CONTINUING EDUCATION

The Prevalence of Work-Related Neck,

Shoulder, and Upper Back Musculoskeletal
Disorders Among Midwives, Nurses, and
Physicians
A Systematic Review
by Maryann H. Long, PhD, CNM, Fiona E. Bogossian, PhD, RN, RM, and Venerina Johnston, PhD,
BPhty

ABSTRACT
With the global shortage of health care workers predicted to worsen, attrition from the work force must be minimized. This
review examined the incidence or prevalence of neck, shoulder, and upper back musculoskeletal disorders, a possible
source of attrition, among midwives, nurses, and physicians. Four electronic databases were systematically searched for
publications meeting inclusion criteria. Reference lists of retrieved articles were hand searched for additional articles. Af-
ter eliminating articles that did not meet inclusion criteria, the remaining articles were assessed for quality and prevalence
or incidence data were extracted. Twenty-nine articles published between 1990 and 2012 were included and assessed
for quality. Median annual prevalence rates were 45% (neck), 40% (shoulder), and 35% (upper back). Methodological
concerns included small sample size, inconsistency of outcome measures, likelihood of non-response bias, and low re-
sponse rates. Midwives, who have not been well studied, demonstrated prevalence somewhat lower than that of nurses
and physicians. [Workplace Health Saf 2013;61(5):223-229.]

A
n adequate supply of healthy workers is essential supply of front-line health care professionals, including
to the effective, efficient functioning of health midwives (Gerein, Green, & Pearson, 2006; McCarthy,
care systems. Currently, however, a global under- Tyrrell, & Lehane, 2003; Tracy, Barclay, & Brodie, 2000),
nurses (Ahmed, Hossain, Rajachowdhury, & Bhuiya,
ABOUT THE AUTHORS 2011; Buerhaus, 2008; Fox & Abrahamson, 2009; Kinfu,
Dr. Long is Clinical Lecturer, School of Nursing and Midwifery, and Re- Dal Poz, Mercer, & Evans, 2009), and physicians (Shel-
search Officer, School of Health and Rehabilitation Sciences; Dr. Bogos- don et al., 2008; Thistlethwaite, Leeder, Kidd, & Shaw,
sian is Associate Professor and Director of Research, School of Nursing
and Midwifery; and Dr. Johnston is Lecturer in Physiotherapy, School of 2008), exists. This shortage is predicted to worsen during
Health and Rehabilitation Sciences, The University of Queensland, Bris- the next decade as professionals from the baby boom gen-
bane, Queensland, Australia.
The authors disclose that they have no significant financial interests in any
eration retire (Buerhaus, Staiger, & Auerbach, 2000; Co-
product or class of products discussed directly or indirectly in this activity, hen, 2009; Jevitt & Beckstead, 2004; Schofield & Beard,
including research support. 2005) and require additional health care due to aging. In
The authors thank Susan E. M. Kellett for editorial assistance.
Address correspondence to Maryann H. Long, PhD, CNM, Edith Cavell Build- addition to educating and deploying new practitioners,
ing, Level 2, School of Nursing and Midwifery, The University of Queensland, efforts to prevent attrition among remaining workers are
Herston Road, Herston, QLD 4006, Australia. E-mail: maryann.long@gmail. increasingly urgent. Some of the factors underlying attri-
com.
Received: March 8, 2012; Accepted: March 25, 2013. tion in midwifery, nursing, and medicine are well-known,
including dissatisfaction with working conditions, lack of

WORKPLACE HEALTH & SAFETY • VOL. 61, NO. 5, 2013 223

 Sidebar of activity occurs. Hence, the objective of this review
was to examine the prevalence and incidence of work-
Criteria Used to Assess Quality related neck, shoulder, and upper back (NSU) muscu-
loskeletal disorders in all three groups of health care
1. The report contained a description of the study providers.
setting and population from which the sample was
drawn. METHODS
The review process followed PRISMA (Moher,
2. Sampling was random or the whole population was Liberati, Tetzlaff, & Altman, 2009) guidelines, which
studied. can be accessed at www.prisma-statement.org/statement.
3. The response rate was greater than 70%. htm. The initial search was completed in March and April
2011, and a supplemental search to update the review was
4. Non-responders were described.
completed in March 2012. Publications were accessed
5. Specific inclusion criteria were applied. by searching PubMed, Medline, CINAHL, and Embase.
6. Demographic information about the study sample
For outcomes of interest, search terms were occupational
was provided.
diseases, occupational injury, musculoskeletal diseases,
musculoskeletal disorders, pain, complaint, symptom,
7. Confidence intervals or standard errors of preva- work-related, neck, shoulder, and upper back. Terms used
lence were presented. to identify desired populations were nurses, midwives,
nurse-midwives, obstetricians, physicians, surgeons, and
Note. Information from Loney, Chambers, Bennett, Roberts,
doctors. The following inclusion criteria were applied:
and Stratford, 1998.
1. Primary research published in English in a peer-
reviewed or professional journal;
2. Publication date between 1990 and 2012;
support, family commitments, inadequate compensation, 3. Study sample included midwives or nurse-mid-
unsatisfactory work–life balance, and ill health (Ball, wives, registered nurses, or physicians/surgeons;
Curtis, & Kirkham, 2002; Fox & Abrahamson, 2009; 4. A prevalence rate (the proportion of the popula-
Kneeland, Kneeland, & Wachter, 2010). The proportion tion with a given condition at a specified time) during a
of “ill health” due to musculoskeletal disorders in these defined period of not more than 12 months, and/or an in-
groups is unknown. cidence rate (the proportion of new cases of a given con-
The World Health Organization (WHO) called at- dition within a specified time period);
tention to the role of occupational hazards and stress in 5. A validated tool was used to measure the outcome,
health care provider attrition in its 2006 World Health musculoskeletal complaints involving the neck, shoulder,
Report, citing as an example the contribution of muscu- and upper back or a combination of these body areas; and
loskeletal disorders to high sickness absence rates among 6. The article title or study objective indicated the
nurses (WHO, 2006). Many research studies into mus- outcomes under study were work-related.
culoskeletal disorders among nurses and physicians have Studies of “nursing personnel” or “nursing staff”
focused on the lower back (Engkvist, Hjelm, Hagberg, were excluded if it could not be determined from the re-
Menckel, & Ekenvall, 2000; Estryn-Behar et al., 1990; port or by contacting the corresponding authors (n = 8)
Hignett, 1996; Karahan, Kav, Abbasoglu, & Dogan, that registered nurses were included in the sample. A sec-
2009; Lorusso, Bruno, & L’Abbate, 2007). Fewer stud- ondary search of reference lists yielded additional articles
ies have focused on the neck, shoulders, and upper back; for evaluation. The primary author screened abstracts or
research shows these areas are also vulnerable (Oude full-text articles and the second author confirmed inclu-
Hengel, Visser, & Sluiter, 2011; Panel on Musculoskel- sion.
etal Disorders and the Workplace, 2001; Sherehiy, Kar- The primary author assessed all included studies for
wowski, & Marek, 2004). quality against seven criteria suggested by Loney, Cham-
Midwives, nurses, and physicians, although they bers, Bennett, Roberts, and Stratford (1998). These cri-
have different roles, share some of the same exposures teria appear in the Sidebar. One point was awarded for
in the workplace. The role of the nurse or physician each positive assessment. Studies that achieved a total of
is generally well understood, but that of the midwife five to seven points were labeled high quality; three to
may be less familiar. Midwives are primary caregivers four points, moderate quality; and one to two points, low
for women during pregnancy, labor, birth, and the post- quality.
natal period (International Confederation of Midwives,
2011). They assume caring functions, similar to those RESULTS
of nursing, and also make clinical decisions and man- In the initial search, 1,383 studies were identified. Of
age procedures usually associated with the physician these, 1,309 studies were excluded based on title alone or
role. Likewise, the development of the nurse practitio- title and abstract, including duplicates. After reading full-
ner role in some countries has blurred the traditional text versions of the remaining 74 studies plus 13 studies
professional boundaries between nurses and physicians retrieved from hand searching reference lists, 62 studies
such that increasing overlap in their respective spheres were excluded because they did not meet inclusion cri-

