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26.  Magnitude of impact and healthcare use for musculoskeletal disorders in the paediaric: a population-based study 
Background
Although musculoskeletal disorders (MSD) are among the most prevalent chronic conditions, minimal attention has been paid to the paediatric population. The aim of this study is to describe the annual prevalence of healthcare contacts for MSD by children and youth age 0-19 years, including type of MSD, care delivery setting and the specialty of the physician consulted.
Methods
Analysis of data on all children with healthcare contacts for MSD in Ontario, Canada using data from universal health insurance databases on ambulatory physician and emergency department (ED) visits, same-day outpatient surgery, and in-patient admissions for the fiscal year 2006/07. The proportion of children and youth seeing different physician specialties was calculated for each physician and condition grouping. Census data for the 2006 Ontario population was used to calculate person visit rates.
Results
122.1 per 1,000 children and youth made visits for MSD. The majority visited for injury and related conditions (63.2 per 1,000), followed by unspecified MSD complaints (33.0 per 1,000), arthritis and related conditions (27.7 per 1,000), bone and spinal conditions (14.2 per 1,000), and congenital anomalies (3 per 1,000). Injury was the most common reason for ED visits and in-patient admissions, and arthritis and related conditions for day-surgery. The majority of children presented to primary care physicians (74.4%), surgeons (22.3%), and paediatricians (10.1%). Paediatricians were more likely to see younger children and those with congenital anomalies or arthritis and related conditions.
Conclusion
One in eight children and youth make physician visits for MSD in a year, suggesting that the prevalence of MSD in children may have been previously underestimated. Although most children may have self-limiting conditions, it is unknown to what extent these may deter involvement in physical activity, or be indicators of serious and potentially life-threatening conditions. Given deficiencies in medical education, particularly of primary care physicians and paediatricians, it is important that training programs devote an appropriate amount of time to paediatric MSD.
doi:10.1186/1471-2474-13-98
PMCID: PMC3493363  PMID: 22691633
27.  A systematic review of musculoskeletal disorders among school teachers 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1471-2474-12-260
PMCID: PMC3250950  PMID: 22087739
28.  Work-life conflict and musculoskeletal disorders: a cross-sectional study of an unexplored association 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1471-2474-12-60
PMCID: PMC3073966  PMID: 21410950
29.  Aetiology and risk factors of musculoskeletal disorders in physically active conscripts: a follow-up study in the Finnish Defence Forces 
Background
Musculoskeletal disorders (MSDs) are the main reason for morbidity during military training. MSDs commonly result in functional impairment leading to premature discharge from military service and disabilities requiring long-term rehabilitation. The purpose of the study was to examine associations between various risk factors and MSDs with special attention to the physical fitness of the conscripts.
Methods
Two successive cohorts of 18 to 28-year-old male conscripts (N = 944, median age 19) were followed for six months. MSDs, including overuse and acute injuries, treated at the garrison clinic were identified and analysed. Associations between MSDs and risk factors were examined by multivariate Cox's proportional hazard models.
Results
During the six-month follow-up of two successive cohorts there were 1629 MSDs and 2879 health clinic visits due to MSDs in 944 persons. The event-based incidence rate for MSD was 10.5 (95% confidence interval (CI): 10.0-11.1) per 1000 person-days. Most MSDs were in the lower extremities (65%) followed by the back (18%). The strongest baseline factors associated with MSDs were poor result in the combined outcome of a 12-minute running test and back lift test (hazard ratio (HR) 2.9; 95% CI: 1.9-4.6), high waist circumference (HR 1.7; 95% CI: 1.3-2.2), high body mass index (HR 1.8; 95% CI: 1.3-2.4), poor result in a 12-minute running test (HR 1.6; 95% CI: 1.2-2.2), earlier musculoskeletal symptoms (HR 1.7; 95% CI: 1.3-2.1) and poor school success (educational level and grades combined; HR 2.0; 95% CI: 1.3-3.0). In addition, risk factors of long-term MSDs (≥10 service days lost due to one or several MSDs) were analysed: poor result in a 12-minute running test, earlier musculoskeletal symptoms, high waist circumference, high body mass index, not belonging to a sports club and poor result in the combined outcome of the 12-minute running test and standing long jump test were strongly associated with long-term MSDs.
