International Journal of Occupational Safety and

Ergonomics

ISSN: 1080-3548 (Print) 2376-9130 (Online) Journal homepage: http://www.tandfonline.com/loi/tose20

Work-related Musculoskeletal Problems and

Associated Factors among Office Workers

Alireza Besharati, Hadi Daneshmandi, Khodabakhsh Zareh, Anahita

Fakherpour & Mojgan Zoaktafi

To cite this article: Alireza Besharati, Hadi Daneshmandi, Khodabakhsh Zareh, Anahita
Fakherpour & Mojgan Zoaktafi (2018): Work-related Musculoskeletal Problems and Associated
Factors among Office Workers, International Journal of Occupational Safety and Ergonomics, DOI:
10.1080/10803548.2018.1501238

To link to this article: https://doi.org/10.1080/10803548.2018.1501238

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Jul 2018.

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Publisher: Taylor & Francis & Central Institute for Labour Protection – National Research Institute (CIOP-
PIB)

Journal: International Journal of Occupational Safety and Ergnomics

DOI: 10.1080/10803548.2018.1501238

Work-related Musculoskeletal Problems and Associated Factors among Office

Workers
Running Title: Work-related Musculoskeletal Problems among Office
Workers
Alireza Besharati, MSc. Occupational Health Unit, Shiraz Health Center, Shiraz University of
Medical Sciences, Shiraz, Iran
Hadi Daneshmandi, Ph.D. Research Center for Health Sciences, Institute of Health, Shiraz
University of Medical Sciences, Shiraz, Iran
Khodabakhsh Zareh, BS. Occupational Health Unit, Shiraz Health Center, Shiraz University of
Medical Sciences, Shiraz, Iran
Anahita Fakherpour, MSc Student. Student Research Committee, Shiraz University of Medical
Sciences, Shiraz, Iran
Mojgan Zoaktafi, MSc. Department of Ergonomics, School of Health, Shiraz University of
Medical Sciences, Shiraz, Iran

Conflicts of interest: None declared.

Acknowledgment:
Hereby, the authors would like to thank those office personnel who participated in this study.
The authors wish to thank Mr. H. Argasi at the Research Consultation Center (RCC) at Shiraz
University of Medical Sciences for his invaluable assistance in editing this manuscript .
Corresponding Author:
Hadi Daneshmandi
Research Center for Health Sciences, Institute of Health, Shiraz Univ. Med. Sci., P.O.Box:
71645-111, Shiraz, I.R.Iran
+98 71 37251001-5 (296)
+98 71 37260225
daneshmand@sums.ac.ir
Abstract:
Purpose: The aim of this study was to investigate musculoskeletal disorders (MSDs) and its
associated factors among Iranian office personnel.
Materials and Methods: In this cross-sectional study, 359 Iranian office workers were included.
Data were gathered using a demographic questionnaire, the Nordic musculoskeletal
questionnaire, the numeric rating scale, rapid office strain assessment (ROSA), and NASA task
load index (NASA-TLX).
Results: Our findings showed that the highest prevalence rate of MSDs within the last 12
months, and the highest pain/discomfort severity were related to the participants’ necks. The
mean performance, mental demand, and effort subscale scores of NASA-TLX were higher than
other subscale (physical demand, temporal demand, and frustration level). ROSA scores showed
that 53.8% of the participants were in action level 1 (low MSDs risk) and the rest (46.2%) were
in action level 2 (high MSDs risk). The pain/discomfort severity in shoulders, elbows,
wrists/hands, thighs, and ankles/feet were correlated to the final ROSA score. Age, gender, body
mass index (BMI), and some NASA-TLX subscales (effort, mental demand, and performance)
were associated with symptoms of MSDs in different body regions.
Conclusions: Improving workplace conditions (both mentally and physically) is suggested for
reducing and eliminating musculoskeletal problems in office workers.

