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1.  Prevalence and risk factors for foot and ankle musculoskeletal disorders experienced by nurses 
Nurses are at high risk of musculoskeletal disorders (MSDs). Although the prevalence of MSDs of the lower back, upper limbs, neck and shoulders have been reported previously in nursing, few studies have evaluated MSDs of the foot and ankle. This study evaluated the prevalence of foot and ankle MSDs in nurses and their relation to individual and workplace risk factors.
A self-administered survey incorporating the Nordic Musculoskeletal Questionnaire (NMQ) was distributed, over a nine-week period, to all eligible nurses (n = 416) working in a paediatric hospital in Brisbane, Australia. The prevalence of MSDs for each of the NMQ body regions was determined. Bivariate and multivariable logistic regression analyses were conducted to examine the relationships between activity-limiting foot/ankle MSDs and risk factors related to the individual (age, body mass index, number of existing foot conditions, smoking history, general physical health [SF36 Physical Component Scale], footwear features) or the workplace (level of nursing position, work location, average hours worked, hours worked in previous week, time since last break from work).
A 73% response rate was achieved with 304 nurses completing surveys, of whom 276 were females (91%). Mean age of the nurses was 37 years (±10), younger than the state average of 43 years. Foot/ankle MSDs were the most prevalent conditions experienced by nurses during the preceding seven days (43.8%, 95% CI 38.2-49.4%), the second most prevalent MSDs to impair physical activity (16.7%, 95% CI 13.0-21.3%), and the third most prevalent MSD, after lower-back and neck problems, during the preceding 12 months (55.3%, 95% CI 49.6-60.7%). Of the nurse and work characteristics investigated, obesity, poor general physical health, existing foot conditions and working in the intensive care unit emerged as statistically significant (p < 0.05) independent risk factors for activity-limiting foot/ankle MSDs.
Foot/ankle MSDs are common in paediatric hospital nurses and resulted in physical activity limitations in one out of every six nurses. We recommend targeted education programs regarding the prevention, self-management and treatment strategies for foot/ankle MSDs. Further research is needed into the impact of work location and extended shift durations on foot/ankle MSDs.
PMCID: PMC4061517  PMID: 24902582
2.  Musculoskeletal disorders in physically active conscripts: a one-year follow-up study in the Finnish Defence Forces 
Musculoskeletal disorders (MSDs) are an important cause for morbidity in military service. They result in disabilities needing long-term rehabilitation and functional impairment leading to premature discharge from military service. The purpose of the study was to investigate the incidence and nature of MSDs in Finnish conscripts.
Two successive arrivals of 18–28-yr-old male conscripts (N = 955, median age 19) were followed for six months. MSDs, including overuse and acute injuries, treated at the garrison clinic were identified and analysed.
During the 12-month study period there were 437 outpatient clinic visits in 955 persons. The occurrence rate was 33% during 6-month service while the event-based incidence was 3.3 per 1000 person-days. Occurrence peaked in summer months. The most common types of MSDs were low back pain (LBP, 20%), lower limb overuse injuries (16%) and sprains or strains (13%). Disorders mostly occurred in combat training in combat gear (40%) and during marching on foot or bicycle (28%). Overuse-related MSDs were more prevalent (66%) than traumatic ones (34%). One-third (34%) of the MSDs were recurrent and 66% were new ones. Disorders of the back and the knee were most frequently recurrent conditions (44% for both). Fractures, knee ligament ruptures, dislocations and muscle strains accounted for the highest number of service days lost. Twenty-four (2.5%) out of 955 conscripts were prematurely discharged due to MSDs.
Preventive measures during military service should be targeted at decreasing low back pain and lower limb overuse injuries, because these inflict the largest burden of MSDs and tend to have a chronic nature.
PMCID: PMC2724399  PMID: 19624829
3.  Low back pain and widespread pain predict sickness absence among industrial workers 
The prevalence of musculoskeletal disorders (MSD) in the aluminium industry is high, and there is a considerable work-related fraction. More knowledge about the predictors of sickness absence from MSD in this industry will be valuable in determining strategies for prevention. The aim of this study was to analyse the relative impact of body parts, psychosocial and individual factors as predictors for short- and long-term sickness absence from MSD among industrial workers.
A follow-up study was conducted among all the workers at eight aluminium plants in Norway. A questionnaire was completed by 5654 workers at baseline in 1998. A total of 3320 of these participated in the follow-up study in 2000. Cox regression analysis was applied to investigate the relative impact of MSD in various parts of the body and of psychosocial and individual factors reported in 1998 on short-term and long-term sickness absence from MSD reported in 2000.
MSD accounted for 45% of all working days lost the year prior to follow-up in 2000. Blue-collar workers had significantly higher risk than white-collar workers for both short- and long-term sickness absence from MSD (long-term sickness absence: RR = 3.04, 95% CI 2.08–4.45). Widespread and low back pain in 1998 significantly predicted both short- and long-term sickness absence in 2000. In addition, shoulder pain predicted long-term sickness absence. Low social support predicted short-term sickness absence (RR = 1.28, 95% CI 1.11–1.49).
Reducing sickness absence from MSD among industrial workers requires focusing on the working conditions of blue-collar workers and risk factors for low back pain and widespread pain. Increasing social support in the work environment may have effects in reducing short-term sickness absence from MSD.
PMCID: PMC200978  PMID: 12956891
sickness absence; musculoskeletal disorders; low back pain; widespread pain; blue-collar workers; social support
4.  Physical activity is associated with a low prevalence of musculoskeletal disorders in the Royal Norwegian Navy: a cross sectional study 
Despite considerable knowledge about musculoskeletal disorders (MSD) and physical, psychosocial and individual risk factors there is limited knowledge about physical activity as a factor in preventing MSD. In addition, studies of physical activity are often limited to either leisure activity or physical activity at work. Studies among military personnel on the association between physical activity at work and at leisure and MSD are lacking. This study was conducted to find the prevalence of MSD among personnel in the Royal Norwegian Navy and to assess the association between physical activity at work and at leisure and MSD.
