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Ergonomics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/terg20

Upper limb musculoskeletal disorders in healthcare personnel a

b

a

Vincenzo Occhionero , Leena Korpinen & Fabriziomaria Gobba a

Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia Italy, Modena, Italy b

Department of Electronics and Communications Engineering, Tampere University of Technology, Tampere, Finland Published online: 20 May 2014.

To cite this article: Vincenzo Occhionero, Leena Korpinen & Fabriziomaria Gobba (2014) Upper limb musculoskeletal disorders in healthcare personnel, Ergonomics, 57:8, 1166-1191, DOI: 10.1080/00140139.2014.917205 To link to this article: http://dx.doi.org/10.1080/00140139.2014.917205

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Ergonomics, 2014 Vol. 57, No. 8, 1166–1191, http://dx.doi.org/10.1080/00140139.2014.917205

Upper limb musculoskeletal disorders in healthcare personnel Vincenzo Occhioneroa, Leena Korpinenb and Fabriziomaria Gobbaa* a

Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia Italy, Modena, Italy; b Department of Electronics and Communications Engineering, Tampere University of Technology, Tampere, Finland

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(Received 7 November 2013; accepted 9 April 2014) The literature on upper limb musculoskeletal disorders (UL-MSD) in different groups of healthcare workers was reviewed: 65 relevant studies were collected. In dentists, the neck was the most frequently affected segment, with prevalences up to 73% and exceeding 50% in 7 out of 12 studies. In dental hygienists and in laboratory technicians, the hand/wrist had the highest prevalence in the majority of the studies. In nurses, the most seriously affected anatomic sites were the neck and shoulders. Physiotherapists had the lowest prevalence of UL-MSD. A high prevalence of upper limb disease, mainly carpal tunnel syndrome, was reported in dentists, dental hygienists, anesthesia nurses and endoscopists. The high prevalence of upper limb disorders/diseases reported in health personnel supports the hypothesis of a significant risk in these workers. However, the possible role of biomechanical overload, as much as that of stress or other personal factors, cannot be currently assessed. Practitioner Summary: Published studies support the hypothesis of a significant risk of upper limb musculoskeletal disorders in healthcare activities. The neck was the most frequently affected segment in dentists, the hand/wrist in dental hygienists and in laboratory technicians, and the neck and shoulders in nurses. Lower prevalence was reported in physiotherapists. A high prevalence of carpal tunnel syndrome was also observed in various healthcare activities. Keywords: healthcare personnel; work-related disorders and diseases; neck; shoulder; elbow; hand– wrist; CTS

Introduction Low back pain is considered one of the most important occupational problems in healthcare personnel since the work of Magora in the 1970s (1974), mainly related to the handling of patients. Nevertheless, a high prevalence of UL-MSD has also been reported in some studies. For the shoulder, for example, a prevalence up to 81% has been observed in dental personnel (Oberg and Oberg 1993) and up to 74% in nurses (Sheikhzadeh et al. 2009), while in a group of Australian nurses, the prevalence of disorders of the shoulder, elbow and wrist/hands were, respectively, 60%, 18% and 38% (Lusted et al. 1996). These disorders are considered to be related to the biomechanical overload of the upper limb (repetitive movements, frequency, force, posture, vibration and others) (Bernard 1997; van Rijn et al. 2009a, 2009b, 2010), which may be present in different healthcare activities and procedures, such as nursing care, dentistry and physiotherapy, or in some steps of laboratory work, e.g. the use of manual pipettes. To the best of our knowledge, the results of research on UL-MSD and biomechanical overload in healthcare personnel has not been recently reviewed. In an attempt to fill this gap, we reviewed the studies published in peer-reviewed scientific journals. Materials and methods A systematic search was conducted in PubMed, EMBASE and Scopus. The following terms were used: cumulative trauma disorders, musculoskeletal disorders, tunnel carpal syndrome, tennis elbow, de quervain, tendinopathy, joint disease, rotator cuff tears, sub-acromial impingement syndrome, bursitis, repetitive movements, repetitive motion, health personnel, dentists, sonographers, nurses, endoscopists, laboratory technicians, physical therapists, surgeon, physician, cardiologist, orthopaedist, ophthalmologist, gastroenterologist, upper limb, neck, shoulder, elbow, wrist, hand. Studies published between January 1990 and July 2013 were considered. Using these terms, 3863 studies were collected. According to a first screening based on the title, 164 articles were considered potentially relevant and selected. The abstract of all these articles was obtained and revised: 34 articles (papers not published in peer-review journals, review studies and others not relevant to our review, e.g. not including groups of health personnel etc.) were excluded. Using the library service of Modena and Reggio Emilia University, we obtained the full text of all the remaining 130 potentially eligible articles. These were revised according to the following inclusion

*Corresponding author. Email: [email protected] q 2014 Taylor & Francis

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criteria: . In extenso original articles written in English or Italian (five articles excluded); . Articles reporting the prevalence of upper limb (neck, shoulder, elbow and hand/wrist) disorders (defined as subjective symptoms referred by the examined subjects) and diseases (diagnosed clinical diseases communicated by the subject or diagnosed by the researchers) in different groups of health personnel, including physicians, nursing staff, technicians, physiotherapists and dental personnel (33 articles excluded). . Minimum threshold of 25 subjects included in the study (11 articles excluded); . Response rate higher than 50% (16 articles excluded); At the end of this stage, a final set of 65 articles was selected and included in the review. Figure 1 summarises the number of studies identified at each stage.

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Results Based on occupational activity, we categorised the workers into eight professional groups: dental personnel, including dental hygienists and technicians (25 papers), nurses (16 papers), physiotherapists (9 papers), sonographers (5 papers), endoscopists (4 papers), laboratory technicians (4 papers), surgeons (1) and ophthalmologists (1). Neck disorders For the dental personnel, the results are reported in Table 1a. They show a wide range of prevalence for symptoms: from 26% to 73% for dentists (Alexopoulos, Stathi, and Charizani 2004; Akesson et al. 1999, respectively) and 54– 68.5% for dental hygienists (Akesson et al. 1999; Anton et al. 2002, respectively) (Tables 1b– 1f).

RESEARCH

PUBMED

EMBASE

SCOPUS

Potentially relevant articles collected: n. 3863

Articles selected by title: n. 164

Excluded by abstract: n. 34

Evaluated articles: n. 130

Excluded by adopted criteria: - Language: n. 5 - Low response rate: n. 16 - Small number of subjects: n. 11 - No prevalence reported: n. 33

Articles included in review: n. 65

Figure 1.

Flowchart of included and excluded studies.

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Table 1a. Prevalence of neck disorders in dental personnel. Neck disorders

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Occupational group

Number of subjects

Mean age (SD)

Prevalence

Biomechanical overload: evaluation/results

Author, year, country

Notes Follow up NMQ Control: 30F nurses; mean age: 41.7: prev. 52% (N.S.) Response rate: 91% NMQ Control: 211 Pharmacists, mean age 36.6 (10.5): prev 38% (OR: 3.17, 95% CI: 2.10 – 4.79)

Dentists

30 (F)

40

73%

No

Akesson et al. (1999), Sweden

Dentists

191 (F)

35.7 (8.3)

66%

No

Aminian, Banafsheh Alemohammad, and Sadeghniiat-Haghighi (2012), Iran

Dentists

68 (39M, 29F)

27.6

58.8%

No

Dentists

285 (209M, 76F)

45.2 (11.9)

57.2%

No

Dentists

268 (29M, 239F)

56.3%

No

Dentists

99 (53M, 46F)

46 (5)

54%

No

Shrestha, Singh, and Niraula (2008), Nepal Leggat and Smith (2006), Australia Szyman´ska (2002), Poland Milerad and Ekenvall (1990), Sweden

Dentists

99 (56M, 43F)

48.8 (7.2)

50%

No

Dentists

220 (26M, 194F)

47%

No

Dentists

92 (59M, 33F)

30.1 (8.7)

43%

Dentists

60M

46 (8.66)

38.3%

No

Dentists

82 (40M, 42F)

M: 39.4 (8.7) F: 36 (6.6)

28%

No

Dentists

430 (231M, 199F)

Dental hygienists

95

37.6 (7.9)

Dental hygienists Dental hygienists

494 (8M, 486F)

44 (9)

61%

30 (F)

4.5

54%

26%

68.5 %

RULA evaluation

Correlation with repetitive movements: OR: 1.75, 95% CI: 1.03 – 2.97 Subjective evaluation of job factors No No

Finsen, Christensen, and Bakke (1998), Denmark Kierklo et al. (2011), Poland Rabiei et al. (2012), Iran Ratzon et al. (2000), Israel Pargali and Jowkar (2010), Iran Alexopoulos, Stathi, and Charizani (2004), Greece

Response rate: 73.1% Original questionnaire Original questionnaire Response rate: 100% NMQ Control: 100 Pharmacists, mean age 46 (5): prev 26% (RR: 2.1, 95% CI: 1.4– 3.1) Response rate: 86% NMQ

Response rate: 58% NMQ NMQ Original questionnaire Response rate: 88%

Anton et al. (2002), USA

Response rate: 100% NMQ

Ylipa¨a¨, Arnetz, and Preber (1999), Sweden Akesson et al. (1999), Sweden

Response rate: 86% Original questionnaire Follow up NMQ Control: 30F nurses, mean age 41.7: prev 52% (N.S.)

Notes: NMQ, Nordic Musculoskeletal Questionnaire; N.S., difference not statistically significant: p . 0.05; M, male subjects; F, female subjects; SD, standard deviation.