Keywords: Musculoskeletal disorders, NASA-TLX, Office workers, Pain, ROSA

1. Introduction
Musculoskeletal disorders (MSDs) are among the most common work-related problems [1].
MSDs are related to the muscles, joints, tendons, and nerves that can affect body regions, such as
neck, upper limbs, and back [2].
Work-related musculoskeletal disorders (WMSDs) are considered as the main contributing factor
in job absenteeism [1], presenteeism [3], reduced quality of life [1], change of occupation,
increment of work related injuries [4], and increased medical expenses due to disability [5].
In many occupations, people spend long hours in front of a computer [6]. Office personnel spend
most of their time in offices in a seated position [7]. Use of computers has increased in
workplaces, which is associated with MSDs-related symptoms with a prevalence rate of more
than 50%, especially in the upper extremities and lower back [8]. Also, pain/discomfort caused
by MSDs, in the neck, shoulders, and lower back, are common among office workers due to the
time spent in a sitting position [9]. Worldwide, MSDs are widespread and have both socio-
economic and personal consequences [10].
Work-related MSDs and pain/discomfort are related to prolonged sitting position, fast-paced
work, static and awkward postures, and highly repetitive movements [11]. In addition,
inappropriate and inadequate workplace conditions can cause MSDs and affect people’s
wellbeing and welfare as well as reduce productivity [7].
Previous studies indicate that overall, work-related MSDs are the reason for 29% of all
workplace-related injuries in the USA [2]. On the other hand, it is estimated that the costs of
work-related MSDs and upper extremity and lower back pain comprise 0.5% and 2% of the
European Union’s gross national product [12].
According to reports, over 77 million people in the USA [13] and 88 million in the European
Union use computers at work [14]. However, the exact statistic about Iranian computer users is
not available.
Office workers perform various activities, such as typing, writing, and reading that can be linked
with prolonged static and awkward postures, repetitive movements, and high mental workloads
[15]. Office personnel as a big group of employees are exposed to MSDs [16]. As stated above,
MSDs are multifactorial work-related problems. Therefore, this study was done to investigate
MSDs and its associated factors among Iranian office workers.
2. Method
In this cross-sectional study, 359 Iranian office employees affiliated to Shiraz University of
Medical Sciences with at least one year of experience were recruited. Employees with underlying
diseases or accidents affecting their musculoskeletal system were excluded from the study. The
participants were selected based on simple random sampling (random number table). All the
respondents participated in this study voluntarily, and signed a written informed consent before
the study. It should be noted that the study was performed in accordance with the Helsinki
Declaration of 1964, and as revised in 2008.

2.1. Data gathering tools:

2.1.1. Demographic questionnaire: The questionnaire included questions about age, weight,
height, job tenure, daily sitting working time, gender, marital status, and education level.
2.1.2. Nordic musculoskeletal questionnaire (NMQ): The general Nordic questionnaire of
musculoskeletal (NMQ) symptoms examines the reported cases of MSDs in different body
regions among the studied population [17]. In this study, the reported musculoskeletal symptoms
were limited to the last 12 months. The psychometric properties of the Persian version of the
NMQ was previously assessed by Choobineh et al. [18].
2.1.3. Numeric rating scale (NRS): The numeric rating scale (NRS) is a unidimensional measure
of pain/discomfort intensity [19].
2.1.4. Rapid office strain assessment (ROSA): ROSA is a picture-based posture checklist
designed to quantify exposure to risk factors in an office work environment. This technique was
developed by Sonne et al. (2012) to determine the level of MSDs risk. The final scores of this
technique (ROSA) showed high inter- and intra-observer reliability (intraclass correlation
coefficients (ICCs) of 0.88 and 0.91, respectively). In this technique, three general parts (A, B
and C) of the office work environment are assessed as follows:
Part A: Chair (height, depth, armrest, and backrest).
Part B: Monitor and telephone.
Part C: Mouse and keyboard.
After completing the ROSA checklist, the related tables are used to calculate the score from each
part, and eventually the final ROSA score is derived. Then, based on the final ROSA score, each
case was interpreted in accordance to the action levels described below:
Action level 1 (final score≤4): The level of MSDs risk is low.
Action level 2 (5≤final score): The level of MSDs risk is high [20].

2.1.5. NASA task load index (NASA-TLX): The NASA task load index (NASA-TLX) is a
subjective, multidimensional assessment tool [21], which rates the perceived mental workload in
order to assess a task, system, or a team's effectiveness or other aspects of performance. This
scale was developed by the human performance group at NASA’s Ames Research Center over a
three-year development cycle that included more than 40 laboratory simulations [22]. NASA-
TLX originally consisted of two parts: Part 1) the total workload is divided into six subscales
including 1) mental, 2) physical and 3) temporal demand, 4) performance, 5) effort, and 6)
frustration. There is a description for each of these subscales that the participants should read
prior to the rating. They are rated for each task within a range of 100 points with 5-point steps.
The second part of NASA-TLX intends to create an individual weighting of these subscales by
allowing the subjects to compare them pairwise based on their perceived importance. In the
present study, we used the first part of this scale (rating/raw NASA-TLX) to assess the mental
workload of the participants.

