Work-Related Musculoskeletal Disorders among Prosthetic and Orthotic Professionals in India - A Cross Sectional Study

Introduction

Musculoskeletal disorders (MSDs) are a growing concern globally.^1,2 MSDs are injuries or disorders that affect the musculoskeletal system in the human body. They are referred to as work-related musculoskeletal disorders (WMSDs), when there is a discrepancy between the physical capacity of the human body and the physical requirements of the task.³ They appear to be the primary cause of morbidity and disability in any workforce, impacting the individual’s quality of life, and working ability, globally.⁴ As indicated by World Health Organisation (WHO), the etiology of WMSD is multifactorial, seemingly being linked to a range of physical hazards, psychosocial hazards, and individual factors that can contribute to WMSD.^5,6

WMSDs are also a cause of concern in the healthcare sector. Allied healthcare professionals are prone to a range of hazards and risks that may lead to a higher chance of occurrence of WMSD.⁷ Prosthetists/Orthotists (P&Os) are a unique group within the allied health profession.⁸ P&Os are at greater risk for workplace injuries compared to other allied healthcare professionals.⁹ As they work in both clinical and manufacturing areas, they often get exposed to various physical tasks such as heavy load lifting, awkward postures, force exertion, repetitive movements, vibration, contact stress, pinch grips, and environmental factors like noise, chemical exposure, illumination, temperature. Notably, the other causative factors for musculoskeletal injuries include exposure to various psychosocial hazards including time pressure, interactions with challenging clients, teamwork challenges, and complex decision making.^10–12

The high rate of prevalence of WMSD sustained by P&Os in Bangkok, Korea, and Australia are of concern to the profession.^11,13–15 The high demand and lower number of professionals increase the extra burden and workload on P&O professionals, and this might be causing WMSDs.¹⁶ Despite having multiple risk factors that might lead to WMSDs, there are a limited number of studies showing the prevalence of WMSDs in P&O professionals, and data on the prevalence of WMSD in P&O professionals in India is still not available. Presumably, the prevalence rate of WMSDs in India will be similar or higher compared to the occurrences in developed countries, given the widespread reliance on hard physical work and frequent manual load handling carried out by the P&Os. As this profession requires skills that refine over time, retaining skilled staff with emphasis on the maintenance of their health becomes need of the hour. Therefore, it is imperative to assess the prevalence of WMSDs in Indian P&Os. The present study was carried out to determine the prevalence rate of musculoskeletal disorders in working P&Os and to identify possible correlations between socio-demographic variables and work-related hazards with discomfort. The outcome of the study might help open avenues for an in-depth investigation and /or may lead to the implementation of preventive measures.

Materials and Methods

The study was a cross-sectional survey carried out among P&Os working in India after obtaining ethical approval from the institution.

Convenient sampling was used to recruit the participants. Rehabilitation Council of India (RCI) registered P&O working professionals with more than one year of experience were included in the study. RCI number from the participants was collected to ensure registration. Those with comorbid conditions such as degenerative disorders, inflammatory, cardiovascular disease, or a history of physical trauma were excluded.

A previously validated questionnaire was used with the addition of some constructs to address profession specific questions.¹⁷ A survey tool was formulated in Google form to elicit information on the prevalence of WMSD and the association between socio–demographic variables and work-related hazards with discomfort. The questionnaire was face validated by a panel made of five experienced P&O professionals. The suggested changes were incorporated and the questionnaires were distributed among ten P&Os for a pilot study to ensure clarity on the content of the questionnaire and the usefulness of this method for measuring prevalence. The Cronbach’s alpha of 0.71, showed good internal reliability of the questionnaire.

To ensure a larger number of responses and for a better outcome from the P&Os, the study was conducted pan India, wherein the final questionnaire (Annexure-1) in the form of Google form link was sent via E-mail, WhatsApp, Facebook, and LinkedIn. The data were collected from 22nd May to 11th July 2022.

The questionnaire was divided into five sections. Section 1 aimed at obtaining informed consent from the participants who will be referred as respondents hereinafter. The respondents were given proper explanation about the objectives, purpose, benefits, and risks (if any), voluntary participation, and assurance about the confidentiality of their responses. Section 2 included nine questions aimed at obtaining baseline data regarding age, gender, educational qualification, work setting, work experience, daily work hours at clinic/workshop, daily work hours at administration, associated medical conditions, and regular exercises. Section 3 adopted from Nordic Questionnaire-Extended,¹⁷ included 11 questions, nine of which aimed at the pain, or discomfort in nine body regions (three each in the upper limbs, spine, and lower limbs) in the past four weeks¹⁸ and the last 12 months¹⁹ instead of career prevalence to reduce recall bias, and the remaining two questions targeted whether they had taken leave or seen a doctor/physician because of pain/ discomfort. Responses were measured using a 4-point ordinal scale with ‘Never’, ‘Sometimes’, ‘Often’, and ‘Always’ responses for finding the frequency of pain.²⁰ Last two questions were asked in dichotomous (yes/no) responses.