224 Copyright © American Association of Occupational Health Nurses, Inc.

teria (Figure). An additional nine studies were identified
in the supplemental search and the full texts reviewed.
Five of these nine studies did not meet inclusion criteria.
Lack of consistency in samples and outcome measures
precluded meta-analysis.
Twenty-six studies were cross-sectional, two re-
ported prevalence from the baseline survey of a prospec-
tive study, one reported both baseline prevalence and
incidence during 2 years in a prospective study, and one
was exclusively a prospective study. Twenty-six stud-
ies examined NSU musculoskeletal disorders among
registered nurses or nursing personnel. Physicians were
the focus of two studies. One of these sampled general
surgeons and the other included all physicians in the se-
lected hospital, representing internal medicine, surgery,
orthopedics, gynecology, and intensive care. Only one
study of midwives, conducted by the authors, was re-
trieved. The quality appraisal results were as follows:
low quality, n = 6; moderate quality, n = 18; and high
quality, n = 5 (Table A, which appears as supplemental
material in the online version of this article). No stud-
Figure. Flow diagram of the review process.
ies reported standard error of prevalence. Table B, which
appears as supplemental material in the online version
of this article, summarizes study details and prevalence data on the neck and shoulder, finding annual prevalence
data for included studies. rates of 15.8%, 60%, and 35%, respectively.
All studies but one (Camerino et al., 2001) identified To achieve the best synthesis possible given the het-
that the Standardized Nordic Musculoskeletal Question- erogeneity of outcome measures, studies rated moder-
naire (NMQ) (Kuorinka et al., 1987), a validated and reli- ate or high in quality that reported annual prevalence of
able measurement tool, was used to establish prevalence symptoms in distinct body parts without reference to a
of musculoskeletal symptoms. Some studies used adapted case definition were identified. In these studies, all three
or translated versions as required by the study setting; for occupational groups were represented and median preva-
example, the Dutch Musculoskeletal Questionnaire is a lence rates were 45% for neck musculoskeletal disorders,
standardized tool that incorporates the NMQ (Bos, Krol, 40% for shoulder musculoskeletal disorders, and 35% for
van der Star, & Groothoff, 2007). The study by Sheikhza- upper back musculoskeletal disorders.
deh, Gore, Zuckerman, and Nordin (2009) described use Two longitudinal studies yielded incidence data for
of a “Musculoskeletal Symptom Survey,” citing three ref- this review. Trinkoff, Le, Geiger-Brown, Lipscomb, and
erences. Investigation of two of these revealed that this Lang (2006) conducted a large prospective cohort study
tool was also the NMQ; hence, the study was considered of nurses in the United States. Participants completed sur-
to have used the NMQ. veys administered in three waves, with an average of 15
Prevalence and incidence of NSU musculoskeletal months between completion of the first and third ques-
disorders were the outcomes reported in the reviewed tionnaires. The researchers reported cumulative incidence
studies. Of the studies reporting prevalence, 25 measured rates of 14% and 17% for musculoskeletal disorders of
12-month period or annual prevalence, the proportion of the neck and shoulder, respectively. Smedley et al. (2003)
the study sample that had experienced one or more epi- followed a cohort of nursing staff in southern England
sodes of an NSU musculoskeletal disorder in the previ- during 2 years. Of 903 staff asymptomatic at baseline,
ous 12 months. One study reported 6-month period preva- 587 remained in the same job and completed at least one
lence; two assessed 1-month prevalence. additional questionnaire within the next 2 years. The in-
Twelve-month period prevalence of any musculo- cidence of neck or shoulder pain in this group was 34%
skeletal disorder symptom among these study samples (Smedley et al., 2003).
varied from 36% to 96% for neck musculoskeletal dis-
orders, 13% to 93% for shoulder musculoskeletal disor- DISCUSSION
ders, and 17% to 91% for upper back musculoskeletal This review examined the prevalence and incidence
disorders. As might be expected, when the outcome was of neck, shoulder, and upper back musculoskeletal dis-
cases according to a threshold definition, prevalence was orders from 29 published studies of midwives, nurses,
lower, with one study reporting around 20% for neck and and physicians. It now remains to examine key findings
shoulder musculoskeletal disorders (Lipscomb, Trinkoff, and offer directions for future research. The dearth of
Brady, & Geiger-Brown, 2004) and one slightly higher at research about midwives as an occupational group is a
28% for neck musculoskeletal disorders (Camerino et al., noteworthy finding. It is also remarkable that prevalence
2001). Hoe, Kelsall, Urquhart, and Sim (2012), Bos et rates for NSU musculoskeletal disorders in the reviewed
al. (2007), and Smedley et al. (2003) presented combined studies approach or equal rates of lower back musculo-