Only in a few works were dentists compared with an appropriate control group. Thus, Milerad and Ekenvall (1990) compared dentists with a group of pharmacists: for the neck, the relative risk (RR) is reported to be 2.1 (95% CI: 1.4 – 3.1), while Aminian, Banafsheh Alemohammad, and Sadeghniiat-Haghighi (2012) found an odds ratio (OR) of 3.2 (95% confidence interval (CI): 2.10 – 4.79). In addition, in most articles prevalence is observed across groups that are inevitably exposed to the biomechanical overload of the upper limbs: as an example, Akesson et al. (1999) found no significant difference in symptom prevalence between dentists/dental hygienists and a group of nurses, but both groups have a

Ergonomics Table 1b.

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Prevalence of neck/shoulder disorders in dental personnel. Neck/shoulder disorders

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Occupational group

Number of subjects

Dentists

30 (F)

Dentists

99 (53M, 46F)

Dental hygienists

30 (F)

Mean age (SD) Prevalence

Biomechanical overload: evaluation/results

Author, year, country

40

85%

No

Akesson et al. (1999), Sweden

46 (5)

36%

No

Milerad and Ekenvall (1990), Sweden

41.5

82%

No

Akesson et al. (1999), Sweden

Notes Follow up NMQ Control: 30F nurses, mean age 41.7: prev 52% ( p # 0.05) Response rate: 100% NMQ Control: 100 Pharmacists, mean age 46 (5): prev 17% (RR: 2.1, 95% CI: 1.4 –3.1) Follow up NMQ Control: 30F nurses, mean age 41.7: prev 52% ( p # 0.05)

Notes: NMQ, Nordic Musculoskeletal Questionnaire; M, male subjects; F, female subjects; SD, standard deviation.

potential occupational risk and frequently a high prevalence of musculoskeletal disorder (MSD) (Corona et al. 2005; Smith et al. 2006). With specific regard to repetitive movements, a significant correlation with symptoms (OR: 1.75, 95% CI: 1.03– 2.97) was observed in dentists by Alexopoulos, Stathi, and Charizani (2004), but the risk was evaluated only subjectively by workers. In nurses too (Table 6a), the prevalence of neck disorders is fairly variable – from 13% (Smith et al. 2003) to 63% (Corona et al. 2005) – but even in this case only a few investigations included an appropriate control group: Harcombe et al. (2009) compared 181 nurses (from various hospital departments, non-homogeneous with each other), with 116 postal workers and 146 office workers showing no significant differences. In this occupational group, strenuous shoulder movements were reported by 46% of participants, and they proved correlated with neck pain (OR: 1.59, 95% IC: 1.04 – 2.43) (Alexopoulos, Burdorf, and Kalokerinou 2003). However, in another group of 314 nurses, pain involving neck, shoulder or arm was not associated with frequent lifting and handling of objects, frequent repetitive work using shoulders, arms, hands or fingers and static work posture, according to Ando et al (2000). In sonographers, the prevalences of neck disorders are among the highest found in health personnel: from 43% (Wihlidal and Kumar 1997) to 83% (Russo et al 2002) (Table 2), while the results were much lower in endoscopists: 10– 46% (Hansel et al. 2009; O’Sullivan, Bridge, and Ponich 2002, respectively) (Tables 3 and 4). In laboratory technicians, the prevalence observed is variable: 44% (Lorusso et al. 2007) to 61.5% (Kalavar and Hunting 1996) (Table 5); in these operators, neck disorders were mainly related to the use of microscopes and/or manual pipettes (Bjo¨rksten, Almby, and Jansson 1994; Kalavar and Hunting 1996) (Tables 6a – 6e). In physiotherapists, neck symptoms, compared with other groups, are among the lowest, ranging from 12% (Salik and Ozcan 2004) to 47.6% (Cromie, Robertson, and Best 2000) (Tables 7a and 7b). Repetitive movements, maintaining the same position for prolonged period of time and transferring patients, were subjectively evaluated by these operators as significant risk factors of their profession (Salik and Ozcan 2004). Cromie, Robertson, and Best (2000) found a correlation with working in the same position for long periods (OR: 1.8, 95% CI: 1.2 –2.7), performing the same task repeatedly (OR: 1.6, 95% CI: 1.1– 2.3) and an insufficient number of breaks during the working day (OR: 1.8, 95% CI: 1.1 –2.9). In the only study on surgeons practicing laparoscopy, the neck prevalence was 13% (Kemal, Srinivas, and Charles 2001); this prevalence was no different from that of another group of surgeons not performing laparoscopy (Table 8). Finally, in the only study on ophthalmologists (Kitzmann et al. 2012), the prevalence was as high as 46% (Table 9), and significantly increased compared with a group of family medicine physicians (21%; p , 0.01).

Shoulder disorders For the shoulder, the highest prevalence of disorders (50 –81%) was observed among dental hygienists (Liss et al. 1995; Oberg and Oberg 1993, respectively) (Table 1c), while a lower prevalence was reported for dentists: from 20% (Alexopoulos, Burdorf, and Kalokerinou 2003) to 65% (Akesson et al. 1999).

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Table 1c. Prevalence of shoulder disorders in dental personnel. Shoulder disorders

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Occupational group

Number of subjects

Dentists

30 (F)

Dentists

285 (209M, 76F)

Dentists

56 (36M, 20F)

Dentists

191 (F)

Dentists

Mean age (SD)

Biomechanical overload: Prevalence Evaluation/results

40

65%

No

45.2 (11.9)

53%

No

48

52%

No

35.7 (8.3)

51.3%

No

99 (53M, 46F)

46 (5)

51%

No

Dentists

68 (39M, 29F)

27.6

47.1%

No

Dentists

99 (56M, 43F)

48.8 (7.2)

40%

No

Dentists Dentists

268 (29M, 239F) 131 (42M, 89F)

46

37.3% 35%

No No

Dentists

92 (59M, 33F)

30.1 (8.7)

25%

No

Dentists

220 (26M, 194F)

20.1%

No

Dentists

430 (231M, 199F)

20%

Dental hygienists Dental hygienists

28 (F)

40

81%

30 (F)

41.5

68%

494

44 (9)

64%

95

37.6 (7.9)

60%

33.2

49.8%

Dental hygienists Dental hygienists Dental hygienists

950 (F)

Author, year, country Akesson et al. (1999), Sweden

Follow up NMQ Control: 30F nurses, age 41.7: prev 37% ( p # 0.05) Leggat and Smith (2006), Response rate: 73.1% Australia Original questionnaire Response rate: 70% Droeze and Jonsson (2005), Netherlands Original questionnaire Response rate: 91% Aminian, Banafsheh NMQ Alemohammad, and Control: 211 Sadeghniiat-Haghighi Pharmacists, age 36.6 (2012), Iran (10.5): prev 39% (OR: 1.63, 95% CI: 1.09– 2.43) Milerad and Ekenvall Response rate: 100% (1990), Sweden NMQ Control: 100 Pharmacists, mean age 46 (5): prev 23% (RR: 2.2, 95% CI: 1.3– 3.3) Shrestha, Singh, and Niraula (2008), Nepal Finsen, Christensen, and Response rate: 86% Bakke (1998), Denmark NMQ Szyman´ska (2002), Poland Original questionnaire Lehto, Helenius, and Response rate: 82% Alaranta (1991), Finland Original questionnaire Rabiei et al. (2012), Iran Response rate: 58% NMQ Kierklo et al. (2011), Poland Alexopoulos, Stathi, and Response rate: 88% Charizani (2004), Greece

Correlation with repetitive movements: N.S. Correlation with the use of vibrating tools (OR: 2.89, 95% CI: 1.2 – 6.95) No Oberg and Oberg (1993), Sweden No Akesson et al. (1999), Sweden

Subjective evaluation of job factors No

Notes

NMQ

Follow up NMQ Control: 30F nurses, mean age 41.7: prev 37% ( p # 0.05) Ylipa¨a¨, Arnetz, and Preber Response rate: 86% (1999), Sweden Original questionnaire Anton et al. (2002), USA Response rate: 100% NMQ

Liss et al. (1995), Canada Response rate: 50% NMQ

Notes: NMQ, Nordic Musculoskeletal Questionnaire; N.S., difference not statistically significant: p . 0.05; M, male subjects; F, female subjects; SD, Standard Deviation.

Ergonomics Table 1d.

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Prevalence of elbow disorders in dental personnel. Elbow Disorders

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Occupational group

Number of subjects

Dentists

30 (F)

Dentists

99 (56M, 43F)

Dentists Dentists

220 (26M, 194F) 131 (42M, 89F)

Dentists

Mean age (SD) Prevalence

Biomechanical overload: evaluation/ results

40

27%

No

48.8 (7.2)

25%

No

15.1%

No

46

13%

No

191 (F)

35.7 (8.3)

11.5%

No

Dental hygienists

95

37.6 (7.9)

21.1%

Dental hygienists

30 (F)

41.5

18%

Subjective evaluation of job factors No

Author, year, country

Notes

Akesson et al. (1999), Follow up Sweden NMQ Control: 30F, nurses, mean age 41.7: prev 11% (N.S.) Finsen, Christensen, Response rate: 86% and Bakke (1998), NMQ Denmark Kierklo et al. (2011), Poland Lehto, Helenius, and Response rate: 82% Original questionnaire Alaranta (1991), Finland Aminian, Banafsheh Response rate: 91% Alemohammad, and NMQ Sadeghniiat-Haghighi Control: 211 Pharmacists, mean age 36.6 (10.5): prev 6% (OR: 1.85, (2012), Iran 95% CI: 0.89 – 3.84) Anton et al. (2002), Response rate: 100% USA NMQ Akesson et al. (1999), Follow up Sweden NMQ Control: 30F nurses, mean age 41.7: prev 11% (N.S.)