Conclusions
The majority of the observed risk factors are modifiable and favourable for future interventions. An appropriate intervention based on the present study would improve both aerobic and muscular fitness prior to conscript training. Attention to appropriate waist circumference and body mass index would strengthen the intervention. Effective results from well-planned randomised controlled studies are needed before initiating large-scale prevention programmes in a military environment.
doi:10.1186/1471-2474-11-146
PMCID: PMC2911403  PMID: 20602765
30.  Effectiveness of early part-time sick leave in musculoskeletal disorders 
Background
The importance of staying active instead of bed rest has been acknowledged in the management of musculoskeletal disorders (MSDs). This emphasizes the potential benefits of adjusting work to fit the employee's remaining work ability. Despite part-time sick leave being an official option in many countries, its effectiveness has not been studied yet. We have designed a randomized controlled study to assess the health effects of early part-time sick leave compared to conventional full-day sick leave. Our hypothesis is that if work time is temporarily reduced and work load adjusted at the early stages of disability, employees with MSDs will have less disability days and faster return to regular work duties than employees on a conventional sick leave.
Methods/Design
The study population will consist of 600 employees, who seek medical advice from an occupational physician due to musculoskeletal pain. The inclusion requires that they have not been on a sick leave for longer than 14 days prior to the visit. Based on the physician's judgement, the severity of the symptoms must indicate a need for conventional sick leave, but the employee is considered to be able to work part-time without any additional risk. Half of the employees are randomly allocated to part-time sick leave group and their work time is reduced by 40–60%, whereas in the control group work load is totally eliminated with conventional sick leave. The main outcomes are the number of days from the initial visit to return to regular work activities, and the total number of sick leave days during 12 and 24 months of follow-up. The costs and benefits as well as the feasibility of early part-time sick leave will also be evaluated.
Conclusion
This is the first randomised trial to our knowledge on the effectiveness of early part-time sick leave compared to conventional full-time sick leave in the management of MSDs. The data collection continues until 2011, but preliminary results on the feasibility of part-time sick leave will be available already in 2008. The increased knowledge will assist in better decision making process regarding the management of disability related to MSDs.
Trial Registration
International Standard Randomised Controlled Trial Number Register, register number ISRCTN30911719
doi:10.1186/1471-2474-9-23
PMCID: PMC2267790  PMID: 18294405
31.  Musculoskeletal disorders in shipyard industry: prevalence, health care use, and absenteeism 
Background
It is unclear whether the well-known risk factors for the occurrence of musculoskeletal disorders (MSD) also play an important role in the determining consequences of MSD in terms of sickness absence and health care use.
Methods
A cross-sectional study was conducted among 853 shipyard employees. Data were collected by questionnaire on physical and psychosocial workload, need for recovery, perceived general health, occurrence of musculoskeletal complaints, and health care use during the past year. Retrospective data on absenteeism were also available from the company register.
Results
In total, 37%, 22%, and 15% of employees reported complaints of low back, shoulder/neck, and hand/wrist during the past 12 months, respectively. Among all employees with at least one MSD, 27% visited a physician at least once and 20% took at least one period of sick leave. Various individual and work-related factors were associated with the occurrence of MSD. Health care use and absenteeism were strongest influenced by chronicity of musculoskeletal complaints and comorbidity with other musculoskeletal complaints and, to a lesser extent, by work-related factors.
Conclusion
In programmes aimed at preventing the unfavourable consequences of MSD in terms of sickness absence and health care use it is important to identify the (individual) factors that determine the development of chronicity of complaints. These factors may differ from the well-know risk factors for the occurrence of MSD that are targeted in primary prevention.
doi:10.1186/1471-2474-7-88
PMCID: PMC1676002  PMID: 17125504
32.  Prospective research on musculoskeletal disorders in office workers (PROMO): study protocol 
Background
This article describes the background and study design of the PROMO study (Prospective Research on Musculoskeletal disorders in Office workers). Few longitudinal studies have been performed to investigate the risk factors responsible for the incidence of hand, arm, shoulder and neck symptoms among office workers, given the observation that a large group of office workers might be at risk worldwide. Therefore, the PROMO study was designed. The main aim is to quantify the contribution of exposure to occupational computer use to the incidence of hand, arm, shoulder and neck symptoms. The results of this study might lead to more effective and/or cost-efficient preventive interventions among office workers.
Methods/Design
A prospective cohort study is conducted, with a follow-up of 24 months. In total, 1821 participants filled out the first questionnaire (response rate of 74%). Data on exposure and outcome is collected using web-based self-reports. Outcome assessment takes place every three months during the follow-up period. Data on computer use are collected at baseline and continuously during follow-up using a software program.
Discussion
The advantages of the PROMO study include the long follow-up period, the repeated measurement of both exposure and outcome, and the objective measurement of the duration of computer use. In the PROMO study, hypotheses stemming from lab-based and field-based research will be investigated.
doi:10.1186/1471-2474-7-55
PMCID: PMC1550718  PMID: 16822300
33.  Prediction of chronic disability in work-related musculoskeletal disorders: a prospective, population-based study 
Background
Disability associated with work-related musculoskeletal disorders is an increasingly serious societal problem. Although most injured workers return quickly to work, a substantial number do not. The costs of chronic disability to the injured worker, his or her family, employers, and society are enormous. A means of accurate early identification of injured workers at risk for chronic disability could enable these individuals to be targeted for early intervention to promote return to work and normal functioning. The purpose of this study is to develop statistical models that accurately predict chronic work disability from data obtained from administrative databases and worker interviews soon after a work injury. Based on these models, we will develop a brief instrument that could be administered in medical or workers' compensation settings to screen injured workers for chronic disability risk.
