Ergonomic risks and problems of the musculoskeletal system for physiotherapists: comparison of employees in the fields of pediatric and adult care

ABSTRACT Objectives. The aim of this study is to compare the ergonomic risk levels, musculoskeletal complaints and quality of life of physiotherapists (PTs) according to their field of work. Methods. A total of 107 volunteer PTs participated in the study, whose information was recorded. Ergonomic risk levels were determined using rapid entire body assessment (REBA). Complaints about the musculoskeletal system of PTs were evaluated with the Cornell musculoskeletal discomfort questionnaire (CMDQ) and quality of life was evaluated by the Nottingham health profile. Results. PTs who worked with pediatric patients (Grouppediatric; n = 47) were younger (p<0.001). PTs who worked with adult patients (Groupadult; n = 60) had a higher daily number of patients (p<0.001). The REBA score did not make a difference between the groups (p = 0.379). The difference was found in the upper back region of the CMDQ (p<0.05). There was no difference between groups for quality of life (p>0.05). Conclusions. Grouppediatric may be working in ergonomically demanding positions, although there is no statistical difference. The injury sites of the musculoskeletal system can differ. However, the reflection of musculoskeletal system problems on quality of life does not show any difference between the groups of PTs.


Introduction
Work-related diseases are health problems that can occur more often in certain occupational groups, where a large number of factors, as well as the profession, are influential in the occurrence of the disease.It is known that work-related diseases are more common than occupational diseases.These injuries/illnesses, although named repetitive strain injury, cumulative trauma or repetitive motion injuries, are basically cases affecting joints, tendons, ligaments, nerves, bones and localized circulatory systems, arising from the work itself, increasing in severity due to work or affected by environmental factors of work.Although these diseases vary according to the line of work, work-related musculoskeletal diseases account for 29-35% of all work-related injuries and diseases [1].
The main problem with work-related diseases, which have become a major public health problem in developed and developing countries, are employees' musculoskeletal system complaints [2].The causes of this condition can be better understood by identifying the risk factors that lead to work-related musculoskeletal problems.Factors such as sitting or standing for long periods, making rotational movements which generally rotate the torso often, lifting heavy objects/patients or transferring heavy objects/patients, not having enough rest time, effort for work that requires strength, stretching that may strain the body or having to work while stretching or flexing the neck more than 20°put pressure on employees [2].The fact that almost all of the risky movements described are also performed by health workers puts health-care providers in a risky group in terms of musculoskeletal problems [3,4].It is known that, against the background of these identified risk factors, health workers are often CONTACT Sabriye Ercan sabriyeercan@gmail.comfaced with work-related musculoskeletal problems [5].Considering the incidence of musculoskeletal system problems among health workers, nurses (84.5%) and physiotherapists (PTs) (83.3%) were reported to be at risk more often than dentists (45.4%) and medical doctors (25.3%) [3].The main reason why the prevalence of musculoskeletal system problems differs among health professionals is stated as the change in movement patterns and ergonomic risks performed as a requirement of work [3,[6][7][8].
PTs, although they are mostly involved in the treatment of pathologies of the musculoskeletal system and have knowledge about ergonomics, are very exposed to ergonomic risks due to the nature of their work [3].The fact that PTs encounter situations such as standing for a long time, working in an inappropriate posture and often applying massage or manual therapy that requires manual dexterity on a routine working day may explain the high prevalence of musculoskeletal system injuries seen in PTs [5].On the other hand, PTs also specialize in various disciplines within their field or may prefer to work in rehabilitation centers that specialize in a particular field and accept patients accordingly [9].This situation gives rise to the fact that the ergonomic risks and the regional distribution of musculoskeletal complaints that PTs are exposed to may differ depending on the field of study they specialize in.
The hypothesis that the ergonomic risks of PTs working with pediatric patients will differ from PTs working with adult patients, and that their musculoskeletal system problems and quality of life may be affected accordingly, which has been the subject of a limited number of studies in the literature [9][10][11], forms the main hypothesis of this study.The objective of this study is to compare the ergonomic risk levels, musculoskeletal complaints and musculoskeletal system problems and quality of life of PTs working with pediatric patients and PTs working with adult patients.

