Abstract
Objective
: This cross-sectional study aimed at analyzing: 1. the main musculoskeletal symptoms (MSS) presented by hospital nursing workers and; 2. personal, occupational, and health factors related to MSS among them.
Method
: Two questionnaires were filled in by 245 nurse technicians (NTs) and licensed practical nurses (LPNs) (response rate 95%) associated with direct patient care sectors from a hospital. These questionnaires were: the standardized version of the Nordic Musculoskeletal Questionnaire (NMQ) and one including questions on 15 demographic independent variables potentially related to outcomes from the NMQ. Univariate analyses and binary logistic regression analyses were performed to identify which variables would explain the occurrence of MSS in different body regions.
Results:
The low back (57%), shoulder (52%), and neck (48%) were identified as the most affected regions. The logistic regression analysis showed that low back symptoms in the last 12 months were significantly associated with LPN activities (OR=2.36; CI=1.24-4.5) and previous sick leave due to MSS (OR=5.97; CI=1.2-29.1). Smoking was significantly associated with symptoms in the low back (OR=2.77; CI=1.13-6.8) and thoracic spine (OR=2.37; CI=1.04-5.40). Physical exercise showed a protective effect on the cervical spine (OR=0.42; CI=0.23-0.77). Previous sick leave was significantly associated with pain in the knees (OR=4.24; CI=1.33-13.5) and in the upper limbs (OR=5.36; CI=1.07-26.7).
Conclusions:
The nursing workers who were evaluated presented a high prevalence of MSS. Previous history of sick leave was strongly associated with the presence of symptoms in various body regions. These results indicate the need for preventive programs in the hospital environment in order to control more severe MSS in nursing professionals.
occupational health; epidemiology; exercise; physical therapy
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and the need to evaluate these symptoms in a broader context for future
preventive and therapeutic programs, the objectives of this study were to
investigate: 1) the main symptoms presented by nurse technicians (NTs) and licensed
practical nurses (LPNs) and 2) the simultaneous relationship between personal,
occupational, and health factors possibly related to the presence of symptoms in
different body regions.
Method
The present epidemiological study followed the STROBE methodology2323. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC,
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of conducting observational epidemiology studies.
Study design
A cross-sectional epidemiological study was carried out to evaluate the prevalence of MSS among NTs and LPNs from a Brazilian hospital and to identify the potentially related factors.
Location of the study
The study was carried out in a hospital in the state of São Paulo, Brazil. The questionnaires were distributed during the work shifts in sectors involving direct patient care. The participants incurred no expense and received no compensation.
Participants and inclusion criteria
Brazilian nursing teams are basically comprised of three occupational groups: nurse technicians, licensed practical nurses, and registered nurses. In Brazil, NTs and LPNs represent most of the nursing workforce. These workers are mainly responsible for activities that involve direct contact with patients and, for this reason, are quite exposed to physical risk factors. Thus, the present study evaluated NTs and LPNs only.
Federal Law 7498/862424. Brasil. Lei nº 7.498/86, de 25 de junho de 1986. Dispõe sobre a regulamentação do exercício da Enfermagem e dá outras providências. Diário Oficial da República Federativa do Brasil; Brasília; 26 jun. 1986. regulates the activities performed by these professionals and states that NTs and LPNs are responsible for most of the direct care of patients. However, activities carried out by NTs require a lower level of decision-making than the ones performed by LPNs and involve mid-level tasks of a repetitive nature.
All of the NTs and LPNs associated with direct patient care at the hospital were invited to participate in the study (n=292); they worked regularly in either day shifts (7:00 am to 7:00 pm) or night shifts (7:00 pm to 7:00 am). The adopted inclusion criteria were: to be registered as an NT or LPN; work in the department responsible for direct patient care, and to be employed for at least 12 months. All participants signed the informed consent form and the research procedures were approved by the Human Research Ethics Committee of Universidade Federal de São Carlos (UFSCar), São Carlos, SP, Brazil (CAAE: 1080.0.00.135-10).