Methods
This is a population-based, prospective study. The study population consists of workers who file claims for work-related back injuries or carpal tunnel syndrome (CTS) in Washington State. The Washington State Department of Labor and Industries claims database is reviewed weekly to identify workers with new claims for work-related back injuries and CTS, and these workers are telephoned and invited to participate. Workers who enroll complete a computer-assisted telephone interview at baseline and one year later. The baseline interview assesses sociodemographic, employment-related, biomedical/health care, legal, and psychosocial risk factors. The follow-up interview assesses pain, disability, and work status. The primary outcome is duration of work disability over the year after claim submission, as assessed by administrative data. Secondary outcomes include work disability status at one year, as assessed by both self-report and work disability compensation status (administrative records). A sample size of 1,800 workers with back injuries and 1,200 with CTS will provide adequate statistical power (0.96 for low back and 0.85 for CTS) to predict disability with an alpha of .05 (two-sided) and a hazard ratio of 1.2. Proportional hazards regression models will be constructed to determine the best combination of predictors of work disability duration at one year. Regression models will also be developed for the secondary outcomes.
doi:10.1186/1471-2474-5-14
PMCID: PMC428578  PMID: 15157280
34.  Gender differences in disability after sickness absence with musculoskeletal disorders: five-year prospective study of 37,942 women and 26,307 men 
Background
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).
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2474-12-37
PMCID: PMC3046931  PMID: 21299856
35.  Work related musculoskeletal disorders amongst therapists in physically demanding roles: qualitative analysis of risk factors and strategies for prevention 
Background
Physiotherapy and occupational therapy are two professions at high risk of work related musculoskeletal disorders (WRMD). This investigation aimed to identify risk factors for WRMD as perceived by the health professionals working in these roles (Aim 1), as well as current and future strategies they perceive will allow them to continue to work in physically demanding clinical roles (Aim 2).
Methods
A two phase exploratory investigation was undertaken. The first phase included a survey administered via a web based platform with qualitative open response items. The second phase involved four focus group sessions which explored topics obtained from the survey. Thematic analysis of qualitative data from the survey and focus groups was undertaken.
Results
Overall 112 (34.3%) of invited health professionals completed the survey; 66 (58.9%) were physiotherapists and 46 (41.1%) were occupational therapists. Twenty-four health professionals participated in one of four focus groups. The risk factors most frequently perceived by health professionals included: work postures and movements, lifting or carrying, patient related factors and repetitive tasks. The six primary themes for strategies to allow therapists to continue to work in physically demanding clinical roles included: organisational strategies, workload or work allocation, work practices, work environment and equipment, physical condition and capacity, and education and training.
Conclusions
Risk factors as well as current and potential strategies for reducing WRMD amongst these health professionals working in clinically demanding roles have been identified and discussed. Further investigation regarding the relative effectiveness of these strategies is warranted.
doi:10.1186/1471-2474-12-24
PMCID: PMC3038991  PMID: 21266039
36.  Who seeks primary care for musculoskeletal disorders (MSDs) with physicians prescribing homeopathic and other complementary medicine? Results from the EPI3-LASER survey in France 
Background
There is a paucity of information describing patients with musculoskeletal disorders (MSDs) using complementary and alternative medicines (CAMs) and almost none distinguishing homeopathy from other CAMs. The objective of this study was to describe and compare patients with MSDs who consulted primary care physicians, either certified homeopaths (Ho) or regular prescribers of CAMs in a mixed practice (Mx), to those consulting physicians who strictly practice conventional medicine (CM), with regard to the severity of their MSD expressed as chronicity, co-morbidity and quality of life (QOL).
Methods
The EPI3-LASER study was a nationwide observational survey of a representative sample of general practitioners and their patients in France. The sampling strategy ensured a sufficient number of GPs in each of the three groups to allow comparison of their patients. Patients completed a questionnaire on socio-demographics, lifestyle and QOL using the Short Form 12 (SF-12) questionnaire. Chronicity of MSDs was defined as more than twelve weeks duration of the current episode. Diagnoses and co-morbidities were recorded by the physician.