Notes: NMQ, Nordic Musculoskeletal Questionnaire; N.S., difference not statistically significant: p . 0.05; M, male subjects; F, female subjects; SD, standard deviation.

In dentists, Milerad and Ekenvall (1990) found an RR of 2.2 compared with pharmacists (95% CI: 1.3– 3.3), and Aminian, Banafsheh Alemohammad, and Sadeghniiat-Haghighi (2012) found an OR of 1.63 (95% CI: 1.09– 2.43). In dentists and in dental hygienists, Akesson et al. (1999) showed a significantly higher prevalence than in nurses. In the same group, Alexopoulos, Stathi, and Charizani (2004) observed no significant relationship with repetitive movements (subjectively assessed), but a correlation was observed with the use of vibrating tools (OR: 2.89, 95% CI: 1.2– 6.95). The data for nurses are presented in Table 6b: the prevalence varied widely, from 22% to 74% (Engels et al. 1994; Sheikhzadeh et al. 2009, respectively). It should be noted that this group is very heterogeneous in that it includes hospital staff engaged in different tasks (medical, surgical, etc.): quite surprisingly, very little attention has been devoted to this problem, and in the majority of studies personnel engaged in different wards were included. Based on the results of Alexopoulos, Burdorf, and Kalokerinou (2003), strenuous shoulder movements as well as primarily repetitive movements reported by 46% of nursing personnel were considered to be correlated with shoulder pain (OR: 2.39, 95% CI: 1.52– 3.75). Coherent results were presented by Smith et al. (2006), showing that shoulder MSDs were associated with manual handling and hard physical work ( p , 0.05). No subjective association between neck, shoulder or arm pain and the frequent lifting and handling of objects along with frequent repetitive work using shoulders, arms, hands or fingers and static work posture, was observed by Ando et al. (2000) in 314 nurses. The prevalence of shoulder disorders (Table 2), as well as the neck, was very high in sonographers (84%) in the only study published to date (Russo et al. 2002). In endoscopists, the values are lower, ranging between 16% and 34% (Battevi et al. 2009; O’Sullivan, Bridge, and Ponich 2002, respectively) (Table 3). In laboratory technicians (Table 5), the observed prevalence ranged from 21% to 58% (Lorusso et al. 2007; Bjo¨rksten, Almby, and Jansson 1994, respectively). A significant increase compared to employees was reported by Bjo¨rksten, Almby, and Jansson (1994); the same authors also showed that shoulder ailments were significantly more frequent in the ‘annually high exposed’ (. 300 hours) group than in the ‘annually low exposed’ (# 300 hours) group, with an OR: 2.4 (95% CI: 1.1 – 5.2).

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Table 1e. Prevalence of hand/wrist disorders in dental personnel. Hand/wrist disorders

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Occupational group

Number of subjects

Mean age (SD) Prevalence

Biomechanical overload: evaluation/ results

Dentists

30 (F)

40

54%

No

Dentists

191 (F)

35.7 (8.3)

50.3%

No

Dentists

99 (56M, 43F)

48.8 (7.2)

50%

No

Dentists

220 (26M, 194F)

47.3%

Dentists

268 (29M, 239F)

44%

No

Dentists

285 (209M, 76F)

34%

No

Dentists

430 (231M, 199F)

26%

Dentists

92 (59M, 33F)

30.1 (8.7)

25%

Correlation with repetitive movements: OR: 2.31, 95% CI: 1.33 – 4.01 Correlation with strenuous shoulder movements (OR: 3.9, 95% CI: 2.24 – 6.79) Correlation with the use of vibrating tools (OR: 2.24, 95% CI: 1.13 –4.44) RULA evaluation

Dentists

56 (36M, 20F)

48

Dentists

131 (42M, 89F)

46

21% Hand 14% Wrist 15%

Dental hygienists Dental hygienists

95

37.6 (7.9)

69.5%

30 (F)

41.5

64%

950 (F)

33.2

47.5%

No

44 (9)

38%

No

24.8%

No

Dental hygienists Dental hygienists Dental hygienists

494 5115

45.2 (11.9)

No No Subjective evaluation of job factors No

Author, year, country

Notes

Akesson et al. (1999), Follow up Sweden NMQ Control: 30F nurses, mean age 41.7: prev 18% ( p # 0.05) Response rate: 91% Aminian, Banafsheh NMQ Alemohammad, and Sadeghniiat-Haghighi Control: 211 Pharmacists, age 36.6 (2012), Iran (10.5): prev 34% (OR: 1.92, 95% CI: 1.28– 2.88) Finsen, Christensen, Response rate: 86% and Bakke (1998), NMQ Denmark Kierklo et al. (2011), Poland Szyman´ska (2002), Original questionnaire Poland Leggat and Smith Response rate: 73.1% (2006), Australia Response rate: 88% Alexopoulos, Stathi, and Charizani (2004), Greece

Rabiei et al. (2012), Iran Droeze and Jonsson (2005), Netherlands Lehto, Helenius, and Alaranta (1991), Finland Anton et al. (2002), USA Akesson et al. (1999), Sweden

Response rate: 58% NMQ Response rate: 100% Original questionnaire Response rate: 82% Original questionnaire

Response rate: 100% NMQ Follow up NMQ Control: 30F nurses, mean age 41.7: prev 18% ( p # 0.05) Liss et al. (1995), Response rate: 50% Canada NMQ Ylipa¨a¨, Arnetz, and Response rate: 86% Preber (1999), Sweden Original questionnaire Lalumandier and Response rate: 91.7% McPhee (2001), USA Original questionnaire

Notes: NMQ, Nordic Musculoskeletal Questionnaire; M, male subjects; F, female subjects; SD, standard deviation.

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Table 1f. Prevalence of upper limb diseases in dental personnel. Occupational group Number of subjects

Mean age (SD)

Dental hygienists Dental hygienists Dental hygienists Dental hygienists Dental hygienists Dental hygienists Dental hygienists

95

37.6 (7.9)

305 (2M, 303F)

44.4 (10.4)

5115 95 940 (F)

37.6 (7.9) 33.2

Diagnosis CTS (symptoms) CTS (symptoms) CTS (symptoms) CTS

Prevalence 42% 39% 25.4% 8.4%

CTS

7%

Median’s mononeuropathy CTS

18%

305 (2M, 303F)

44.4 (10.4)

305 (2M, 303F)

44.4 (10.4)

Dental hygienists

305 (2M, 303F)

44.4 (10.4)

Shoulder tendinitis

13%

Dental hygienists

305 (2M, 303F)

44.4 (10.4)

Elbow tendinitis

6%

Dental hygienists

305 (2M, 303F)

44.4 (10.4)

Hand/wrist tendinitis

7%

Dentists

291 (F)

48%

Dentists

1079 (906M, 173F)

49.8 (10.6)

Dentists

1079 (906M, 173F)

49.8 (10.6)

Dentists

1079 (906M, 173F)

49.8 (10.6)

Osteoarthritis (finger’s hand) CTS (symptoms) Median’s mononeuropathy CTS

Dentists

1016 (945M, 171F)

Dental assistants Dental technician

35 (11M, 24F)

23.3 (5.6)

120 (9M, 111F)

44.8

54 (6)

Neuropathy (symptoms) Median’s mononeuropathy CTS

5.6%

28% 13% 4.8%

29% 26 % 15.6%

Author, year, country Anton et al. (2002), USA Werner et al. (2002), USA Lalumandier and McPhee (2001), USA Anton et al. (2002), USA Liss et al. (1995), Canada Werner et al. (2002), USA Werner et al. (2002), USA

Notes Response rate: 100% Anamnestic diagnosis Anamnestic diagnosis Response rate: 91.7% Anamnestic diagnosis Response rate: 93% EMG Response rate: 50% EMG

EMG Swedish female population (35– 54): 2.9% Werner et al. (2002), Control: 142F employees: USA prev 2%; 219F industrial workers: prev 13% Werner et al. (2002), Control: 142F employees: USA prev 4%; 219F industrial workers: 11% Werner et al. (2002), Control: 142F employees: USA prev 6%; 219F industrial workers: prev 6% Solovieva et al. (2006), Response rate: 68% Finland RX Hamann et al. (2001), Response rate: 59% USA Anamnestic diagnosis Hamann et al. (2001), Response rate: 59% USA Diagnosis EMG Hamann et al. (2001), Response rate: 59% USA EMG (1997) General Swedish population, mean age 50: prev 2.7% Stockstill et al. (1993), Response rate: 98% USA Original questionnaire Greathouse et al. (2009) Response rate: 74.5% USA, EMG EMG Nakla´dalova´, Fialova´, and Korycanova´ (1995), Czech Republic

Notes: CTS, carpal tunnel syndrome; M, male subjects; F, female subjects; SD, standard deviation; EMG, electromyography.

A relatively low prevalence was observed in physical therapists: 10– 42% (respectively, West and Gardner 2001; Rozenfeld et al. 2010) (Table 7a). Cromie, Robertson, and Best (2000) showed a correlation with performing the same task repeatedly (OR: 1.7, 95% CI: 1.1 –2.7) and an insufficient number of breaks during the working day (OR: 1.8, 95% CI: 1.1 – 3.0). Finally, in the study on ophthalmologists (Kitzmann et al. 2012), the prevalence was 11% (Table 9), not significantly different compared with family medicine physicians. Elbow disorders The elbow is a less-studied body segment in the literature and the least affected by MSDs in the groups examined. In dental staff (Table 1d), in fact, the prevalence ranged between 11.5% (Aminian, Banafsheh Alemohammad, and SadeghniiatHaghighi 2012) and 27% (Akesson et al. 1999) for dentists, and between 18% and 21% for dental hygienists (Akesson et al. 1999; Anton et al. 2002, respectively).

