This systematic review and meta-analysis evaluated the prevalence of WRMSDs in perioperative nurses and their association with personal characteristics. Musculoskeletal disorders are one of the highest contributors to global disability. [34] Recently, the World Health Organization estimated that between 20–33% of general population live with a painful musculoskeletal condition [35]. In particular, WRMSDs remain the most common work-related health problem in the European Union and workers in all sectors and occupations can be affected. Of all workers in the European Union with a work-related health problem, 60% identify musculoskeletal disorders as their most serious issue [6].
Specifically, health-care professionals might be at high risk of incurring in musculoskeletal disorders(36). Our results are in line with literature for other health-care professionals. According to a recent systematic review, nearly three out of four nurses employed in a hospital, suffered from pain or discomfort in at least one of any of musculoskeletal district during the past 12 months of work(5). In this review, the three musculoskeletal districts mostly affected where: lower back (65.3%), knees (56.2%) and neck (49.8%)(5). Also, results from a cross-sectional study conducted on nursing aides working in nursing homes showed that 87.4% of the study population experienced musculoskeletal disorders in the previous year (lower back 41.4%, shoulders 53%, knees 37.5%) [37]. Furthermore, a high prevalence of WRMSD has been also observed in X-ray technologists with an overall 12-months prevalence of low back pain of 75.1% and a 64.2% of the neck-shoulder segment [13]. In particular, the operating room setting appears to be at high risk of developing WRMSDs. Epstein et al. reported, among a large sample of surgeons and interventionalists, an overall 12-month prevalence of neck pain of 60%, of shoulder pain of 52%, of back pain of 49% and of upper extremities of 35% [38].
The highest prevalence of musculoskeletal disorders in the working population is attributable to disorders at the back district. Consistently, the general population shows a low back pain life-time prevalence between 51–90% [39]. Just for the low back district, it has been estimated that approximately $50 billion per year is spent in the United States [40]. Nursing has been identified amongst the top professions at risk of low back pain [41]. Our results showed that more than 60% of perioperative nurses suffered from work-related low back pain and this is particularly relevant if we consider that perioperative nurses, in general, could be highly exposed to both physical and temporal risk factors, such as low temperature, highly repetitive tasks at high force, often using vibrating instruments. Furthermore, perioperative health-care professionals have to maintain static postures during surgical procedures for an extended time [42]. The impossibility of switching body positions is a relevant contributor to fatigue and health problems related to the low back district [43].
Several personal characteristics could be related to WRMSDs. Among these characteristics, the female gender seems to be associated with a greater risk of lower-back problems both in nurses [44, 45] and in the population of operating room nurses [17, 20, 21, 24, 28, 32]. Despite this, in our review female gender was not a significant predictor of low back disorders. Traditionally, gender has not been considered a predictor of WRMSDs, but a confounding or modifying factor due to the mixed exposure to work and extra-work activities. However, according to some recent studies, employed women seem to have an increased risk of WRMSDs, in particular in the upper-body musculoskeletal district. The most likely explanation of the increased risk of WRMSDs in female workers might be the differences in somatic, hormonal, and psychological aspects. Furthermore, women are more prone to WRMSDs in cold working environments [46] and there can be differences in repetitive procedures used between male and female gender [47]. Moreover, women are usually more in charge of the domestic work, and this futher burden could increase musculoskeletal issues [48]. The combined work-home exposure to musculoskeletal demands could also reduce the opportunity for recovery time, and for strengthening body muscles with a higher risks of overweight consequences [49].
Percentages of overweight and obesity are high among employed adults with rising rates over the past few decades(50,51). Several studies have linked a high BMI with musculoskeletal disorders and the repetitive work [52, 53]. This statement could have been true especially for our population, particularly exposed to prolonged repetitive tasks in awkward postures. Surprisingly, although some studies [17, 25, 27, 28] considered in our meta-analysis reported an association between an increased BMI and WRMDs, the meta-regression results did not confirm this assumption. This might be due to a younger age of perioperative nurses compared to other nursing roles [54], and that the BMI alone could not represent a reliable predictor.
It is also known that musculoskeletal disorders related to work are a major cause of disability in older workers [55]. In this regard, more than one third of the nursing workforce in the United States is between the ages of 50 and 64 [56]. In our sample, mean age was lower with an average age of 36.7 years. This could be explained in part by the fact that perioperative nurses begin their career usually right after the graduation. And that through the years they usually change their position from the operation room to outpatients’ settings, usually with minor physical burden. This assumption could explain the absence of association in the meta-regression. Only a few studies [16, 17, 19, 27, 28] have shown a correlation between age and WRMSDs.
In the operating room setting several interventions may be adopted to reduce WRMSDs with a multidisciplinary approach. In this regard, environmental and ergonomic factors should be taken into great consideration. Particular attention should be given to the evaluation of repetitive motions and prolonged restricted posture, handling heavy weight, forceful gripping, low temperatures, the use of vibrating instruments and to the frequency, intensity, and duration of each task performed at work. Possible ergonomic interventions to minimize risks and reduce the incidence of work-related low back disorders should include: propping alternating feet on foot stools, using anti-fatigue mats, using sit/stand stools, and limiting standing times, wearing appropriate footwear, implementing postural exercises such as regular contraction and relaxation of muscles during the surgical procedures [57]. Moreover, perioperative nurses could benefit from ergonomic education and physical rehabilitation, if needed. Also, organizational strategies can be adopted to allow a more effective management of human resources, especially when assigning workers to specific jobs or tasks such as job mechanization, job rotation, job enlargement, and the design of a safe work environment [58].
This review has some potential limitations. Data from the articles included in the meta-analysis may not represent the general population heterogeneously, in fact about a quarter of the studies were conducted in Iran, limiting the generalizability due to contextual factors. The high heterogeneity in the meta-analyses could be related to the different clinical settings where the studies were conducted. It was not possible to stratify by surgical specialties due to the lack of data. Also, within the same surgical specialty the surgical procedures could differ between countries or for the adoption of specific surgical technique. Furthermore, the role of perioperative nurses could differ between countries. Moreover, prevalence of WRMSDs was assessed through self-reported measures, further studies using clinical examination could increase the reliability of findings. Lastly, the lack of data from included studies could have limited the results of the meta-regression. Despite these limitations, this is the first systematic review conducted on this topic providing a meta-analysis.