Results
A total of 825 GPs included 1,692 MSD patients (predominantly back pain and osteoarthritis) were included, 21.6% in the CM group, 32.4% Ho and 45.9% Mx. Patients in the Ho group had more often a chronic MSD (62.1%) than the CM (48.6%) or Mx (50.3%) groups, a result that was statistically significant after controlling for patients' characteristics (Odds ratio = 1.43; 95% confidence interval (CI): 1.07 - 1.89). Patients seen by homeopaths or mixed practice physicians who were not the regular treating physician, had more often a chronic MSD than those seen in conventional medicine (Odds ratios were1.75; 95% CI: 1.22 - 2.50 and 1.48; 95% CI: 1.06 - 2.12, respectively). Otherwise patients in the three groups did not differ for co-morbidities and QOL.
Conclusion
MSD patients consulting primary care physicians who prescribed homeopathy and CAMs differed from those seen in conventional medicine. Chronic MSD patients represented a greater proportion of the clientele in physicians offering alternatives to conventional medicine. In addition, these physicians treated chronic patients as consulting rather than regular treating physicians, with potentially important impacts upon professional health care practices and organisation.
doi:10.1186/1471-2474-12-21
PMCID: PMC3034723  PMID: 21247493
37.  Musculoskeletal disorders in physically active conscripts: a one-year follow-up study in the Finnish Defence Forces 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1471-2474-10-89
PMCID: PMC2724399  PMID: 19624829
38.  The effect of forearm posture on wrist flexion in computer workers with chronic upper extremity musculoskeletal disorders 
Background
Occupational computer use has been associated with upper extremity musculoskeletal disorders (UEMSDs), but the etiology and pathophysiology of some of these disorders are poorly understood. Various theories attribute the symptoms to biomechanical and/or psychosocial stressors. The results of several clinical studies suggest that elevated antagonist muscle tension may be a biomechanical stress factor. Affected computer users often exhibit limited wrist range of motion, particularly wrist flexion, which has been attributed to increased extensor muscle tension, rather than to pain symptoms. Recreational or domestic activities requiring extremes of wrist flexion may produce injurious stress on the wrist joint and muscles, the symptoms of which are then exacerbated by computer use. As these activities may involve a variety of forearm postures, we examined whether changes in forearm posture have an effect on pain reports during wrist flexion, or whether pain would have a limiting effect on flexion angle.
Methods
We measured maximum active wrist flexion using a goniometer with the forearm supported in the prone, neutral, and supine postures. Data was obtained from 5 subjects with UEMSDs attributed to computer use and from 13 control subjects.
Results
The UEMSD group exhibited significantly restricted wrist flexion compared to the control group in both wrists at all forearm postures with the exception of the non-dominant wrist with the forearm prone. In both groups, maximum active wrist flexion decreased at the supine forearm posture compared to the prone posture. No UEMSD subjects reported an increase in pain symptoms during testing.
Conclusion
The UEMSD group exhibited reduced wrist flexion compared to controls that did not appear to be pain related. A supine forearm posture reduced wrist flexion in both groups, but the reduction was approximately 100% greater in the UEMSD group. The effect of a supine forearm posture on wrist flexion is consistent with known biomechanical changes in the distal extensor carpi ulnaris tendon that occur with forearm supination. We infer from these results that wrist extensor muscle passive tension may be elevated in UEMSD subjects compared to controls, particularly in the extensor carpi ulnaris muscle. Measuring wrist flexion at the supine forearm posture may highlight flexion restrictions that are not otherwise apparent.
doi:10.1186/1471-2474-9-47
PMCID: PMC2362125  PMID: 18405370
39.  Prevalence of musculoskeletal disorders in dentists 
Background
The prevalence of musculoskeletal complaints in dentists is high although relatively few studies had focus in this profession. The aim of this study was to investigate the relations between physical, psychosocial, and individual characteristics and different endpoints of musculoskeletal complaints of low back, neck, shoulders and hand/wrist.
Methods
A questionnaire survey was carried out among 430 dentists (response 88%) in Thessaloniki, Greece. Questions include data on physical and psychosocial workload, need for recovery, perceived general health and (i) the occurrence of musculoskeletal complaints in the past 12 months, (ii) chronic complaints during at least 1 month, complaints which led to (iii) sickness absence, and (iv) medical care seeking. In logistic regression analysis odds ratios were estimated for all relevant risk factors.
Results
62% of dentists reported at least one musculoskeletal complaint, 30% chronic complaints, 16% had spells of absence and, 32% sought medical care. Self-reported factors of physical load were associated with the occurrence of back pain (OR = 1.59), shoulder pain (OR = 2.57) and, hand/wrist pain (OR = 3.46). With the exception of hand/wrist complaints, the physical factors were not associated with chronic complaints and musculoskeletal sickness absence. Physical load showed a trend with the number of musculoskeletal complaints with ORs of 2.50, 3.07 and 4.40 for two, three and four musculoskeletal complaints, respectively. No consistent influence of psychosocial factors on complaints, chronicity, sickness absence and medical care seeking was observed. A perceived moderate general health was a significant factor for chronic complaints, comorbidity and medical care seeking where high perceived exertion was significant for absenteeism. Living alone was also related with increased absenteeism due to shoulder pain (OR = 5.01) and hand/wrist (OR = 4.07).