1174 Table 2.

V. Occhionero et al. Prevalence of neck, shoulder, elbow and hand/wrist disorders in sonographers Neck disorders

Occupational group

Number of subjects

Sonographers

211 (23M, 188F)

Sonographers

96 13M, 83F)

Mean age (SD)

Biomechanical overload: evaluation/ results Prevalence 83%

No

42.7%

No

Author, year, country

Notes

Russo et al. (2002), Canada Wihlidal and Kumar (1997), Canada

Response rate: 92% Original questionnaire Response rate: 61.5% Original questionnaire

Russo et al. (2002), Canada

Response rate: 92% Original questionnaire

Wihlidal and Kumar. (1997), Canada

Response rate: 61.5% Original questionnaire

Shoulder disorders

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Sonographers

211 (23M, 188F)

84%

No Elbow disorders

Sonographers

96 (13M, 83F)

20.8%

No

Hand/wrist disorders Sonographers

211 (23M, 188F)

Sonographers

96 (13M, 83F)

Sonographers Sonographers

340 (258M, 82F) 2041 (1500M, 541F)

41.5 (7.2) 42.1 (7.2)

61% (Wrist) 56% (Hand) 33.3%

No

Russo et al. (2002), Canada

Response rate: 92% Original questionnaire

No

13.5% 5.3%

No No

Wihlidal and Kumar (1997), Canada Mirk et al. (1999), Italy Magnavita et al. (1999), Italy

Response rate: 61.5% Original questionnaire Original questionnaire Response rate: 74.6% Original questionnaire

Notes: M, male subjects; F, female subjects; SD, standard deviation.

The results observed for nurses (Engels et al. 1994; Sheikhzadeh et al. 2009, respectively) (Table 6c) vary greatly, from 3% to 52%. In the only work on sonographers (Table 2), the prevalence was 20.8% (Wihlidal and Kumar 1997), while for endoscopists, it ranged from 8% to 15% (O’Sullivan, Bridge, and Ponich 2002; Buschbacher 1994, respectively) (Table 3). Higher values (18 – 36%) were observed for laboratory technicians (Bjo¨rksten, Almby, and Jansson 1994; Kalavar and Hunting 1996, respectively) (Table 5). It should be mentioned that the research by David and Buckle (1997) comparing technicians using/not using manual pipettes showed a significant risk increase of elbow disorders in the first group (OR 3.24, 95% CI: 1.2 –9.2). In physiotherapists, the prevalence was the lowest, varying between 2% (Rugelj 2003) and 16% (Rozenfeld et al. 2010) (Table 7b). Cromie, Robertson, and Best (2000) found a subjective correlation with performing the same task repeatedly (OR: 2.4, 95% CI: 1.4 – 4.2) and with an insufficient number of breaks during the working day (OR: 2.6, 95% CI: 1.4– 4.7). Finally, in ophthalmologists (Kitzmann et al. 2012), the prevalence was 1% (Table 9), i.e. not different from family medicine physicians. Hand/wrist disorders For hand/wrist disorders, the reported prevalence varied between 15% (Lehto, Helenius, and Alaranta 1991) and 54% for dentists (Akesson et al. 1999), and between 24.8% and 69.5% for dental hygienists (Lalumandier and McPhee 2001; Anton et al. 2002, respectively) (Table 1e). The hand/wrist disorders were observed to increase significantly in dentists and dental hygienists compared with a group of nurses (Akesson et al. 1999). In the dentists, disorders significantly correlated with repetitive movements subjectively assessed by questionnaires: OR: 2.31, 95% CI: 1.33 –4.01, with strenuous shoulder movements (OR: 3.9, 95% CI: 2.24– 6.79) and with the use of vibrating tools (OR: 2.24, 95% CI: 1.13 – 4.44) (Alexopoulos, Burdorf, and Kalokerinou 2003).

Ergonomics Table 3.

1175

Prevalence of neck/shoulder/elbow and hand/wrist disorders in endoscopists. Neck disorders

Biomechanical overload: evaluation/ Mean age results Occupational group Number of subjects (SD) Prevalence Endoscopists 122 (ERCP) Endoscopists 265 (252M, 13F) (gastroenterologists) Endoscopists 71 (59M) (gastroenterologists)

46%

No

47.8 (8.6)

13%

No

45.1

10.4%

No

Author, year, country

Notes

O’Sullivan, Bridge, and Response rate: 74% Ponich (2002), Canada Original questionnaire Buschbacher (1994), USA Response rate: 72% Original questionnaire Hansel et al. (2009), USA Response rate: 63% Original questionnaire

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Shoulder disorders Endoscopists

176 (68M, 108F)

Endoscopists 265 (252M, 13F) (gastroenterologists) Endoscopists 122

42.8

34.3%

47.8 (8.6)

19% 16%

OCRA evaluation No No

Battevi et al. (2009), Italy Response rate: 98% Original questionnaire Buschbacher (1994), USA Response rate: 72% Original questionnaire O’Sullivan, Bridge, and Response rate: 74% Ponich (2002), Canada Original questionnaire

Elbow disorders Endoscopists 265 (252M, 13F) (gastroenterologists) Endoscopists 176 (68M, 108F) Endoscopists

47.8 (8.6)

15%

42.8

11.8%

122

8%

No OCRA evaluation No

Buschbacher (1994), USA Response rate: 72% Original questionnaire Battevi et al. (2009), Italy Response rate: 100% Original questionnaire O’Sullivan, Bridge, and Response rate: 74% Ponich (2002), Canada Original questionnaire

Hand/wrist disorders Endoscopists

122

Endoscopists 71 (59M) (gastroenterologists) Endoscopists 265 (252M, 13F) (gastroenterologists)

36%

No

45.1

16.7%

No

47.8 (8.6)

14%

No

O’Sullivan, Bridge, and Response rate: 74% Ponich (2002), Canada Original questionnaire Hansel et al. (2009), USA Response rate: 63% Original questionnaire Buschbacher (1994), USA Response rate: 72% Original questionnaire

Notes: M, male subjects; F, female subjects; SD, standard deviation; ERCP, endoscopic retrograde cholangiopancreatography.

In the nurse group, (Table 6d) prevalence is quite similar: between 22% and 61% (Lagerstro¨m et al. 1995; Smith et al. 2003, respectively). The prevalence in sonographers is highly variable: data showed values ranging between 5% (Magnavita et al. 1999) and 61% (Russo et al. 2002) (Table 2). In contrast, the prevalence is less variable in endoscopists: 14 –36% (Buschbacher 1994; O’Sullivan, Bridge, and Ponich 2002, respectively) (Table 3). A similar prevalence was observed in laboratory technicians, ranging from 21% (Lorusso et al. 2007) to 59% (David and Buckle 1997) (Table 5). As for the elbow, the risk of hand/wrist disorders increased in technicians using manual pipettes: OR: 2.75 (95% CI: 1.39 –5.45) (David and Buckle 1997). A relation with the year/hours of pipetting was observed by Bjo¨rksten, Almby, and Jansson (1994): the laboratory technicians reporting . 300 hours of mean annual exposure for pipetting had a significant, fivefold risk of hand ailments compared with those exposed for # 300 hours as a mean (OR: 5, 95% CI: 2.1 –11.5). The prevalence observed in physiotherapists was low: 12 –36% (Table 7b) (Glover 2002; Rozenfeld et al. 2010, respectively), but a relation with performing the same task repeatedly (OR: 2.6, 95% CI: 1.6 – 4.1), and with an insufficient number of breaks during the working day (OR: 2.2, 95% CI: 1.4 –3.8), was observed by Cromie, Robertson, and Best (2000). In the study on surgeons practicing laparoscopy, the hand prevalence was 16% (Kemal, Srinivas, and Charles 2001), with no significant difference compared with a group of surgeons not performing laparoscopy (Table 8). Finally, in ophthalmologists (Kitzmann et al. 2012), the prevalence was 17% (Table 9), i.e. not increased compared with family medicine physicians.

1176 Table 4.

V. Occhionero et al. Prevalence of upper limb disease in sonographers and Endoscopists.

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Occupational group

Number of subjects Mean age (SD)

Diagnosis

Prevalence Author, year, country

Sonographers

35

Tendinitis

16.7%

Sonographers

35

Epicondylitis

9.4%

Sonographers

35

Bursitis

9.4%

Sonographers

35

CTS

5.2%

Sonographers

35

Tenosynovitis

3.1%

Sonographers

44

CTS

4.5%

Tendinitis

53%

42.1 (7.2)

CTS

1.7%

41.5 (7.2) 47.8 (8.6)

CTS CTS

1.5% 6%

Sonographers

211 (23M, 188F)

Sonographers

2041 (1500M, 541F)

Sonographers 340 (258M, 82F) Endoscopists 265 (gastroenterologists)

38.2

Wihlidal and Kumar (1997), Canada Wihlidal and Kumar (1997), Canada Wihlidal and Kumar (1997), Canada Wihlidal and Kumar (1997), Canada Wihlidal and Kumar (1997), Canada Schoenfeld et al. (1999), Israel Russo et al. (2002), Canada Magnavita et al. (1999), Italy Mirk et al. (1999), Italy Buschbacher (1994), USA

Notes Response rate: 61.5% Original questionnaire Response rate: 61.5% Original questionnaire Response rate: 61.5% Original questionnaire Response rate: 61.5% Original questionnaire Response rate: 61.5% Original questionnaire Response rate: 86% Original questionnaire Response rate: 92% Original questionnaire Response rate: 74.6% Original questionnaire Original questionnaire Response rate: 72% Original questionnaire

Notes: M, male subjects; F, female subjects; SD, standard deviation; CTS, carpal tunnel syndrome.