2.2. Implementation of the study

The participants completed the demographic and Nordic questionnaires, and NASA-TLX scale at
their workplace. The NASA-TLX scale was completed during their work shift. In addition, the
ROSA technique was used to assess the MSDs risk level for each participant. To assess the
intensity of musculoskeletal pain/discomfort, the subjects were rated NRS on Monday at the start
and at the end of their work shift. Then, the difference between the NRS scores at the start and at
the end of the work shift during their work day was calculated and regarded as their measure of
musculoskeletal pain/discomfort.

2.3. Factors associated with MSDs in different body regions

For this purpose, we used multiple logistic regression (Forward Wald). In the first step, the
association between variables, such as age, body mass index (BMI), job tenure, working h/day,
gender, marital status, educational level, NASA-TLX subscales (mental demand, physical
demand, temporal demand, performance, effort, frustration level) and ROSA level with MSDs in
different body regions were surveyed via a χ2 test with a significance level of P≤0.25. For this
purpose, the quantitative variables were divided into two categories (age≤35 years and age>35
years, BMI≤24.9 and BMI>25, job tenure≤10 years and job tenure>10 years, working h/day≤8
hours and working h/day>8 hours, NASA-TLX scores≤66 and NASA-TLX scores>66 for all the
subscales). Subsequently, all the independent variables that had significant association were
included in the multivariate logistic regression model.

2.4. Statistical analysis

In this study, data were analyzed using SPSS software, version 16.0 (SPSS Inc. Chicago, IL,
USA) using χ2 test, multiple logistic regression, and Spearman correlation. Since the data did not
appear to follow a normal distribution, the Spearman correlation coefficient was used to evaluate
the correlation between musculoskeletal pain/discomfort, and the final score of ROSA. Also, the
Kolmogorov-Smirnov test was used to test the data’s normality.

3. Results
Table 1 summarizes personal details of the office workers participating in the study.
Table 2 shows the prevalence rate of the reported MSD symptoms in different body regions
among the office workers during the past 12 months. In addition, this table shows the mean±
standard deviation of pain/discomfort in different body regions among the studied participants.
As shown in this table, the mean pain/discomfort score in the neck, shoulders, and lower back
was higher than the other body regions.
Table 3 shows the mean± standard deviation rating score of NASA-TLX subscales. As shown in
this table, the mean scores of performance, mental demand, and effort subscales of the NASA-
TLX scale were higher than the other subscales (physical demand, temporal demand, and
frustration level).
Table 4 shows the results of physical exposure assessment to musculoskeletal risks by the ROSA
technique among the surveyed office workers.
Table 5 shows the correlation between the pain/discomfort score in different body regions and
the final ROSA technique score. As shown in this table, the pain/discomfort in the shoulders,
elbows, wrists/hands, thighs, and ankles/feet were correlated with the final ROSA score. Based
on the rule of thumb in interpreting the size of correlation coefficient, these values (correlation
coefficients) were in the negligible correlation category (0–0.3) [23].
Table 6 demonstrates the multiple logistic regression output for detecting the potential risk
factors for MSDs in different body regions.

