Work-related musculoskeletal disorders among hospital workers

Introduction

Work-related musculoskeletal disorders (MSDs) are a serious problem among hospital personnel, and in particular the nursing staff. Of primary concern are back injuries and shoulder strains which can both be severely debilitating. The nursing profession is one of the most risky occupations for low back pain. The primary cause for MSDs in nursing is patient handling tasks such as lifting, transferring, and repositioning of patients. Changes in technology and increasing demands in the health care industry necessitate new approaches to prevent and control occupational injuries and diseases MSDs among hospital workers.^[1].

Musculoskeletal load in hospitals

Manual handling and awkward postures may cause cumulative disorders of the musculoskeletal system of health care workers in hospital.

Manual handling

A manual handling operation in hospitals means moving or supporting a load by a person's hands or arms, or by some other form of body effort. Patient handling includes the use of force by a person to lift, lower, push, pull, carry, move, and support another person. Among the different types of work tasks of hospital staff, patient handling is the most important risk factor for low-back pain and a higher number of daily patient transfers increases the risk of a back injury ^[2]. Patient characteristics highly influence the risk. Overweight patients increase the load on the low back as well as patients with different levels of physical disability. To handle the patient, hospital workers have to use a higher physical effort, which induces a higher load on the musculoskeletal system ^[2] Heavy manual labour, awkward postures and previous or existing MSDs further increase the risk. For preventing MSDs when handling patients, it is essential to use appropriate handling techniques with the necessary assistive devices and to mobilise the patient’s resources. Having more healthcare staff working at the same time can also be necessary. Through the early reporting of symptoms, proper treatment and task specific return to work plans (including improved working conditions), most people recover from their injuries and return to full-time employment. However, for a few individuals an injury may cause them to take long periods off work, and possibly, even leave work entirely.

Awkward postures

Examples of awkward postures are prolonged standing, significant sideways twisting, reaching above shoulder height, one handed lifting/carrying. Awkward postures such as kneeling or squatting are specific physical activities encountered commonly in the health care sector. Working in awkward postures can result in static loading of the soft tissues, which can result in an accumulation of metabolites, thereby accelerating disc degeneration and ultimately leading to disc herniation. Awkward postures are those in which joints are held or moved away from the body's natural position. The closer the joint is to its end of range of motion, the greater the stress is that is placed on the soft tissues of that joint, such as muscles, nerves, and tendons.

If prolonged sitting is not the main risk factor for developing low back pain (LBP), combined exposure to prolonged sitting in awkward postures may increase the risk. In addition, prolonged sitting is a common aggravating factor for many subjects with LBP. Spinal flexion can negatively affect spinal proprioception, and can be associated with LBP^[1].

In awkward postures muscles cannot perform efficiently, thus increasing muscle strain. Moreover, the amount of strain on passive structures, i.e. tendons and ligaments, is increased as well. Fixed awkward postures cause muscle and tendon fatigue and joint pain.

MSDs among hospital workers

Low back pain

LBP can be caused by numerous work situations in hospitals. The exact cause is often unclear, but back pain is more common in jobs that involve heavy manual handling, manual handling in awkward postures, repetitive tasks, sitting for a long period of time (if the workplace is not correctly arranged or adjusted to fit the person), working with computers, poor posture, pushing, pulling or dragging loads that require excessive force, working beyond normal capacity and limits.

A higher prevalence of LBP has often been shown among medical staff, particularly compared with other hospital and industrial workers^[1]. Nurses, surgeons, odontologists have one of the highest rates of back and other musculoskeletal injury of all occupations. Back injuries are most frequent, with annual prevalence ranging from 30% to 60%, along with neck (about 40%) and shoulder injuries (about 47%). The percentage of nurses who reported ever changing jobs for a neck, shoulder or back MSD was 6%–11%, respectively.

The data from the European Working Conditions Survey (EWCS) also show a high percentage of workers in the healthcare sector reporting MSDs. In the healthcare sector almost 1 out of 2 workers report backache (47%). It should be noted that the EWCS doesn't make a distinction between work-related and non-work-related complaints. With the figure of 47%, the healthcare sector ranks in the top 4 of the sectors where back complaints are reported most frequently ^[5].