Materials and methods
PTs who completed their education at least at the undergraduate level formed the sample for the study.The PTs who worked with adult patients (Group adult ) were those who carried out 'outpatient' treatments in the physical medicine and rehabilitation departments of hospitals.The PTs who received pediatric patients (Group pediatric ) were PTs working in special education and rehabilitation centers.PTs were informed about the work to be done, and those who volunteered were included in the study.Those who did not volunteer to participate in the study and those who were pregnant did not participate in the study.
After the descriptive and sociodemographic information of the PTs was recorded, observations were made in working environments and the ergonomic risk levels were determined using rapid entire body assessment (REBA).The complaints of the musculoskeletal system of PTs were evaluated with the Cornell musculoskeletal discomfort questionnaire (CMDQ) and quality of life was evaluated by the Nottingham health profile.

Rapid entire body assessment
REBA is a tool aimed at ergonomically evaluating the whole body in different dynamic and static processes shown during work (Figure 1(a,b)).During the REBA assessment, the torso, neck and legs are examined within the scope of Group A; upper arms, lower arms and wrists are examined within the scope of Group B. Group C is the REBA result score obtained by combination of the scores given to Group A and Group B. A REBA result score of 1 point means 'intervention is not necessary (insignificant)', 2-3 points means 'intervention may be necessary (low risk)', 4-7 points means 'intervention is necessary (moderate risk)', 8-10 points means 'intervention is required in a short time (high risk)' and 11-15 points means 'immediate intervention is required (very high risk)' [12].

Cornell musculoskeletal discomfort questionnaire
In the CMDQ, musculoskeletal complaints related to work in different body regions within the last 1-week period are examined with 54 questions.Complaints are questioned on the dimensions of frequency, severity and impact, and weighted points are calculated according to the answers given.A total of 0-90 points can be obtained for each body region.An increase in the score indicates that the complaint is worsening.The validity and reliability of the questionnaire in Turkish were ensured by Erdinç et al. [13].

Nottingham health profile
This assessment tool has been developed to identify people's health-related problems.The profile consists of six subdimensions (energy, pain, emotional reactions, sleep, social isolation and physical mobility) and a total of 38 questions.Each of the questions can be answered 'yes' or 'no'.The number of questions answered 'yes' in each subgroup is divided by the total number of questions in the same subgroup and the result is multiplied by 100.Thus, a value between 0 and 100 can be obtained for each sub-dimension.An increase in the score received means that the severity of the problem has increased [14].The validity and reliability of the Nottingham health profile in Turkish was ensured by Küçükdeveci et al. [15].

Ethical aspect of the research
The research was approved at the meeting of the Ethics Committee of Süleyman Demirel University (March 22, 2022; number 56/1).

Power analysis
At the end of the study, G * Power version 3.1.9.7 was used for post-hoc power analysis.The α error probability was 0.05, effect size d was 1.00, non-centrality parameter δ was 5.01, critical t value was 1.98, df was 100.18 and power (1 -β error probability) was found to be 0.99, and the adequacy of the power of the study was determined.

Statistical analysis
Data were analyzed using SPSS version 23.0.After descriptive analysis, the suitability of the data for the normal distribution was examined with the Shapiro-Wilk test.Since it was determined that the data were not distributed normally, the Mann-Whitney U test and χ 2 tests were used for difference analysis.The data were presented as frequency (n), percentage (%) and mean ± standard error (minimum-maximum).A p value of 0.05 was considered significant.

Results
A total of 107 PTs, 60 working with pediatric patients (Group pediatric ) and 47 working with adult patients (Group adult ), participated in the study.Of the participants, it was found that those who took part in Group pediatric were younger (p < 0.001) and had a lower duration of professional experience (p < 0.001).It was found that the PTs in Group adult had higher daily patient numbers (p < 0.001) and used shorter annual vacation periods (p = 0.010) (Table 1).
There was no difference in the other descriptive characteristics of PTs grouped according to the professional field in which they work, except for marital status (Table 2).
Although Group pediatric had a higher REBA score, it was observed that this did not make a statistical difference (Table 3).
It was observed that complaints about the musculoskeletal system, except for the upper back region, did not make a difference between the groups.According to our hypothesis, although PTs working with pediatric patients worked in a wider range of motions (kneeling, excessive shoulder elevation, etc.) and challenging postures, the REBA score did not make a statistical difference between the groups.It was found that complaints in the upper back region became apparent among the PTs in Group adult (p = 0.042) (Table 4).However, no difference was determined in terms of health profile according to the groups (Table 5).