Hospital department characteristics
A hospital's emergency department is accessible to the general population and is designed to assist patients with or without risk of death who require immediate health care2525. Brasil. Ministério da Saúde. Grupo de Trabalho - Unidade de Sistema de Desenvolvimento de Serviços de Saúde. Terminologia básica em saúde. Brasília: Centro de Documentação do Ministério da Saúde; 1985. p. 1-49.. Patient referral is carried out according to the complexity of the cases treated. Simple cases are dealt with at the emergency care units and more complex cases are sent to other units of the hospital. Hospital wards are departments for patients who do not need constant observation. One companion is allowed to stay with each patient all the time. Intensive Care Units (ICUs) are departments in which high level technology equipment is used for the care of critically ill patients. ICU patients need constant observation, as well as continuous medical and nursing care2525. Brasil. Ministério da Saúde. Grupo de Trabalho - Unidade de Sistema de Desenvolvimento de Serviços de Saúde. Terminologia básica em saúde. Brasília: Centro de Documentação do Ministério da Saúde; 1985. p. 1-49.. In these departments the circulation of both staff and visitors is restricted and controlled. It is important to emphasize that the physical and mental demands of each department vary due to the different levels of assistance, complexity, technology, and nurse-patient relationship of each department.
Evaluated variables and data sources
Two questionnaires were applied: the standardized Nordic Musculoskeletal
Questionnaire (NMQ) and a questionnaire specifically designed for the present
study that included 15 independent variables potentially related to the response
variables of the NMQ2626. Kuorinka I, Jonsson B, Kilbom A, Vinterberg H, Biering-Sørensen
F, Andersson G, et al. Standardized Nordic questionnaire for the analysis of
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. In the customized questionnaire, personal, occupational, and health
factors were included based on relevant, previously published epidemiological
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2727. Krantz G, Ostergren PO. Double exposure. The combined impact of
domestic responsibilities and job strain on common symptoms in employed Swedish
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and on the authors' own experience2929. Coury HJCG, Moreira RFC, Dias NBD. Evaluation of workplace
exercise effectiveness on neck, shoulder and low back pain control: a systematic
review. Rev Bras Fisioter. 2009;13:461-479.
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30. Sato TO, Coury HJCG. Evaluation of musculoskeletal health
outcomes in the context of job rotation and multifunctional jobs. Appl Ergon.
2009;40(4):707-12. PMid:18675951.
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3131. Moreira RFC, Foltran FA, Albuquerque-Sendín F, Mancini MC, Coury
HJCG. Comparison of randomized and nonrandomized controlled trials evidence
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control. Work. 2012; 41:4782-4789. PMid:22317457.. The questions were structured as direct queries. Pilot tests were run
before the questionnaires were applied to evaluate the clarity of the content
and time taken to respond to the questions.
The following information was covered by the questionnaire: 1) occupational aspects - work department (emergency room, hospital wards or intensive care), shift (day or night), job position (NT or LPN), time in this position (years), time at the institution (years), other paid activity (yes or no); 2) personal characteristics - gender (male or female), age (in years), body mass index classification (normal, overweight, obese), marital status (married or single), children (yes or no), routine housework (yes or no); 3) health condition: regular physical activity (yes or no), smoking (yes or no), and history of sick leave of more than 15 days due to musculoskeletal disorders (yes or no).
The Brazilian version of the NMQ3232. Barros ENC, Alexandre NMC. Cross-cultural adaptation of the
Nordic musculoskeletal questionnaire. Int Nurs Rev. 2003;50(2):101-8.
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was used to identify the presence of symptoms in the previous 7 days and
previous 12 months in different regions of the body, the impairment these
symptoms caused in daily life activities (DLAs) and whether or not medical
assistance was sought for the symptom. The questionnaires were answered by the
workers during their work shift. It should be mentioned that there was no
interference from superiors or compensation for the workers.
Independent and dependent variables
The discrete independent variables: age, time in the current job position, and
time at the institution were categorized according to quartiles (Table 1). The BMI values were categorized
as: 1) normal (≤25), 2) overweight (>25 and <30), and 3) obese
(>30)3333. Rahman M, Berenson AB. Accuracy of current body mass index
obesity classification for white, black, and Hispanic reproductive-age women.
Obstet Gynecol. 2010 May;115(5):982-8. PMid:20410772 PMCid:PMC2886596.
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.
All dependent variables were dichotomous (presence or absence). Variables related to neck, thoracic spine, and lumbar spine symptoms were grouped under the term "spine segment". Variables related to shoulder, elbow, wrist, and hand symptoms were grouped as "upper limb (UL) segment". Variables related to hip, thigh, knee, ankle, and foot symptoms were grouped as "lower limb segment". The dependent variable "symptoms in any body region" corresponded to the nine body regions evaluated by the NMQ.
Controlling sources of bias
Initial clarification was given to all participants to prevent misunderstandings in their responses. If asked, additional information was provided individually, avoiding interpretations or any other form of inducement toward particular responses.
Sample size
All NTs and LPNs who were present (i.e. not on leave, vacation or day off) when the evaluation took place (n=292) were evaluated. The final sample consisted of 245 workers who matched the study's inclusion criteria.