Conclusions
The physical load among dentists seems to put them at risk for the occurrence of musculoskeletal disorders. More than one and severe complaints are related to perceived general health while high perceived exertion and social characteristics are associated with sickness absence. Chronic symptoms seem to determine medical care seeking. Ergonomic interventions may have a greater impact in prevention of hand/wrist complaints. When investigating the influence of work-related risk factors on musculoskeletal health, psychosocial and other personal characteristics should be taken into account.
doi:10.1186/1471-2474-5-16
PMCID: PMC441388  PMID: 15189564
40.  BMC Musculoskeletal Disorders reviewer acknowledgement 2014 
doi:10.1186/s12891-015-0463-z
PMCID: PMC4319223  PMID: 25656078
41.  Aging enhances serum cytokine response but not task-induced grip strength declines in a rat model of work-related musculoskeletal disorders 
Background
We previously reported early tissue injury, increased serum and tissue inflammatory cytokines and decreased grip in young rats performing a moderate demand repetitive task. The tissue cytokine response was transient, the serum response and decreased grip were still evident by 8 weeks. Thus, here, we examined their levels at 12 weeks in young rats. Since aging is known to enhance serum cytokine levels, we also examined aged rats.
Methods
Aged and young rats, 14 mo and 2.5 mo of age at onset, respectfully, were trained 15 min/day for 4 weeks, and then performed a high repetition, low force (HRLF) reaching and grasping task for 2 hours/day, for 12 weeks. Serum was assayed for 6 cytokines: IL-1alpha, IL-6, IFN-gamma, TNF-alpha, MIP2, IL-10. Grip strength was assayed, since we have previously shown an inverse correlation between grip strength and serum inflammatory cytokines. Results were compared to naïve (grip), and normal, food-restricted and trained-only controls.
Results
Serum cytokines were higher overall in aged than young rats, with increases in IL-1alpha, IFN-gamma and IL-6 in aged Trained and 12-week HRLF rats, compared to young Trained and HRLF rats (p < 0.05 and p < 0.001, respectively, each). IL-6 was also increased in aged 12-week HRLF versus aged normal controls (p < 0.05). Serum IFN-gamma and MIP2 levels were also increased in young 6-week HRLF rats, but no cytokines were above baseline levels in young 12-week HRLF rats. Grip strength declined in both young and aged 12-week HRLF rats, compared to naïve and normal controls (p < 0.05 each), but these declines correlated only with IL-6 levels in aged rats (r = -0.39).
Conclusion
Aging enhanced a serum cytokine response in general, a response that was even greater with repetitive task performance. Grip strength was adversely affected by task performance in both age groups, but was apparently influenced by factors other than serum cytokine levels in young rats.
doi:10.1186/1471-2474-12-63
PMCID: PMC3072947  PMID: 21447183
42.  Incidence and prevalence of upper-extremity musculoskeletal disorders. A systematic appraisal of the literature 
Background
A systematic appraisal of the worldwide incidence and prevalence rates of UEDs available in scientific literature was executed to gauge the range of these estimates in various countries and to determine whether the rates are increasing in time.
Methods
Studies that recruited at least 500 people, collected data by using questionnaires, interviews and/or physical examinations, and reported incidence or prevalence rates of the whole upper-extremity including neck, were included.
Results
No studies were found with regard to the incidence of UEDs and 13 studies that reported prevalence rates of UEDs were included. The point prevalence ranged from 1.6–53%; the 12-months prevalence ranged from 2.3–41%. One study reported on the lifetime prevalence (29%). We did not find evidence of a clear increasing or decreasing pattern over time. The case definitions for UEDs used in the studies, differed enormously. Therefore, it was not possible to pool the data.
Conclusion
There are substantial differences in reported prevalence rates on UEDs. Main reason for this is the absence of a universally accepted way of labelling or defining UEDs. If we want to make progress in this field, the first requirement is to agree on unambiguous terminology and classification of EUDs.
doi:10.1186/1471-2474-7-7
PMCID: PMC1434740  PMID: 16448572
43.  Mental disorders in a population sample with musculoskeletal disorders 
Background
Studies using clinical and volunteer samples have reported an elevated prevalence of mood disorders in association with rheumatoid arthritis and osteoarthritis. Clinical studies using anxiety rating scales have reported inconsistent results, but studies using diagnostic instruments have reported that anxiety disorders may be even more strongly associated with arthritis than is depression. One study reported an association between lifetime substance use disorders and arthritis.
