Assessment and evaluation of work-related musculoskeletal disorders among nuclear medicine professionals in India: A cross-sectional study

1 Introduction

Musculoskeletal disorders (MSDs) are an umbrella term to describe health problems that commonly affect the body’s musculoskeletal system of allied health professionals [1]. It is defined as dysfunctions or injuries that affect the tendons, nerves, muscles, joints, ligaments, bones, cartilages, and spinal discs. It also includes tears, pain, strains, soreness, sprains, and injuries in the connective tissues which occur in the musculoskeletal system of the human body [2].

The International Labor Organization (ILO) and the World Health Organization (WHO) state that MSDs are a “new epidemic” of work-related diseases that should be studied, researched, and solved. In healthcare professionals, work-related musculoskeletal disorders (WMSD) are found to be most common and are in a relationship with ergonomic hazards with increasing prevalence rates of 28% to 96% over a year [3]. MSD are related to the environment of work, working ergonomics and work performance, and significantly give rise to any sort of pain or discomfort in the body. Therefore, MSD distinguish themselves from occupational illness and distress, which show a direct cause-and-effect association between a single risk factor and a specific disease including gender-related factors in work activities, whereas occupational diseases do not [4, 5].

WMSD are also the most prevalent illnesses among biomedical scientists, allied health workers worldwide including medical imaging professionals [6, 29]. Similarly in India, ergonomic hazards are the leading and most important cause of disability during the working years [7]. The well-known risk factors of WMSD are physical demands on the muscle that can be characterized by combinations of duration and intensity of work, static muscle activity, constrained postures, and repeated movements for prolonged periods [8]. Nuclear medicine professionals (NMP) handling unsealed radiations are healthcare practitioners who prepare and administer radiolabeled drugs to perform imaging studies on patients to diagnose and plan for radiation treatments as well. Proper shielding to reduce radiation hazard using lead aprons, thyroid shields, reducing the exposure to scattered radiation, and the distance from the source of radiation are important factors protecting individuals from radiation exposure [9]. These lead garments are heavy which leads and causes MSD, fatigue, and discomfort to the working individuals as well expressed by interventionalists [10, 11]. In addition to wearing lead aprons, moving lead bricks, lead containers used as shielding to protect against the direct radiation from the radioactive particles during isotope preparation. In the clinical setting, the nuclear medicine individuals handle heavy collimator cart, lifting radionuclide generators, moving lead barriers and carry heavy-weight lead bricks which leads to many cumulative trauma disorders [12].

Although there are studies in the literature that examined WMSD and working ergonomics in radiologists, clinical radiologists, interventional radiologists and radiological technologists, radiographers and biomedical scientists [9, 30], to the best of our knowledge, no study specifically examined NMP. Therefore, there is the need for occupational therapists to study the occupational hazards faced by NMP to prevent MSDs. This study therefore attempted to explore WMSD among NMP in India.

2 Materials and methods

3 Results

A link to the study was sent through email to 455 NMP and 124 (27.3%) responses were received. Of these, 91 responses were selected on the basis of the inclusion and exclusion criteria of the study.

Table 1 shows the demographic variables of the participants. Of the total participants, 82(90.1%) were male and 9(9.9%) were female. In age distribution, the maximum number of participants were grouped in the range between 36–45 years, 53(58.2%). The majority of participants (36(39.6%)) had 6–10 years of work experience. Among these participants, 56(61.5%) had to work up to 48 hours and 35(38.5%) had to work more than 48 hours a week. The majority of participants (64(70.3%)) weighed from 75–100 kg and 39(42.9%) participants were more than 170 cm in height and 45(47.3%) were found to be overweight in terms of body mass index.

Table 2 presents the multiple facilities (modalities) for NMP. In the total number of respondents, the majority were working in PET-CT 87(95.6%) and gamma camera facility 85(93.4%).

The common protective wear used by the NMP were lead aprons which were used by all 91 participants, gonad shields used by 9 (9.9%) and thyroid shield by 13 (14.3%) participants. The lead aprons were typically worn for ten hours each day, weighing around 5 kilograms. Gonad shields were utilized for an average of four hours daily, with an average weight of 470 grams. Thyroid shields were worn for an average of two hours daily, weighing approximately 300 grams.