WORKPLACE HEALTH & SAFETY • VOL. 61, NO. 5, 2013 225

skeletal disorders, which have been reported to range be- an for both neck and upper back. Although all study par-
tween 40% and 75% for nurses (Alexopoulos, Burdorf, ticipants were qualified midwives, approximately 47%
& Kalokerinou, 2003; Hignett, 1996; Larese & Fiorito, were working in nursing when surveyed. Prevalence rates
1994; Warming, Precht, Suadicani, & Ebbehøj, 2009) and did not differ significantly according to practice role, but
between 33% and 68% for physicians (Oude Hengel et it was not possible to analyze prevalence by duration of
al., 2011). This finding suggests that the NSU region mer- midwifery practice due to missing data; hence, the impact
its similar research focus. Most of the studies were rated of exposure to midwifery practice on prevalence of NSU
at least moderate in quality, yet several methodological musculoskeletal disorders could not be determined.
problems were observed. Two studies, one of midwives (Long et al., 2012)
Across the reviewed studies, the researchers found and the other of nurses (Serranheira, Cotrim, Rodrigues,
substantial variation in prevalence rates. Similar varia- Nunes, & Sousa-Uva, 2012), reported data from online
tion in prevalence has been observed by other researchers surveys, an increasingly common data collection tech-
(Oude Hengel et al., 2011). This phenomenon could be nique. The studies also shared other characteristics: re-
a consequence of variation in the precision of outcome sponse rates were less than 5%, although the sample sizes
definition. It is not clear from every report exactly which were large, 1,388 and 2,140, respectively, and approxi-
symptoms were included in the study questions. For ex- mately 15% of each sample worked in non-clinical roles.
ample, when “pain” is the only outcome variable assessed Regarding possible non-response bias, however, the two
in the questionnaire, respondents with symptoms they studies differed. Serranheira et al. (2012) described a
judge more annoying than painful may consider them- study focus on musculoskeletal disorders in their recruit-
selves unaffected and give a negative answer, leading to ment materials. In contrast, the stated themes of the Nurs-
lower prevalence. es’ and Midwives’ e-Cohort Study, which provided the
On the other hand, several studies observed rates that data in Long et al. (2012), were broad (“Work/Life Bal-
were well above the calculated median. Sheikhzadeh et ance” and “Staying Healthy”) and thus less likely to pro-
al. (2009) obtained 71% (neck), 74% (shoulder), and 45% mote disproportionate participation by individuals with
(upper back) prevalence rates using “symptoms” as the musculoskeletal disorders (Turner et al., 2008).
outcome variable. The small sample of participants who Other methodological issues were noted. Most re-
were perioperative personnel (nurses and surgical techni- searchers did not analyze differences between those
cians, n = 50) was recruited and surveyed at departmental who did and did not respond, again raising the possibil-
administrative meetings, leading to the possibility of re- ity of non-response bias and overestimation of preva-
sponse bias. Yeung, Genaidy, and Levin (2004) described lence. Confidence intervals indicate the precision of
very high prevalence (> 90%) for NSU musculoskeletal prevalence rates; however, most studies did not provide
disorders among their sample of 97 nurses. However, they these data.
described a recruitment procedure in which unit manag- Some study samples included small proportions of
ers requested volunteers, a method that could have result- registered nurses. Some samples labeled “nursing person-
ed in a biased sample. Conversely, two large studies with nel” may have included ancillary staff such as housekeep-
high response rates, one with 330 participants and a 98% ing and dietary workers or supervisory nurses, whose
response rate (Smith et al., 2005) and the other with 844 job descriptions have little in common with that of staff
participants and a 74% response rate (Smith, Mihashi, nurses. Together, these two issues limit applicability of
Adachi, Koga, & Ishitake, 2006a), found shoulder mus- results to populations of staff nurses. Surgeons in training
culoskeletal disorder prevalence of more than 70%. This comprised 36% of the sample of Szeto et al. (2009); in
finding may be an accurate reflection of prevalence in the Kitzmann et al. (2012), 50% of the family practitioners
populations studied, although it should be noted that one and 75% of the eye care physicians were still in train-
of these studies received a low quality rating (Smith et ing. These samples may limit generalizability of results to
al., 2005). fully qualified practitioners or to the medical profession
Matsudaira et al. (2011) demonstrated 1-month at large.
prevalence rates approximately twice those of Hoe et Work-relatedness of the musculoskeletal disorders
al. (2012). Both were studies of nurses with large sam- under investigation was not explicit in the article titles,
ple sizes and moderate response rates. Differences in with one exception (Szeto et al., 2009). Hence, it was
outcome measures between the studies (e.g., Hoe et al. necessary to infer, from the occupational categories in-
[2012] specified pain lasting at least 1 day) may explain cluded and the study objectives, that work-related mus-
the discrepant prevalence rates. culoskeletal disorders were the research focus. Most
Non-response bias may account for the 83% prev- studies assessed workplace exposures (n = 24) and this
alence of neck discomfort in the study by Szeto et al. additional information substantiated the assumption that
(2009) of general surgeons (n = 135, 27% response rate). musculoskeletal disorders in these samples were indeed
This figure contrasts sharply with the findings of Smith et work-related.
al. (2006a), who studied a much larger sample of physi- Prevalence and incidence were identified by self-
cians (n = 286) with a much higher response rate (79%) report in all included studies. Self-report to determine
and found a prevalence of 42% for neck symptoms. case status has been linked with both over- and under-
Midwives in the study by Long, Johnston, and Bo- estimation of prevalence of health outcomes (Silverstein,
gossian (2012) had symptom prevalence below the medi- Stetson, Keyserling, & Fine, 1997), although Perreault,