Methods
Data from iteration 1.2 of the Canadian Community Health Survey (CCHS) were used. This was a large-scale national Canadian health survey which administered the World Mental Health Composite International Diagnostic Interview to a sample of 36,984 subjects randomly selected from the national population. In the CCHS 1.2, subjects were asked whether they had been diagnosed by a health professional with arthritis or rheumatism.
Results
Subjects reporting arthritis or rheumatism had an elevated prevalence of mood, anxiety and substance use disorders. The strength of association resembled that seen in an omnibus category reporting any chronic condition, but was weaker than that seen with back pain or fibromyalgia. The effect of arthritis or rheumatism interacted with age, such that the odds ratios became smaller with increasing age. Mood and anxiety disorders, along with arthritis or rheumatism made an independent contribution to disability.
Conclusion
Arthritis is associated with psychiatric morbidity in the general population, and this morbidity is seen across a variety of mental disorders. The strength of association is consistent with that seen in persons with other self-reported medical conditions.
doi:10.1186/1471-2474-7-37
PMCID: PMC1482703  PMID: 16638139
44.  Upper body and lower limbs musculoskeletal symptoms and health inequalities in Europe: an analysis of cross-sectional data 
Background
Musculoskeletal disorders are the most frequent occupational diseases in Europe. However, their multifactorial aetiology poses several challenges concerning not only the estimation of relative prevalence rates across occupational groups but also how the co-occurrence of known risk factors might differ between disorders of the upper and lower limbs. Against this background, the following objectives are pursued: (1) to estimate the relative odds and prevalence rates of self-reported disorders of the upper limbs and/or shoulders and neck (upper body) and the lower limbs for major ISCO-88 occupational groups, (2) to evaluate to what extent the associations between known risk factors differ for musculoskeletal disorders of the upper body and the lower limbs.
Methods
Statistical analysis of cross-sectional data from the European Working Conditions Survey 1995-2010. The probability of reporting upper body and lower limbs pain in the survey sample 2010 is estimated by mixed logistic regression models using the Markov chain Monte Carlo Sampler. Independent variables include some known physical and psychosocial risk factors.
Results
Concerning the first objective, an excess risk of reporting musculoskeketal disorders of the upper body was observed among craft workers (ISCO 7), machine operators (ISCO 8) and workers in elementary occupations (ISCO 9). Concerning musculoskeletal disorders of the lower limbs, service and sales workers (ISCO 5) and workers in ISCO groups 7, 8 and 9 reported symptoms more frequently. Regarding the second objective, similar association patterns were observed for upper body and lower limbs symptoms. Major physical risk factors associated with both symptom types were very frequent exposure to tiring positions, carrying heavy loads and performing repetitive tasks. Standing appears to be an important risk factor for lower limbs symptoms only.
Conclusions
Results suggest that the unequal burden of exposure has not changed substantially across occupational groups since 1995, and that there is urgent need of delivering and evaluating the effects of specific interventions targeting workers at high risk of developing musculoskeletal disorders.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2474-15-285) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2474-15-285
PMCID: PMC4153890  PMID: 25160775
Social determinants of health; Musculoskeletal symptoms in Europe; Occupational diseases; Lower limbs symptoms; Upper limbs and/or shoulder and neck symptoms
45.  A systematic review of studies using pedometers as an intervention for musculoskeletal diseases 
Background
Physical activity (PA) plays an important role in the prevention and management of a number of chronic conditions. Aim: to investigate the evidence for effectiveness of pedometer-driven walking programs to promote physical activity among patients with musculoskeletal disorders (MSDs).
Method
A comprehensive systematic review was performed using 11 electronic databases up to 20 February 2014. Keywords and MeSH terms included “musculoskeletal disorders”, “walking”, and “pedometer”. Randomized controlled trials, published in English, that examined the effects of a pedometer-based walking intervention to increase physical activity levels and improve physical function and pain in patients with musculoskeletal disorders were included.
Result
Of the 1996 articles retrieved, seven studies ranging in date of publication from 1998 to 2013 met the inclusion criteria, allowing data extraction on 484 participants with an age range of 40 to 82 years. Interventions lasted from 4 weeks to 12 months and the results across studies showed significant increases in step count (p < 0.05) following the intervention. Across these studies, there was a mean increase in PA of 1950 steps per day relative to baseline. Four studies reported improved scores for pain and/or physical function at the intervention completion point relative to controls.