Diseases of the upper limb tract In a minority of investigations (16), the presence of established diseases of the upper limbs was evaluated, and the methods applied to collect data (questionnaire, physical examination and/or electromyography (EMG)) vary significantly across different studies. The most carefully scrutinised disease is carpal tunnel syndrome (CTS), for which there is sufficient evidence of a correlation with biomechanical overload of the upper limbs (Bernard 1997; van Rijn et al. 2009a, 2009b, 2010). In dental hygienists, a high prevalence of symptoms of CTS, ranging from 7% to 42%, was highlighted by several authors (Anton et al. 2002; Lalumandier and McPhee 2001; Werner et al. 2002) (Table 1f). However, the prevalence of cases of CTS, defined by the presence of symptoms and confirmed by the results of EMG, was lower, ranging from 5.6% (Werner et al. 2002) to 8.4% (Anton et al. 2002), and comparable results (7%) were reported by Liss et al. (1995). In reviewed studies on dentists (Table 1f), 28% of the examined population reported symptoms of CTS, as documented by Hamann et al. (2001). At the same time, considering both symptoms and EMG results, prevalence rates of 4.8% and 15.6%, respectively, were reported by Hamann et al. (2001) and Nakla´dalova´, Fialova´, and Korycanova´ (1995). In sonographers (Table 4), a lower prevalence of anamnestic CTS was found, ranging from 1.5% and 5.2% (Mirk et al. 1999; Wihlidal and Kumar 1997, respectively). In a study by Buschbacher (1994), 6% of endoscopists reported a clinical diagnosis of CTS. Finally, Diaz (2001) showed a 16% prevalence of CTS (anamnestic diagnosis) in the anesthesia nursing department, significantly higher (OR: 3.23, 95% CI: 1.27 – 8.17) compared with a group of surgery nurses (Table 6e). With regard to the other diseases of the upper limb, tendinitis of the shoulder, elbow and hand/wrist was, respectively, reported by 13%, 6% and 7% of the dental hygienists examined by Werner et al. (2002). In sonographers, other studies observed tendinitis (16.7% and 53%) (Wihlidal and Kumar 1997; Russo et al. 2002, respectively), bursitis (9.4%) (Wihlidal and Kumar 1997) and tenosynovitis (3.1%) (Wihlidal and Kumar 1997), although the data-set is lacking. Finally, in dentists, a 48% prevalence of osteoarthritis in the fingers, based on radiographs of both hands, was observed by Solovieva et al. (2006) (Table 1f). Discussion In dentists, the neck was the most severely affected body region in all studies but one (where, in any case, it ranked second): prevalence ranged from 26% to 73% (Alexopoulos, Stathi, and Charizani 2004; Akesson et al. 1999, respectively), exceeding 50% in 7 out of 12 studies (Table 1a). In dental hygienists, the highest prevalence was observed for the shoulder (50 – 81%; Liss et al. 1995; Oberg and Oberg 1993, respectively) and for the hand/wrist (from 24.8% to 69.5%; Lalumandier and McPhee 2001; Anton et al. 2002).

44%

41.1 (8.4)

Laboratory 128 technicians (manual pipettes)

41.1 (8.4)

18%

23%

32.6 (7.6)

21%

35.9%

43.1 (11.5)

176 (74M, 102F)

41%

43

43

58%

53.4%

43.1 (11.5)

41.1 (8.4)

61.5%

Prevalence

43

Mean age (SD)

78 (22M, 56F)

Laboratory 78 (22M, 56F) technicians (microscopists) 80 (29M, 51F) Laboratory technicians (manual pipettes)

Laboratory technicians (microscopists) Laboratory technicians (microscopists)

128 Laboratory technicians (manual pipettes)

Laboratory 78 (22M, 56F) technicians (microscopists) Laboratory 176 (74M, 102F) technicians (microscopists) 128 Laboratory technicians (manual pipettes)

Number of subjects

No

No

No

Elbow disorders

No

Significantly more frequent in the ‘annually high exposed’ (.300 hours) group than in the ‘annually low exposed’ (#300 hours) group (OR ¼ 2.4, 95% CI ¼ 1.1 – 5.2) No

Shoulder disorders

No

No

No

Biomechanical overload: evaluation/results

Neck disorders

Prevalence of neck/shoulder/elbow and hand/wrist in laboratory technicians.

Occupational group

Table 5.

Response rate: 92.1% Original questionnaire

Response rate: 69% Original questionnaire

Notes

Response rate: 69% Original questionnaire

Response rate: 92.1% Original questionnaire

Response rate: 69% Original questionnaire

Response rate: 55% NMQ Control: 85 Technicians who not using manual pipettes; age 37.4: prev 8% (OR: 3.24, 95% CI: 1.2– 9.2) Bjo¨rksten, Almby, and Response rate: 81% Jansson (1994), Original questionnaire Sweden Control: 25,378 Employees: prev 13% (N.S.)

David and Buckle (1997), England

Kalavar and Hunting (1996), USA

Lorusso et al. (2007), Italy

Kalavar and Hunting (1996), USA

Bjo¨rksten, Almby, and Response rate: 81% Original questionnaire Jansson (1994), Control: 25,378 Employees: prev: 48% ( p , 0.05) Sweden

Bjo¨rksten, Almby, and Response rate: 81% Original questionnaire Jansson (1994), Control: 25,378 Employees: prev: 47% (N.S.) Sweden

Lorusso et al. (2007), Italy

Kalavar and Hunting (1996), USA

Author, year, country

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Ergonomics 1177

43.1 (11.5)

21%

The laboratory technicians with . 300 hours of mean annual exposure for pipetting had a significant risk compared with those exposed for # 300 hours (OR: 5 95% IC: 2.1 –11.5) No

No

No

Hand/wrist disorders

Biomechanical overload: evaluation/results

Neck disorders

Response rate: 55% NMQ Control: 85 Technicians not using manual pipettes; age 37.4: prev 34% (OR: 2.74, 95% CI: 1.39– 5.45) Response rate: 69% Original questionnaire

Notes

Lorusso et al. (2007), Italy

Response rate: 92.1% Original questionnaire

Bjo¨rksten, Almby, and Response rate: 81% Jansson (1994), Original questionnaire Sweden Control: 25,378 Employees: prev 24% ( p , 0.01)

Kalavar and Hunting (1996), USA

David and Buckle (1997), England

Author, year, country

Notes: NMQ, Nordic Musculoskeletal Questionnaire; N.S., difference not statistically significant: p . 0.05; M, male subjects; F, female subjects; SD, standard deviation.

176 (74M, 102F)

44%

41.1 (8.4)

Laboratory technicians (microscopists)

56.4%

43

59%

Prevalence

Laboratory 78 (22M, 56F) technicians (microscopists) Laboratory 128 technicians (manual pipettes)

Mean age (SD)

32.6 (7.6)

Number of subjects

Laboratory 80 (29M, 51F) technicians (manual pipettes)

Occupational group

Table 5 – continued

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1178 V. Occhionero et al.

100 (26M, 74F)

844F

565 181 (12M, 169F)

32

688F

351 (67M, 284F)

428 1163 (70M, 1093F)

282F

Nurses

Hospital nurses

Hospital nurses Hospital nurses

Nurses (orthopaedics) Hospital nurses

Hospital nurses

Nurses (endoscopy) Nurses

Hospital nurses

628 (79M, 549F)

91 (18M, 73F)

Nurses

Nurses (home nursing)

47 (8)

29.3 (8.4) 13.2%

27%

31.3%

42.8%

32.6 29.5 (8.5)

43%

45%

46% 45.8%

47%

48%

52%

53% 52%

54.7%

63%

37.7

34.0 (9.2)

49 (9) 45

37

43.9 (9.1)

40 46

32.9 (8.8)

34.5 (7)

No

Notes

NMQ

Smith et al. (2003), South Korea

Response rate: 94% Original questionnaire Response rate: 70% NMQ

Response rate: 84.1% NMQ Response rate: 90% Original questionnaire

Response rate: 84% Original questionnaire NMQ Darby, Gallo, and Fields (2013), USA NMQ Trinkoff et al. (2002), USA Response rate: 74% NMQ Smith et al. (2004a), China Response rate: 92% NMQ Lusted et al. (1996), Australia NMQ

Alexopoulos, Burdorf, and Kalokerinou (2003), Greece

Lagerstro¨m et al. (1995), Sweden

Original questionnaire Control: 100 Physiotherapists, age 35.9 (7): prev 84% ( p , 0.01) Smith et al. (2006), Japan Response rate: 72.6% NMQ Josephson et al. (1997), Sweden Original questionnaire Harcombe et al. (2009), New Zealand Response rate: 58% Control: 116 postal employees: prev 51%(N. S.) 146 office employees: prev 51% (N.S.) Sheikhzadeh et al. (2009), USA MSS, JDQ, PEQ

Corona et al. (2005), Italy

Author, year, country

Subjective evaluation of job factors Subjective evaluation of job factors Subjective evaluation of Smith et al. (2004b), China job factors Ando et al. (2000), Japan No association between frequent lifting and handling of objects, frequent repetitive work using shoulders, arms, hands or fingers and static work posture No Engels et al. (1994), Netherlands

Subjective evaluation of job factors Subjective evaluation of job factors Correlation with strenuous shoulder movements (OR: 1.59, 95% CI: 1.04 – 2.43) No No

No No

No

No

Mean age Biomechanical overload: (SD) Prevalence evaluation/results

Neck disorders

Notes: NMQ, Nordic Musculoskeletal Questionnaire; MSS, Musculoskeletal Symptom Survey; JDQ, Job Description Questionnaire; PEQ, Psychometric Evaluation Questionnaire; N.S., difference not statistically significant: p . 0.05; M, male subjects; F, female subjects; SD, standard deviation.