Discussion
As a result of this study, although it was observed that PTs working in the pediatric field were in ergonomically challenging postures, there was no statistical difference between the groups in terms of ergonomic risk score.The prevalence ranking of musculoskeletal problems showed differences between the groups.The neck (40%), lower back (40%), upper back (23.3%) and right knee (23.3%) showed the highest prevalence in Group pediatric , while the upper back (60%), neck (40%), lower back (30%) and right shoulder (26.7%) were the most affected body regions in Group adult .A difference was determined between the groups in terms of the prevalence of the upper back region.The weighted score of musculoskeletal system complaints for Group pediatric was calculated as the lower back, right and left wrist regions; and for Group adult as the upper back, neck and lower back regions.The difference between the groups was formed by the weighted score of the upper back region.The quality of life, however, was not affected.a,b = There is a difference between groups with different exponential letters.Group adult = physiotherapists working with adult patients; Group pediatric = physiotherapists working with pediatric patients.PTs are among the groups that most often face musculoskeletal problems associated with work among health workers [3].In this area, it is possible to come across studies that determine the prevalence of musculoskeletal system problems, conducted on different samples [5].In a study conducted in our country [16], the prevalence of PTs having a musculoskeletal system injury at least once in their lifetime was found to be 58%.The affected regions were reported as lower back (26%), hand-wrist (18%), shoulder (14%) and neck (12%), respectively [16].A study conducted in the UK [17], as a result of surveying PTs with a standardized Nordic questionnaire, found that the 1-year prevalence of musculoskeletal system problems was 58%, with the lower back region (44%) the most affected body region.Another important aspect is that musculoskeletal system complaints of PTs were observed within the first 5 years of their profession (32%) and often before the age of 30 years (59%) [17].According to the data of a study in Slovenia [18], the prevalence of PTs experiencing lifelong neck-lower back pain (LBP) was determined to be 73.7%.It has been emphasized that the age group that often experiences complaints of LBP is in the age range 31-50 years.In particular, the activity of lifting patients and supporting them during their ambulation has been shown to be the major cause of musculoskeletal system injuries.The neck (19.5%), shoulder (15%) and hand-wrist (15%) were reported as risky regions, in addition to the lower back region [18].The affected regions and prevalence rates determined in our study were consistent with the literature.In addition, the difference observed in the distribution of regional effect rates in Group pediatric and Group adult PTs was an expected result.The higher duration of occupational experience of PTs working with adult patients may be related to complaints observed in the upper back region.According to this inference, it can be thought that with the increase of occupational exposures to PTs, the upper back region may be affected by the vertebral column first.
Ergonomic risk assessment is needed for professional groups where work-related musculoskeletal problems are so intense.According to research that evaluated ergonomic risks using a structured questionnaire, improper posture, lifting weight, being under excessive workload, having to apply manual orthopedic techniques and doing the same movement in a repetitive manner have been associated with ergonomic risk factors for musculoskeletal system injuries [19][20][21].In the light of these data and information [19][20][21], it can be said that work-related risk factors such as repeating the same movement many times, working in the same body position for a long time, having to stand with narrow joint movement limits, having a high number of patients during the day and having to continue their work despite being injured increase the injuries that PTs have due to their profession and increase the rate of injuries [16].In this context, the fact that complaints in the upper back region were observed in Group adult with a higher duration of professional experience may also be a result of longer exposure to risk, regardless of the work field.In a study in which Sung et al. [10] evaluated PTs with rapid upper limb assessment (RULA), they identified observable symptoms for 84.9% of PTs who work with adults, 81.8% of PTs working with children and 69.6% of PTs working in pain control.In particular, they noted the fact that PTs working with adults under too much load resulted in receiving high RULA scores for the wrist and arm.In the research by Sung et al. [10] it was thought that the risk scores of PTs working with adult patients may have been higher because the ergonomic risks of the upper extremity alone were evaluated with RULA.In our study, ergonomic risk was evaluated with REBA, which examines the entire body.According to REBA tests, the ergonomic risks of PTs were most often found to be moderate-high.According to the REBA risk rate classification, no difference was determined between PTs working with pediatric patients and PTs working with adult patients.Although REBA is a standardized method, scoring based on classified angular changes may be the reason why we were unable to confirm the hypothesis that we expected to find a difference between the groups.
It has also been discussed in different studies that the affected regions of the musculoskeletal system may differ according to the field of work of PTs [22][23][24].According to this, the lumbar region was affected in PTs working in the field of orthopedic rehabilitation, and the lower back and neck regions were affected in those working in the field of neurological rehabilitation [22].In a study that examined only female PTs working with pediatric patients, the neck (41.37%), lower back (31.03%) and upper back (31.03%) were the most common body regions with the prevalence of pain [11].In a different sample, it was reported that PTs working with pediatric patients often experience lower back (81.8%),neck (54.5%) and foot/ankle (45.4%) problems [23].This frequency ranking was consistent with the order of prevalence rates that we determined for PTs working with pediatric patients in our study.In our sample, the knee region rather than the foot/ankle was affected in the lower extremity.It was observed that in the weighted score for musculoskeletal complaints, the scores of the wrist region exceeded the score for neck, upper back and knee complaints.It is believed that this is due to the fact that PTs working with pediatric patients often use manual techniques.The reason for the prevalence of complaints of the upper back region in PTs working with adult patients has been interpreted as the fact that this group often has to stand and carry out operations in inappropriate postures for long periods or with increasing duration of occupational exposure.The vertebral region first affected may be the upper back.Although it has been reported in the literature that PTs face work-related musculoskeletal problems, the effect of this on their quality of life has not been studied.In our research, this deficiency in the literature has been corrected.There was no difference in the sub-dimension scores of the Nottingham health profile between the groups we examined.
In addition to taking part in the post-diagnosis treatment process, PTs are also actively involved in the field of preventive health services, such as reducing risks before the development of diseases/injuries [25].Currently, institutions such as public hospitals, private hospitals, special education and rehabilitation centers, private clinics and sports teams contribute to health care in fields such as neurology, orthopedics, pediatrics, geriatrics, cardiopulmonary, sports medicine, oncology, obstetrics, etc., in our country [26].The number of PTs per capita in our country for this profession is not yet at the desired level [27].In addition, although there is an increase in the quota for physiotherapy and rehabilitation undergraduate education every year in the university examinations organized by the Student Selection and Placement Center, graduated PTs have employment problems [27].According to the results of a scientific study conducted in Türkiye, 22.9% of graduated PTs do not work.Of those PTs who are actively working, 44.6% are engaged in the field of pediatric rehabilitation work [27].According to data from another survey, it is understood that the average age of PTs who work at special education and rehabilitation centers that provide pediatric rehabilitation services is typically relatively young (27.19 ± 4.37 years) and that they start working in the field of pediatric rehabilitation in the early period of their professional lives.Of these PTs, 23.5% think about changing their profession/field of work at the first opportunity and 16.4% think about changing their profession/field of work within 5 years [26].The descriptive results obtained in our study are similar to studies in which the fields of work of PTs and their descriptive characteristics are presented in the national literature [26,27].The results have been interpreted as a reflection of Türkiye's PT employment policies.