Section 4 featured eight questions on physical hazards. Those items that were already identified as the main causative factors for musculoskeletal injuries in the Orthotic and Prosthetic field, were taken from previously used “A Participative Hazard Identification and Risk Management” APHIRM toolkit for physical task demands.²¹ Items were measured using a 5-point ordinal scale from ‘very small extent’ to ‘very large extent’. One question pointed towards occupational tasks causing pain, the respondents had to choose the relevant answers, in addition to specifying any other task contributing to pain during work.

Section 5 included four questions related to psychosocial hazards using single-item measures of job satisfaction, work-life balance using a 5-point response scale from ‘very dissatisfied’ to ‘very satisfied’, team support scale while working with co-workers from ‘major problem’ to ‘very good’ and workload rating from ‘very low’ to ‘very high’. All responses were marked on a 5-point scale. One item was added as a recommendation for future research.

Data analysis

Responses to the questionnaire were assessed using IBM SPSS 22.0 and R environment ver.3.3.2. Sample characteristics were analysed using descriptive statistics. Results on continuous measurements were presented as mean ± SD (min-max) and results on categorical measurements were presented in numbers (%).

The prevalence of WMSD was determined based on the pain and discomfort experienced by the participants in one or more body regions, which they felt sometimes, often, or always, over the past 12 months and four weeks.

The categorical measurements of physical and psychosocial hazards were expressed as numbers (%). Chi-square test was used for determining the association between socio-demographic variables and work-related hazards with discomfort. Significance was assessed at 5% level of significance.

Results

A total of 162 responses were received out of 237, hence the total response rate was 68%. One hundred and twenty P&Os (77 males and 43 females) were included as per inclusion and exclusion criteria.

Demographic details of the participants

Demographic characteristics are presented in Table 1. Majority of the respondents were in the age group of 21- 30 years, higher participation from males and graduates was evident. One-half of the respondents had work experience of 1-5 years and a large number of them were working in multi-national companies.

Prevalence of WMSDs

WMSDs were reported by 95% (n=114) of the respondents in the last 12 months and 92% (110) in the last four weeks. Based on the anatomical location of the pain, all nine body regions were affected, with the most prevalent anatomic regions being the lower back: 79%, neck: 68%, feet/ankles: 60%, knees: 59%, and wrists/ hands: 57% in last 12 months, while in the last four weeks, lower back: 70%, neck: 56%, feet/ankles: 53%, knees: 59%, and shoulders: 49% (Table 2).

The frequency of pain in nine body parts is shown in Table 3.

Pain was “Always” present among 5% (feet/ankles), 4.2% (lower back), and 3.3% (knees). Approximately 55% of P&Os “sometimes” experienced pain in the neck and lower back. Approximately 16% of the respondents took leave from work due to WMSD and 28% visited the doctor for pain.

Risk factors and their association with WMSDs

The association between sociodemographic variables and site-specific musculoskeletal pain is presented in Table 4.

Pain in the lower back was seen more in females (p=0.044). A significant association was found between pain in knees (0.002), lower back (0.057), ankles (0.03), and regular exercises.The association between physical hazards and psychosocial hazards with discomfort is presented in Table 5.

A significant association was noticed between:

• a. Psychosocial hazards - job satisfaction (0.004), work-life balance (0.003), workload (0.004), and discomfort.
• b. Physical hazards - lift or carry heavy things, holding or gripping things, work in twisted or awkward postures with a p-value of 0.002, 0.010, 0.048, respectively, and discomfort.

A list of 11 routine occupational tasks was made to assess the risk factors in the daily working of P&O (Figure 1).

Approximately 32% of the respondents self-reported pain while doing assessment (32%), casting (26%), positive cast rectification (17%), pop mixing and filling (9%), and long-time standing (4%).

Discussion

The present study was the first of its kind, carried out amongst the P&Os working in India to determine the prevalence of WMSDs. As the cause of WMSD is multifactorial, this study also considered other factors like socio-demographic, physical, and psychosocial factors that were previously identified as risk factors for WMSD.