Statistical methods
The data were descriptively analyzed by calculating the frequencies, quartiles, means, and standard deviation. A univariate analysis was carried out with the chi-square association test (χ2). The independent variables significantly associated (P≤0.25) with the dependent variables were included in a logistic regression model3434. Hosmer DW, Lemeshow S. Model-Building strategies and methods for logistic regression. In: Hosmer DW, Lemeshow S. Applied Logistic Regression. New York: John Wiley & Sons; 1989. p. 82-134.. The objective of the logistic regression analysis was to identify which variables explain the occurrence of musculoskeletal symptoms in different body regions. The data were analyzed in SPSS 11.5.
Results
Subjects
Out of the 292 LPN and NT active workers in the direct patient care sectors, 258 matched the study inclusion criteria. Thirteen workers did not participate because on the day of data collection they either had the day off (n=8), were absent from work (n=4) or they were unavailable to answer the questionnaire (n=1). Therefore, the sample included 245 individuals, representing 95% of the eligible subjects. There were 226 women and 19 men; the mean age was 35.5 years old (±10.7; min. 19 and max. 68). The mean time that the participants had been employed in their current position was 8.6 years (±8.5; min. 1 and max. 47) and the mean time at the institution was 6.8 years (±7.3; min. 1 and max. 47). The demographic characteristics of the sample (n=245) regarding occupational, personal, and health aspects are presented in Table 2.
Demographic characteristics of the sample regarding occupational, personal, and health aspects.
The evaluated population consisted predominantly of women (92.2%) who did not exercise regularly in their free time (70.6%) and were exposed to double work shifts due to housework (91.8%). Most subjects (55.2%) were in the overweight or obese categories and approximately 53% had been nurses for less than 5 years.
The number and percentage of symptomatic workers evaluated by the NMQ, as well as for the categories: 'spine', 'UL', 'lower limb', and 'at least one body region' are presented in Table 3.
Table 3 shows the high prevalence of MSS in at least one body region among the evaluated nursing professionals, both in the last 12-month and seven-day periods. The symptoms led the worker to seek medical assistance and impaired the performance of DLAs in approximately 1/3 of the individuals affected.
Analysis of the symptoms according to the body region showed that during the previous 12 months the spine was the most affected part in 3 out of 4 individuals evaluated, followed by the lower limbs and the ULs. Considering the regions individually, the lumbar spine, shoulder and cervical spine were the regions with the highest prevalence of symptoms in the previous 12 months, followed by the thoracic spine and the ankle and foot regions.
Regarding the effects of symptoms on the performance of DLAs, more than 1/4 of the individuals experienced some impairment. The lumbar region was the most critical, followed by the cervical spine, thoracic spine, ankle, and foot. Among the professionals evaluated, the spine was identified as the part that most affected the DLAs. Symptoms in at least one body region led more than 1/3 of the participants to seek medical assistance, and symptoms in the lumbar region were the most prevalent.
The logistic regression showed the variables associated with the presence of MSS in the evaluated population. The results of this analysis are presented in Table 4.
The logistic regression analysis (Table 4) showed that spinal pain in the last 12 months, particularly in the lumbar region, was significantly associated with job position, i.e. LPNs presented with more symptoms. Despite the differences in work demand between departments, there was no relationship between job sector and musculoskeletal symptoms. Smoking was significantly associated with thoracic spine symptoms; physical exercise had a protective effect on the cervical spine. Pain in the lower limbs, particularly in the knees, was significantly associated with the presence of previous sick leave; and UL symptoms were significantly more frequent in women.
DLA impairment due to symptoms in different body regions, particularly the lumbar spine followed by the spine in general, shoulders, and thoracic spine, were significantly associated with a history of previous sick leave due to musculoskeletal problems (Table 4). DLA impairment due to UL symptoms was also significantly associated with housework.
Seeking medical assistance was associated with previous sick leave due to MSS in general, particularly in the cervical spine and ULs (Table 4). Having another paid occupation also led workers who experienced pain in the thoracic spine and shoulders to seek medical assistance. Job position as an LPN was associated with seeking medical assistance for lumbar pain.
Discussion
The most prevalent body regions for symptoms in the previous 12 months were the
lumbar spine, shoulders, and neck, followed by the thoracic spine and the ankle and
foot region. Similar results were found in studies that used the NMQ to evaluate
LPNs and NTs in Brazil1111. Gurgueira GP, Alexandre NMC, Correa HR Fo. Prevalência de
sintomas musculoesqueléticos em trabalhadores de enfermagem. Rev Latino-Am
Enferm. 2003;11(5):608-13. http://dx.doi.org/10.1590/S0104-11692003000500007
http://dx.doi.org/10.1590/S0104-11692003...