Conclusion
This study provides strong evidence for the effectiveness of pedometer walking interventions in increasing PA levels for patients with MSDs. Our findings suggest that a combination of interventions is likely to be the most effective strategy to maximize health benefits in the short term. Further research should include larger sample sizes, and longer intervention durations are required to support the role of pedometer walking interventions as a long term intervention for management of musculoskeletal disorders.
doi:10.1186/1471-2474-15-231
PMCID: PMC4115486  PMID: 25012720
Motion sensors; Physical activity; Motivation tools; Pedometer; Chronic disease; Step counter
46.  Walking ability during daily life in patients with osteoarthritis of the knee or the hip and lumbar spinal stenosis: a cross sectional study 
Background
Degenerative musculoskeletal disorders are among the most frequent diseases occurring in adulthood, often impairing patients' functional mobility and physical activity. The aim of the present study was to investigate and compare the impact of three frequent degenerative musculoskeletal disorders -- knee osteoarthritis (knee OA), hip osteoarthritis (hip OA) and lumbar spinal stenosis (LSS) -- on patients' walking ability.
Methods
The study included 120 participants, with 30 in each patient group and 30 healthy control individuals. A uniaxial accelerometer, the StepWatch™ Activity Monitor (Orthocare Innovations, Seattle, Washington, USA), was used to determine the volume (number of gait cycles per day) and intensity (gait cycles per minute) of walking ability. Non-parametric testing was used for all statistical analyses.
Results
Both the volume and the intensity of walking ability were significantly lower among the patients in comparison with the healthy control individuals (p < 0.001). Patients with LSS spent 0.4 (IQR 2.8) min/day doing moderately intense walking (>50 gait cycles/min), which was significantly lower in comparison with patients with knee and hip OA at 2.5 (IQR 4.4) and 3.4 (IQR 16.1) min/day, respectively (p < 0.001). No correlations between demographic or anthropometric data and walking ability were found. No technical problems or measuring errors occurred with any of the measurements.
Conclusions
Patients with degenerative musculoskeletal disorders suffer limitations in their walking ability. Objective assessment of walking ability appeared to be an easy and feasible tool for measuring such limitations as it provides baseline data and objective information that are more precise than the patients' own subjective estimates. In everyday practice, objective activity assessment can provide feedback for clinicians regarding patients' performance during everyday life and the extent to which this confirms the results of clinical investigations. The method can also be used as a way of encouraging patients to develop a more active lifestyle.
doi:10.1186/1471-2474-11-233
PMCID: PMC2958990  PMID: 20939866
47.  Shoulder disorders in female working-age population: a cross sectional study 
Background
Musculoskeletal disorders (MSDs) are among the most common pathologies in the general population. However, research into the prevalence of upper arm MSDs is hampered by a lack of uniformity in case definition, and by the absence of a gold standard for measurement. Furthermore, some sectors of the population have benefited from extensive research whilst others have largely been ignored. Study Design: Cross-sectional study. Objectives: to investigate the prevalence of shoulder MSDs in a working age female population not exposed to specific occupational risk factors such as heavy and/or repetitive work, assessing the differences in prevalence recorded by using three different standard measurement tools.
Methods
302 working aged women were enrolled in this study (age 20–55 years). Each subject underwent three different assessments: standardized questionnaires for symptoms and disability and the SF36 health survey, a clinical assessment performed by a blinded orthopaedic specialist, and an imaging assessment by means of ultrasound (US) and Magnetic Resonance (MR) if indicated.
Results
According to the questionnaire 77 subjects (25.5%) complained of shoulder pain whilst 225 (74.5%) were asymptomatic. According to the clinical examination, 31 subjects (10.3%) resulted positive, whereas 271 subjects (89.7%) had normal shoulders. According to the imaging findings, 26 subjects (8.6%) had alterations to the anatomical structures of the shoulder, whilst 276 subjects (91.4%) had no detectable abnormalities in either shoulder. In all assessments, the prevalence increased with age (p = 0.001).
Conclusion
Depending on the outcome measure used, the prevalence of reported MSDs of the shoulder varies considerably. There is a striking difference between the prevalence of subjective reported symptoms and the standardized clinical/imaging examinations. However, the results of all the assessments did concur in one aspect; there was a significant trend of increased prevalence of shoulder MSDs with age. When looking at reported prevalence, this study shows the importance of noting the measurement method used before making comparisons, as it can vary considerably. The epidemic of shoulder pain reported is not indicative of an epidemic of shoulder pathology.
doi:10.1186/1471-2474-15-118
PMCID: PMC4233642  PMID: 24708552
Shoulder; Musculoskeletal disorders; Prevalence; Women; Pain; Clinical examination; Shoulder imaging
48.  Inflammatory biomarkers in serum in subjects with and without work related neck/shoulder complaints 
Background
Although it has recently been recognised that inflammation is important in the development of work-related musculoskeletal disorders (MSDs), the exact pathophysiological pathways are unknown.