A questionnaire about musculoskeletal disorders, physical activity and background data (employment status, age, gender, body mass index, smoking, education and physical stressors) was completed by 2265 workers (58%) 18 to 70 years old in the Royal Norwegian Navy. Multiple logistic regression with 95% confidence intervals was used to assess the relationship between physical activity and musculoskeletal disorders.
A total of 32% of the workers reported musculoskeletal disorders often or very often in one or more parts of the body in the past year. The most common musculoskeletal disorders were in the lower back (15% often or very often), shoulders (12% often or very often) and neck (11% often or very often). After adjustment for confounders, physical activity was inversely associated with musculoskeletal disorders for all body sites except elbows, knees and feet.
The one-year prevalence of musculoskeletal disorders among workers in the Royal Norwegian Navy was rather low. A physically active lifestyle both at work and at leisure was associated with fewer musculoskeletal disorders among personnel in the Royal Norwegian Navy. Prospective studies are necessary to confirm the cause and effect in this association.
PMCID: PMC1929072  PMID: 17601352
5.  Musculoskeletal disorder risk factors among nursing professionals in low resource settings: a cross-sectional study in Uganda 
BMC Nursing  2014;13:7.
Musculoskeletal disorders (MSD) constitute one of the main occupational hazards among health care workers. However, few epidemiological studies on work related MSD among nursing professionals have been carried out in Africa. The purpose of this study was to assess the work related musculoskeletal disorders and associated risk factors among nursing professionals in Uganda.
This was a cross-sectional study of MSD among 880 nursing professionals from five selected hospitals in Uganda. Data was collected using a questionnaire adapted from the Dutch Musculoskeletal and Nordic Musculoskeletal questionnaires. Descriptive (mean, standard deviation and percentages) and inferential (Chi square test and logistic regression analysis) statistics were used to analyse data. Alpha level was set at p < 0.05.
A total of 741 completed questionnaires were analysed (response rate 85.4%). The average age of the respondents was 35.4 (SD 10.7) years and a majority were female (85.7%). The average working hours per week was 43.7 (SD 18.9 hours). The 12-month period-prevalence of MSD at anybody site was 80.8%. The most common site of MSD was the lower back (61.9%). Significant risk factors for reported MSD included often working in a slightly bent posture (adjOR 2.25, 95% CI 1.20-4.26), often working in a slightly twisted posture for long (adjOR 1.97, 95% CI 1.03-3.77), mental exhaustion (adjOR 2.05, 95% CI 1.17-3.5), being absent from the work station for more than 6 months due to illness or an accident (adjO|R, 4.35, 95% CI 1.44-13.08) and feeling rested after a break (adjOR 2.09, 95% CI 1.16-3.76).
Musculoskeletal disorders affect more than 80% of nursing professionals in Uganda with the most commonly, affected site being the lower back. Significant risk factors for MSD include; being absent from the work station for more than 6 months due to illness or an accident, working in awkward postures, pushing/pulling of heavy loads and mental exhaustion. There is a need for greater advocacy, better working conditions and adoption of strategies to reduce occupational injuries.
PMCID: PMC3940025  PMID: 24565421
Musculoskeletal disorders; Risk factors; Uganda
6.  Work-life conflict and musculoskeletal disorders: a cross-sectional study of an unexplored association 
The health consequences of work-family or rather work-life conflict (WLC) have been studied by numerous researchers. The work-related causes of musculoskeletal disorders (MSD) are also well explored. And stress (at work) has been found to be a consequence of WLC as well as a cause of MSD. But very little is known about a potential association between WLC and MSD and the possible mediating role of stress in this relationship.
Survey data collected in 2007 among the workforces of four large companies in Switzerland were used for this study. The study population covered 6091 employees. As the exposure variable and hypothesized risk factor for MSD, WLC was measured by using a 10-item scale based on an established 18-item scale on work-family conflict. The outcome variables used as indicators of MSD were (low) back pain and neck/shoulder pain. Stress as the assumed intervening variable was assessed by a validated single-item measure of general stress perception. Correlation coefficients (r), standardized regression coefficients (β) and multiple adjusted odds ratios (OR) were calculated as measures of association.
WLC was found to be quite strongly associated with MSD (β = .21). This association turned out to be substantially confounded by physical strain at work, workload and job autonomy and was considerably reduced but far from being completely eliminated after adjusting for general stress as another identified risk factor of MSD and a proven strong correlate of WLC (r = .44). A significant and relevant association still remained (β = .10) after having controlled for all considered covariates. This association could be fully attributed to only one direction of WLC, namely the work-to-life conflict. In subsequent analyses, a clear gradient between this WLC direction and both types of MSD was found, and proved to be consistent for both men and women. Employees who were most exposed to such work-to-life conflict were also most at risk and showed a fivefold higher prevalence rate (19%-42%) and also an up to sixfold increased relative risk (OR = 3.8-6.3) of suffering greatly from these types of MSD compared with the least exposed reference group showing very low WLC in this direction. Including stress in the regression models again reduced the strength of the association significantly (OR = 1.9-4.1), giving an indication for a possible indirect effect of WLC on MSD mediated by stress.
Future research and workplace interventions for the prevention of MSD need to consider WLC as an important stressor, and the MSD risk factor identified in this study.
PMCID: PMC3073966  PMID: 21410950
7.  Assessing the impact of waste picking on musculoskeletal disorders among waste pickers in Mumbai, India: a cross-sectional study 
BMJ Open  2015;5(9):e008474.