The results were alarming as the prevalence rate of WMSD among Indian P&Os was found to be 95% in the past 12 months and 92% in the past four weeks. Further, the study showed high prevalence in India compared to other countries. Salmani (2016) also highlighted that the majority of population had experienced some form of symptoms during the last 12 months.¹¹ Do-young Jung et al., (2012) reported a 70% prevalence of WMSD in Korea,¹⁵ S. Anderson (2021) et al., reported 80% prevalence in Australia,¹³ Pawita Saiariya et al., (2014) reported a prevalence of 63.2% in the last 12 months and 31.6% in last seven days in Bangkok.¹⁴ The data in the present study support the epidemiological studies of India that indicated occupation specific prevalence to be as high as 90%.¹

The results suggested that WMSDs were more prevalent in the age group of 21-30 years which was in accordance with previously reported studies. Cromie et al., (2008)²² reported younger professionals having a higher prevalence of work-related musculoskeletal problems. Shekhawat et al., (2020)²⁰ reported professionals with less than five years of practice, experiencing more discomfort/pain. It may be because senior professionals are more competent in overcoming physically stressful situations by selecting coping strategies.

The lower back is the most affected region in accordance with other reported studies. Sriariyawong A (2014)¹⁴ reported pain in the lower back, followed by shoulder, ankles/feet, and knees, while Salmani reported the most prevalent MSD symptoms in the past 12 months in the lower back (42.9%), shoulders (40.5%) and knees (40.5%).¹¹ However in this study, most affected regions were low back (79%) and neck (68%), followed by feet/ ankles (60%). This may suggest the association between lifting/carrying heavy things, long-time standing, repetitive movements, awkward or twisted postures, and the body regions most commonly affected such as the lower back, ankles/feet, and neck.

A minor population in the present study experienced pain “always” in the lower back and feet/ankles, while a majority of the population experienced pain “often” in the lower back, feet /ankles, & knees. It was also reported that “sometimes” the pain was experienced in the shoulder, neck, wrists/hands regions. Furthermore, there was an association between female respondents and lower back pain. The results of this study agree with the results of other studies showing a high prevalence of lower back pain among female respondents.²³

The respondents in the present study with a regular exercise schedule experienced less pain/discomfort in the lower back, feet/ankle, and knee regions indicating the importance and benefits of regular exercise. Our results agree with the results of the study by Sarah et al., (2018) that reported association of range of work-related physical and psychosocial factors with an increased risk of reporting WMSDs.¹²

Our study also demonstrated a significant association between job dissatisfaction, dissatisfaction with work life balance, and high workload that may be the risk factor for the high prevalence of pain/discomfort which is corroborated by Do-young Jung et al., (2012) who found a statistically significant correlation between job stress and pain intensity.¹⁵ Ismail Maakip et al., (2020) also suggested that poor work-life balance is a risk factor associated with WMSD.²⁴

It was also evident in our study that participants felt more discomfort/pain while doing some specific occupational tasks like assessment, casting, positive cast rectification, and mixing of Plaster of Paris (pop). These results agree with those reported by Rina et al., (2020) which showed a high risk of WMSD during casting, while applying pop bandage, and modification of positive cast during rectification.¹⁰

Our results also showed a strong association between lifting or carrying a moderate or heavy load, grip/hold things to a large extent with pain/discomfort, and a significant association between working in awkward or twisted postures which is supported by reports of Salmani et al., (2016).¹¹ The data supports the theory given by Sarah et al., (2017) that high noise exposure may result in hearing loss and other adverse health outcomes.²⁵

Around 16% of the participants in our study were absent from work due to pain/discomfort while 28% visited a doctor/physiotherapist due to pain/discomfort. WMSDs is a complex problem that often results in significant lost work time and income^6,18 and affects the professional’s daily life. Retention of staff is important as allied health professionals develop and refine their skills over time. Injury prevention is an important aspect of retention and requires a systematic approach to capture and address all relevant hazards, some of which have been identified in the current study.

Limitations of the study

This cross-sectional survey has inherent limitations which include issues with recall or information biases; hence causation cannot be inferred.

Conclusion

The results identified a high rate of prevalence (95%, and 92% in the last 12 months, and last four weeks, respectively) of WMSDs in P&Os working in India which is a concern for the related profession. A significant association was found between sociodemographic variables and work-related hazards. A large prospective study may be carried out for a better outcome and to further explore the work-related risk factors for developing prevention strategies and guidelines to improve the P&O work environment and prevent work related injuries.

Conflict of interest

There is no conflict of interest.

Acknowledgment

We would like to thank the management of Mobility India who always motivates us to do new research in the area of prosthetics & orthotics. We are also grateful to Mr. Jodi Oakman, Associate Professor, at La Trobe University who shared the list of hazard items in the APHIRM Toolkit Survey