226 Copyright © American Association of Occupational Health Nurses, Inc.

Brisson, Dionne, Montreuil, and Punnett (2008) showed
that self-report compares well with objective exami- IN SUMMARY
nation. Mehlum, Veiersted, Waersted, Wergeland, and
Kjuus (2009) concluded that self-report of work-related- The Prevalence of Work-
ness was generally accurate when compared with experts’
assessments.
Related Neck, Shoulder, and
Inconsistency of outcome variables limits meaning- Upper Back Musculoskeletal
ful comparisons. This problem has been reported else-
where (Huisstede, Bierma-Zeinstra, Koes, & Verhaar,
Disorders Among Midwives,
2006; Sherehiy et al., 2004; Sluiter, Rest, & Frings-Dre- Nurses, and Physicians
sen, 2001). Terminology used to elicit survey responses
A Systematic Review
and describe musculoskeletal disorders in the reviewed
studies included disease, injury, disorder, complaint, Long, M. H., Bogossian, F. E., & Johnston, V.
ache, discomfort, pain, numbness, and tingling. Workplace Health & Safety 2013; 61(5), 223-229.
The cumulative incidences of neck and shoulder
symptoms in the longitudinal study by Trinkoff et al. (2006)
were 14% and 17%, respectively. It is tempting to add
these rates together and compare them with the incidence
1 With a worldwide shortage of midwives, nurses,
and physicians predicted to worsen, strategies to
retain these professionals in the work force are
obtained by Smedley et al. (2003) for the neck/shoulder needed. Musculoskeletal disorders are one pos-
unit. However, the study by Smedley et al. tracked symp- sible source of attrition from the work force that
toms, whereas the incidence rates in the study by Trinkoff may merit investigation.
et al. were of cases according to the study’s case defini-
tion. Moreover, a case in the study by Trinkoff et al. could
be counted as both a neck and a shoulder case if the case
definition were met for both areas (Alison Trinkoff, RN,
2 The median annual prevalence of work-related
neck, shoulder, and upper back musculoskeletal
disorders ranged from 35% to 45%. The neck
ScD, FAAN, Professor, University of Maryland School of
was the body part most often affected.
Nursing, personal communication, December 28, 2009);
hence, no comparison was made.
Despite extensive and repeated searching of pub-
lished English literature, evidence of NSU musculoskel- 3 Most of the studies were rated moderate in qual-
ity. Methodologic concerns encountered included
problems with sampling (small sample sizes,
etal disorders in midwives was limited to one study. This
sample bias, heterogeneity) and inconsistency
deficiency may be attributable to the viewpoint that mid-
of outcome measures.
wifery is simply a specialized field of nursing. Indeed,
Trinkoff, Lipscomb, Geiger-Brown, and Brady (2002)
indicated in an explanatory footnote to the demographic
table that the “advanced practice role” category included, CONCLUSIONS AND RECOMMENDATIONS
among others, nurse midwives (p. 173). Bru, Mykletun, Work-related NSU musculoskeletal disorders are
and Svebak (1993), however, made a distinction between prevalent among nurses and physicians, although studies
midwives and nurses, postulating that the former expe- in the latter population are comparatively few. If mid-
rienced different psychological stressors. Smedley et al. wives have exposures similar to those of nurses and phy-
(2003) excluded 19 respondents because they reported sicians, work-related NSU musculoskeletal disorders are
working in “midwifery or non-nursing jobs” (p. 865). likely to be equiprevalent among midwives.
The authors may have done so because they recognized It is clear that additional confirmatory studies of
that the practice of midwifery is different from that of work-related NSU musculoskeletal disorders among
nursing. midwives are urgently needed. Ideally, future studies in
To the authors’ knowledge, this is the first review all three of these occupational groups must include lon-
focusing on NSU to present work-related musculoskel- gitudinal designs to elicit incidence as well as prevalence
etal disorder prevalence or incidence data from mid- rates. Study design must address methodological con-
wives, nurses, and physicians in an attempt to analyze cerns identified in this review by clearly defining and re-
information about the professionals who provide direct porting outcome variables and recruiting study samples
patient care. The quality appraisal tool used was spe- of adequate size using methods designed to minimize
cific to prevalence studies and based on evidence from bias. Such studies could yield accurate, valid, and gener-
the literature. Despite the variable quality of the studies, alizable findings and may assist with efforts to minimize
all were retained in the review to achieve a more vivid work force attrition or premature retirement due to mus-
picture of prevalence from a broad range of geographic culoskeletal disorders.
locations. However, some limitations must be acknowl-
edged. Studies published in languages other than Eng- REFERENCES
lish could not be included due to cost, and eligible ar- Ahmed, S. M., Hossain, M. A., Rajachowdhury, A. M., & Bhuiya, A. U.
(2011). The health workforce crisis in Bangladesh: Shortage, inap-
ticles may have been inadvertently missed in the search propriate skill-mix and inequitable distribution. Human Resources
process.