To assess the prevalence of musculoskeletal disorders (MSDs) as well as the impact of the occupation of waste picking on complaints of MSDs among waste pickers. The study attempts to understand the risk factors for MSDs in various areas of the body.
A cross-sectional household survey was conducted using a case-control design. The survey instrument for measuring musculoskeletal symptoms was adopted from a standardised Nordic questionnaire. The impact of the occupation of waste picking on MSDs was analysed using the propensity score matching (PSM) method.
The study population consisted of waste pickers (n=200) who had been working for at least a year and a control group (n=213) selected from among or living close to the same communities.
The 12-month prevalence of MSDs was higher among waste pickers (79%) compared to controls (55%) particularly in the lower back (54–36%), knee (48–35%), upper back (40–21%) and shoulder (32–12%). Similar patterns were observed in the 12-month prevalence of MSDs which prevented normal activity inside and outside the home, particularly for the lower back (36–21%), shoulder (21–7%) and upper back (25–12%) for waste pickers and controls. Analysis of the impact of waste picking on complaints of MSDs suggests that the occupation of waste picking raises the risk of MSDs particularly in the shoulder, lower and upper back. Older age and longer duration of work are significant risk factors for MSDs.
The findings suggest a relatively higher prevalence of MSDs among waste pickers, particularly in the lower and upper back and shoulder, compared to controls. Preventive measures and treatment to minimise the burden of MSDs among waste pickers are strongly recommended.
PMCID: PMC4593149  PMID: 26408284
8.  Musculoskeletal disorders among construction workers: a one-year follow-up study 
Work-related musculoskeletal disorders (MSDs) are an important cause of functional impairments and disability among construction workers. An improved understanding of MSDs in different construction occupations is likely to be of value for selecting preventive measures. This study aimed to survey the prevalence of symptoms of MSDs, the work-relatedness of the symptoms and the problems experienced during work among two construction occupations: bricklayers and supervisors.
We randomly selected 750 bricklayers and 750 supervisors resident in the Netherlands in December 2009. This sample was surveyed by means of a baseline questionnaire and a follow-up questionnaire one year later. The participants were asked about complaints of the musculoskeletal system during the last six months, the perceived work-relatedness of the symptoms, the problems that occurred during work and the occupational tasks that were perceived as causes or aggravating factors of the MSD.
Baseline response rate was 37%, follow-up response was 80%. The prevalence of MSDs among 267 bricklayers and 232 supervisors was 67% and 57%, respectively. Complaints of the back, knee and shoulder/upper arm were the most prevalent among both occupations. Irrespective of the body region, most of the bricklayers and supervisors reported that their complaints were work-related. Complaints of the back and elbow were the most often reported among the bricklayers during work, whereas lower arm/wrist and upper leg complaints were the most often reported among the supervisors. In both occupations, a majority of the participants perceived several occupational physical tasks and activities as causes or aggravating factors for their MSD. Recurrent complaints at follow-up were reported by both bricklayers (47% of the complaints) and supervisors (31% of the complaints). Participants in both occupations report that mainly back and knee complaints result in additional problems during work, at the time of follow-up.
A substantial number of the bricklayers and the supervisors report musculoskeletal disorders, mainly back, knee and shoulder/upper arm complaints. The majority of the bricklayers and half of the supervisors believe that their complaints are work-related. Irrespective of occupation, participants with MSDs report substantial problems during work. Workplace intervention measures aimed at occupational physical tasks and activities seem justified for both occupations.
PMCID: PMC3489781  PMID: 23061990
Construction industry; Longitudinal study; Work-related musculoskeletal disorders
9.  Work disability benefits due to musculoskeletal disorders among Brazilian private sector workers 
BMJ Open  2011;1(1):e000003.
To evaluate the prevalence and characteristics of disability benefits due to musculoskeletal disorders (MSD) granted to Brazilian private sector workers.
This was a population-based epidemiological study of MSD-related benefits among registered private sector workers (n=32 959 329). The prevalence (benefits/10 000 workers/year) of work disability benefits was calculated by gender, age, state, Human Development Index (HDI), economic activity, MSD type and work-relatedness.
The prevalence of MSD-related benefits in Brazil among registered private sector workers in 2008 was 93.6/10 000 workers. The prevalence increased with age, and was higher for women (112.2) than for men (88.1), although the former had shorter benefit duration. The gender-adjusted prevalence by state varied from 16.6 to 90.3 for non-work-related, and from 7.8 to 59.6 for work-related benefits. The Brazilian states with a high–very high HDI had the highest prevalence. The top four most common types of MSD-related benefits were due to back pain, intervertebral disc disorders, sinovitis/tenosynovitis and shoulder disorders.
MSD is a frequent cause of work disability in Brazil. There were differences in prevalence among economic activities and between states grouped by HDI. This study demonstrates that further evaluation of the contributing factors associated with MSD-related disability benefits is required. Factors that should be considered include production processes, political organisation, socioeconomic and educational characteristics, the compensation and recording systems, and employee–employer power relationships. These factors may play an important role in the prevalence of MSD-related disability benefits, especially in countries with large socioeconomic iniquities such as Brazil.
Article summary
Article focus
Musculoskeletal disorders (MSD) are a major cause of disability worldwide.
The prevalence and distribution of MSD among Brazilian workers are not well known.
This article evaluates the prevalence and characteristics of disability benefits due to MSD granted to Brazilian private sector workers.
Key messages
The prevalence of MSD-related benefits among registered Brazilian private sector workers in 2008 was 93.6/10 000 workers, with the top four most common benefits being due to back pain, intervertebral disc disorders, sinovitis/tenosynovitis and shoulder disorders.
This study demonstrates that further evaluation of the contributing factors associated with MSD-related disability benefits is required and should assess the production processes, political organisation, socioeconomic and educational characteristics, the compensation and recording systems, and employee–employer power relationships.