LBP can be acute and chronic. Acute occupational LBP is usually felt just after lifting a heavy object, moving suddenly, or sitting in awkward posture. The pain may be mild, or it can be so severe that it is impossible to move. Chronic occupational LBP develops over a period of time. It can be caused by performing strenuous activities for a long period of time, such as awkward postures or manual handling.

For example, frequent manual handling (patient lifting, supporting) and working in awkward postures (sitting or standing for a long period of time) can cause a chronic occupational LBP, which is clinically diagnosed as a herniated disk. The symptoms of a herniated disk may be a sharp pain in one part of the leg, hip, or buttocks and numbness in other parts.

Work related neck and upper limb disorders

There is a lot of literature that is focused on LBP among healthcare workers, but there is almost no literature on occupational cervicobrachial disorders or neck, shoulder, and arm pain. Handling patients may cause not only LBP, but also neck, shoulder, and arm pain, as it potentially exerts an excessive burden on the neck, shoulders, and arms^[4]. Especially patient handling tasks that involve reaching, pushing, and pulling can lead to neck and shoulder pain in nurses ^[6].

Causes of upper limb disorders (ULDs) are repetitive work, awkward postures, sustained or excessive force, carrying out occupational tasks for a long period, poor working environment and organisation, individual differences and susceptibility (some workers are more affected by certain risks).

The most common ULDs among health care workers are tenosynovitis, tendinitis, carpal tunnel syndrome, De Quervain's disease, thoracic outlet syndrome, tension neck syndrome, shoulder capsulitis and cervical spondylosis.

Tension neck syndrome

Neck pain is a discomfort in any of the structures in the neck. These include muscles and nerves as well as spinal vertebrae and the cushioning disks in between. Neck pain may also come from areas near the neck such as the shoulder, jaw, head, and upper arms. It can be felt as numbness, tingling or weakness in the arm, hand or elsewhere if the neck pain involves nerves. For example, significant muscle spasm is caused by a pinched nerve or a slipped disk pressing on a nerve. A common cause of neck pain is muscle strain or tension.

The major occupational risk causing the tension neck syndrome for the health care workers are prolonged awkward postures such as bending over a desk for hours, placing computer monitor too high or too low, etc.

Cervical spondylosis

Cervical spondylosis (cervical spine syndrome) is a disorder in which there is abnormal wear on the cartilage and bones of the neck (cervical vertebrae). Cervical spondylosis is caused by chronic degeneration of the cervical spine, including the cushions between the neck vertebrae (cervical disks) and the joints between the bones of the cervical spine. The major occupational risk factors are prolonged awkward posture and manual handling. The major symptoms are neck pain (may radiate to the arms or shoulder), neck stiffness that gets worse over time, loss of sensation or abnormal sensations in the shoulders, arms, weakness of the arms, headaches, particularly in the back of the head.

Shoulder tendonitis, bursitis, and impingement syndrome

Two types of tendonitis can affect the shoulder:

1. Biceps tendinitis causes the pain in the front or side of the shoulder and may travel down to the elbow and forearm. Pain may also occur when the arm is raised overhead. The pain can be aggravated by reaching, pushing, pulling, lifting, raising the arm above shoulder level, or lying on the affected side. Squeezing of the rotator cuff is called shoulder
2. impingement syndrome.

Major occupational risk factors causing these types of tendonitis for health care workers are repetitive wrist and shoulder motions, sustained hyper extension of arms, and prolonged load on shoulders. The symptoms for tendonitis are pain, weakness, and swelling, burning sensation or dull ache over affected area.

Thoracic outlet syndrome

Thoracic outlet syndrome is a condition that involves pain in the neck and shoulder, numbness and tingling of the fingers, and a weak grip. As blood vessels and nerves pass by or through the collarbone (clavicle) and upper ribs, they may not have enough space. Pressure (compression) on these blood vessels or nerves can cause symptoms in the arms or hands. Problems with the nerves cause almost all cases of thoracic outlet syndrome. Compression can be caused by an extra cervical rib (above the first rib) or an abnormal tight band connecting the spinal vertebra to the rib.