WORKPLACE HEALTH & SAFETY • VOL. 61, NO. 5, 2013 227

 for Health, 9(3). doi:10.1186/1478-4491-9-3 wife. Retrieved from www.internationalmidwives.org
Alexopoulos, E. C., Burdorf, A., & Kalokerinou, A. (2003). Risk factors Jevitt, C. M., & Beckstead, J. W. (2004). Retirement among Florida’s
for musculoskeletal disorders among nursing personnel in Greek certified nurse-midwives: An impending workforce crisis. Journal
hospitals. International Archives of Occupational and Environmen- of Midwifery and Women’s Health, 49(1), 39-46.
tal Health, 76(4), 289-294. Josephson, M., Lagerström, M., Hagberg, M., & Wigaeus Hjelm, E.
Ball, L., Curtis, P., & Kirkham, M. (2002). Why do midwives leave? (1997). Musculoskeletal symptoms and job strain among nursing
Retrieved from www.rcm.org.uk personnel: A study over a three year period. Occupational and Envi-
Bos, E., Krol, B., van der Star, L., & Groothoff, J. (2007). Risk fac- ronmental Medicine, 54(9), 681-685.
tors and musculoskeletal complaints in non-specialized nurses, IC Karahan, A., Kav, S., Abbasoglu, A., & Dogan, N. (2009). Low back
nurses, operation room nurses, and X-ray technologists. Interna- pain: Prevalence and associated risk factors among hospital staff.
tional Archives of Occupational and Environmental Health, 80(3), Journal of Advanced Nursing, 65(3), 516-524.
198-206. Kinfu, Y., Dal Poz, M. R., Mercer, H., & Evans, D. B. (2009). The health
Bru, E., Mykletun, R. J., & Svebak, S. (1993). Neuroticism, extraver- worker shortage in Africa: Are enough physicians and nurses being
sion, anxiety and type A behaviour as mediators of neck, shoulder trained? Bulletin of the World Health Organization, 87(3), 225-230.
and lower back pain in female hospital staff. Personality and Indi- Kitzmann, A. S., Fethke, N. B., Baratz, K. H., Zimmerman, M. B.,
vidual Differences, 15(5), 485-492. Hackbarth, D. J., & Gehrs, K. M. (2012). A survey study of muscu-
Buerhaus, P. I. (2008). Current and future state of the US nursing work- loskeletal disorders among eye care physicians compared with fam-
force. Journal of the American Medical Association, 300(20), 2422- ily medicine physicians. Ophthalmology, 119(2), 213-220.
2424. Kneeland, P. P., Kneeland, C., & Wachter, R. M. (2010). Bleeding tal-
Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. (2000). Implications of ent: A lesson from industry on embracing physician workforce chal-
an aging registered nurse workforce. Journal of the American Medi- lenges. Journal of Hospital Medicine, 5(5), 306-310.
cal Association, 283(22), 2948-2954. Kuorinka, I., Jonsson, B., Kilbom, A., Vinterberg, H., Biering-Sørensen,
Camerino, D., Cesana, G. C., Molteni, G., De Vito, G., Evaristi, C., & F., Andersson, G., & Jørgensen, K. (1987). Standardised Nordic
Latocca, R. (2001). Job strain and musculoskeletal disorders of Ital- questionnaires for the analysis of musculoskeletal symptoms. Ap-
ian nurses. Occupational Ergonomics, 2(4), 215-223. plied Ergonomics, 18(3), 233-237.
Choobineh, A., Rajaeefard, A., & Neghab, M. (2006). Association be- Larese, F., & Fiorito, A. (1994). Musculoskeletal disorders in hospital
tween perceived demands and musculoskeletal disorders among nurses: A comparison between two hospitals. Ergonomics, 37(7),
hospital nurses of Shiraz University of Medical Sciences: A ques- 1205-1211.
tionnaire survey. International Journal of Occupational Safety and Lipscomb, J., Trinkoff, A., Brady, B., & Geiger-Brown, J. (2004).
Ergonomics, 12(4), 409-416. Health care system changes and reported musculoskeletal disorders
Cohen, S. A. (2009). A review of demographic and infrastructural fac- among registered nurses. American Journal of Public Health, 94(8),
tors and potential solutions to the physician and nursing shortage 1431-1435.
predicted to impact the growing US elderly population. Journal of Loney, P. L., Chambers, L. W., Bennett, K. J., Roberts, J. G., & Strat-
Public Health Management and Practice, 15(4), 352-362. ford, P. W. (1998). Critical appraisal of the health research literature:
De Souza Magnago, T. S., Lisboa, M. T., Griep, R. H., Kirchhof, A. L., Prevalence or incidence of a health problem. Chronic Diseases in
& Guido, L. (2010). Psychosocial aspects of work and musculo- Canada, 19(4), 170-176.
skeletal disorders in nursing workers. Revista Latino-Americana de Long, M. H., Johnston, V., & Bogossian, F. E. (2012). Helping women
Enfermagem, 18(3), 429-435. but hurting ourselves? Neck and upper back musculoskeletal symp-
Engkvist, I. L., Hjelm, E. W., Hagberg, M., Menckel, E., & Ekenvall, toms in a cohort of Australian midwives. Midwifery. doi:10.1016/j.
L. (2000). Risk indicators for reported over-exertion back injuries midw.2012.02.003
among female nursing personnel. Epidemiology, 11(5), 519-522. Lorusso, A., Bruno, S., & L’Abbate, N. (2007). A review of low back
Estryn-Behar, M., Kaminski, M., Peigne, E., Maillard, M. F., Pelle- pain and musculoskeletal disorders among Italian nursing person-
tier, A., Berthier, C., . . . Leroux, J. M. (1990). Strenuous working nel. Industrial Health, 45(5), 637-644.
conditions and musculo-skeletal disorders among female hospital Matsudaira, K., Palmer, K. T., Reading, I., Hirai, M., Yoshimura, N., &
workers. International Archives of Occupational and Environmental Coggon, D. (2011). Prevalence and correlates of regional pain and
Health, 62(1), 47-57. associated disability in Japanese workers. Occupational and Envi-
Fabunmi, A. A., Oworu, J. O., & Odunaiya, N. A. (2008). Prevalence of ronmental Medicine, 68(3), 191-196.
musculoskeletal disorders among nurses in University College Hos- McCarthy, G., Tyrrell, M. P., & Lehane, E. (2003). Turnover rate in
pital, Ibadan. West African Journal of Nursing, 19(1), 21-25. nursing and midwifery: The Irish experience. Nursing Times Re-
Fox, R. L., & Abrahamson, K. (2009). A critical examination of the U.S. search, 8(4), 249-263.
nursing shortage: Contributing factors, public policy implications. Mehlum, I. S., Veiersted, K. B., Waersted, M., Wergeland, E., & Kjuus,
Nursing Forum, 44(4), 235-244. H. (2009). Self-reported versus expert-assessed work-relatedness of
Gerein, N., Green, A., & Pearson, S. (2006). The implications of short- pain in the neck, shoulder, and arm. Scandinavian Journal of Work,
ages of health professionals for maternal health in sub-Saharan Af- Environment & Health, 35(3), 222-232.
rica. Reproductive Health Matters, 14(27), 40-50. Mehrdad, R., Dennerlein, J. T., Haghighat, M., & Aminian, O. (2010).
Harcombe, H., McBride, D., Derrett, S., & Gray, A. (2009). Prevalence Association between psychosocial factors and musculoskeletal
and impact of musculoskeletal disorders in New Zealand nurses, symptoms among Iranian nurses. American Journal of Industrial
postal workers and office workers. Australian and New Zealand Medicine, 53(10), 1032-1039. doi:10.1002/ajim.20869
Journal of Public Health, 33(5), 437-441. Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred
Hernandez, L., Genaidy, A., Davis, S., Guo, L., & Alhemood, A. (1998). reporting items for systematic reviews and meta-analyses: The
A study of musculoskeletal strain experienced by nurses. Occupa- PRISMA statement. Annals of Internal Medicine, 151(4), 264-269.
tional Ergonomics, 1(2), 123-133. Oude Hengel, K. M., Visser, B., & Sluiter, J. K. (2011). The prevalence
Hignett, S. (1996). Work-related back pain in nurses. Journal of Ad- and incidence of musculoskeletal symptoms among hospital physi-
vanced Nursing, 23(6), 1238-1246. cians: A systematic review. International Archives of Occupational
Hoe, V. C., Kelsall, H. L., Urquhart, D. M., & Sim, M. R. (2012). Risk and Environmental Health, 84(2), 115-119. doi:10.1007/s00420-
factors for musculoskeletal symptoms of the neck or shoulder alone 010-0565-8
or neck and shoulder among hospital nurses. Occupational and En- Panel on Musculoskeletal Disorders and the Workplace. (2001). Epi-
vironmental Medicine, 69(3), 198-204. demiologic evidence. In Musculoskeletal disorders and the work-
Huisstede, B. M., Bierma-Zeinstra, S. M., Koes, B. W., & Verhaar, J. A. place: Low back and upper extremities (pp. 85-183). Washington,
(2006). Incidence and prevalence of upper-extremity musculoskel- DC: National Academy Press.
etal disorders: A systematic appraisal of the literature. BMC Muscu- Perreault, N., Brisson, C., Dionne, C. E., Montreuil, S., & Punnett,
loskeletal Disorders, 7(7). L. (2008). Agreement between a self-administered question-
International Confederation of Midwives. (2011). Definition of the mid- naire on musculoskeletal disorders of the neck-shoulder region