These factors may play an important role in the prevalence of MSD-related disability benefits, especially in countries with large socioeconomic iniquities such as Brazil.
Strengths and limitations of this study
All employed workers with a registered job in the private sector were analysed (32 959 329 workers). Prevalence was adjusted by gender, age and category of benefit (work-related or non-work-related). This initial descriptive study provides some baseline data on the magnitude of the problem. The data may be used for future comparisons and to evaluate the effectiveness of prevention programs. The strength of this paper is that it supplies information which could be useful in the implementation of an occupational health policy to reduce MSD. One of the limitations is that it only includes data from registered workers although there are many non-registered workers in Brazil. Another limitation is that this study depends on the quality of the data recorded by the National Insurer (NI) of the Brazilian Ministry of Social Insurance.
PMCID: PMC3191405  PMID: 22021719
10.  A systematic review of musculoskeletal disorders among school teachers 
Musculoskeletal disorders (MSD) represent one of the most common and most expensive occupational health problems in both developed and developing countries. School teachers represent an occupational group among which there appears to be a high prevalence of MSD. Given that causes of MSD have been described as multi-factorial and prevalence rates vary between body sites and location of study, the objective of this systematic review was to investigate the prevalence and risk factors for MSD among teaching staff.
The study involved an extensive search of MEDLINE and EMBASE databases in 2011. All studies which reported on the prevalence and/or risk factors for MSD in the teaching profession were initially selected for inclusion. Reference lists of articles identified in the original search were then examined for additional publications. Of the 80 articles initially located, a final group of 33 met the inclusion criteria and were examined in detail.
This review suggests that the prevalence of self-reported MSD among school teachers ranges between 39% and 95%. The most prevalent body sites appear to be the back, neck and upper limbs. Nursery school teachers appear to be more likely to report suffering from low back pain. Factors such as gender, age, length of employment and awkward posture have been associated with higher MSD prevalence rates.
Overall, this study suggests that school teachers are at a high risk of MSD. Further research, preferably longitudinal, is required to more thoroughly investigate the issue of MSD among teachers, with a greater emphasis on the possible wider use of ergonomic principles. This would represent a major step forward in the prevention of MSD among teachers, especially if easy to implement control measures could be recommended.
PMCID: PMC3250950  PMID: 22087739
11.  High and specialty-related musculoskeletal disorders afflict dental professionals even since early training years 
Journal of Applied Oral Science  2013;21(4):376-382.
To determine how early musculoskeletal disorders (MSDs) develop in dental professionals and to explore the potential differences among distinct dental specialties.
Material and Methods
271 dental postgraduates majoring in five dental specialties were recruited, i.e., orthodontics, prosthodontics, endodontics, periodontics and alveolar surgery. 254 age-matched non-dental postgraduates served as the control. The standardized Nordic questionnaire on MSDs and a self-report questionnaire regarding correlative factors (only for dental postgraduates) were answered through emails. Reliability of responses was assessed applying test-retest method.
The intraclass correlation coefficient of participants' answers ranged from 0.89 to 0.96. Dental postgraduates had significantly higher prevalence of MSDs than the control group, especially at neck, upper back and lower back. In all dental specialties included, high prevalence of MSDs was reported at neck (47.5%-69.8%), shoulders (50.8%-65.1%), lower back (27.1%-51.2%) and upper back (25.6%-46.5%), with lower prevalence at elbows (5.1%-18.6%), hips (3.4%-16.3%) and ankles (5.1%-11.6%). Periodontics students reported the worst MSDs in most body regions except wrists and knees, which were more prevalent for prosthodontic and alveolar surgery students, respectively. Furthermore, year of clinical work, clinical hours per week and desk hours per week were found as risk factors for MSDs, whereas physical exercise and rest between patients as protective factors.
High and specialty-related MSDs afflict dental professionals even since very early stage of careers. Prevention aimed at the specialty-related characteristics and the risk/protective factors revealed in this study should be introduced to dental personnel as early as possible.
PMCID: PMC3881886  PMID: 24037079
Occupational health; Musculoskeletal diseases; Specialty; Dentists; Dental education
12.  Musculoskeletal disorders among staff in South Korea’s largest nursing home 
Although musculoskeletal disorders (MSD) represent a significant occupational issue for most nursing home staff, few epidemiological studies have been conducted in Korea.
We investigated the prevalence of, and risk factors for, MSD within South Korea’s largest nursing home using a previously validated, self-reporting questionnaire.
From a total of 130 registered employees, 91 (70.0%) successfully completed questionnaires were obtained. The majority were female (80.2%, n=73), with an age range of 27 to 62 years and an average age of 47.0 years (SD 8.0). MSD occurred in varying amounts and was classified into distinct categories depending on body site. The most commonly affected region was the shoulder (reported by 35.2%), followed by the arm (22.0%), knee (20.9%) and lower back (19.8%). Three statistically significant risk factors were consistently identified among all 4 MSD sites: manually handling patients (OR 5.1 to 20.8), changing a patient’s clothes (OR 6.7 to 30.1) and working as a nursing aide (OR 3.7 to 74.3).
Overall, the present results suggest that employment within a South Korean nursing home incurs certain hazards depending on job description and daily work tasks. The MSD prevalence differed from other occupations within South Korea and previous nursing home studies.
PMCID: PMC2723262  PMID: 21432112
musculoskeletal disorders; nursing home; Korea; low back pain; self-reported
13.  Stability and change in health behaviours as predictors for disability pension: a prospective cohort study of Swedish twins 
BMC Public Health  2011;11:678.
Stability or changes of health behaviours have not been studied in association with incidence of disability pension (DP). The aims were to (1) investigate if stability or changes in health behaviours predict DP due to musculoskeletal diagnosis (MSD), (2) to evaluate if an association exists for DP in general, and (3) after taking familial confounding into account.