12. Barbosa AA, Santos AMC, Gonçalves RV, Viana SO, Sampaio RF.
Prevalência de dor osteomuscular na equipe de enfermagem no hospital da policia
militar de Minas Gerais. Fisioter Mov. 2006;19(3):55-63.
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1313. Magnago TSBS, Lisboa MTL, Griep RH, Kirchhof ALC, Guido LA.
Psychosocial Aspects of Work and Musculoskeletal Disorders in Nursing Workers.
Rev Latino-Am Enferm. 2010;18(3):429-35.
http://dx.doi.org/10.1590/S0104-11692010000300019
http://dx.doi.org/10.1590/S0104-11692010...
, as well as in studies from other countries with nursing assistants77. Ando S, Ono Y, Shimaoka M, Hiruta S, Hattori Y, Hori F, et al.
Associations of self-estimated workloads with musculoskeletal symptoms among
hospital nurses. Occup Environ Med. 2000;57(3):211-6. PMid:10810105
PMCid:PMC1739924. http://dx.doi.org/10.1136/oem.57.3.211
http://dx.doi.org/10.1136/oem.57.3.211...
,
99. Lagerström M, Wenemark M, Hagberg M, Hjelm EW. Occupational and
individual factors related to musculoskeletal symptoms in five body regions
among Swedish nursing personnel. Int Arch Occup Environ Health.
1995;68(1):27-35. PMid:8847110. http://dx.doi.org/10.1007/BF01831630
http://dx.doi.org/10.1007/BF01831630...
,
1818. Josephson M, Lagerström M, Hagberg M, Wigaeus Hjelm E.
Musculoskeletal symptoms and job strain among nursing personnel: a study over a
three year period. Occup Environ Med. 1997;54(9):681-5. PMid:9423583
PMCid:PMC1128844. http://dx.doi.org/10.1136/oem.54.9.681
http://dx.doi.org/10.1136/oem.54.9.681...
,
1919. Augusto VG, Sampaio RF, Tirado MGA, Mancini MC, Parreira VF. A
look into Repetitive Strain Injury/ Work-Related Musculoskeletal Disorders
within physical therapists' clinical context. Rev Bras Fisioter.
2008;12(1):49-56.
http://dx.doi.org/10.1590/S1413-35552008000100010
http://dx.doi.org/10.1590/S1413-35552008...
,
3535. Tezel A. Musculoskeletal complaints among a group of Turkish
nurses. Int J Neurosci. 2005;115(6):871-80. PMid:16019580.
http://dx.doi.org/10.1080/00207450590897941
http://dx.doi.org/10.1080/00207450590897...
,
3636. Feng CK, Chen ML, Mao IF. Prevalence of and risk factors for
different measures of low back pain among female nursing aides in Taiwanese
nursing homes. BMC Musculoskelet Disord. 2007;8:52. PMid:17593305
PMCid:PMC1920507. http://dx.doi.org/10.1186/1471-2474-8-52
http://dx.doi.org/10.1186/1471-2474-8-52...
.
A mean of 92.1% of the participants of these studies reported symptoms in at least one body region compared to 93.5% in the present study, indicating a very high and similar prevalence (Table 5). The percentages per region were also high and similar between the other studies and the present one: 65.8 and 57% for the lumbar spine, 50.3 and 52% for the shoulder, and 49.3 and 48% for the neck, respectively. Most of the studies in Table 5 also identified the lumbar spine, neck, and shoulder as the most prevalent regions for MSS among nursing professionals.
A high prevalence of MSS in the lumbar spine, shoulder, and neck regions was reported
by nursing professionals2828. Smith DR, Wei N, Zhao L, Wang RS. Musculoskeletal complaints and
psychosocial risk factors among Chinese hospital nurses. Occup Med (Lond).
2004;54(8):579-82. PMid:15576874.
http://dx.doi.org/10.1093/occmed/kqh117
http://dx.doi.org/10.1093/occmed/kqh117...
,
3737. Smedley J, Inskip H, Trevelyan F, Buckle P, Cooper C, Coggon D.
Risk factors for incident neck and shoulder pain in hospital nurses. Occup
Environ Med. 2003;60(11):864-9. PMid:14573717 PMCid:PMC1740408.
http://dx.doi.org/10.1136/oem.60.11.864
http://dx.doi.org/10.1136/oem.60.11.864...
. The activities performed in direct patient care usually involve upper limb
force, trunk flexion, and extension movements causing an impact on the
musculoskeletal system, particularly for the spine and shoulder regions1717. Hoogendoorn WE, Van Poppel MN, Bongers PM, Koes BW, Bouter LM.