314 (F)

Hospital nurses

Nurses (assistance to 30 (5M, 25F) disabled) Hospital nurses 180 (F)

Number of subjects

Prevalence of neck disorders in nurses.

Occupational group

Table 6a.

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Ergonomics 1179

47.6% 42.8%

37.7

49 (9) 29.5 (8.5)

Nurses 428 (endoscopy) Hospital nurses 314

100 (26M, 74F)

628 (79M, 549F)

Nurses

Nurses

29.3 (8.4)

34.5 (7)

45

22%

28%

35.1%

35.2%

37%

38.9%

39%

40%

No

No

No

No

Correlation with strenuous shoulder movements (OR: 2.39, 95% CI: 1.52– 3.75)

Subjective evaluation of job factors

No

No association between frequent lifting and handling of objects, frequent repetitive work using shoulders, arms, hands or fingers and static work posture Subjective evaluation of job factors

Notes

Response rate: 90% Original questionnaire

NMQ

NMQ

Smith et al. (2004a), China Response rate: 92% NMQ Harcombe et al. (2009), Response rate: 58% New Zealand Control: 116 postal employees: prev 49% (N.S.) 146 office employees: prev 38% (N.S.) Smith et al. (2004b), China Response rate: 84.1% NMQ Alexopoulos, Burdorf, and Response rate: 84% Kalokerinou (2003), Original questionnaire Greece NMQ Smith et al. (2003), Response rate: 70% South Korea NMQ Trinkoff et al. (2002), Response rate: 74% USA NMQ Corona et al. (2005), Italy Original questionnaire Control: 100 Physiotherapists, mean age 35.9 (7): prev 40% (N. S.) Engels et al. (1994), Response rate: 94% Netherlands Original questionnaire

Lagerstro¨m et al. (1995), Sweden Darby, Gallo, and Fields (2013), USA Ando et al. (2000), Japan

Sheikhzadeh et al. (2009), MSS, JDQ, PEQ USA Smith et al. (2006), Japan Response rate: 72.6% NMQ Josephson et al. (1997), Original questionnaire Sweden Lusted et al. (1996), NMQ Australia

Author, year, country

Notes: NMQ, Nordic Musculoskeletal Questionnaire; MSS, Musculoskeletal Symptom Survey, JDQ, Job Description Questionnaire; PEQ, Psychometric Evaluation Questionnaire; N.S., difference not statistically significant: p . 0.05; M, male subjects; F, female subjects; SD, standard deviation.

1163 (70M, 1093F)

Hospital nurses 351 (67M, 284F) 47 (8)

37

Hospital nurses 180 (F)

91 (18M, 73F)

3.6

Hospital nurses 181 (12M, 169F)

Nurses (home nursing) Nurses

34.0 (9.2) 46

Hospital nurses 282F

Subjective evaluation of job factors

53% No

Subjective evaluation of job factors

60%

60%

Association with manual handling, hard physical work ( p , 0.05) No

71.9%

Nurses 30 (5M, 25F) (assistance to disabled) Hospital nurses 688F

Hospital nurses 565

Subjective evaluation of job factors

Biomechanical overload: evaluation/results

shoulder disorders

74%

Prevalence

43.9 (9.1) 32.9 (8.8) 45

Mean age (SD)

Nurses 32 (orthopaedics) Hospital nurses 844F

Number of subjects

Prevalence of shoulder disorders in nurses.

Occupational group

Table 6b.

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1180 V. Occhionero et al.

30 (5M, F25)

100 (26M, 74F)

181 (12M, 169F)

180 (F)

91 (18M, 73F)

628 (79M, 549F)

Nurses (assistance to disabled) Nurses

Hospital nurses

Hospital nurses

Nurses (home nursing)

Nurses

29.3 (8.4)

47 (8)

32.6

46

34.5 (7)

37.7

43.9 (9.1)

Mean age (SD)

3%

8%

10%

13%

14%

18%

52%

Prevalence

No

Subjective evaluation of job factors No

No

Subjective evaluation of job factors Subjective evaluation of job factors No

Biomechanical overload: evaluation/results

Elbow disorders

Smith et al. (2003), South Korea Engels et al. (1994), Netherlands

Smith et al. (2004b), China

Harcombe et al. (2009), New Zealand

Corona et al. (2005), Italy

Lusted et al. (1996), Australia

Notes

Original questionnaire Control: 100 Physiotherapists: mean age 35.9 (7): prev: 40% (N.S.) Response rate: 58% Control: 116 postal employees: prev 30% (N.S.); 146 Office employees: prev 21% (N.S.) Response rate: 84.1% NMQ Response rate: 70% NMQ Response rate: 94% Original questionnaire

NMQ

Sheikhzadeh et al. (2009), USA MSS, JDQ, PEQ

Author, year, country

Notes: NMQ, Nordic Musculoskeletal Questionnaire; MSS, Musculoskeletal Symptom Survey; JDQ, Job Description Questionnaire; PEQ, Psychometric Evaluation Questionnaire; N.S., difference not statistically significant: p . 0.05; M, male subjects; F, female subjects; SD, standard deviation.

32

Nurses (orthopaedics)

Number of subjects

Prevalence of elbow disorders in nurses.

Occupational group

Table 6c.

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Ergonomics 1181

30 (5M, 25F)

Nurses (assistance to disabled) Nurses

180 (F)

181 (12M, 169F)

688F

Hospital nurses

Hospital nurses

Hospital nurses

46

32.6

47 (8)

34.5 (7)

37.7

43.9 (9.1)

Mean age (SD)

22%

24%

27.8%

28.6%

29%

38%

61%

Prevalence

Subjective evaluation of job factors

Subjective evaluation of job factors

No

Subjective evaluation of job factors Subjective evaluation of job factors No

Biomechanical overload: evaluation/results

Hand/wrist disorders Notes

Sheikhzadeh et al. (2009), MSS, JDQ, PEQ USA Lusted et al. (1996), NMQ Australia Corona et al. (2005), Italy Original questionnaire Control: 100 Physiotherapists: age 35.9 (7): prev 40% (N.S.) Smith et al. (2003), South Response rate: 70% Korea NMQ Smith et al. (2004b), Response rate: 84.1% China NMQ Harcombe et al. (2009), Response rate: 58% New Zealand Control: 116 postal employees: prev 48% (N.S.) 146 Office employees: prev 33% (N.S.) Lagerstro¨m et al. (1995), NMQ Sweden

Author, year, country

Notes: NMQ, Nordic Musculoskeletal Questionnaire; MSS, Musculoskeletal Symptom Survey; JDQ, Job Description Questionnaire; PEQ, Psychometric Evaluation Questionnaire; N.S., difference not statistically significant: p . 0.05; M, male subjects; F, female subjects; SD, standard deviation.

91 (18M, 73F)

Nurses (home nursing)

100 (26M, 74F)

32

Nurses (orthopaedics)

Number of subjects

Prevalence of hand/wrist disorders in nurses.

Occupational group

Table 6d.

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1182 V. Occhionero et al.

Ergonomics

1183

Table 6e. Prevalence of upper limb diseases in nurses. Occupational group

Number of subjects

Mean age (SD)

Nurses (anesthesia)

63F

42 (9.3)

Diagnosis Prevalence CTS

16%

Author, year, country Diaz (2001), USA

Notes Anamnestic diagnosis Control: 181F nurses (operating room), mean age 38.4 (7.5): prev 5.5% (OR: 3.23; 95% CI: 1.27– 8.17)

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Notes: M, male subjects; F, female subjects; SD, standard deviation; CTS, carpal tunnel syndrome.