The study sample was 16,713 like-sexed twin individuals born in Sweden between 1935-1958 (6195 complete twin pairs) who had participated in two surveys 25 years apart, were alive, and not pensioned at the time of the latest survey. Cox proportional hazards analysis was used to assess the associations (hazard ratios (HR) with 95% confidence intervals (CI)) between stability and change in health behaviours (physical activity, tobacco and alcohol use, body mass index (BMI)), and number of pain locations collected at two time points 25 years apart and the incidence of DP until 2008.
During the follow-up, 1843 (11%) individuals were granted DP with 747 of these due to MSD. A higher proportion of women were granted DP than men. Increase in BMI and stable use of tobacco products were predictors for DP due to MSD (HR 1.21-1.48) and DP in general (HR 1.10-1.41). The stability in the frequency of physical activity and increased frequency of physical activity were protective factors for DP due to MSD only when accounting for familial confounding. However, the number of pain locations (stability, increase, or decrease) was the strongest predictor for future DP due to MSD (HR 3.69, CI 2.99-4.56) and DP in general (HR 2.15, CI 1.92-2.42). In discordant pair analysis, the HRs for pain were lower, indicating potential familial confounding.
Health behaviours in adulthood, including an increase in pain locations were associated with the incidence of DP. The association between physical activity and DP was especially related to adulthood choices or habits, i.e., the individual decision about frequency of exercising. Thus, it is important to e.g. increase public awareness of the potential beneficial effects of exercise throughout life to avoid permanent exclusion from the labour market for medical reasons.
PMCID: PMC3176221  PMID: 21880151
14.  VIP in construction: systematic development and evaluation of a multifaceted health programme aiming to improve physical activity levels and dietary patterns among construction workers 
BMC Public Health  2012;12:89.
The prevalence of both overweight and musculoskeletal disorders (MSD) in the construction industry is high. Many interventions in the occupational setting aim at the prevention and reduction of these health problems, but it is still unclear how these programmes should be designed. To determine the effectiveness of interventions on these health outcomes randomised controlled trials (RCTs) are needed. The aim of this study is to systematically develop a tailored intervention for prevention and reduction of overweight and MSD among construction workers and to describe the evaluation study regarding its (cost-)effectiveness.
The Intervention Mapping (IM) protocol was applied to develop and implement a tailored programme aimed at the prevention and reduction of overweight and MSD. The (cost-) effectiveness of the intervention programme will be evaluated using an RCT. Furthermore, a process evaluation will be conducted. The research population will consist of blue collar workers of a large construction company in the Netherlands.
The intervention programme will be aimed at improving (vigorous) physical activity levels and healthy dietary behaviour and will consist of tailored information, face-to-face and telephone counselling, training instruction (a fitness "card" to be used for exercises), and materials designed for the intervention (overview of the company health promoting facilities, waist circumference measuring tape, pedometer, BMI card, calorie guide, recipes, and knowledge test).
Main study parameters/endpoints
The intervention effect on body weight and waist circumference (primary outcome measures), as well as on lifestyle behaviour, MSD, fitness, CVD risk indicators, and work-related outcomes (i.e. productivity, sick leave) (secondary outcome measures) will be assessed.
The development of the VIP in construction intervention led to a health programme tailored to the needs of construction workers. This programme, if proven effective, can be directly implemented.
Trial registration
Netherlands Trial Register (NTR): NTR2095
PMCID: PMC3280176  PMID: 22289212
Obesity/overweight; Musculoskeletal disorders; RCT; Energy balance related behaviour; Physical activity; Dietary behaviour; Construction workers; Intervention mapping
15.  Work-related musculoskeletal discomfort of dairy farmers and employed workers 
Dairy farming is physically demanding and associated with a high frequency of musculoskeletal disorders (MSD). This study investigated and compared work-related MSD, ergonomic work factors and physical exertion in farmers and employed farm workers on dairy farms in Sweden.
The study comprised 66 dairy farmers, and 37 employed dairy farm workers. A modified version of the general Standardised Nordic Questionnaire was used for analyses of perceived MSD in nine different parts of the body. Perceived physical discomfort was assessed using questions concerning ergonomic work factors. A rating scale was used for analyses of perceived physical exertion. Information about participant demographics was also collected. The response rate amounted to 70%.
The most frequently reported MSD in farmers and farm workers were located in the lower back (50% and 43%, respectively) and the shoulders (47% and 43%, respectively). MSD were also frequently reported in the neck (33%) among farmers, and in the hands/wrist (41%) among farm workers. MSD in the elbows (23%) and feet (21%) were significantly more frequently reported by farmers than farm workers (5%). Female farmers and farm workers both reported significantly higher frequencies of MSD in the neck (48% and 56%, respectively) and hands/wrists (44% and 61%, respectively) than their male colleagues (24% and 5%; 10% and 21%, respectively). In addition, female farm workers had significantly higher reported frequencies of MSD in the upper and lower back (39% and 61%, respectively) than their male counterparts (5% and 26%, respectively). Milking was perceived as a weakly to moderately physically demanding work task. Repetitive and monotonous work in dairy houses was the ergonomic work factor most frequently reported as causing physically discomfort among farmers (36%) and farm workers (32%), followed by lifting heavy objects (17% and 27%, respectively). Female workers had significantly more reported discomfort from repetitive and monotonous work than their male counterparts (50% and 16%, respectively).
Despite the technical developments on modern dairy farms, there is still a high prevalence of MSD and discomfort from ergonomic work factors, particularly among female workers.