Limitations
Due to the fact that the research pattern is cross-sectional, the inability to calculate the incidence of musculoskeletal injuries is a limitation of this study.In addition, it is a limitation that device-based ergonomic risk analysis has not been performed instead of an observational method such as REBA.On the other hand, ergonomic risks and rates of affection of musculoskeletal system effects belonging to PTs working with pediatric patients, which have been studied in a limited number of studies in the literature, are being studied for the first time in our country, to the best of our knowledge.In this context, the findings we have presented contribute to both the national and international literature.

Conclusion
As a result, although no statistically significant differences have been determined, PTs working with pediatric patients face a wider range of motions (kneeling, excessive shoulder elevation, etc.) and challenging postures.Affected regions in the musculoskeletal system and questionnaire scores differ according to the work field of PTs.However, the difference detected, especially in the upper back region, may be due to the difference in occupational exposure between the groups.On the other hand, the level of reflection of musculoskeletal system problems on quality of life did not show any difference between PTs.

Figure 1 .
Figure 1.Physiotherapists (PTs) working with (a) pediatric patients (Group pediatric ) and (b) adult patients (Group adult ) with rapid entire body assessment (REBA) at work.

Table 2 .
Socio-demographic characteristics of the groups.: p < 0.05, independent-sample Mann-Whitney U and χ 2 tests.Note: Numerical values highlighted in bold have statistical significance. *

Table 3 .
Ergonomic risk levels of the groups.
Independent-sample Mann-Whitney U and χ2 tests.Note: Group adult = physiotherapists working with adult patients; Group pediatric = physiotherapists working with pediatric patients; REBA = rapid entire body assessment.

Table 1 .
Descriptive features of the groups.

Table 4 .
CMDQ weighted scores according to group.: Numerical values highlighted in bold have statistical significance.a,b = There is a difference between groups with different exponential letters.CMDQ = Cornell musculoskeletal discomfort questionnaire; Group adult = physiotherapists working with adult patients; Group pediatric = physiotherapists working with pediatric patients.

Table 5 .
Nottingham health profile scores according to group.