Physical load during work and leisure time as risk factors for back pain. Scand
J Work Environ Health. 1999;25(5):387-403. PMid:10569458.
http://dx.doi.org/10.5271/sjweh.451
http://dx.doi.org/10.5271/sjweh.451...
,
3535. Tezel A. Musculoskeletal complaints among a group of Turkish
nurses. Int J Neurosci. 2005;115(6):871-80. PMid:16019580.
http://dx.doi.org/10.1080/00207450590897941
http://dx.doi.org/10.1080/00207450590897...
,
3838. Waters TR, Nelson A, Proctor C. Patient handling tasks with high
risk for musculoskeletal disorders in critical care. Crit Care Nurs Clin North
Am. 2007;19(2):131-43. PMid:17512469.
http://dx.doi.org/10.1016/j.ccell.2007.02.008
http://dx.doi.org/10.1016/j.ccell.2007.0...
. Along these lines, Tullar et al.3939. Tullar JM, Brewer S, Amick BC 3rd, Irvin E, Mahood Q, Pompeii
LA, et al. Occupational safety and health interventions to reduce
musculoskeletal symptoms in the health care sector. J Occup Rehabil.
2010;20(2):199-219. PMid:20221676. http://dx.doi.org/10.1007/s10926-010-9231-y
http://dx.doi.org/10.1007/s10926-010-923...
recognized the role of patient transfer and lifting activities on the
presence of musculoskeletal disorders among healthcare workers. The main risk
factors for the development of musculoskeletal disorders among these workers are:
pushing occupied beds, lateral patient transfers, repositioning patients in bed,
making occupied beds, as well as lifting and carrying heavy equipment over long
distances4040. Waters T, Collins J, Galinsky T, Caruso C. NIOSH research
efforts to prevent musculoskeletal disorders in the healthcare industry. Orthop
Nurs. 2006;25(6):380-9. PMid:17130760.
http://dx.doi.org/10.1097/00006416-200611000-00007
http://dx.doi.org/10.1097/00006416-20061...
.
Even though the results presented in Table 5
were from different countries and involve different cultures and availability of
equipment, the MSS prevalence was high in all of them. Several aspects seem to
contribute to this in different ways, such as mean worker age, time in job position,
patient impairments, and technology available for facilitating patient
transportation3939. Tullar JM, Brewer S, Amick BC 3rd, Irvin E, Mahood Q, Pompeii
LA, et al. Occupational safety and health interventions to reduce
musculoskeletal symptoms in the health care sector. J Occup Rehabil.
2010;20(2):199-219. PMid:20221676. http://dx.doi.org/10.1007/s10926-010-9231-y
http://dx.doi.org/10.1007/s10926-010-923...
,
4141. Videman T, Ojajärvi A, Riihimäki H, Troup JD. Low back pain
among nurses: a follow-up beginning at entry to the nursing school. Spine (Phila
Pa 1976). 2005;30(20):2334-41.
http://dx.doi.org/10.1097/01.brs.0000182107.14355.ca
http://dx.doi.org/10.1097/01.brs.0000182...
.
The results of the logistic regression showed that previous sick leave due to
musculoskeletal pain was strongly associated with seeking medical assistance due to
MSS. Similar results were found among general workers evaluated by Haahr et al.4242. Haahr JP, Frost P, Andersen JH. Predictors of health related job
loss: a two-year follow-up study in a general working population. J Occup
Rehabil. 2007;17(4):581-92. PMid:17957450.
http://dx.doi.org/10.1007/s10926-007-9106-z
http://dx.doi.org/10.1007/s10926-007-910...
. Even though sick leave policies vary according to each country's
legislation, in general, these benefits are given only after medical confirmation of
the seriousness of the injury and degree of functional impairment4343. Kivimaki M, Head J, Ferrie JE, Shipley MJ, Vahtera J, Marmot MG.
Sickness absence as a global measure of health: evidence from mortality in the
Whitehall II prospective cohort study. BMJ. 2003;327:364 PMid:12919985
PMCid:PMC175810 . http://dx.doi.org/10.1136/bmj.327.7411.364
http://dx.doi.org/10.1136/bmj.327.7411.3...
. Therefore, an association between sick leave, severe symptoms, the search
for medical assistance, and DLA impairment is not surprising. Another aggravating
factor is poor recovery after musculoskeletal injury. According to Rosenman et
al.4444. Rosenman KD, Gardiner JC, Wang J, Biddle J, Hogan A, Reilly MJ,
et al. Why most workers with occupational repetitive trauma do not file for
workers' compensation. J Occup Environ Med. 2000;42(1):25-34. PMid:10652685.
http://dx.doi.org/10.1097/00043764-200001000-00008
http://dx.doi.org/10.1097/00043764-20000...