228 Copyright © American Association of Occupational Health Nurses, Inc.

 and a physical examination. BMC Musculoskeletal Disorders, 9. skeletal complaints and psychosocial risk factors among physicians
doi:10.1186/1471-2474-9-34 in mainland China. International Journal of Industrial Ergonomics,
Schofield, D. J., & Beard, J. R. (2005). Baby boomer doctors and 36(6), 599-603.
nurses: Demographic change and transitions to retirement. Medical Smith, D. R., Wei, N., Zhao, L., & Wang, R. S. (2004). Musculoskeletal
Journal of Australia, 183(2), 80-83. complaints and psychosocial risk factors among Chinese hospital
Serranheira, F., Cotrim, T., Rodrigues, V., Nunes, C., & Sousa-Uva, A. nurses. Occupational Medicine, 54(8), 579-582.
(2012). Nurses’ working tasks and MSDs back symptoms: Results Szeto, G. P.., Ho, P., Ting, A. C., Poon, J. T., Cheng, S. W., & Tsang,
from a national survey. Work, 41, 2449-2451. R. C. (2009). Work-related musculoskeletal symptoms in surgeons.
Sheikhzadeh, A., Gore, C., Zuckerman, J. D., & Nordin, M. (2009). Journal of Occupational Rehabilitation, 19(2), 175-184.
Perioperating nurses and technicians’ perceptions of ergonomic risk Tezel, A. (2005). Musculoskeletal complaints among a group of Turk-
factors in the surgical environment. Applied Ergonomics, 40(5), ish nurses. International Journal of Neuroscience, 115(6), 871-880.
833-839. Thistlethwaite, J. E., Leeder, S. R., Kidd, M. R., & Shaw, T. (2008).
Sheldon, G. F., Ricketts, T. C., Charles, A., King, J., Fraher, E. P., & Addressing general practice workforce shortages: Policy options.
Meyer, A. (2008). The global health workforce shortage: Role of Medical Journal of Australia, 189(2), 118-121.
surgeons and other providers. Advances in Surgery, 42, 63-85. Tinubu, B. M., Mbada, C. E., Oyeyemi, A. L., & Fabunmi, A. A. (2010).
Sherehiy, B., Karwowski, W., & Marek, T. (2004). Relationship between Work-related musculoskeletal disorders among nurses in Ibadan,
risk factors and musculoskeletal disorders in the nursing profession: South-west Nigeria: A cross-sectional survey. BMC Musculoskel-
A systematic review. Occupational Ergonomics, 4(4), 241-279. etal Disorders, 11, 12.
Silverstein, B. A., Stetson, D. S., Keyserling, W. M., & Fine, L. J. Tracy, S., Barclay, L., & Brodie, P. (2000). Contemporary issues in the
(1997). Work-related musculoskeletal disorders: Comparison of workforce and education of Australian midwives. Australian Health
data sources for surveillance. American Journal of Industrial Medi- Review, 23(4), 78-88.
cine, 31(5), 600-608. Trinkoff, A. M., Le, R., Geiger-Brown, J., Lipscomb, J., & Lang, G.
Sluiter, J. K., Rest, K. M., & Frings-Dresen, M. H. (2001). Criteria (2006). Longitudinal relationship of work hours, mandatory over-
document for evaluating the work-relatedness of upper-extremity time, and on-call to musculoskeletal problems in nurses. American
musculoskeletal disorders. Scandinavian Journal of Work, Environ- Journal of Industrial Medicine, 49(11), 964-971.
ment & Health, 27(Suppl. 1), 1-102. Trinkoff, A. M., Lipscomb, J. A., Geiger-Brown, J., & Brady, B. (2002).
Smedley, J., Inskip, H., Trevelyan, F., Buckle, P., Cooper, C., & Cog- Musculoskeletal problems of the neck, shoulder, and back and
gon, D. (2003). Risk factors for incident neck and shoulder pain in functional consequences in nurses. American Journal of Industrial
hospital nurses. Occupational and Environmental Medicine, 60(11), Medicine, 41(3), 170-178.
864-869. Turner, C., Bain, C., Schluter, P. J., Yorkston, E., Bogossian, F., Mc-
Smith, D. R., Choe, M. A., Jeon, M. Y., Chae, Y. R., An, G. J., & Jeong, Clure, R., & Huntington, A. (2008). Cohort profile: The Nurses and
J. S. (2005). Epidemiology of musculoskeletal symptoms among Midwives e-Cohort Study. A novel electronic longitudinal study.
Korean hospital nurses. International Journal of Occupational International Journal of Epidemiology, 38(1), 53-60. doi:10.1093/
Safety and Ergonomics, 11(4), 431-440. ije/dym294
Smith, D. R., Kondo, N., Tanaka, E., Tanaka, H., Hirasawa, K., & Ya- Warming, S., Precht, D. H., Suadicani, P., & Ebbehøj, N. E. (2009).
magata, Z. (2003). Musculoskeletal disorders among hospital nurses Musculoskeletal complaints among nurses related to patient han-
in rural Japan. Rural and Remote Health, 3(3), 241. dling tasks and psychosocial factors—based on logbook registra-
Smith, D. R., Mihashi, M., Adachi, Y., Koga, H., & Ishitake, T. (2006a). tions. Applied Ergonomics, 40(4), 569-576.
A detailed analysis of musculoskeletal disorder risk factors among World Health Organization. (2006). The world health report 2006:
Japanese nurses. Journal of Safety Research, 37(2), 195-200. Working together for health. Retrieved from www.who.int/
Smith, D. R., Wei, N., Kang, L., & Wang, R. S. (2004). Musculoskeletal whr/2006/en/index.html
disorders among professional nurses in mainland China. Journal of Yeung, S. S., Genaidy, A., & Levin, L. (2004). Prevalence of musculo-
Professional Nursing, 20(6), 390-395. skeletal symptoms among Hong Kong nurses. Occupational Ergo-
Smith, D. R., Wei, N., Zhang, Y. J., & Wang, R. S. (2006b). Musculo- nomics, 4(3), 199-208.