The major occupational risks causing the thoracic outlet syndrome for health care workers are prolonged shoulder flexion and extending arms above shoulder height. The major symptoms for the syndrome are pain, numbness, and tingling in the little and ring fingers, and the inner forearm, pain and tingling in the neck and shoulders (carrying something heavy may make the pain worse), signs of poor circulation in the hand or forearm (a bluish colour, cold hands, or a swollen arm).

Frozen shoulder

The joint capsule of the shoulder joint has ligaments that hold the shoulder bones to each other. When the capsule becomes inflamed, the shoulder bones are unable to move freely in the joint.

The major occupational risks causing the frozen shoulder syndrome for health care workers are prolonged awkward posture and manual handling. The major symptoms of the syndrome are decreased motion of the shoulder, pain, stiffness. Frozen shoulder (shoulder capsulitis) always starts with severe pain that prevents a person from moving his/her arm. The lack of movement leads to stiffness and then to even less motion. Over time people with frozen shoulder become unable to perform activities such as reaching over or behind the head.

Tennis elbow and golfer’s elbow

Tennis elbow (lateral epicondylitis) refers to an injury to the outer elbow tendon. These conditions can also occur with any activity that involves repetitive wrist turning or hand gripping, such as odontologist’s tool use, hand shaking, or twisting movements. Pain occurs near the elbow, sometimes radiating into the upper arm or down to the forearm. Golfer’s elbow is an injury to the inner tendon of the elbow.

Occupational risk of golfer`s elbow (medial epicondylitis) is repeated or forceful rotation of the forearm and bending of the wrist at the same time. The major symptoms are pain, weakness, and swelling, burning sensation or a dull ache over the affected area.

De Quervain's disease

De Quervain's disease occurs when the tendons around the base of the thumb are irritated or constricted. Thickening of the tendons can cause pain and tenderness along the thumb side of the wrist. Synovia allows the tendons to slide easily through the tunnel. Any swelling of the tendons located near these nerves can put pressure on the nerves. This can cause wrist pain or numbness in the fingers.

The major occupational risk causing the De Quervain's disease for health care workers is repetitive hand twisting and forceful gripping. The major symptoms of this disease are pain that may be felt over the thumb side of the wrist; swelling that may be seen over the thumb side of the wrist, numbness that may be experienced on the back of the thumb and index finger.

Tenosynovitis

Tenosynovitis is inflammation of the lining of the sheath that surrounds a tendon. The major occupational risk factors for this inflammation to occur are repetitive wrist and shoulder movement, sustained hyper extension of arms, prolonged load on shoulders. The major symptoms are difficulty and pain when moving a joint; joint swelling in the affected area; pain and tenderness around a joint, especially the hand and wrist; redness along the length of the tendon.

Carpal tunnel syndrome

Carpal tunnel syndrome occurs when the median nerve, becomes pressed or squeezed at the wrist. The carpal tunnel houses the median nerve and tendons. Sometimes, thickening from irritated tendons or other swelling narrows of the tunnel causes the median nerve to be compressed. The major symptoms are pain that often first appears in hand during the night, weakness, or numbness in the hand and wrist that radiates up the arm. Symptoms usually start gradually, with frequent burning, tingling, or itching numbness in the palm of the hand and the fingers, especially the thumb and the index and middle fingers. Decreased grip strength may make it difficult to form a fist, grasp small objects, or perform other manual tasks. In chronic or untreated cases, the muscles at the base of the thumb may waste away.

The major occupational risk factors causing the syndrome for health care workers are repetitive wrist motions as working with the computer and forceful movements of the hand and wrist during work.

Lower limb disorders

Lower limb swelling

Gravity may cause painless swelling in legs and swelling is particularly noticeable in the lower part of the body. Foot, leg, and ankle swelling for health care workers are common with the following situations: prolonged standing (such as surgeon work), or sitting (such as laboratory worker’s and odontologist’s job).