The same body segments were most frequently affected in laboratory technicians; in this group, a high prevalence of disorders was observed in the elbow as well (from 18% to 36%), (Bjo¨rksten, Almby, and Jansson 1994; Kalavar and Hunting 1996, respectively). In nurses, the body segments most frequently affected by disorders were usually the neck (13–63%; Smith et al. 2003; Corona et al. 2005, respectively) and the shoulder (22–74%; Engels et al. 1994; Sheikhzadeh et al. 2009), while the least affected was the elbow (3–52%; Engels et al. 1994; Sheikhzadeh et al. 2009, respectively). It appears worth observing that the prevalence of neck and shoulder disorders reported in various studies was similar to that for the low back, currently considered one of the most important occupational problems in this group (Alexopoulos, Burdorf, and Kalokerinou 2003; Ando et al. 2000; Corona et al. 2005; Darby, Gallo, and Fields 2013; Lusted et al. 1996; Sheikhzadeh et al. 2009; Smith et al. 2004a, 2004b, 2006). In sonographers, the neck was identified as the most frequently affected region (43 – 83%) (Wihlidal and Kumar 1997; Russo et al. 2002, respectively). Finally, physiotherapists seem the occupational group referring the lowest prevalence of UL-MSD: in six out of nine studies, the most severely affected region was the neck, showing prevalence rates ranging from 12% to 47.6% (Salik and Ozcan 2004; Cromie, Robertson, and Best 2000, respectively), whereas the hand/wrist was emphasised in the three remaining studies (prevalence range 12.5 – 35.7; Glover 2002, Rozenfeld et al. 2010, respectively). However, a relation with occupational activity is suggested by the results of Cromie, Robertson, and Best (2000). The UL-MSD are also common in the general population, even if the prevalence reported by various authors is quite variable; e.g. in the Dutch general population, the prevalence rates were 31%, 30.3%, 11% and 17.5% for the neck, shoulder, elbow and hand/wrist disorders (Picavet and Schouten 2003); data reported by Harlow et al. (1999) in a sample of Mexican women are coherent: 26.4% had neck and shoulder disorders, and 18% suffered from hand/wrist disorders; for the shoulder, researchers have reported values from 4.7% to 46.7% in various general populations (Luime et al. 2004). In a study of various working populations, Coˆte´ et al. (2009) have observed rates of neck disorders between 27% and 48%. Comparing this data with those reported in the healthcare workers, we can assert that UL-MSD represent a major problem in this occupational group, underestimated so far. The evaluation of studies on the UL-MSD in the healthcare personnel has shown that there are important limitations. The first problem is the lack of adequate evaluation of the biomechanical overload of the upper limb, e.g. by using currently available methods such as OCRA (Occhipinti, Colombini, and Occhipinti 2008), HAL (ACGIH 2006), RULA (McAtamney and Nigel Corlett 1993) or others. Only in two articles were these methods applied, notably the RULA in the study by Rabiei et al. (2012), showing that the severity of pain in dentists was related to a higher action level of score, and the OCRA in the study by Battevi et al. (2009), showing the presence of a significant risk in operators performing endoscopic examinations for at least 180 minutes. In other studies, the risk was subjectively evaluated by the operators, and compared with disorders. In dentists, a correlation with neck disorders (OR: 1.75, 95% CI: 1.03–2.97) and hand/wrist disorders (OR: 2.31, 95% CI: 1.33–4.01), but not with shoulder disorders, was reported by Alexopoulos, Stathi, and Charizani (2004); in nurses, strenuous shoulder movements as well as primarily repetitive movements (reported by 46% of participants) correlated with shoulder pain (OR: 2.39, 95% CI: 1.52–3.75) and neck pain (OR: 1.59, 95% CI: 1.04–2.43) (Alexopoulos, Burdorf, and Kalokerinou 2003). In sonographers, some specific muscular efforts, such as gripping the transducer, applying sustained pressure and scanning with flexed or hyperextended wrist, were significantly related to an increasing severity of symptoms in the hand, wrist and forearm area (Mirk et al. 1999). In physical therapists, the number of hours per week performing rehabilitation treatments was associated with an increased risk of MSD in shoulder/elbow (OR: 1.04, 95% CI: 1.0–1.09), and the number of hours per week performing manual treatments was associated with an increased risk in the wrist/thumb (OR: 1.11, 95% CI: 1.05–1.17) (Rozenfeld et al. 2010).

536 (118M, 418F)

123 (41M, 82F)

126 (80M, 46F)

2593 (275M, 2318F) 928 (505M, 483F)

217 (39M, 178F) 133 (6M, 127F)

370 (104M, 266F)

120 (28M, 92F)

123 (41M, 82F)

536 (118M, 418F)

126 (80M, 46F)

928 (505M, 483F)

133 (6M, 127F)

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Number of subjects

39.5 (9.1)

43 (12)

33.7 (6.8)

38

30.4 (6.9)

37.9 (9.5)

39.5 (9.1)

43 (12)

39.5 (12)

33.7 (6.8)

38

Mean age (SD)

15%

18.9%

22.2%

22.9%

42.2%

12%

18%

20% 19.5%

24.7%

25.7%

31.1%

45.5%

47.6%

Prevalence

Biomechanical overload: evaluation/results

Neck disorders Author, year, country

West and Gardner (2001), Australia Rugelj (2003), Slovenia

Bork et al. (1996), USA

Glover (2002), England

Adegoke et al. (2008), Nigeria

Rozenfeld et al. (2010), Israel

Salik and Ozcan (2004), Turkey

No

No

Rugelj (2003), Slovenia

Bork et al. (1996), USA

Correlation with performing the Cromie, Robertson, and Best (2000), same task repeatedly (OR: 1.7, Australia 95% CI: 1.1– 2.7) Insufficient number of breaks during the working day (OR: 1.8, 95% CI: 1.1– 3.0) No Adegoke et al. (2008), Nigeria

No

Shoulder disorders

Repetitive movements: subjective risk factor

15% of respondents reported that Holder et al. (1999), USA performing repetitive tasks caused an occupational injury

No No

No

No

No

Correlation with working in the Cromie, Robertson, and Best (2000), Australia same position for long periods (OR: 1.8, 95% CI: 1.2 – 2.7) Performing the same task repeatedly (OR: 1.6, 95% CI: 1.1– 2.3) Insufficient number of breaks during the working day (OR: 1.8, 95% CI: 1.1– 2.9) No Rozenfeld et al. (2010), Israel

Prevalence of neck and shoulder disorders in physiotherapists.

Occupational group

Table 7a.

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Response rate: 58.1% NMQ Response rate: 80% NMQ Response rate: 78% Original questionnaire

Response rate: 69.8% Cromie’s questionnaire Response rate: 67.9% NMQ

Response rate: 69.8% Cromie’s questionnaire Response rate: 58.1% NMQ Response rate: 73.4% NMQ Response rate: 80% NMQ Response rate: 53% Response rate: 78% Original questionnaire Response rate: 67% Original questionnaire Contr: 253 Assistants mean age: 35.1 (8.6): prev 16% Response rate: 59% Original questionnaire

Response rate: 67.9% NMQ

Notes

1184 V. Occhionero et al.

120 (28M, 92F)

370 (104M, 266F)

217 (39M, 178F)

Physiotherapists

Physiotherapists

Physiotherapists

37.9 (9.5)

30.4 (6.9)

39.5 (12)

10%

14%

14%

14.8%

Glover (2002), England

No

West and Gardner (2001), Australia

Repetitive movements: Salik and Ozcan (2004), Turkey subjective risk factor 15% of respondents reported that Holder et al. (1999), USA performing repetitive tasks caused an occupational injury

No

Notes: NMQ, Nordic Musculoskeletal Questionnaire; M, male subjects; F, female subjects; SD, standard deviation.

2593 (275M, 2318)

Physiotherapists

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Response rate: 73.4% NMQ Response rate: 59% Original questionnaire Response rate: 67% Original questionnaire Control: 253 Assistants: mean age 35.1 (8.6): prev 18% Response rate: 53%

Ergonomics 1185

536 (118M, 418F)

370 (104M, 266F)

928 (505M, 483F)

126 (80M, 46F)

2593 (275M, 2318F)

217 (39M, 178F) 133 (6M, 127F)

123 (41M, 82F)

928 (505M, 483F)

370 (104M, 266F)

536 (118M, 418F)

126 (80M, 46F)

120 (28M, 92F)

133 (6M, 127F)

217 (39M, 178F) 2593 (275M, 2318F)

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists

Physiotherapists Physiotherapists 39.5 (12)

39.5 (9.1)

30.4 (6.9)

33.7 (6.8)

38

37.9 (9.5)

43 (12)

39.5 (9.1)

39.5 (12)

33.7 (6.8)

43 (12)

37.9 (9.5)

38

14% 12.5%

15%

18%

20.6%

21.8%

23%

29.6%

35.7%

3% 2.3%

5.5%

5.6%

8%

11%

13.2%

16%

Mean age (SD) Prevalence

Notes

Rozenfeld et al. (2010), Israel

Response rate: 69.8% Cromie’s questionnaire No Bork et al. (1996), USA Response rate: 80% NMQ Holder et al. (1999), USA Response rate: 67% 15% of respondents reported that Original questionnaire performing repetitive tasks caused an Control: 253 Assistants mean age 35.1 occupational injury (8.6): prev 15% Correlation with performing the same Cromie, Robertson, and Best (2000), Australia Response rate: 67.9% NMQ task repeatedly (OR: 2.6, 95% CI: 1.6 – 4.1) Insufficient number of breaks during the working day (OR: 2.2, 95% CI: 1.4 –3.8) No Adegoke et al. (2008), Nigeria Response rate: 58.1% NMQ Repetitive movements: subjective risk Salik and Ozcan (2004), Turkey Response rate: 59% factor Original questionnaire No Rugelj (2003), Slovenia Response rate: 78% Original questionnaire No West and Gardner (2001), Australia Response rate: 53% No Glover (2002), England Response rate: 73.4% NMQ

No

Hand/wrist disorders

Rozenfeld et al. (2010), Israel

Author, year, country

Response rate: 69.8% Cromie’s questionnaire. Correlation with performing the same Cromie, Robertson, and Best (2000), Australia Response rate: 67.9% NMQ task repeatedly (OR: 2.4, 95% CI: 1.4 – 4.2) Insufficient number of breaks during the working day (OR: 2.6, 95% CI: 1.4 –4.7) No Holder et al. (1999), USA Response rate: 67% Original questionnaire Control: 253 Assistants: mean age 35.1 (8.6): prev 6% No Bork et al. (1996), USA Response rate: 80% NMQ No Adegoke et al. (2008), Nigeria Response rate: 58.1% NMQ No Glover (2002), England Response rate: 73.4% NMQ No West and Gardner (2001), Australia Response rate: 53% No Rugelj (2003), Slovenia Response rate: 78% Original questionnaire

No

Biomechanical overload: evaluation/ results

Elbow disorders

Notes: NMQ, Nordic Musculoskeletal Questionnaire; M, male subjects; F, female subjects; SD, standard deviation

123 (41M, 82F)

Number of subjects

Prevalence of elbow and hand/wrist disorders in physiotherapists.

Physiotherapists

Occupational group

Table 7b.