, this is often due to the workers' lack of access to qualified
rehabilitation services.
Job position was a major factor for spine-related outcomes; LPNs had a greater chance
of presenting symptoms and seeking medical assistance than NTs. This subject still
seems to be controversial in the literature. In a number of countries, the education
level of nursing assistants is lower than registered nurses and they are
acknowledged to have a greater predisposition to low back pain than registered
nurses1818. Josephson M, Lagerström M, Hagberg M, Wigaeus Hjelm E.
Musculoskeletal symptoms and job strain among nursing personnel: a study over a
three year period. Occup Environ Med. 1997;54(9):681-5. PMid:9423583
PMCid:PMC1128844. http://dx.doi.org/10.1136/oem.54.9.681
http://dx.doi.org/10.1136/oem.54.9.681...
,
3535. Tezel A. Musculoskeletal complaints among a group of Turkish
nurses. Int J Neurosci. 2005;115(6):871-80. PMid:16019580.
http://dx.doi.org/10.1080/00207450590897941
http://dx.doi.org/10.1080/00207450590897...
,
3838. Waters TR, Nelson A, Proctor C. Patient handling tasks with high
risk for musculoskeletal disorders in critical care. Crit Care Nurs Clin North
Am. 2007;19(2):131-43. PMid:17512469.
http://dx.doi.org/10.1016/j.ccell.2007.02.008
http://dx.doi.org/10.1016/j.ccell.2007.0...
. Considering that the names used to classify nursing professionals vary from
country to country according to the work organization and the workers' educational
level, direct comparisons between groups should be avoided. Despite this, as
previously described, both NTs and LPNs perform highly demanding physical tasks.
Nevertheless, LPNs are exposed to a higher cognitive overload due to accumulated
activities and the greater complexity of their tasks, which could explain the
present results for these two job positions.
Housework was associated with symptoms. However, this result must be interpreted with caution, since the negative value found for the β coefficient could suggest that performing housework would reduce the probability of DLA impairment by 0.194 due to UL symptoms. In fact, this association might be interpreted as an antalgic, rather than a protective factor.
Women had a 30% greater chance of developing UL symptoms than men. A review
study4545. Treaster DE, Burr D. Gender differences in prevalence of upper
extremity musculoskeletal disorders. Ergonomics.
2004;47(5):495-526. reinforces this finding, demonstrating that women have a greater tendency to
present upper MSS than men. Among several other factors, an association between
housework, gender, and UL symptoms is recurrent in several studies. Nordander et
al.4646. Nordander C, Ohlsson K, Balogh I, Hansson GA, Axmon A, Persson
R, et al. Gender differences in workers with identical repetitive industrial
tasks: exposure and musculoskeletal disorders. Int Arch Occup Environ Health.
2008;81(8):939-47. PMid:18066574. http://dx.doi.org/10.1007/s00420-007-0286-9
http://dx.doi.org/10.1007/s00420-007-028...
hypothesize that the dedication of free time to housework reduces the
recovery period required by the muscle groups involved at work and increases the
risk of injury, particularly for physically demanding jobs, as is the case of the
evaluated workers.
Regarding personal risks, smoking was identified as an important factor for symptoms
in the thoracic region, lumbar region, and spine in general. Power et al.4747. Power C, Frank J, Hertzman C, Schierhout G, Li L. Predictors of
low back pain onset in a prospective British study. Am J Public Health.
2001;91(10):1671-8. PMid:11574334 PMCid:PMC1446853.
http://dx.doi.org/10.2105/AJPH.91.10.1671
http://dx.doi.org/10.2105/AJPH.91.10.167...
and Bejia et al.4848. Bejia I, Younes M, Jamila HB, Khalfallah T, Ben Salem K, Touzi
M, et al. Prevalence and factors associated to low back pain among hospital
staff. Joint Bone Spine. 2005;72(3):254-9. PMid:15850998.
http://dx.doi.org/10.1016/j.jbspin.2004.06.001
http://dx.doi.org/10.1016/j.jbspin.2004....
also found a positive association between lumbar pain and smoking for
individuals who performed physically demanding activities. Nevertheless, Lagerström
et al.99. Lagerström M, Wenemark M, Hagberg M, Hjelm EW. Occupational and
individual factors related to musculoskeletal symptoms in five body regions
among Swedish nursing personnel. Int Arch Occup Environ Health.