Varicose veins

Prolonged standing in awkward postures as well as very long walking provokes varicose veins for the medical staff. When working in awkward prolonged standing posture the veins' valves do not function properly, causing blood to remain in the vein and resulting in swollen, twisted, and sometimes painful veins that are filled with an abnormally large amount of blood. In result the veins will enlarge when blood is pooling. This process usually occurs in the veins of the legs. Varicose veins are common, affecting mostly women. The symptoms are fullness, heaviness, aching, and sometimes pain in the legs, visible, enlarged veins, mild swelling of ankles, brown discoloration of the skin at the ankles, and skin ulcers near the ankle.

Prevention of MSDs in hospital workers

Prevention of MSDs in hospitals is based on prevention strategies, such as reduction of physical demands, improvements in work organisation, personnel training, medical treatment and rehabilitation and return to work strategies to prevent disability from MSD ^[7][8]. When considering preventive actions, it is also very important to change attitudes and the point of view to ergonomics in the hospital work environment both on organisational and individual levels.

Ergonomics

Mechanical equipment and assisting devices

The choice of mechanical equipment and assisting devices affects the way in which people perform handling tasks. Nowadays numerous mechanical equipment which is designed to help in patient handling or make the task itself less physically demanding is available. The mechanical equipment at hospital environment – such as, lifters, bath or hygiene chair and vehicle lifts – help to reduce manual transfers and assists patients in their daily life. Assisting devices such as handling slings, lifting sheets, sliding boards, stretchers, lifting belts, lifting frames, turntables, trapeze/monkey rings, and grab bars can be used to reduce the risks associated with handling patients.

Coveralls

Clothing should allow the health care workers to move freely. Tight coveralls may create friction between the skin and the cloth, and furthermore may require additional muscle effort and lead to an increased risk of a muscle strain. A testing trial of clothing, as it will be finally used, is therefore recommended. Appropriate staff footwear should also be used, e.g. low heels and non-slip soles with a good grip for wet areas give a firm base while handling loads. Shoes should provide good foot support, be comfortable for the entire day and provide a good base for manual handling activities. Waterproof aprons should be available in wet areas as well.

Organisational level

Organisational level of prevention of MSDs in hospital consists of workplace risk assessment, ergonomic/technical interventions (workplace design, ergonomic work equipment and tools, protective equipment), health care workers training and working out the returning to work strategies to prevent disabilities from MSDs.

Workplace risk assessment on ergonomic situation of hospitals enables the employer to make changes in the workplace environment. Working environments for patient handling require floors which are even, non-slip and stable. Floors may become uneven if floor coverings are poorly laid or allowed to fall into disrepair. The working heights of baths, beds, chairs and other equipment should be adjustable whenever possible. Extreme temperature, humidity or air movement may induce a range of symptoms such as drowsiness, fatigue or loss of sensation, which in turn may affect the performance of the task. Adequate lighting must be provided and maintained. The workload should be organized in such a way as to minimize manual patient handling operations and provide furniture and equipment that effectively reduce handling operations, and to distribute handling tasks evenly throughout the shift (i.e. employees in handling operations should be rotated to minimise repetitive or prolonged work), and to allow the personnel adequate rest and recovery periods. It is useful to break up work periods involving a lot of repetition with several short breaks instead of one break at lunchtime.

Appropriate training must be provided to health care workers before any patient handling tasks are performed. Early assessment of health problems and rehabilitation plans by an occupational health physician should be applied to employees who experience pain or other symptoms thought to be associated with manual patient handling.

Individual level

Every health care worker should find the right, individual working position for him/her – workplaces and equipment for workers of different sizes, build, strength and, for example, for left-handed workers, should be designed. Platforms, adjustable chairs and footrests, as well as tools with grips should be made available in different sizes. The position, height and layout of the workplace should be arranged so that it would be appropriate for each worker of the work team.

Each health care worker should reduce the amount of force used individually by sliding instead of lifting, and they should ensure that all handles used are well maintained and easy to manipulate without requiring the application of unnecessary force.

Hospital employees should be trained to use the right tools and equipment for the job instead of manual handling, and eventually reduce the amount of force required to perform tasks. Such equipment should not only be given to workers, but the workers should be well trained on how to use the equipment.