies.

On the basis of this research, attention should be given to body mechanics during transfers, lifting, carrying, moving, and handling tasks to minimize the load that they are prone to and the occupational risk of working physiotherapists. The results of this study include to rest between sessions and alternate the scheduling of more and less physically demanding patients during the day to reduce the total workload. They are also advised to take days off work and vacations when injury or fatigue occurs to allow time for recovery.

4.1 Limitations of the study

A major limitation was that all data collection had been conducted during the COVID-19 pandemic, and no studies have expressed if going through the pandemic might have had an impact on therapists and their reporting of clinical complaints. Another potential limitation is the fact that this is the first time that the QEC outcome is being used in Arabic language. Future research in this topic is recommended to study the relationships between the specialty working therapists (e.g. neurology, orthopaedics, or paediatrics) and the level of exposure to overload in Jordan since each of those specialties might have some specifications that do not apply to other specialties. Also, future studies are recommended to include larger sample size and consider the inclusion of other locations in the country.

5 Conclusion

The prevalence of WMSDs is very high among physiotherapists in Jordan. This prevalence was not different from PTs working in other countries.

Gender, BMI and job satisfaction are important factors that might affect WMSDs.

The findings of this study suggest a need for interventions and prevention methods in order to minimize the prevalence of WMSDs.

Further research is needed to identify the structure and function domain and environment domain that may be contributing to this type of injuries, with a view to formulating preventive strategies.

Ethical approval

All participants provided written informed consent prior to the study. The study was approved by the Institutional Research Committees of Jordan University of Science and Technology (AA-20200060).

Footnotes

Acknowledgments

The authors would like to thank all participants in the study.

Funding

The study was supported by the Jordan University of Science and Technology (Grant number AA-20200060).

Conflict of interest

The authors report no conflicts of interest.

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