4. Discussion
This study was done to investigate MSDs and their related factors in Iranian office workers. The
mean±standard deviations of age and job tenure were 34.54±7.41 and 3.80±1.85 years,
respectively. 19.5% of the participants were men and 80.5% were women.
Our results showed that the highest prevalence rates of MSD symptoms in the last 12 months
were related to the neck (60.16%), lower back (57.10%), and shoulders (54.03%). In a previous
study, it was reported that the prevalence rate of MSD symptoms among office personnel ranged
from 40-80% [24]. Choobineh et al. reported that the highest prevalence rates of MSD symptoms
among Iranian office workers in the past 12 months were related to the lower back (45.1%), neck
(41.7%), and upper back (36.6%) [25]. Another study showed that the highest prevalence rates of
MSD symptoms among Iranian office workers were linked to the neck (42%), lower back (42%),
and shoulders (41%) [26]. Other researchers found that the neck, lower back, and upper back had
the highest prevalence rates of MSDs among office workers [27]. The findings of our study and
other previous studies on Iranian office workers showed that the neck, lower back, and shoulder
regions of this working group were at risk of MSDs. The risk factors for MSDs in these body
regions (neck, lower back, and shoulders) can be attributed to static and awkward postures,
inappropriate workstation design, and repetitive movements [28].
Our findings showed that the highest score of musculoskeletal pain/discomfort were related to
the neck (2.36), shoulders (2.07), and lower back (2.02). This shows that the reported symptoms
of MSDs are in accordance with the perceived musculoskeletal pain/discomfort among the
participants.
We found that the mean scores of performance, mental demand, and effort subscales of the
NASA-TLX were higher than other subscales (physical demand, temporal demand, and
frustration level). Bridger and Brasher inferred that NASA-TLX can be used to measure the
cognitive demands of office workers [29]. Safari et al. showed that office workers had the lowest
mental workload among studied working groups (spinning, weaving, repair, supervisor, office,
doubling) [30]. The findings of Darvishi et al.’s study revealed that effort, mental demands, and
temporal demands had the highest mean score in the NASA-TLX scale between office workers.
Also, the results of this study showed that the mean scores of all the subscales of NASA-TLX
among the participants with MSD symptoms were significantly higher than the other groups
(subjects without MSD symptoms) [27].
The results of the ROSA technique showed that the mean score of the chair section was higher
than that of the other sections (mouse and keyboard, and monitor and telephone). This shows that
the parameters associated with the chair section should be considered as a priority, and should be
corrected. In addition, our findings showed that 53.8% of the participants were in action level 1
(low MSDs risk), and the other workers were in action level 2 (high MSDs risk).
Our study showed that the severity of musculoskeletal pain/discomfort in the shoulders, elbows,
wrists/hands, and ankles/feet had a low correlation with the final ROSA score. Sonne and
Andrews found a high correlation between the final ROSA score and total body discomfort [31].

4.1. Factors associated with MSDs in different body regions

Our findings showed that age had a significant association with MSD symptoms in the neck,
shoulders, and wrists/hands with odds ratios ranging from 1.56 to 2.03. This means that as age
increased, the chance of MSDs increased [32, 33]. Gender had a significant association with
MSD symptoms in the shoulders with OR of 2.15. This meant that incidence of MSDs in female
workers was 2.15 times more than their male counterparts, and this result was in line with a
World Health Organization (WHO) report [34, 35]. BMI was significant for the knees and
ankles/feet regions with odds ratios ranging from 1.90 to 2.10. This means that with increased
BMI, the chance of MSD symptoms rose as well, which is consistent with other studies [36, 37].
The effort subscale of NASA-TLX was associated with the presence of MSDs in the shoulders
and upper back of the participants with odds ratios ranging from 1.75 to 1.89. The mental
demand subscale of NASA-TLX was associated with the presence of MSDs in the wrists/hands of
the participants with an odds ratio of 2.83. The performance subscale of NASA-TLX was
associated with the presence of MSDs in the upper back and thighs of the participants with odds
ratios ranging from 1.97 to 1.99. In this context, the findings of previous studies showed that
different dimensions of mental workload can affect the prevalence of MSDs in office workers
and other occupational groups [38–41]. The results on the elbows and lower back showed that no
variables were associated with these regions (no variables remained in the multiple logistic
regression model).

4.2. Limitations of the study

Due to the cross-sectional nature of this study and the self-report method for data gathering, our
findings have to be cautiously interpreted. Since this study was done among office workers, the
results cannot be generalized to other working groups.

5. Conclusion
Work-related musculoskeletal discomfort/pain and symptoms mainly occur due to physical
(static and poor postures, repetitive movements, non-ergonomic workstation design, etc.),
psychological (stress, mental workload, etc.), and organizational (improper work-rest cycle, lack
of job enrichment, etc.) factors at workplaces. Improvement in working conditions, proper design
and layout of workplace by organizations and effective ergonomics interventions in the work
environments are recommended. Workplace analysis, controlling the related risk factors, medical
management, and training people to prevent and eliminate WMSDs are necessary.