1995;68(1):27-35. PMid:8847110. http://dx.doi.org/10.1007/BF01831630
http://dx.doi.org/10.1007/BF01831630...
found no such association in a study conducted with NTs.
It has been acknowledged that nicotine causes vasoconstriction which reduces the
amount of oxygen and nutrients available to muscles, ligaments, and intervertebral
discs, increasing chances for degenerative processes in the intervertebral
discs4949. Akmal M, Kesani A, Anand B, Singh A, Wiseman M, Goodship A.
Effect of nicotine on spinal disc cells: a cellular mechanism for disc
degeneration. Spine (Phila Pa1976). 2004;29(5):568-575.
http://dx.doi.org/10.1097/01.BRS.0000101422.36419.D8
http://dx.doi.org/10.1097/01.BRS.0000101...
and injuries5050. Uematsu Y, Matuzaki H, Iwahashi M. Effects of nicotine on the
intervertebral disc: an experimental study in rabbits. J Orthop Sci.
2001;6(2):177-182. PMid:11484105. http://dx.doi.org/10.1007/s007760100067
http://dx.doi.org/10.1007/s007760100067...
. Furthermore, continued smoking affects lung clearance, causing an
accumulation of secretion and increasing coughing reflexes5151. Bennett WD, Chapman WF, Gerrity TR. Ineffectiveness of cough for
enhancing mucus clearance in asymptomatic smokers. Chest. 1992;102(2):412-6.
PMid:1643924. http://dx.doi.org/10.1378/chest.102.2.412
http://dx.doi.org/10.1378/chest.102.2.41...
, which overloads intercostal muscles and increases intra-abdominal pressure.
The main biological mechanisms triggered by smoking that could explain spinal
symptoms are linked to: 1) coughing reflexes; 2) increased fibrin deposition which
leads to chronic inflammation; and 3) reduced blood flow and oxygenation of the
tissues, which affect the metabolic balance of the discs and accelerate degenerative
processes leaving the spine more susceptible to mechanical deformations and
injuries5252. Goldberg MS, Scott SC, Mayo NE. A review of the association
between cigarette smoking and the development of nonspecific back pain and
related outcomes. Spine (Phila Pa 1976). 2000;25(8):995-1014.
http://dx.doi.org/10.1097/00007632-200004150-00016
http://dx.doi.org/10.1097/00007632-20000...
.
It is important to consider that, even though several epidemiological studies have
reported an association between smoking and lumbar pain, factors such as the variety
of definitions of lumbar pain, the multiple causes of the symptoms, and the
variations in evaluation approaches and results make it difficult to come to a
conclusive understanding of the literature88. Lorusso A, Bruno S, L'Abbate N. A review of low back pain and
musculoskeletal disorders among Italian nursing personnel. Ind Health.
2007;45(5):637-44. PMid:18057806. http://dx.doi.org/10.2486/indhealth.45.637
http://dx.doi.org/10.2486/indhealth.45.6...
,
5353. Buchanan AV, Weiss KM, Fullerton SM. Dissecting complex disease:
the quest for the Philosopher's Stone? Int J Epidemiol. 2006;35(5):562-71.
PMid:16540539. http://dx.doi.org/10.1093/ije/dyl001
http://dx.doi.org/10.1093/ije/dyl001...
and limit comparison of the results.
Among the personal aspects investigated here, some attenuating factors were
identified, such as the protective effect of physical exercise against neck
symptoms. This subject still seems to be controversial in the literature. Lagerström
et al.99. Lagerström M, Wenemark M, Hagberg M, Hjelm EW. Occupational and
individual factors related to musculoskeletal symptoms in five body regions
among Swedish nursing personnel. Int Arch Occup Environ Health.
1995;68(1):27-35. PMid:8847110. http://dx.doi.org/10.1007/BF01831630
http://dx.doi.org/10.1007/BF01831630...
identified that a poor physical condition increases the chance of cervical
symptoms by 1.43, which supports the possibility that exercise has a protective
effect against neck symptoms. However, other studies have reported that the
incidence of neck pain in workers who exercise regularly in their free time is
similar to that of those who do not5454. Eriksen W, Natvig B, Knardahl S, Bruusgaard D. Job
characteristics as predictors of neck pain. A 4-year prospective study. J Occup
Environ Med. 1999;41(10):893-902. PMid:10529945.
http://dx.doi.org/10.1097/00043764-199910000-00010
http://dx.doi.org/10.1097/00043764-19991...