PMCID: PMC3534013  PMID: 23152974
Ergonomic work factors; Work environment; Physical exertion; Dairy farming; Milking; Agriculture; Questionnaire; Rating scale
16.  Low physical fitness is a strong predictor of health problems among young men: a follow-up study of 1411 male conscripts 
BMC Public Health  2011;11:590.
Military service in Finland is compulsory for male citizens and annually about 90% of 19-year-old men enter into the service. Approximately 15% of them are discharged due to medical reasons constituting a group of young men who are at risk of being marginalised in society. The purpose of the study was to evaluate predictive associations between medical discharge from the compulsory military service and various intrinsic risk factors, including socio-economic, health, health behavior, and physical fitness outcomes.
We followed four successive cohorts of conscripts who formed a representative sample of Finnish young men (18-28 years old, median age 19 yrs) for 6 months. To exclude injuries and illnesses originating before the onset of service, conscripts discharged from the service at the medical screenings during the 2-week run-in period were excluded from the analyses. Data regarding medical discharge were charted from computerised patient records. Predictive associations between medical discharge and intrinsic risk factors were examined using multivariate Cox's proportional hazard models.
Of 1411 participants, 9.4% (n = 133) were discharged prematurely for medical reasons, mainly musculoskeletal (44%, n = 59) and mental and behavioral (29%, n = 39) disorders. Low levels of physical fitness assessed with a 12-min running test (hazard ratio [HR] 3.3; 95% confidence interval [CI]: 1.7-6.4), poor school success (HR 4.6; 95% CI: 2.0-11.0), poor self-assessed health (HR 2.8; 95% CI: 1.6-5.2), and not belonging to a sports club (HR 4.9; 95% CI: 1.2-11.6) were most strongly associated with medical discharge in a graded manner. The present results highlight the need for an improved pre-enlistment examination and provide a new means of identifying young persons with a high risk for discharge.
The majority of the observed risk factors are modifiable. Thus preventive measures and programs could be implemented. The findings suggest that increasing both aerobic and muscular fitness is a desirable goal in a pre-training program before entering military service. Attention to appropriate waist circumference and strategies addressing psychological well-being may strengthen the preventive program. Optimally the effectiveness of these programs should be tested in randomized controlled intervention studies.
PMCID: PMC3166930  PMID: 21787401
epidemiology; exercise; fitness testing; sporting injuries
17.  Risk factors of acute and overuse musculoskeletal injuries among young conscripts: a population-based cohort study 
Military service in Finland is compulsory for all male citizens and annually about 80% of 19-year-old men enter into the service. The elevated risk for many chronic diseases and loss of function among those who are inactive and unfit can be often detected already in youth. On the other hand, activity-induced injuries among young are true public health issue. The purpose of the present prospective cohort follow-up study was to evaluate predictive associations between acute or overuse injuries and their various intrinsic risk factors.
Four successive cohorts of conscripts who formed a representative sample of Finnish young men were followed for 6 months. At the beginning of the service, the risk factors of injuries were measured and recorded and then the acute and overuse injuries treated at the garrison clinic were identified. Predictive associations between injuries and their risk factors were examined by multivariate Cox’s proportional hazard models.
Of the 1411 participants, 27% sustained an acute injury and 51% suffered from overuse injury. Concerning acute injuries, highest risk for severe injuries were detected among conscripts with low fitness level in both the standing long-jump and push-up tests (hazard rate, HR=5.9; 95% CI: 1.6‒21.3). A history of good degree in school sports was not a protective factor against acute injuries. High waist circumference and, on the other hand, being underweight according to BMI increased the HR for overuse injuries. Brisk leisure time physical activity before military entry was a protective factor against overuse injuries. Poor result in Cooper’s test was a warning signal of elevated risk of overuse injuries.
We confirmed previous findings that low level of physical fitness is predictor for musculoskeletal injuries during intensive physical training. The U-shaped relationship between body composition and overuse injuries was noticed indicating that both obesity and underweight are risk factors for overuse injuries. Persons with excellent sports skills according to their earlier degrees in school sports had similar HR for acute injuries than those with poorer degrees. This indicates that school-age sports skills and fitness do not carry far and therefore preventive programmes are needed to prevent activity-induced injuries.
PMCID: PMC4429711  PMID: 25925549
Risk factors; Sporting injuries; Physical fitness; Physical activity; Military training
18.  Musculoskeletal disorders among nursing staff: a comparison of five hospitals in Uganda 
Low and middle income countries have severe nursing staff shortages which is associated with risk of poor quality of patient care and increased patient exposure to adverse events. This is accompanied with increased risk of musculoskeletal disorders to the nursing staff. This paper sets out to identify and compare factors associated with musculoskeletal disorders among nursing staff in 5 different hospitals in Uganda.
This was a cross sectional study on nurses from 5 different hospitals in Uganda. The study used a 12 month recall of reported Musculoskeletal disorders (MSD) among nurses. Ethical approval was obtained. Logistic regression analysis and ANOVA were used. The level of significance was set at 0.05 for all statistical tests.
There were 755 respondents of whom 433 (58.4%) were nurses. The prevalence of MSD at anybody site was 80.8%. There were significant differences in reported MSD among nursing staff across different hospital settings which were worse in the public hospitals as compared to the private and private not for profit hospitals (p <0.001). Age (adjusted OR 1.03, 95% CI 1.01-1.06), self reported poor general health status (adj OR 4.5, 95% CI 2.8-7.24) and stress as suggested by waking up tired in the morning (adj OR 3.4, 95% CI 2.17-5.32) were significant associated factors for MSD in this population.
Reported MSD among nursing staff across 5 different hospitals is worse in public as compared to private hospitals. Age, self reported poor general health status and stress were important factors for MSD in this population.
PMCID: PMC4085942  PMID: 25018829
Musculoskeletal disorders; nurses; public and private hospitals; Uganda
19.  Main clinical, therapeutic and technical factors related to patient's maximum skin dose in interventional cardiology procedures 
The British Journal of Radiology  2012;85(1012):433-442.
