Original Article

Comparison of Musculoskeletal Pain Prevalence between

Medical and Surgical Specialty Residents in a Major Hospital in
Riyadh, Saudi Arabia
Abdullah Alsultan, Salman Alahmed, Abdullah Alzahrani1, Faisal Alzahrani1, Emad Masuadi
College of Medicine, King Saud bin Abdulaziz University for Health Sciences, 1Department of Orthopedic Surgery, King Abdulaziz Medical City,
National Guard Health Affairs, Riyadh, Saudi Arabia

Abstract
Objectives: Musculoskeletal disorders are an occupational hazard between physicians. Physicians whose practice involves physical
undertakings, such as surgeons, are prone to musculoskeletal pain, which can lead to decreased productivity. This study aimed to compare
surgical and nonsurgical specialties musculoskeletal pain prevalence, as well as assess whether certain factors contribute to their pain.
Methods: A cross‑sectional study that utilized a self‑administered questionnaire handed out to 140 conveniently selected surgical and
nonsurgical residents at King Abdulaziz Medical City, Riyadh. The questionnaire included a demographics section and a section inquiring
about nine anatomical areas derived from the Nordic Musculoskeletal Questionnaire. Results: The mean age was 27 years old, and 79% were
male. Surgical residents comprised 39% (n = 55) of the participants. Of all the residents, 82.9% (n = 116) suffered from a musculoskeletal
complaint, with the majority involving the lower back (53%). Surgical residents were more likely to take time off work (16% vs. 4%) and
attributed their pain to their profession (38% vs. 15%). Lower back pain was related positively to body mass index (P = 0.04). Multivariate
logistical regression revealed that being a surgeon (odds ratio [OR] = 5.08 and confidence interval [CI] = 0.27–94.14) and spending time doing
interventional procedures (10 h; OR = 0.97 and CI = 0.05–18.61) are predisposing factors to musculoskeletal pain. Conclusion: Ergonomic
changes are needed to enhance productivity and decrease time off work. Surgical residents need to be aware of the risk of experiencing
musculoskeletal pain and be educated on ways to avoid or cope with their pain.

Keywords: Ergonomics, lower back pain, nordic musculoskeletal questionnaire, occupational hazards, orthopedics, shoulder pain

Introduction bending and twisting, manual handling, abnormal postures,

and forceful movements are important predisposing factors
Occupational risks are hazardous events encountered in
to musculoskeletal disorders.[7,8] A national cross‑sectional
the workplace. These may include chemical, biological,
study done in the United Kingdom by Babar‑Craig et al.
psychosocial, and physical hazards. [1] Musculoskeletal
disorders a term defining complaints, symptoms, or pains to
the musculoskeletal system, which can range from mild and Address for correspondence: Abdullah Alsultan,
College of Medicine, King Saud bin Abdulaziz University for Health Sciences,
intermittent to severe and chronic causing morbidity.[2,3] To add, Riyadh, Saudi Arabia.
they are one of the most stressing issues faced by health‑care E‑mail: alsultan086@ksau‑hs.edu.sa
workers, especially surgeons, that maintain a still posture for a Salman Alahmed,
prolonged time.[4,5] A study conducted in 2011/2012 showed an College of Medicine, King Saud bin Abdulaziz University for Health Sciences,
Riyadh, Saudi Arabia.
estimated 1.1 million individuals suffered from occupational E‑mail: alahmed601@ksau‑hs.edu.sa
hazards with musculoskeletal disorders being the second
most common cause of the following mental disorders.[6] Received : 08-07-2018 Revised : 18-08-2018
Studies concerned with the epidemiology of musculoskeletal Accepted : 31-08-2018 Published Online : 04-10-2018
disorders in health‑care providers showed that repetitive
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How to cite this article: Alsultan A, Alahmed S, Alzahrani A, Alzahrani F,

DOI: Masuadi E. Comparison of musculoskeletal pain prevalence between medical
10.4103/jmsr.jmsr_36_18 and surgical specialty residents in a major hospital in Riyadh, Saudi Arabia.
J Musculoskelet Surg Res 2018;2:161-6.