WORKPLACE HEALTH & SAFETY • VOL. 61, NO. 5, 2013 229

 1

Table A. Results of study quality appraisal

Study Sampling Response

First author setting & random or or Non- Specific Demographic CIs or Total Quality
Year population whole followup responders inclusion information SEPs rating
described population rate > 70% described criteria given given

Alexopoulos 2006 + - Greek + - + + - Greek 4 M

Dutch - Dutch 3

Bos 2007 + - - - - + - 2 L

Camerino 2001 + - + + - + - 4 M

Choobineh 2006 + + - - + + - 4 M

Fabunmi 2008 + - + - - + - 3 M

Harcombe 2009 + - - - + + - 3 M

Hernandez 1998 - - - - - + - 1 L

Hoe 2012 + - - - + + - 3 M
 2

Table A (continued)
Study Sampling Response
First author setting & random or or Non- Specific Demographic CIs or Total Quality
Year population whole followup responders inclusion information SEPs rating
described population rate > 70% described criteria given given
Josephson 1997 + - - - - - - 1 L

Lipscomb 2004 + + + - + + - 5 H

Long 2012 + + - - + + - 4 M

De Souza + - + - + + - 4 M
Magnago 2010

Matsudaira 2011
+ + - - + + - 4 M

Mehrdad 2010 + + + - + + - 5 H

Serranheira 2012 + + - - + + - 4 M

Sheikhzadeh 2009 + - - - - + - 2 L

Smedley 2003 + - - + inc + + - inc 4 M

prev - prev 3
Smith et al., 2003
+ - + - - + - 3 M
 3

Table A (continued)
Study Sampling Response
First author setting & random or or Non- Specific Demographic CIs or Total Quality
Year population whole followup responders inclusion information SEPs rating
described population rate > 70% described criteria given given
Smith, Wei, Zhao,
Wang 2004 + - + - - + - 3 M

Smith, Wei,
Kang, Wang 2004 + - + - - + - 3 M

Smith 2005
+ - + - - - - 2 L

Smith, Mihashi,
Adachi, Koga, - + + - - + - 3 M
Ishitake 2006

Smith, Wei,
Zhang, Wang + - + - - + - 3 M
2006

Szeto 2009 + - - - - + - 2 L

Tezel 2005 + + + - + + - 5 H

Tinubu 2010 + - + - - + - 3 M

Trinkoff 2006 + + + - + + - 5 H`
 4

Table A (continued)
Study Sampling Response
First author setting & random or or Non- Specific Demographic CIs or Total Quality
Year population whole followup responders inclusion information SEPs rating
described population rate > 70% described criteria given given

Trinkoff 2002 + + + - + + - 5 H

Yeung 2004 + - - - - + + 3 M

+, present; -, absent; CIs, confidence intervals; SEPs, standard errors of prevalence; inc, incidence; prev, prevalence; H,
high; M, moderate; L, low.
Table B. Prevalence and incidence of work-related neck, shoulder, and upper back musculoskeletal disorders in studies of midwives, nurses and
physicians

Author, year Study type Sample characteristics Outcome measures Prevalence Limitations

Quality rating Tool used Neck Shoulder Upper back

12-month period prevalence

Alexopoulos et al. Cross-sectional Nursing staff at Greek hospitals Pain G 47% G 37% -- Non-random sample
2006 n = 351 (90% response rate) Non-responders not
Greek (G): M 60% RNs D 39% D 41% -- described
and at Dutch nursing homes NMQ No CI
Dutch (D): M n = 393 (64% response rate) D: few RNs
13% RNs

Bos et al. 2007 Cross-sectional RNs at 8 university hospitals in the Complaints Non-random sample
Netherlands No CI
L n = 2883 Dutch Musculoskeletal 60% combined -- Non-responders not
(60% response rate) Questionnaire described
No specific inclusion
criteria

Camerino et al. Cross-sectional RNs at large hospitals in Milan, Italy Symptoms above a defined Non-random sample
2001 n = 1007 threshold No CI
M (87% response rate) 27.6% -- 16.5% No specific inclusion
Validated questionnaire criteria
developed by Italian Ergonomic
Research Unit on Posture and
Movement

Choobineh et al. Cross-sectional Random sample of RNs at 12 Symptoms No response rate given
2006 university hospitals in Shiraz, Iran 36.4% 39.8% 46.4% Non-responders not
M n = 641 described
(100% response rate) NMQ No CI

1
Table B (continued)

Author, year Study type Sample characteristics Outcome measures Prevalence Limitations

Quality rating Tool used Neck Shoulder Upper back

12-month period prevalence

Non-responders not
Fabunmi et al. 2008 Cross-sectional RNs at University College Hospital, Disorders 52.3% 44.9% 26.2% described
Ibadan, Nigeria Non-random sample
M n = 214 No specific inclusion
(92.7% response rate) NMQ criteria
No CI

Harcombe et al. Cross-sectional RNs selected from registration list in Pain 52% 39% -- Small sample
2009 New Zealand Non-random sample
M n = 181 NMQ Non-responders not
(64.6% response rate) described
No CI

Hernandez et al. Cross-sectional RNs Ache, pain, injury 56% 33% 75% Small sample
1998 volunteer No description of
L USA, specific location not given sample/population
n = 14 NMQ Non-random sample
(response rate not given) Non-responders not
described
No specific inclusion
criteria
No CI

Josephson et al. Cross-sectional Nursing staff at a county hospital in Symptoms 53% 60% 30% Non-random sample
1997 Baseline survey in a northern Sweden Non-responders not
cohort study n = 565 described
39% RNs NMQ No specific inclusion
L (response rate not given) criteria
No CI

2
Table B (continued)

Author, year Study type Sample characteristics Outcome measures Prevalence Limitations

Quality rating Tool used Neck Shoulder Upper back

12-month period prevalence

Lipscomb et al. Cross-sectional Random sample of RNs on Cases according to study case 20% 17% -- Non-responders not
2004 registration list in 2 USA states definition described
H n = 1163 No CI
(74% response rate) NMQ