The study aimed to characterise the factors related to the X-ray dose delivered to the patient's skin during interventional cardiology procedures.
We studied 177 coronary angiographies (CAs) and/or percutaneous transluminal coronary angioplasties (PTCAs) carried out in a French clinic on the same radiography table. The clinical and therapeutic characteristics, and the technical parameters of the procedures, were collected. The dose area product (DAP) and the maximum skin dose (MSD) were measured by an ionisation chamber (Diamentor; Philips, Amsterdam, The Netherlands) and radiosensitive film (Gafchromic; International Specialty Products Advanced Materials Group, Wayne, NJ). Multivariate analyses were used to assess the effects of the factors of interest on dose.
The mean MSD and DAP were respectively 389 mGy and 65 Gy cm−2 for CAs, and 916 mGy and 69 Gy cm−2 for PTCAs. For 8% of the procedures, the MSD exceeded 2 Gy. Although a linear relationship between the MSD and the DAP was observed for CAs (r=0.93), a simple extrapolation of such a model to PTCAs would lead to an inadequate assessment of the risk, especially for the highest dose values. For PTCAs, the body mass index, the therapeutic complexity, the fluoroscopy time and the number of cine frames were independent explanatory factors of the MSD, whoever the practitioner was. Moreover, the effect of technical factors such as collimation, cinematography settings and X-ray tube orientations on the DAP was shown.
Optimising the technical options for interventional procedures and training staff on radiation protection might notably reduce the dose and ultimately avoid patient skin lesions.
PMCID: PMC3486680  PMID: 22457404
20.  Gender differences in disability after sickness absence with musculoskeletal disorders: five-year prospective study of 37,942 women and 26,307 men 
Gender differences in the prevalence and occupational consequences of musculoskeletal disorders (MSDs) are consistently found in epidemiological studies. The study investigated whether gender differences also exist with respect to chronicity, measured as the rate of transition from sickness absence into permanent disability pension (DP).
Prospective national cohort study in Norway including all cases with a spell of sickness absence > eight weeks during 1997 certified with a MSD, 37,942 women and 26,307 men. The cohort was followed-up for five years with chronicity measured as granting of DP as the endpoint. The effect of gender was estimated in the full sample adjusting for sociodemographic factors and diagnostic distribution. Gender specific analyses were performed with the same explanatory variables. Finally, the gender difference was estimated for nine diagnostic subgroups.
The crude rate of DP was 22% for women and 18% for men. After adjusting for all sociodemographic variables, a slightly higher female risk of DP remained. However, additional adjustment for diagnostic distribution removed the gender difference completely. Having children and working full time decreased the DP risk for both genders, whereas low socioeconomic status increased the risk similarly. There was a different age effect as more women obtained a DP below the age of 50. Increased female risk of chronicity remained for myalgia/fibromyalgia, back disorders and "other/unspecified" after relevant adjustments, whereas men with neck disorders were at higher risk of chronicity.
Women with MSDs had a moderately increased risk of chronicity compared to men, when including MSDs with a traumatic background. Possible explanations are lower income, a higher proportion belonging to diagnostic subgroups with poor prognosis, and a younger age of chronicity among women. When all sociodemographic and diagnostic variables were adjusted for, no gender difference remained, except for some diagnostic subgroups.
PMCID: PMC3046931  PMID: 21299856
21.  Associations Between Academic Stressors, Reaction to Stress, Coping Strategies and Musculoskeletal Disorders Among College Students 
The adverse health effects of stress are enormous, and vary among people, probably because of differences in how stress is appraised and the strategies individuals use to cope with it. This study assessed the association between academic stress and musculoskeletal disorders (MSDs) among 1365 undergraduates.
This was a cross-sectional study conducted in a Nigerian university at the beginning of the 2010/2011 academic session with the same group of participants. The Life Stress Assessment Inventory, Coping Strategies Questionnaire, and Short Musculoskeletal Function Assessment were administered as tools of data gathering.
Students' stress level and associated MSDs were higher during the examination period than the pre-examination periods. Stressors were significantly associated with increased risk of MSDs in both sexes were those related to changes (odds ratio (OR) = 1.7, p = 0.002) and pressures (OR = 2.09, p = 0.001). Emotional and physiological reactions to stress were significantly associated with MSDs in both sexes, with higher odds for MSDs in females, whereas cognitive and behavioral reactions showed higher odds (though non-significant) in males. The risk of MSDs was higher in respondents who adopted avoidance and religious coping strategies compared with those who adopted active practical and distracting coping strategies.
Stress among students could be significantly associated with MSDs depending on individuals' demographics, stressors, reactions to stress, and coping methods. Interventions to reduce stress-induced MSDs among students should consider these factors among others.
PMCID: PMC3742887  PMID: 23950626
Academic stressors; Coping strategies; Musculoskeletal disorders
22.  Active epidemiological surveillance of musculoskeletal disorders in a shoe factory 
Aims: (1) To evaluate an active method of surveillance of musculoskeletal disorders (MSDs). (2) To compare different criteria for deciding whether or not a work situation could be considered at high risk of MSDs in a large, modern shoe factory.
Methods: A total of 253 blue collar workers were interviewed and examined by the same physician in 1996; 191 of them were re-examined in 1997. Risk factors of MSDs were assessed for each worker by standardised job site work analysis. Prevalence and incidence rates of carpal tunnel syndrome, rotator cuff syndrome, and tension neck syndrome were calculated for each of the nine main types of work situation. Different criteria used to assess situations with high risk of MSDs were compared.