Methods
We investigated serum concentrations of inflammatory cytokines in 35 female supermarket cashiers with repetitive work tasks and work related neck/shoulder complaints, compared with those from 25 women without MSDs (6 supermarket cashiers and 19 middle-school teachers or faculty staff). None of the subjects were pregnant or lactating, and showed no signs of rheumatoid arthritis, systemic lupus erythematosus, cancer, diabetes, coronary artery disease or inadequately controlled hypertension. Serum levels of IL-1α, IL-1β, IL-6, IL-8, IL-10, IL-12, MCP-1, MIP-1α, MIP-1β, TNF-α, GM-CSF, CTGF and CRP were analysed.
Results
The women with pain related to MSD had higher serum concentrations of MIP-1β (median, 25th-75th percentile: 90.0 pg/mL, 62.5-110 vs. 73.1 pg/mL, 54.6-88.3; p = 0.018), IL-12 (0.26 pg/mL, 0.26-0.26 vs. 0.26 pg/mL, 0.26-0.26; p = 0.047) and CRP (0.5 mg/L, 0.5-1.6 vs. 0.5 mg/L, 0.5-0.5; p = 0.003), than control subjects. Levels of MIP-1α, MIP-1β and CRP were correlated with the reported intensity of neck/shoulder pain (r = 0.29, p = 0.03 for MIP-1α; r = 0.29, p = 0.02 for MIP-1β and r = 0.43, p = 0.001 for CRP). No statistically significant differences in serum levels were found for the remaining cytokines.
Conclusions
Otherwise healthy females with ongoing work-related neck/shoulder pain showed higher serum concentrations of MIP-1β, IL-12 and CRP than controls, and the levels of MIP-1α, MIP-1β and CRP were correlated to pain intensity. These results support previous findings that inflammatory processes play a part in work related MSDs.
doi:10.1186/1471-2474-15-103
PMCID: PMC3973377  PMID: 24669872
Work related; Musculoskeletal disorders; Inflammation; Biomarker; Cytokine
49.  The usefulness of on-site physical therapy-led triage services for professional orchestral musicians – a national cohort study 
Background
Australian professional orchestral musicians reported a lifetime prevalence of musculoskeletal injuries that had interfered with playing at 84%. Physical therapy-led triage clinics may be a practical method to manage the impact of high performance-related musculoskeletal disorders (PRMDs) in professional orchestral musicians. This study aimed to: a) collect information on presenting injuries, b) determine the participant’s provisional diagnosis, c) evaluate uptake of an on-site triage service, d) measure participant satisfaction, and e) identify factors influencing attendance.
Methods
Eight triage sessions were run on a fortnightly basis during a designated lunch break between rehearsal calls in seven premier symphony orchestras in Australia; a total population of 483 musicians. The participants received one or a combination of: a) education and advice relating to their provisional diagnosis, b) basic acute management and/or c) a referral to a suitable medical practitioner or allied health professional for further consultation or treatment. A three-month follow-up questionnaire was completed and a qualitative narrative themes-based analysis was undertaken to summarise participant and physical therapist feedback. Uptake, participant satisfaction and factors influencing attendance were measured.
Results
99 initial consultations (83 individuals) were conducted with more females (61%) utilizing the service than males (49%). The most common injury complaints were in the shoulder (22%), neck (18%), upper back (18%), and hand (8%). 66% of these were diagnosed as PRMDs. Of these injuries, 94% were considered preventable, 93% continued to affect playing, 68% were severe requiring a referral for further management, and 46% were recurrent. The advice at the triage service was rated as helpful or very helpful by 79% of the musicians, whilst 68% responded they were likely or very likely to continue to use the service if it was offered in the future. Of the participants that followed through with the referral advice, 67% reported that the referral advice was helpful or very helpful. Musicians’ and physical therapists’ written feedback indicated their acknowledgement for the need of this service. The main suggestions for improving attendance were increasing the music-specific physical therapy knowledge of therapists and overcoming competing time demands.
Conclusion
On-site health services for musicians may facilitate better injury management by providing immediate and specific health advice.
Trial registration
ACTRN12612000220864
doi:10.1186/1471-2474-14-98
PMCID: PMC3614523  PMID: 23506482
Injury management; Performance-related musculoskeletal disorders; Performing arts medicine; Physical therapy; Prevention
50.  Low back pain and widespread pain predict sickness absence among industrial workers 
Background
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.
Methods
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.
Results
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).
Conclusions
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.
doi:10.1186/1471-2474-4-21
PMCID: PMC200978  PMID: 12956891
sickness absence; musculoskeletal disorders; low back pain; widespread pain; blue-collar workers; social support

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