© 2018 Journal of Musculoskeletal Surgery and Research | Published by Wolters Kluwer ‑ Medknow 161
 Alsultan, et al.

included 325 ear, nose, and throat physicians, 72% had back Sample
or neck pains or both inferring their pains to long microscopic This study was a cross‑sectional design that utilized a
work and bending forward while sitting.[9] Other risk factors, self‑administered questionnaire, which was handed out
which were similar to general surgeons, included endoscopic at wards, resident lounges, and resident activity rooms to
procedures, frequent bending, and prolonged still postures.[10,11] conveniently selected surgical and nonsurgical residents. The
In comparison with medical specialties, a cross‑sectional study sample size was calculated using PiFace[19] and was determined
was done in 2012 in India, which compared musculoskeletal to be 85 nonsurgical and 55 surgical residents to achieve a
pain prevalence in dentists, surgeons, and physicians. This 5% level of significance and to achieve a power of 80% in
study found that the highest rates of musculoskeletal pains detecting the difference of at least 15% between surgical and
were among dentists (61%), followed by surgeons (37%) and nonsurgical residents.
least in physicians (20%).[11] A study conducted by Auerbach
et al. in 2011 revealed that spine surgeons scored higher levels Instruments
of musculoskeletal pains (disk degenerative diseases and The questionnaire, which was developed by Knudsen et al.,[20]
herniation, carpal tunnel syndrome, and lateral epicondylitis) has two main parts: demographics and symptoms sections.
when compared to the general public.[12] The cover page of the questionnaire was an informed consent.
The demographics section inquired about age, gender, weight,
Physical discomforts can be disregarded or ignored by height, residency level, average number of hours spent doing
physicians to provide optimum patient care. Physicians are interventional procedures/operating/week, handedness, most
susceptible to bending, twisting, lifting heavy loads, and
commonly used eyewear, and most commonly employed
maintaining an awkward posture for a long time, which is
operating/procedural position. The symptoms section
all considered risk factors for musculoskeletal pains.[7,8,13]
included nine different anatomical areas derived from the
The societal burden of injuries to physicians will be inflicted
Nordic Musculoskeletal Questionnaire (NMQ). These areas
through their decreased productivity, absence from work, and
are as follows: neck, shoulders, elbows, wrists/hands, upper
cost of treatment.[14‑16] In the United Kingdom, 116 million
back, lower back, hips/thighs, knees, and ankles/feet. In
working days were lost from the general population due to
case a participant answers negatively toward a certain area,
musculoskeletal disorders (lower back pain) between 1994
the questionnaire asks to skip to the next area; however, in
and 1995.[17] In addition, Mollazadeh and Saraei found that of
case of a positive response, the participant was asked further
690 medical personnel in Tehran teaching hospital during 290
questions about interference with work over the last year,
working days between 2014 and 2015, 180 participants had
sick leaves with a sickness absence rate of 0.011/year and an difficulties over the past week, and description of the pain’s
absence frequency rate of 0.68/year, 18% of them were related character (pain, stiffness, weakness, paresthesia, or others).
to the musculoskeletal system.[18] Participants were also asked to rate their pain’s severity (mild,
moderate, or severe) and whether the participants attributed
In Saudi Arabia, multiple articles were found in the literature their pain to their work. The demographic data served as a
on the prevalence of musculoskeletal pains in different grouping variable for the study, while the NMQ results served
specialties of the health‑care system. However, studies as the outcome variables.
comparing the prevalence of musculoskeletal pains in
surgical to nonsurgical medical specialties were not found. In Data management and statistical plan
addition, the literature review did not show any similar local Data were entered into SPSS 20, IBM, Armonk, NY, United
studies. This study would serve as a benchmarking tool for States of America. Categorical variables were described as
addressing and reducing the physical stressors experienced frequencies and percentages. Chi‑Square test and logistic
by both surgical and nonsurgical physician. We aimed to regressions were used to assess the relationship between the
see the differences in the rates of musculoskeletal disorders, outcome variable (categorical variables for musculoskeletal
between only surgical and nonsurgical residents at King pain) and baseline characteristics.
Abdulaziz Medical City due to the fact that consultants were
fewer in number to meet the sample size, easier accessibility Results
to residents as opposed to consultants, and vast differences
The demographic profile of all residents who participated in the
between different consultants ages in comparison to resident
study is shown in Table 1. Gender distribution was 79% of male
during their training. Our results stress the importance of
residents and 21% of female residents (3.7:1, male‑to‑female
creating an ergonomically safe work environment for surgical
ratio). In the surgical group, there were 9 female residents (male
and nonsurgical health professionals.
residents: n = 46), and in the nonsurgical group, there were
21 female residents (male residents: n = 64). Residents’ mean
Materials and Methods age was 27 years (range: 24–34). The majority of residents
Setting were overweight. Surgical and nonsurgical resident distribution
This study was conducted in King Abdulaziz Medical City, a was 39% and 61% (n = 55 and 85, respectively), in accordance
government‑funded tertiary hospital in Riyadh, Saudi Arabia. with the sample size calculation.