Results: On the basis of prevalence data, three types of work situation were detected to be at high risk of MSDs: cutting, sewing, and assembly preparation. The three types of work situations identified on the basis of incidence data (sewing preparation, mechanised assembling, and finishing) were different from those identified by prevalence data. At least one recognised risk factor for MSDs was identified for all groups of work situations. The ergonomic risk could be considered as serious for the four types of work situation having the highest ergonomic scores (sewing, assembly preparation, pasting, and cutting).
Conclusion: The results of the health surveillance method depend largely on the definition of the criteria used to define the risk of MSDs. The criteria based on incidence data are more valid than those based on prevalence data. Health and risk factor surveillance must be combined to predict the risk of MSDs in the company. However, exposure assessment plays a greater role in determining the priorities for ergonomic intervention.
PMCID: PMC1740318  PMID: 12107293
23.  Mediterranean-style diet reduces metabolic syndrome components in obese children and adolescents with obesity 
BMC Pediatrics  2014;14:175.
The beneficial effects of the Mediterranean diet have been amply proven in adults with cardiovascular risk factors. The effects of this diet have not been extensively assessed in pediatric populations with obesity, insulin resistance (IR) and metabolic syndrome (MetS). The aim of this study was to assess the efficacy of the Mediterranean style diet (MSD) to decrease cardiovascular risk factors in children and adolescents with obesity.
Participants were randomly assigned to a MSD rich in polyunsaturated fatty acids, fiber, flavonoids and antioxidants (60% of energy from carbohydrate, 25% from fat, and 15% from protein, (n = 24); or a standard diet (55% of carbohydrate, 30% from fat and 15% from protein, (n = 25), the caloric ingest was individualized. At baseline and 16-week of intervention, the glucose, triglycerides (TG), total cholesterol (TC), HDL-C, LDL-C were measured as well as the body composition and anthropometric data. The diet compliance was determined by the 24-hour recalls.
Paired Student’s t and Macnemar’s test were used to compare effects in biochemical, body composition, anthropometric, and dietary variables.
The MSD group had a significantly decrease in BMI, lean mass, fat mass, glucose, TC, TG, HDL-C and LDL-C. (p < 0.05); the diet compliance increased consumption of omega 9 fatty acids, zinc, vitamin E, selenium, and decreased consumption of saturated fatty acids (p < 0.05). The standard diet group decrease in glucose levels and frequency of glucose >100 mg/dL (p < 0.05).
The MSD improves the BMI, glucose and lipid profile in children and adolescents with obesity and any MetS component.
PMCID: PMC4102089  PMID: 24997634
Obesity; Metabolic syndrome; Mediterranean diet; Children; Adolescents
24.  Neuromuscular training with injury prevention counselling to decrease the risk of acute musculoskeletal injury in young men during military service: a population-based, randomised study 
BMC Medicine  2011;9:35.
The rapidly increasing number of activity-induced musculoskeletal injuries among adolescents and young adults is currently a true public health burden. The objective of this study was to investigate whether a neuromuscular training programme with injury prevention counselling is effective in preventing acute musculoskeletal injuries in young men during military service.
The trial design was a population-based, randomised study. Two successive cohorts of male conscripts in four companies of one brigade in the Finnish Defence Forces were first followed prospectively for one 6-month term to determine the baseline incidence of injury. After this period, two new successive cohorts in the same four companies were randomised into two groups and followed prospectively for 6 months. Military service is compulsory for about 90% of 19-year-old Finnish men annually, who comprised the cohort in this study. This randomised, controlled trial included 968 conscripts comprising 501 conscripts in the intervention group and 467 conscripts in the control group. A neuromuscular training programme was used to enhance conscripts' motor skills and body control, and an educational injury prevention programme was used to increase knowledge and awareness of acute musculoskeletal injuries. The main outcome measures were acute injuries of the lower and upper limbs.
In the intervention groups, the risk for acute ankle injury decreased significantly compared to control groups (adjusted hazards ratio (HR) = 0.34, 95% confidence interval (95% CI) = 0.15 to 0.78, P = 0.011). This risk decline was observed in conscripts with low as well as moderate to high baseline fitness levels. In the latter group of conscripts, the risk of upper-extremity injuries also decreased significantly (adjusted HR = 0.37, 95% CI 0.14 to 0.99, P = 0.047). In addition, the intervention groups tended to have less time loss due to injuries (adjusted HR = 0.55, 95% CI 0.29 to 1.04).
A neuromuscular training and injury prevention counselling programme was effective in preventing acute ankle and upper-extremity injuries in young male army conscripts. A similar programme could be useful for all young individuals by initiating a regular exercise routine.
Trial registration identifier number NCT00595816.
PMCID: PMC3084158  PMID: 21481230
25.  Musculoskeletal Disorders Among Full-Time Homemakers in Poor Communities 
Women & health  2005;42(2):1-14.
To examine factors associated with self-reported musculoskeletal disorders (MSD) among full-time female homemakers.
Data on socio-demographic characteristics, lifestyle and health were collected on 1266 married women aged 15-59 years living in poor suburbs in the outskirts of Beirut, Lebanon. Independent associations with MSD of factors and characteristics were examined using odds ratios (ORs) derived from multiple logistic regression.
Women’s age, weight, and number of children were significantly, positively, independently associated with self-reported MSD, while women’s conduct of specific household tasks were not. Women with MSD were more likely to be stressed than women without MSD (OR = 1.5).
A major finding of this study was the positive association between distress and musculoskeletal disorders. The measures used to assess women’s involvement in housework did not account for the duration of time spent performing each household task. Better measures of domestic labor, including housework and childcare, are required to understand better their impact on the health of full-time homemakers and on MSD in particular. Intervention programs to alleviate MSD in full-time homemakers should address psychosocial factors.
PMCID: PMC1821091  PMID: 16537297
Homemakers; currently married; women; musculoskeletal disorders; distress

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