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1186 V. Occhionero et al.

Ergonomics Table 8.

1187

Prevalence of elbow and hand/wrist disorders in surgeon. Neck disorders

Occupational group

Biomechanical Number overload: of Mean age subjects (SD) Prevalence evaluation/results

Surgeon (practicing laparoscopy)

204

41.6 (6.1)

13%

No

Author, year, country Kemal, Srinivas, and Charles (2001), India

Notes Response rate: 58% Original questionnaire Control group: 73 surgeons (having no laparoscopic experience) mean age: 37 (8.4): 6% (N.S.)

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Hand/wrist disorders Surgeon (practicing laparoscopy)

204

41.6 (6.1)

16%

No

Kemal, Srinivas, and Charles (2001), India

Response rate: 58% Original questionnaire Control group: 73 surgeons (having no laparoscopic experience) mean age: 37 (8.4): 8.6% (N.S.)

Notes: SD, standard deviation; N.S., difference not statistically significant: p . 0.05.

In nurses, strenuous shoulder movements proved to be correlated with neck pain (OR: 1.59, 95% CI: 1.04 – 2.43) and shoulder pain (OR: 2.39, 95% CI: 1.52 –3.75) (Alexopoulos, Burdorf, and Kalokerinou 2003), and coherent results were presented by Smith et al. (2006), showing that shoulder MSDs were associated with manual handling and hard physical work ( p , 0.05). However, no subjective association between upper limb pain and frequent lifting and handling of objects, repetitive work and static work posture was observed by Ando et al. (2000); similarly, no association was demonstrated between manual handling or perceived physical exertion and increased MSD (Smith et al. 2004b). Table 9.

Prevalence of elbow and hand/wrist disorders in ophthalmologists. Neck disorders

Occupational group Ophthalmologists

Number of subjects 94

Mean age (SD) Prevalence 41.5 (10.9)

46%

Biomechanical overload: evaluation/results Subjective evaluation of job factors

Author, year, country

Notes

Response rate: 99% Kitzmann et al. (2012), Original questionnaire Control group: 73 family medicine physicians USA mean age: 42.4 (11.4):21% ( p , 0.01)

Shoulder disorders Ophthalmologists

94

41.5 (10.9)

11%

Subjective evaluation of job factors

Kitzmann Response rate: 99% et al. (2012), Original questionnaire USA Control group: 73 family medicine physicians mean age: 42.4 (11.4): 11% (N. S.)

Elbow disorders Ophthalmologists

94

41.5 (10.9)

1%

Subjective evaluation of job factors

Response rate: 99% Kitzmann et al. (2012), Original questionnaire Control group: 73 family medicine USA physicians mean age: 42.4 (11.4): 3% (N.S.)

Hand/wrist disorders Ophthalmologists

94

41.5 (10.9)

17%

Subjective evaluation of job factors

Notes: SD, standard deviation; N.S., difference not statistically significant: p . 0.01.

Kitzmann Response rate: 99% et al. (2012), Original questionnaire USA Control group: 73 family medicine physicians mean age: 42.4 (11.4): 7% (N.S.)

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Kitzmann et al. (2012) compared the subjective prevalence of some job-related risk factors in a group of ophthalmologists and family medicine physicians: an increased prevalence was observed for ‘performing the same task repeatedly’ (45% vs. 22%; p , 0.01), ‘working in awkward or cramped positions’ (57% vs. 15%; p , 0.01), ‘working in the same position for long periods’ (55% vs. 18%; p , 0.01) and ‘bending or twisting the back’ (35% vs. 5%; p , 0.01). The prevalence of neck disorders was significantly higher in ophthalmologists. In other studies, repetitive movements, posture and other factors were subjectively considered as important risk factors by dental hygienists (Anton et al. 2002), sonographers (Magnavita et al. 1999; Russo et al. 2002; Wihlidal and Kumar 1997), nurses (Lagerstro¨m et al. 1995; Lusted et al. 1996; Sheikhzadeh et al. 2009; Smith et al. 2004a) and physical therapists (Adegoke, Akodu, and Oyeyemi 2008; Bork et al. 1996; Glover 2002; Salik and Ozcan 2004; West and Gardner 2001). In any case, an evaluation of these results is difficult and disputable. Another problem is that the authors have applied different methods, not fully comparable, for the collection and definition of symptoms or diagnosis of disease. For example, while some studies used standardised questionnaires (e.g. the Nordic Musculoskeletal Questionnaire in Kuorinka et al. 1987) which take into consideration the appearance of symptoms during the last year and in the last week, others have applied original questionnaires considering different symptoms, and different observation periods, e.g. symptoms during the last month or in previous years. A further limitation is that only a few works draw a comparison with appropriate control groups. Among the rare examples, Milerad and Ekenvall (1990) compared dentists with a group of pharmacists, which revealed a significant increase in symptoms in the neck (RR 2.1, 95% CI: 1.4– 3.1) and shoulders (RR: 2.2, 95% CI: 1.3 –3.3); this result was confirmed by another similar study, where the OR neck symptoms in dentists compared with pharmacists was 3.2 (95% CI: 2.10 –4.79) (Aminian, Banafsheh Alemohammad, and Sadeghniiat-Haghighi 2012). In another study (Bjo¨rksten, Almby, and Jansson 1994), shoulder disorders increased in laboratory technicians compared with a group of employees ( p , 0.05). However, in Harcombe et al. (2009), neck symptoms did not increase compared with the two groups of employees. In some works, results were compared across different groups of healthcare workers, as in the study by Akesson et al. (1999), which compared dentists and dental hygienists with a group of nurses of similar mean age, noting an increased risk for neck/ shoulder, shoulder and hand/wrist, but not for neck and elbow disorders. The representativeness of this comparison is limited by the fact that in nurses, it is impossible to exclude a functional overload of the upper limb. Another problem is that nurses from different medical and surgical branches were included in the comparison: nurses are a very heterogeneous group of workers with markedly different activities and risks, as demonstrated by the high variablility in the prevalence of symptoms. The study by David and Buckle (1997) may be considered more indicative: it compared technicians using manual pipettes with technicians who did not use them. In this case, an increased risk for elbow (OR: 3.24, 95% CI: 1.2 –9.2) and hand/wrist disorders (OR: 2.75, 95% CI: 1.39 – 5.45) was demonstrated. Regarding upper limb disease, a high prevalence, in particular of CTS, was reported in 5 –16% of dentists (Lagerstro¨m et al. 1995; Oberg and Oberg 1993, respectively), 6 –8% of dental hygienists (Ylipa¨a¨, Arnetz, and Preber 1999; Anton et al. 2002, respectively), 6% of endoscopists (Buschbacher 1994), 1.5 – 5% of sonographers (Mirk et al. 1999; Wihlidal and Kumar 1997, respectively) and 16% of anesthesia nurses (Diaz 2001). The reason for the high variability in the prevalence reported by the studies may be that in a few studies, a clinical diagnosis based on EMG was directly obtained by researchers, yet in others, an anamnestic diagnosis was made. The incidence of rotator cuff syndrome, lateral epicondylitis, trigger finger and CTS was also recently reported by Chung et al. (2013) to be significantly higher in the nurses than in a reference group (all p , 0.05). In the general population, a prevalence of 1–4% is generally reported for comparative purposes (Atroshi et al. 1999; Cimmino et al. 2002; Papanicolaou, McCabe, and Firrel 2001). In a recent study, Dale et al. (2013) found a prevalence of 7.8% of CTS in workers recruited primarily from such industry sectors as manufacturing, production, service, construction and the healthcare. Finally, it is worth mentioning that 12 studies performed on physicians (especially in surgeons) were collected in the first phase of the systematic search. Still, it was not possible to include these studies in the review because they were not prevalence studies, the response rate was lower than 50% or the number of subjects included was , 25. This suggests the need for high-quality new studies on this occupational group. Conclusion The analysis of the articles shows that the biomechanical overload of the upper limbs and the correlated upper limb symptoms has been inadequately studied in healthcare personnel so far. Particularly poor are the data on risk assessment: different methods are currently applied for an evaluation of biomechanical overload of the upper limb in studies in working populations, but have been applied in only 2 papers out of the 65 included in this review, and even a subjective evaluation of the risk by the operators was collected in a few studies. Another problem is the comparability of results: even if the number of studies on the prevalence of upper limb symptoms

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and diseases as well as biomechanical overload is not small (65 articles collected in this review), substantially different methods were applied for symptom or disease definition and risk evaluation. Furthermore, many of the works include other significant limitations, such as the heterogeneity of operators included in the same group (e.g. nurses) and the lack of appropriate controls, if any. With these limitations, the results of studies on healthcare workers suggest a high prevalence of upper limb symptoms/ disorders, particularly in the neck/shoulder, and of CTS in dental personnel. The prevalence in nurses is highly variable, but this may be due to the fact that the authors studied distinctly different nursing staff. Although a few studies are available, they suggest an increase in the prevalence of upper limb symptoms in laboratory technicians, particularly those using manual pipettes. Physiotherapists are the group with the lowest prevalence of symptoms in spite of the relation with occupational activity suggested by some results. Data are limited and insufficiently comparable for any conclusion to be drawn on other groups. The possible role of biomechanical overload in the induction of upper limb disorders and diseases in healthcare workers, such as that of stress or other personal factors, was ignored in the large part of the studies, so cannot be currently assessed: these aspects deserve adequate attention in future studies in the field.

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Upper limb musculoskeletal disorders in healthcare personnel.

The literature on upper limb musculoskeletal disorders (UL-MSD) in different groups of healthcare workers was reviewed: 65 relevant studies were colle...
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