Research Article

Musculoskeletal Disorders in Medical and Surgical Residents in a Tertiary Care Center in Pakistan

Hareem Usman Khan, Montasir Junaid*, Muhammad Sohail Halim, Anwar Suhail and Sadaf Qadeer Ahmed

1Stanford University, Palo Alto, California, USA
2Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
3Aga Khan University and Hospital, Karachi, Pakistan
4Sir Syed College of Medical Science for girls, Karachi, Pakistan

Published Date: 22/12/2020

*Corresponding author:Montasir Junaid, Consultant-Otolaryngology –Head and Neck Surgery, Armed Forces Hospital Southern Region, Khamis Mushait, Address: Villa 301- La Fontaine, Near Okaz Bakery, Madina Askari Road, Khamis Mushait, Saudi Arabia

DOI: 10.51931/OAJCS.2020.01.000015

Abstract

Context: Back and neck pain are the two biggest causes of disability worldwide. Physicians and surgeons continually work significantly prolonged hours in an environment which makes them even more prone to injuries.

Objective: The purpose of the study is to assess the prevalence of neck and lower back and its severity and risk factors among different medical specialties in a developing country.

Methods: A cross-sectional study was conducted at a tertiary care facility at Karachi, Pakistan. Residents from various medical specialties were invited to fill out a structured 38-question questionnaire. Questions related to the age, gender, working hours, presence of neck and back pain, history of trauma, history of back pain, frequency of pain, and whether they sought treatment for their pain were included in the questionnaire. Pain score was calculated using Oswestrylow back pain and neck disability questionnaire. Statistical analysis was performed using Stata v16.1.

Results: Musculoskeletal disorders (MSD) are common among medical and surgical residents as 50 % suffered from back pain while 54 %reported experiencing neck pain. Prolonged working hours, gender and prior history were identified as risk factors.

Conclusion: More attention should be directed to improving the physical environments in which the residents are operating, and support and training should be offered to keep an effective ergonomic posture that can prevent or decrease their work-related MSD manifestations.

Key Message: This article describes the prospective study that describes the prevalence of neck and lower back pain among residents of various specialities. The result indicates that it is common among residents and attention should be given towards its prevention among the training physicians.

Keywords: Musculoskeletal disorders, Back pain, Neck pain, Residents

Introduction

The global burden of disease study has consistently ranked low-back pain and neck pain as the biggest and fourth biggest causes of disability worldwide, respectively, counting years lived with disability DALY [1-5]. On average, 60-80% of people are affected by neck and back pain during their lifetime(6).
Healthcare providers are at even greater risk of work-related musculoskeletal disorders. A quick search of the literature reveals that numerous studies have been conducted on the prevalence of musculoskeletal pain in nursing staff, and its effects on their physical and mental well-being at their workplace and beyond. Based on these studies several health care institutions have implemented guidelines and proper training to rectify this issue [7-9], but sadly the same cannot be said for doctors.

 

Physicians and surgeons continually work significantly prolonged hours in an environment which makes them prone to injuries. Although the nature and ergonomics of various tasks differ among different medical specialties, extensive work hours, lack of rest and difficult working positions, during prolonged procedures, exert stress on the spine repeatedly which can result in neck and lower back pain and can potentially be debilitating. The few studies that do assess the risks of healthcare related musculoskeletal disorders have mostly been conducted in developed countries. There is a dearth of literature on the topic from developing countries where the working conditions are much harsher and work hours longer. This occupational injury is not just a physical hazard but it also results in significant mental and financial burden on the individual and the healthcare system. Various studies attribute musculoskeletal injuries at work, to lack of productivity, absenteeism and even earlier retirement in some cases [10,11],. In US alone the annual direct financial cost of treating Musculoskeletal disease is around 200 million.(6) A similar report from the UK, published in November 2020, demonstrated that work-related injuries and ill health resulted in £16.2 billion cost to taxpayers [12],. With this study we aim to assess the prevalence of neck and lower back and its severity and risk factors among different medical specialties in a developing county.

Materials and Methods

This cross-sectional study was conducted at a tertiary care facility at Karachi, Pakistan (January 2016-January 2018)Residents from various medical specialties were invited to fill out a structured 38-question questionnaire. Specialties like pathology, community medicine, general medicine, pediatric medicine, and psychiatry were included into medicine and allied group; otolaryngology, orthopedics, neurosurgery, urology, pediatric surgery and cardiothoracic surgery were group into surgery and allied. Other specialties included in the study were anesthesia, emergency medicine and dentistry. Incomplete questionnaire and refusal to consent for the study were the key exclusions. Ethical approval was obtained from the institutional review board.