Table 3 describes the problems that occurred in the body parts in the last 12 months and last 7 days, and body trouble prevented from work in the last 12 months. Results shows that knees were the most affected in the last 12 months, last 7 days and prevented from normal work in the last 12 months by 70.3%, 65.9% and 58.2% respectively. Shoulder trouble affectations in the last 12 months, last 7 days and prevented from normal work in the last 12 months by 39.6%, 24.2% and 37.4% respectively. Neck trouble was the third most affected area in the last 12 months, last 7 days and prevented from normal work in the last 12 months by 34.1%, 20.9% and 33.0% respectively. Hips/thighs were marked to be less affected in the last 12 months, last 7 days and prevented from normal work in the last 12 months by 2.2%, 1.1% and 1.1% respectively.

Table 4 describes the mean and SD of weight, duration, instruments used by the NMP and also the multiples of each instrument in their settings. Lead pot/containers, lead bricks, L bench lead shield, and lead syringe holders were the instruments used by NMP for a mean duration of 9.02±5.148, 10.00±5.820, 43.91±29.065 and 4.05±1.722 hours a week with a mean weight of 8.68±6.914,11.51±9.292, 10.46±9.597, 3.83±3.757 kilograms respectively. The number of lead pot/containers in their settings had a mean number of 10.14±5.626, lead bricks 62.85±34.656, L bench lead shield 3.05±1.089 and lead syringe holder 4.54±1.782.

Table 5 shows that the demographic variables had significant associations with different body parts. The p-values corresponding to the demographic variables (body mass index, age and weight) were less than 0.05 and were significant at a 5% level; hence, we can state that there is a significant association with elbow, low back, and knees respectively. Similarly, the p-values corresponding to the demographic variables experience and height were less than.01 and were highly significant at 1%. Hence, we can state that there is a high association with the neck and upper back respectively.

In Table 6 the p-value corresponding to the instrument used mobile lead screen, lead curtain and qc phantoms for gamma camera/PET was less than.05 and was significant at 5%; hence we state a say that there is significant association between trouble in the shoulder and hands/wrists respectively for the last 12 months.

In the current study, the mean working hours of the participants in a week was 49.04±4.22, where 56(61.5%) participants had to work up to 48 hours and 35(38.5%) participants had to work more than 48 hours a week. This might be explained by the fact that half of the Indian workers work for more than 8 hours a day as per the International Labor Organization; working more than 48 hours a week is considered to be overwork [14]. In a study by Alghadir, Zafar and Iqbal, it was reported that working more than 30 hours a week was one of the risk factors associated with WMSD among dentists [15]. The majority (64(70.3%)) of the participants weighed from 75–100 kg and 9(9.9%) of the participants weighed more than 100 kg with a mean weight of 84.88±13.33 kg. In this study, 39(42.9%) of the participants were more than 170 cm in height, 27(29.7%) from 161–170 cm, and 25(27.5%) were up to 160 cm in height with an overall mean height of 168.02±8.083 cm. 45(47.3%) participants were determined to be overweight in terms of body mass index and 34(37.4%) were obese with a mean weight of 84.88±13.33 kg. This might be because of the increasing obesity rate among Indians [16].

Using the NMQ, the current study found the trouble in the various body parts, during the previous one year and last seven days and also about whether this trouble has stopped them from doing their regular routine. The findings of this study shows that knees were most affected, but there was also substantial affectation of shoulders and neck. This finding is consistent with the study by Morrison et al. [17], where musculoskeletal pain among interventional radiologists was higher for neck and shoulders. Similarly, Kawthalkar et al. showed that radiologists experienced neck pain frequently [18].

In the current study, participants worked in multiple modalities, most of them worked in positron emission tomography-CT (87(95.6%)), gamma camera modality (85(93.4%)), and low dose radionuclide therapy modality (84(92.3)). In India, after 2010 with the introduction of PET-CT technologies, there has been an immense growth reflecting the rising demand for advanced diagnostic procedures highlighting the significance of these advancements in nuclear medicine.

In a study conducted by Kim and Roh among radiologists, it was stated that maneuvering equipment for magnetic resonance imaging and using portable radiation equipment creates burdens on the different regions of the body, more frequently in the lower back and shoulders [19]. This is consistent with our study, where 36(39.6%) participants reported shoulder pain which prevented 32(35.1%) participants from doing their work.