Long et al. 2012 Cross-sectional All Australian midwives enrolled in Ache, pain, discomfort 40.8% -- 24.5% Low overall response
Baseline survey in a an online longitudinal health and rate
cohort study work-life study NMQ Non-responders not
n = 1388 described
M 53% working in midwifery No CI
47% working in nursing
(2.3% response rate overall)

De Souza Magnago Cross-sectional Nursing staff at a university hospital Pain, discomfort Few RNs
et al. in southern Brazil 68% 62.2% -- Non-random sample
2010 M n = 491 Non-responders not
29.7% RNs NMQ described
(93% response rate) No CI

Non-responders not
Mehrdad et al. 2010 Cross-sectional RNs at a large hospital in Tehran, Symptoms 46.3% 48.6% 43.5% described
Iran No CI
H n = 317
(91% response rate) NMQ

Serranheira et al. Cross-sectional RNs in Portugal Ache, pain, discomfort 48.6% -- 44.5% Low response rate
2012 n = 2140 Non-responders not
M (3.4% response rate) NMQ described
No CI

3
Table B (continued)

Author, year Study type Sample characteristics Outcome measures Prevalence Limitations

Quality rating Tool used Neck Shoulder Upper back

12-month period prevalence

Sheikhzadeh et al. Cross-sectional Nursing staff and surgical technicians Symptoms 71% 74% 45% Small sample
2009 at an orthopedic hospital in New Non-random sample
L York City, USA Non-responders not
n = 32 NMQ described
% RNs not stated No specific inclusion
(64% response rate) criteria
No CI

Smedley et al. 2003 Cross-sectional Nursing staff at a hospital in southern Pain Non-random sample
baseline survey in a England 35% combined -- No specific inclusion
cohort study n = 1157 criteria
76% RNs NMQ No CI
M (56% response rate)

Smith et al. 2003 Cross-sectional RNs at 3 care facilities in a rural area Ache, pain, discomfort 36.8% 61.1% 29.1% Non-random sample
of central Japan Non-responders not
M n = 247 described
(78.7% response rate) NMQ No specific inclusion
criteria

Non-random sample
Smith, Wei, Zhao, Cross-sectional RNs at a large teaching hospital in Complaints 45% 40% 37% Non-responders not
Wang 2004 Shijiazhuang city, Hebei province, described
M China No specific inclusion
n = 282 NMQ criteria
(92% response rate) No CI

4
Table B (continued)

Author, year Study type Sample characteristics Outcome measures Prevalence Limitations

Quality rating Tool used Neck Shoulder Upper back

12-month period prevalence

Non-random sample
Smith, Wei, Kang, Cross-sectional RNs at a large teaching hospital in Ache, pain, discomfort 42.8% 38.9% 38.9% Non-responders not
Wang 2004 Shijiazhuang city, Hebei province, described
M China No specific inclusion
n = 180 NMQ criteria
(84.1% response rate) No CI

Smith et al. 2005 Cross-sectional RNs at a large teaching hospital In Symptoms 62.7% 74.5% 29.7% Non-random sample
Gangneung city, Korea Non-responders not
L n = 330 described
(97.9% response rate) NMQ No specific inclusion
criteria
No demographic data
No CI

Minimal description of
Smith, Mihashi, Cross-sectional RNs at a large teaching hospital in Symptoms 54.7% 71.9% 33.9% setting/population
Adachi, Koga, Japan Non-responders not
Ishitake 2006 M n = 844 described
(74% response rate) NMQ No specific inclusion
criteria
No CI

Non-random sample
Smith, Wei, Zhang, Cross-sectional Physicians at a large teaching hospital Symptoms 42.3% 37.8% 29% Non-responders not
Wang 2006 in Shijiazhuang city, Hebei province, described
M China No specific inclusion
n = 286 NMQ criteria
(79.2% response rate) No CI

5
Table B (continued)

Author, year Study type Sample characteristics Outcome measures Prevalence Limitations

Quality rating Tool used Neck Shoulder Upper back

Szeto et al. 2009 Cross-sectional General surgeons in the Hong Kong Symptoms 82.9% 57.8% 52.6% Non-random sample
public health system Non-responders not
L n = 135 described
(27% response rate) NMQ No specific inclusion
criteria
No CI

Tinubu et al. 2010 Cross-sectional RNs at 3 hospitals in Ibadan, Nigeria Pain, discomfort 28.0% 12.6% 16.8% Non-random sample
n = 118 Non-responders not
M (80% response rate) described
NMQ No specific inclusion
criteria
No CI

Trinkoff et al. 2002 Cross-sectional Random sample of RNs on Symptoms 45.8% 35.1% -- Non-responders not
registration list in 2 USA states described
H n = 1163 (74% response rate) NMQ No CI

Yeung et al. 2004 Cross-sectional RNs at two hospitals in Hong Kong Ache, pain, discomfort 96% 93% 91% Small sample
n = 97 Non-random sample
M (60% response rate) Non-responders not
described
No specific inclusion
criteria
Recruitment method
6-month period prevalence

Tezel et al. 2005 Cross-sectional Nursing staff at 4 large general Complaints 54% 46% -- Small sample
hospitals in Erzurum, Turkey Non-responders not
H n = 120 NMQ described
25% RNs No CI
(100% response rate)

6
Table B (continued)

Author, year Study type Sample characteristics Outcome measures Prevalence Limitations

Quality rating Tool used Neck Shoulder Upper back

1-month period prevalence

Hoe et al. 2011 Cross-sectional RNs at 3 public hospitals in Pain for at least 1 day 17.2% 11.6% -- Non-random sample
Melbourne, Australia Non-responders not
M n = 1111 NMQ 15.8% combined described
% RNs not stated No CI
(38.6% response rate)

Matsudaira et al. Cross-sectional RNs at Tokyo University Hospital Pain 31% 22% -- Non-responders not
2011 n = 599 described
M (56% response rate) NMQ No CI

Incidence studies
Incidence

Smedley et al. 2003 Prospective cohort Nursing staff at a hospital in Symptoms 34% combined -- Non-random sample
southern England No CI
M n = 587
% RNs not stated NMQ
(65% follow-up rate)

Trinkoff et al. 2006 Prospective cohort Random sample of RNs on Ache, pain, discomfort 14% 17.3% -- Non-responders not
registration list in 2 USA states described
H n = 2624 No CI
(86% follow-up rate) NMQ

L, low; M, moderate; H, high; NMQ, Nordic Musculoskeletal Questionnaire; CI, confidence interval