162 Journal of Musculoskeletal Surgery and Research ¦ Volume 2 ¦ Issue 4 ¦ October-December 2018
 Musculoskeletal Pain in Residents, Riyadh

Table 1: Demographics
n (%)
Gender
Male 110 (79)
Female 30 (21)
Age
25 49 (36)
26 24 (18)
27 26 (19)
28+ 37 (27)
BMI
Underweight 6 (4)
Chart 1: Most painful areas reported by surgical and nonsurgical residents
Normal 56 (40)
Overweight 62 (45) more likely to attribute their pain to their profession (38% vs.
Obese 15 (11) 15%; P ≤ 0.001). As for the severity of pain when comparing
Specialty both groups, there is a noticeable, however statistically
Surgical 55 (39) insignificant, higher or more painful rating reported by surgical
Nonsurgical 85 (61) residents. Body mass index (BMI), classified as underweight
Residency level (BMI below 18.5), normal (BMI between 18.5 and 25),
R1 75 (54) overweight (BMI between 25 and 29), and obese (BMI higher
R2 26 (19) than 30), did not affect reports of pain, except when it came
R3 24 (17) to participants’ lower back (P = 0.04), with 40% (n = 25) of
R4 15 (11) underweight/normal reported pain compared to 62.9% (n = 39)
Average number of hours spent doing interventional of overweight and 60% (n = 9) of obese residents. Reports of
procedures/operating per week
time lost, attribution of pain to the profession, and pain severity
0 53 (38)
1‑5 27 (20)
are shown in Table 3.
6‑10 30 (22) Univariate logistical regression was done to determine the
11+ 28 (20) likelihood of experiencing musculoskeletal pain with each
Handedness baseline characteristic, as depicted in Table 4. While there was
Right 123 (88) no significant result with any of the characteristics analyzed,
Left 12 (9)
surgical residents were more likely to report musculoskeletal
Both 5 (4)
pain than nonsurgical residents (odds ratio [OR] = 5.08 and
Do you use eyewear?
confidence interval [CI] = 0.27–94.14). Moreover, residents
No 110 (80)
who spent more time doing interventional procedures or in the
Yes 28 (20)
Most commonly employed operating/procedural position
operating room reported having musculoskeletal pain more
Sitting 8 (6)
often (10 h; OR = 0.97 and CI = 0.05–18.61).
Standing 68 (49)
None 64 (46) Discussion
BMI: Body mass index
Work‑related musculoskeletal complaints are a prevalent
issue among health‑care providers. Previous literature has
Reports of pain in all areas of interests are depicted in Chart 1. identified high rates of musculoskeletal disorders among
The majority of residents who suffer from pain suffered from surgeons, physicians, and dentists.[13,21,22] This study found
either lower back (53%) or neck pain (39%). When asked that musculoskeletal complaints are similarly high among
to characterize exactly what they felt, 64% reported feeling nonsurgical specialty and surgical residents. When asked
general pain, and 18% felt stiffness in the affected areas. Only whether the musculoskeletal complaints were related to the
26% had symptoms in the 12 months before their participation nature of their profession, a significant difference was noted
in the study and 24% had symptoms 7 days prior. While both between surgical and nonsurgical specialty residents where
groups complained of musculoskeletal pain in varying degrees, more surgical specialty residents attributed their occupation
there was a significant difference when surgical and nonsurgical as a cause for their musculoskeletal complaints.
groups were compared, specifically in the complaint of
In our cross‑sectional study, we found that 83% of the study
knees (P = 0.001), shoulder (P = 0.01), wrists/hands (P = 0.02),
population had at least one painful or stressing musculoskeletal
elbow (P = 0.02), and hips/thighs (P = 0.04), as shown in Table 2.
complaint with lower back and neck pain being the most
Surgical residents also seem to be more likely to lose time common complaints, respectively. Compared with a previous
from work due to their pain (16% vs. 4%; P = 0.02) and were article on a similar population, elbow pain and back pain