6. Suggestions
The following solutions are recommended to reduce the adverse effects of computer use among
office personnel:
– Improving general working conditions, such as the layout of equipment, housekeeping, and
environmental features (e.g. lighting, noise, and temperature).
– Using ergonomic peripheral devices, such as mouse and keyboard to prevent awkward
postures.
– Using prompting software, such as stretch break and Compu stretch.
– Using active workstations, such as sit-stand, in lieu of traditional desks.
– Using an appropriate work-rest schedule.
– Walking to a colleague’s desk instead of phoning or emailing.
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Table 1: Some personal details of the studied office workers (N=359)
Quantitative variable M±SD
Age (years) 34.54±7.41
Weight (kg) 66.52±15.27
Stature (cm) 164.08±13.53
BMI 25.29±13.65
Job tenure (years) 3.80±1.85
Working h/day 8.13±1.88

Qualitative variable No. (%)

Gender
Male 70 (19.5)
Female 289 (80.5)

Marital status
Single 130 (36.22)
Married 229 (63.78)

Educational level
Associate degree and lower 77 (21.44)
Bachelor of science and higher 282 (78.56)
Note: BMI= body mass index
Table 2: Frequency of reported MSDs symptoms in different body regions among office workers
during the last 12 months (N=359)
MSDs Severity of pain
Body region
No. % M±SD
Neck 216 60.16 2.36±2.39
Shoulders 194 54.03 2.07±2.48
Elbows 49 13.64 1.31±2.31
Wrists/hands 174 48.46 1.75±2.64
Upper back 175 48.74 1.67±2.01
Lower back 205 57.10 2.02±2.71
Thighs 63 17.54 1.53±2.23
Knees 176 49.02 1.57±2.40
Ankles/feet 125 34.81 1.62±2.17
Note: MSDs= musculoskeletal disorders
Table 3: M±SD of rating score of NASA-TLX subscales of the participants (N=359)
NASA-TLX subscale M±SD
Mental demand 73.53±24.06
Physical demand 54.64±28.46
Temporal demand 69.88±23.40
Performance 74.84±20.65
Effort 73.32±21.89
Frustration level 60.06±30.19
NASA total 67.68±15.52
Note: TLX= task load index
Table 4: Assessment of physical exposure to musculoskeletal risks by ROSA technique in office
workers (N=359)
Result of the ROSA technique
Section
M±SD
Chair 4.41±1.66
Monitor and telephone 2.46±1.06
Mouse and keyboard 3.01±1.22

Action level No. (%)

1 193 (53.8)
2 166 (46.2)
Note: ROSA= rapid office strain assessment
Table 5: The correlation between pain/discomfort severity score in different body regions and
final score of ROSA
Body region r p
Neck 0.009 0.874
Shoulders 0.116 0.032
Elbows 0.187 0.001
Wrists/hands 0.128 0.018
Upper back 0.093 0.133
Lower back 0.054 0.322
Thighs 0.139 0.010
Knees 0.076 0.165
Ankles/feet 0.179 0.001
Note: ROSA= rapid office strain assessment;
r= Spearman correlation coefficient;
p= p-value, significance level α= 0.05
Table 6: Modelling on the association between potential risk factors and MSDs in the different
body regions of participants using multiple logistic regression (N=359)
Association between potential risk factors and MSDs
MSDs in body region
Potential risk factor OR 95% CI p
Neck Age (years) 2.03 1.27, 3.24 0.003
≤35: Reference
>35
Shoulders Age (years) 1.62 1.03, 2.56 0.035
≤35: Reference
>35

Gender 2.15 1.24, 3.74 0.006

Male: Reference
Female

Effort 1.75 1.11, 2.77 0.016

≤66: Reference
>66
Elbows - - - -
Wrists/hands Age (years) 1.56 1.01, 2.42 0.045
≤35: Reference
>35

Mental Demand 2.83 1.16, 2.87 0.009

≤66: Reference
>66
Upper back Performance 1.99 1.22, 3.24 0.006
≤66
>66: Reference

Effort 1.89 1.16, 3.08 0.010

≤66: Reference
>66
Lower back - - - -
Thighs Performance 1.97 1.11, 3.48 0.019
≤66
>66: Reference
Knees BMI 2.10 1.34, 3.27 0.001
≤24.9: Reference
>25
Ankles/feet BMI 1.90 1.21, 2.99 0.005
≤24.9: Reference
>25
Note: MSDs= musculoskeletal disorders; OR= odds ratio; CI= confidence interval; BMI= body mass index;
p= p-value, significance level α= 0.05