Questions related to the age, gender, working hours, presence of neck and back pain, history of trauma, history of back pain, frequency of pain, and whether they sought treatment for their pain were included in the questionnaire. Pain in the lumbar region, below the thoracic vertebrae up to the hips, was defined as back pain. While pain in the cervical vertebrae region was defined as neck pain. Pain score was calculated using Oswestry low back pain and neck disability questionnaire [13]. Statistical analysis was performed using Stata v15.1 (Stata Corp, TX). Frequencies were compared using the chi-square test and Fisher exact test. Chi2 and ANOVA were used to assess the differences among the study groups for age, gender, BMI, mean pain score, working hours per week. Univariate logistic regression modeling was utilized to assess the probability of neck and back pain based on gender, specialty of medicine and working hours. Statistical significance for the study was deemed at a p value of <0.05.

Results

One hundred and thirty (130) residents from various specialties of medicine and surgery were included in the study. The demographics for the study population has been shown in Table 1. Mean age for all the subjects was 29.43 ± 3.66 years. 51.54% of subjects were females. Mean BMI of the study group was 24.54 ± 3.57. There was no statistical difference in the BMI of the study groups (p 0.12). Majority (70.59%) of the residents from surgery and allied had long working hours (115-125 hours) per week. While all the residents from dentistry had the least working hours per week (65-75 hours). Seventeen (13.08%) subjects had a history of neck and back pain prior to starting residency. Sixty-seven (67) subjects (51.54%) had complaints of back pain at the time of the study (Table 2). The proportions of residents with highest complaints of back pain belonged to surgery and allied (78.43%) followed by emergency medicine (66.67%). Back pain was lowest in dentistry (14.29%) and radiology (22.22%). The mean pain score for back pain was the highest in dentistry, followed by radiology. Residents belonging to surgery and allied had the highest frequency of back pain with 13.73 residents complaining of back pain every day while approx. 37% of the residents complaining of back pain once or more times per week. Back pain was the most severe at work in 33% of the study population. The frequency of subjects complaining of the back pain being the worst at work was highest amongst surgery and allied (43.14%) followed by anesthesia (42.86%).

Seventy (70) subjects (53.85%) had complaints of neck pain at the time of the study (Table 3). The proportions of residents with highest complaints of neck pain belonged to dentistry (100%) followed by radiology and emergency medicine (66.67%). Neck pain was lowest in anesthesia (12.43%). The mean pain score for neck pain was the highest in anesthesia, followed by surgery and allied. Residents belonging to dentistry had the highest frequency of neck pain with approximately 71% residents complaining of neck pain once or more times per week. Neck pain was the most severe at work in 32.31% of the study population. The frequency of subjects complaining of the back pain being the worst at work was highest amongst dentistry (57.14%) followed by emergency medicine (50%).

Gender was a significant risk factor for back pain, with 63.49% males reporting back pain (p: 0.008). However, there was no statistically significant difference in gender for neck pain (p: 0.17). Mean age of subjects complaining of neck and back pain was not significantly different in subjects with or without neck and back pain (p>0.05). The mean BMI among individuals with lower back pain was 25.09 compared to 23.95 among subjects who did not report back pain, however this difference was not statistically significant (p: 0.06). Similarly, subjects with neck pain had a mean BMI of 25.35 while those without had a BMI of 23.59. Though Increase BMI is a causative factor for pain in Weight bearing joints, in our study It was more significant for neck pain. (p: 0.005). Majority of the subjects with back pain had long working hours of 49% of the subjects working 115-125 hours per week compared to only 5% of the subjects working the same amount in the group that did not have complaints of back pain (Table 4). Univariate logistic regression identified gender, specialty and more hours of work per week as significant risk factors for back pain (Table 5). While these risk factors were not significant for neck pain. The probability of neck and back pain for working hours per week has been shown in Figure 1.

Table 1: Demographics.

Table 2: Back pain.

Table 3: Neck Pain.

Table 4: Distribution Analysis.

Table 5: Univariate Logistic Regression.

Figure 1: Probability of Neck and Back Pain by Working Hours Per Week.

Discussion

Sustained unnatural postures and repetitive prolonged procedures often leads to temporary or sustained injuries resulting in disability. These include injuries affecting muscles, tendons, and nerves [14] Physicians who perform procedures like surgeries and medical interventions have a higher risk for work-related musculoskeletal disorders. In our study, 51-53% of the subjects had either neck pain, back pain or both during the residency training. While only 13% of the subjects had a history of neck and back pain prior to residency.