NMP in this current study reported the usage of personal protective wear in their work. All 91 participants used lead aprons and only 9 participants used gonad shields, which is similar to the findings reported by Rose et al., who found that 92.6% of participants consistently used lead aprons [11]. The average weight of lead apron in the current study was found to be 5 kg; in a similar study by Cheon et al. the weight was reported to be around 7 kg [20]. Handling high radiating particles, it is necessary to wear personal protective gear. The study by AbuAlRoos et al. supports this current discussion stating that the weight of lead aprons and maintaining awkward positions give rise to MSDs during the work routine [12].

The current study also found that the knees and ankles gave most trouble amongst NMP and had a significant association with the weight of the participants and use of gonad shield respectively. As is already known, obese people are vulnerable to knee problems [21]. In this study, along with body weight, continuous physical maneuvering of heavy equipment, moving collimator cart and wearing the gonad shield may further add trouble to the knees and ankle joints, as has also been reported by Augner and Kaiser [24].

In the current study the association between height of the individual and neck pain was found to be highly significant [21]. Similarly, Kao et al.’s study showed that 61.9% reported neck pain due to work posture and movement [22]. As it is already known that work posture could be a possible cause for neck pain, the association between neck pain and height of the participant and working posture, Harris, Yang and Sanford stated that an individual’s occupation and time spent at work is also a risk factor for neck pain [23].

NMP in the current study worked more than 48 hours a week, which could also be a possible risk factor for neck pain. This study also found that there is a high significance between the work ‘experience as NMP and trouble in the upper back. Similarly, a study conducted by Augner and Kaiser discussed that upper back pain was the second most frequent musculoskeletal symptom in radiology technologists [24]. There was a significant association between the age and low back pain in the participants. The current study showed an increasing prevalence of low back pain with age consistent to the study by Augner and Kaiser [24].

In the current study, a significant association was found between the body mass index and pain in the elbow, which could have been due to inappropriate and frequent handling of heavy nuclear medicine equipment. Similarly, Herquelot et al. found that elbow pain and body mass index were marked as one of the significant risk factors for workers [25]. By giving an association between the instruments used by the NMP and the various body parts that experienced trouble, the current study found that the use of mobile lead screens and trouble in shoulders had a significant association, which is in line with the study by Kim and Roh [19]. Shoulders may have been more frequently affected due to repetitive movements and inappropriate working postures for a prolonged period of time [19].

The current study found a significant association between the use of lead curtains and quality control phantoms for gamma camera and trouble in wrist/hand. In a study conducted by Kim, almost one-quarter (24.7%) of the radiologists had wrist/hand pain in the year preceding their study and the authors concluded that it might be related to the use of computers and work place instruments [26].

The limitation of the current study could be its method as it was a cross-sectional online survey and a long questionnaire. The significance of the study is that it tried to explore and identify the various possible factors related to work and musculoskeletal disorders among working NMP in the Indian context. The collected information in the study may help the therapist and NMP understand the trouble in the various body parts experienced by the NMP. Since the current study explored and identified the musculoskeletal trouble in the body parts, future studies can more specifically examine the nature of the work, postures maintained during work, and also analyze the working ergonomics of NMP in India

5 Conclusions

WMSD pose a significant risk to NMP due to factors such as repetitive tasks, heavy equipment handling, and awkward postures inherent to the work environment. Commonly affected areas include the neck, shoulders and knees. Mobile lead screens used in procedures contribute to shoulder issues, while tasks involving lead curtains and quality control phantoms can lead to wrist/hand problems. Mitigating WMSD risks requires ergonomic interventions, such as proper training, workstation optimization to reduce awkward postures, incorporating regular breaks to prevent prolonged periods of static posture, and equipment designed to reduce strain on the musculoskeletal system. The current study shows that there are associations between the use of mobile lead screens and shoulders and between wrists/hands associated with lead curtains and QC phantoms for gamma camera /PET.

It is crucial to acknowledge the multifactorial nature of WMSD, influenced by individual demographics and variable factors such as age, height, weight, body mass index, years of experience, and instrument usage. Cultivating a culture of workplace health and safety encourages early reporting of discomfort, enabling timely intervention to prevent serious injuries. The findings from the current study may help in devising safe handling methods of various nuclear medicine equipment.