Journal of Musculoskeletal Surgery and Research ¦ Volume 2 ¦ Issue 4 ¦ October-December 2018 163
 Alsultan, et al.

is also the cause of chronic pains, loss of working days, and

Table 2: Pain comparison
care seeking. Even though no resident suffered a potentially
Surgical Nonsurgical P career‑ending injury in our study, which can be explained by
residents, n (%) residents, n (%) the young age of our study population, it was the cause of
Neck 23 (41.8) 31 (36.5) 0.52 multiple absenteeism from work. Of all the surgical residents,
Shoulders 22 (40) 18 (21.2) 0.01 16% had days lost from work and more than a third of surgeons
Upper back 13 (23.6) 18 (21.2) 0.73
attributed their complaints to their occupation compared to
Elbows 11 (20.0) 6 (7.1) 0.02
4.7% of nonsurgical residents. The nonsurgical population
Lower back 33 (60.0) 41 (48.2) 0.17
were similar to Rambabu and Suneetha’s medical population
Wrists/hands 14 (25.5) 9 (10.6) 0.02
regarding time lost from work, 6% versus our population’s
Hips/thighs 9 (16.4) 5 (5.9) 0.04
Knees 17 (30.9) 8 (9.4) 0.001
4.7%; however, the surgical population was almost double of
Ankles/feet 13 (23.6) 12 (14.1) 0.15
ours, 29% versus 16%.[11]
In the current study, we found no association between BMI,
musculoskeletal pain, and associated symptoms after the
Table 3: Time lost univariate logistic regression was done. This was similar to
Surgical Nonsurgical P what Al-Mohrej et al. found when assessing musculoskeletal
residents, n (%) residents, n (%) pain complaints and its association with BMI among dental
Lost time from work practitioners working in Riyadh.[24] Rambabu and Suneetha,
No 46 (83.6) 81 (95.3) 0.020 on the other hand, found that being overweight or obesity
Yes 9 (16.4) 4 (4.7) was a significant risk factor for musculoskeletal pain when
Do you attribute the assessing dentists, surgeons, and physicians.[11] In addition,
pain to your job
when compared to nonmedical specialties, there was a clear
No 11 (20) 61 (71.8) <0.001
association between BMI and musculoskeletal complaints.
Yes 21 (38.2) 13 (15.3)
For example, Moreira‑Silva et al. found a clear association
Maybe 23 (41.8) 11 (12.9)
Pain severity
between weight and musculoskeletal complaints when
Mild 26 (47.3) 44 (56.4) 0.3 assessing Portuguese factory workers. Overweight/obese
factory workers in Portugal reported more frequent pains in
their shoulders and wrist/hand in the past 12 months compared
were the main complaints, respectively.[23] Our population’s with their normal‑weight counterparts.[25]
most common musculoskeletal complaints (lower back and
neck) were similar to Rambabu and Suneetha’s reports in both Previous literature has suggested that female surgeons have
surgical and nonsurgical medical professions.[11] a higher prevalence of musculoskeletal pains than male
surgeons. However, these reports had a limited number of
Nonsurgical residents reported less musculoskeletal complaints female surgeons participating.[5,26] Adam et al. reported that
than the surgical resident in our study. While both groups female gender was associated with approximately double
complained of musculoskeletal pain in varying degrees, there the risk of reported pain in common anatomical sites when
was a significant difference when surgical and nonsurgical assessing the prevalence of musculoskeletal pain among
groups were compared, and surgical specialty residents gynecologic surgeons, where female surgeons were nearly 50%
scored higher musculoskeletal complaints specifically in the of the population.[27] This was very similar to Alsiddiky et al.
complaints of the shoulder, elbow, wrists/hands, hips/thighs, reporting where female dental practitioners had double the
and knees.
risk of lower back pain.[24] This was also evident across health
Our survey results were comparable to previous studies, professionals in general where female health professionals had
notably in our surgical population. Knudsen et al. reported 1.9 times higher risk for developing musculoskeletal disorders
that orthopedic surgeons complained of musculoskeletal pains than their male counterparts.[23] However, in our population
specifically in the neck (59.4%), lower back (54.8%), upper being a male proved to be not statistically significant protective
back (35.5%), and shoulders (34.4%), whereas our surgical factor from musculoskeletal pain.
residents reported pains in the lower back (60%), neck (41.8%),
Even though no association was evident between age, prolonged
shoulders (40%), and upper back (23.6%).[20] Auerbach et al.
working hours, and musculoskeletal pain in our population,
found comparable results when surveying spine surgeons’
which could be explained by the fact that they are a younger
musculoskeletal complains as follows: lower back (62.2%),
age group. Previous literature linked age with increased risk
neck (59.4%), and shoulders (48.5%). These results are of
of general musculoskeletal pains.[23,24,28] Furthermore, the
concern due to our population being younger residents in their
prevalence of musculoskeletal pain significantly increased with
early career stages.
the increase of age over 50 years.[29] Studies have also identified
Occupational musculoskeletal comorbidities are a prevalent extended working hours in ergonomically challenging positions
issue as reported in our study and numerous other articles. It as a prominent risk factor for musculoskeletal pains.[30,31]