,
5555. Luime JJ, Koes BW, Miedem HS, Verhaar JA, Burdorf A. High
incidence and recurrence of shoulder and neck pain in nursing home employees was
demonstrated during a 2-year follow-up. J Clin Epidemol. 2005;58(4):407-13.
PMid:15862727. http://dx.doi.org/10.1016/j.jclinepi.2004.01.022
http://dx.doi.org/10.1016/j.jclinepi.200...
. This controversy may be related to the definition of physical exercise
because when the control of this variable (exercise) is increased, its protective
effect becomes more consistent.
Systematic reviews about the effects of exercise on musculoskeletal pain in active
workers2929. Coury HJCG, Moreira RFC, Dias NBD. Evaluation of workplace
exercise effectiveness on neck, shoulder and low back pain control: a systematic
review. Rev Bras Fisioter. 2009;13:461-479.
http://dx.doi.org/10.1590/S1413-35552009000600002
http://dx.doi.org/10.1590/S1413-35552009...
,
3131. Moreira RFC, Foltran FA, Albuquerque-Sendín F, Mancini MC, Coury
HJCG. Comparison of randomized and nonrandomized controlled trials evidence
regarding the effectiveness of workplace exercise on musculoskeletal pain
control. Work. 2012; 41:4782-4789. PMid:22317457. found a protective effect in the occupational environment against lumbar and
cervical pain in workers with heavy and sedentary activities, respectively. Martins
and Marzialle5656. Martins LV, Marziale MH. Assessment of proprioceptive exercises
in the treatment of rotator cuff disorders in nursing professionals: a
randomized controlled clinical trial. Rev Bras Fisioter. 2012;16(6):502-9.
PMid:23117648.
http://dx.doi.org/10.1590/S1413-35552012005000057
http://dx.doi.org/10.1590/S1413-35552012...
also identified benefits of therapeutic exercises for nursing workers with
shoulder pain.
Additionally, a cohort study5757. Van den Heuvel SG, Heinrich J, Jans MP, Van der Beek AJ, Bongers
PM. The effect of physical activity in leisure time on neck and upper limb
symptoms. Prev Med. 2005;41(1):260-7. PMid:15917020.
http://dx.doi.org/10.1016/j.ypmed.2004.11.006
http://dx.doi.org/10.1016/j.ypmed.2004.1...
with 1,742 symptomatic and asymptomatic workers demonstrated that regular
involvement in sports for at least 10 months per year reduced the risk of symptoms
in the neck and shoulder regions (OR:0.82). Thus, in the case of exercise carried
out regularly in an occupational environment, as well as the regular practice of
sports, there was a protective effect of physical activity on musculoskeletal pain
in active workers.
Limitations and final considerations
The cross-sectional design of the present study does not allow for causal
relations to be established between the symptoms and exposure to the tasks
performed by NTs and LPNs. According to Punnett and Wegman5858. Punnett L, Wegman DH. Work-related musculoskeletal disorders:
the epidemiological evidence and the debate. J Electromyogr Kinesiol.
2004;14(1):13-23. PMid:14759746.
http://dx.doi.org/10.1016/j.jelekin.2003.09.015
http://dx.doi.org/10.1016/j.jelekin.2003...
, another limitation associated with cross-sectional studies carried out
in work environments is the selection bias due to the exclusive evaluation of
active workers, which can underestimate the symptoms of the full staff as it
does not include data from individuals on leave.
A positive aspect of this study was the evaluation of personal factors and their participation in work-related disorders, which has not been clearly established so far. Considering the high prevalence of MSS among the evaluated professionals and the impairments that these symptoms might cause, public policy should encourage their prevention to reduce sick leave. Stimulating physical exercise, organizing anti-smoking campaigns, controlling risk factors through ergonomic intervention, ensuring proper training and breaks are some of the measures that should also be undertaken.
Conclusion
The LPNs and NTs evaluated in this study showed a high prevalence of musculoskeletal disorders, and the most affected regions were the lumbar spine, shoulder, and neck. The spinal symptoms caused the greatest DLA impairment and were the most frequent reason for seeking medical assistance, which suggests that disorders in this region were severe.
Previous history of sick leave due to MSS was the strongest variable associated with the presence of symptoms in several body regions. This result shows the importance of preventive programs designed for hospital work environments in order to control more severe musculoskeletal consequences among nursing professionals such as those identified in the present study.
Acknowledgements
To the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brasilia, DF, Brazil (Processes 147025/2010-9; 301.772/2010-0; 473.126/2010).
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Publication Dates
-
Publication in this collection
18 July 2014 -
Date of issue
Aug 2014
History
-
Received
04 Aug 2013 -
Reviewed
17 Jan 2014 -
Accepted
17 Feb 2014