Work environment and working conditions of surgeons has been described as equal to, if not at times harsher than, those of certain industrial workers [14,15]. Often, the surgeons are required to work in repetitive, awkward unnatural postures for hours, leading to higher risk of work-related musculoskeletal disorders (MSDs). Nevertheless, these factors differ according to each physician specialty. Such higher-than-normal observations among physician and surgeons have been witnessed in other studies demonstrating higher prevalence estimates of work-related MSDs. The incidence of MSDs in surgeons was observed to be comparable to labor-intensive occupations, such as coal miners, manufacturing laborers, and physical therapists when compared to healthy controls [14]. Advancement in the field of medicine also resulted in advancement in the surgical tools and techniques, providing some relief, however, physician and surgeons are continuing to experience MSDs, demonstrating the need for interventions and advanced in surgical tools. Unfortunately, majority of the studies assessing the burden of MSDs in healthcare workers have been conducted in developed countries and do not necessarily reflect the risks associated with healthcare work in developing nations. In the index study, we aim to ascertain the burden of MSDs in the physicians and surgeons, in order to provide baseline information for future intervention.

There were 130 residents identified as involved in patientcare who completed the survey. Data collected from this comprehensive 38-question survey were analyzed using chi-square. Sixty-seven (67) subjects (51.54%) had complaints of back pain at the time of the study. The proportions of residents with highest complaints of back pain belonged to surgery and allied (78.43%) followed by emergency medicine (66.67%). While neck pain was highest in radiology and emergency medicine residents (66.7%). The mean back pain score was the highest in dentistry and radiology while neck pain score was the highest in anesthesia. This reiterates the findings observed in studies conducted in other parts of the world. In literature, it has been observed that approximately 47% to 71% of surveyed otolaryngologists reported back or neck pain associated with their surgical practice [16-18] which could be attributed to microscope work and prolonged sitting. Such findings have also been observed in various medical and/or surgical specialties [19-23].The significance of these self-reported findings has demonstrated the dearth of awareness and adequate trainings to prevent long-term disability in healthcare professionals.

In our study, gender was a significant risk factor for back pain, with 63.49% males reporting back pain. However, there was no statistically significant difference in gender for neck pain. This finding has been in contrast with the literature where studies have reported higher incidence of MSDs in females compared to male respondents [23-25], This has been attributed to the lower pain threshold and the tendency for females to seek medical attention more than males [25-28]. This discrepancy between our results and the other studies might be explained by the higher number of female residents in our study belonging to medicine and allied specialties, while more male residents belonged to surgery and allied specialties. The inherent differences in the working postures and the duration of procedures among these specialties may have confounded the effect of gender.

We found that a significantly higher percentage of those with back and neck pain manifestations have prolonged working hours, and higher BMI compared to those who had no symptoms. Residents experiencing back and neck pain experienced the most severe pain at work compared to being at home. History of back pain prior to the residency was also a significant contributor to the morbidity. Such findings highlight the strenuous working conditions which exacerbates the pain being experienced by residents. Furthermore, increased forces across the joints likely play a role in the relationship between a higher BMI and weight-bearing joints (back and lower extremities), compared to non-weight-bearing joints (shoulder/neck and upper extremities) [29] .Adequate trainings and pain management will significantly improve the physical discomfort in such circumstances. It has also been demonstrated that workplace physical exercise is more effective than home-based exercise in reducing musculoskeletal pain, increasing muscle strength and reducing the use of analgesics among healthcare workers [30].

There is a need for repeating this study with long-term follow-up to assess the coping mechanisms being utilized by these healthcare providers in the long run which will provide useful insights into designing an effective strategy towards prevention. We need to devise primary as well as secondary prevention strategies to decrease the prevalence of MSDs among medical and surgical residents so that can effectively take care of patient and focus on their work. This study used a self-reported questionnaire to be completed by the study participants, who described their own conditions. There is a possibility that they may have overestimated their past experiences owing to the recall bias.

Conclusion

Musculoskeletal disorders (MSD) are common among medical and surgical residents as fifty percent suffered from back pain while fifty four percent reported experiencing neck pain, that were related to various healthcare specialties, probable risk factors were prolonged working hours, gender and prior history. More attention should be directed to improving the physical environments in which the residents are operating. Moreover, residents should be trained to keep an effective ergonomic posture that can prevent or decrease their work-related MSD manifestations.

Funding

None

Conflict of Interests

None

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