164 Journal of Musculoskeletal Surgery and Research ¦ Volume 2 ¦ Issue 4 ¦ October-December 2018
 Musculoskeletal Pain in Residents, Riyadh

environment in which health‑care professionals practice.

Table 4: Risk factors of musculoskeletal pain
Long‑term studies combating the limitations of this study
P OR 95% CI may give a better estimate of risk factors and methods of
Gender eliminating them to provide a safer work environment, bearing
Male 0.62 0.72 0.20‑2.59 in mind the societal investment put in the health‑care systems.
Female* Furthermore, expanding on this study by inquiring about other
Age specialties working in the hospital and the areas, they occupy
25 0.48 1.67 0.38‑7.23 such as wards, laboratories, and clinics.
26 0.67 0.71 0.15‑3.34
27 0.28 0.39 0.07‑2.11 Ethical considerations
28+* Ethical approval was granted by King Abdullah International
BMI Medical Research Center’s institutional review board. All
Underweight/normal 0.17 1.8 0.01‑2.11 willing participants were given a summary of the study’s
Overweight 0.28 0.27 0.02‑2.92 aim attached to the consent sheet. Complete confidentiality
Obese* was ensured, and participants were informed that they could
Specialty withdraw themselves at any given time. Participants also
Surgical 0.27 5.08 0.27‑94.14 received a faculty member’s contact information in case they
Nonsurgical* had any questions regarding the study later on.
Residency level
R1 0.49 2.01 0.26‑15.23 Financial support and sponsorship
R2 0.60 1.76 0.20‑15.47 Nil.
R3 0.36 2.99 0.28‑31.43
R4*
Conflicts of interest
Average number of hours spent doing
There are no conflicts of interest.
interventional procedures/operating per week
Author’s contributions
0 0.42 0.23 0.007‑7.92
AS and SA contrived the idea and designed this study, did the
5 0.68 0.49 0.01‑15.02
literature review, assembled the questionnaires, gathered the
10 0.98 0.97 0.05‑18.61
data needed, entered the data on SPSS, wrote the proposal
11+*
*Reference group. CI: Confidence interval, OR: Odds ratio, BMI: Body
and manuscript. AZ and FZ offered guidance and mentorship,
mass index and shared their expertise in the field of orthopedics and
musculoskeletal pain. EM did the statistical analysis and
Limitations of the study aided in interpretation of data. All authors have reviewed and
As with all convenient sampling studies, this study is highly approved the manuscript and are responsible for the content
vulnerable to have biases that both over‑ and under‑represent and similarity index of the manuscript.
the overall population as well as selection bias. The sample
studied represents residents from one institute; King Abdulaziz References
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