International Journal of Industrial Ergonomics 74 (2019) 102838

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International Journal of Industrial Ergonomics

journal homepage: www.elsevier.com/locate/ergon

The investigation of work-related musculoskeletal disorders among female T

workers in a hazelnut factory: Prevalence, working posture, work-related
and psychosocial factors
Sevim Acaröz Candana,∗, Ulku Kezban Sahinb, Sinan Akoğlua
a
Ordu University, Faculty of Health Sciences, Department of Physical Therapy and Rehabilitation, Ordu, Turkey
b
Giresun University, Vocational School of Health Services, Department of Therapy and Rehabilitation, Giresun, Turkey

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Work-related musculoskeletal disorders (WMSDs) are the most common occupational health pro-
Kyphosis blems in the industrialized world. The identification of WMSDs specific to occupation is essential to plan and
Lordosis implement preventative programs. This study investigated the prevalence of WMSDs and determined the factors
Musculoskeletal disease related to the severity of the most common disorders among female workers in a hazelnut factory.
Neck pain
Methods: A total of 114 female workers were examined in this cross-sectional study using the Nordic
Postural lower back pain
Musculoskeletal Questionnaire, the Dutch Musculoskeletal Questionnaire, and an author-developed ques-
tionnaire (for socio-demographic characteristics and psychosocial factors). Working posture, craniovertebral
angle, thoracic kyphosis angle (TKA), and lumbar lordosis angle were evaluated based on a photogrammetry
method using the ImageJ program.
Results: The prevalence of WMSDs in at least one body part during the last 12 months was 92.1%. The highest
prevalence of WMSDs was in the lower back (61.4%), neck (57.9%), shoulder (53.6%), and upper back (45.6%).
The least affected part was the elbow. Lower back, shoulder, and neck disorders were the most common causes of
activity limitation. The severity of lower back pain was associated with stress in the workplace and work-related
factors. The neck pain severity was related to craniovertebral angle and work-related factors. The shoulder pain
severity increased with TKA and employment duration. TKA was related to upper back pain severity.
Conclusions: WMSDs are common among female workers in a hazelnut factory. Reorganizing of working posture,
work-related factors, and stress at work may be beneficial to decrease the prevalence of WMSDs and pain se-
verity.
Relevance to Industry; The female workers in the hazelnut factory are vulnerable to the work-related mus-
culoskeletal disorders, particularly in the spinal region. The employers should endeavor to improve the health of
the workers by the adjustment of the working posture and environmental factors.

1. Introduction
Work-related musculoskeletal disorders (WMSDs) are one of the
major occupational health hazards in the industrialized world
(Anderson et al., 1997). WMSDs are important workplace problems
affecting occupational health, productivity, the careers of employees,
and leading to economic loss. Related to their importance, governments
have developed policies to reduce the prevalence of WMSDs by taking
precautions against risk factors (Kim and Nakata, 2014). Commonly
known risk factors for WMSDs are awkward posture, prolonged static
work, repetitive movements, manual material handling, forceful exer-
tion and vibration (Punnett and Wegman, 2004). Furthermore,
psychosocial factors such as job satisfaction, stress in the workplace and
daily life may cause WMSDs (Costa, 2010). The number of studies about
WMSDs has increased in recent years. The studies on prevalence and
risk factors for WMSDs in office workers, health professions and factory
workers are common (Abaraogu et al., 2015; Anyfantis and Biska, 2018;
Kocur et al., 2019; Nejati et al., 2015). It is known that WMSDs also
occur as a consequence of rigorous working conditions in agricultural
production processes (Choobineh et al., 2009; Kirkhorn et al., 2010;
Merino et al., 2019; Thetkathuek et al., 2018).
Hazelnuts are one of the most commonly consumed hard-shelled
fruits in the world and its products are used in many food industries.
The leading producer countries are Turkey, Italy, USA, and Spain (Tous,

∗
Corresponding author.
E-mail address: sevimcandan@odu.edu.tr (S. Acaröz Candan).

https://doi.org/10.1016/j.ergon.2019.102838
Received 22 March 2019; Received in revised form 6 August 2019; Accepted 23 August 2019
0169-8141/ © 2019 Elsevier B.V. All rights reserved.
S. Acaröz Candan, et al.
2005). Turkey is responsible for 73% of world production and exports
84% of its production, which accounts for around 20% of total agri-
cultural exports from Turkey (Kılıç and Alkan, 2006). In addition to the
share of production and exports belonging to the hazelnut sector in the
country's economy, the hazelnut sector also contributes to the economy
of the region by providing significant employment opportunities in
factories, especially for the female population in the Black Sea Region.
The female workers' percentage in hazelnut industries is 83.3% (Avcı
and Erdoğan, 2015). It should be noted since female workers are vul-
nerable to WMSDs in terms of muscle activity concerning capacity
(Nordander et al., 2008). Because the hazelnut production process from
harvesting in the orchard to the processing at the factory such as ha-
zelnut sack carrying-placement, crushing, roasting, selection, and
packing tasks requires challenging physical exertion. The machines
(lifter, crushing machine, oven, packing machine, vacuum) are used in
all tasks except for hazelnut selection, which is performed manually
only by the women. A previous study showed that the hazelnut selec-
tion constitutes a high risk for upper extremity WMSD due to the re-
quiring the bi-manually repetitive flexion and extension of wrist and
fingers, supination and pronation of the elbow on a conveyor belt
(Colantoni et al., 2013). However, the prevalence of upper extremity
WMSD was not reported. Another difference among the tasks of ha-
zelnut production process is whether it is static because the hazelnut
selection task is carried out four and half hours nonstop, totally nine
hours in a static position with the excessive posterior tilt of the pelvis,
decreased lordosis of the lumbar and cervical spine, excessive kyphosis
of the thoracic spine, and a protracted head. Unfortunately, besides
repetitive movement characteristics, regarding the mentioned features
of the selection task, this task may be physically compelling for female
workers unusually for the spinal regions.
The prolonged sitting position, slumped posture and repetitive
upper extremity movements during hazelnut selection task are known
to be risk factors for WMSDs (Punnett and Wegman, 2004). Even
though the workers in the hazelnut factories are exposed to various risk
factors, there is no study about the WMSDs in hazelnut factory workers.
Therefore, the objectives of this cross-sectional study were primarily to
determine the prevalence of WMSDs among female workers in a ha-
zelnut factory and secondarily to investigate the relationship between
the pain severity of high prevalence WMSDs and factors regarding
working posture, work-related and psychosocial factors.
2. Materials and methods
2.1. Participants
The population of this study included female workers in a hazelnut
factory. One-hundred and sixty-two workers were screened for elig-
ibility criteria. A total of 39 workers were not included in the study due
to the exclusion criteria. Voluntary participation was rejected by 8 fe-
male workers. A total of 114 female workers participated in the study.
The participants were workers in the hazelnut selection department.
The inclusion criteria were: 1) age > 18 years, and 2) had at least 12
months of continuous working experience in hazelnut selection.
Exclusion criteria were pregnancy, working in a standing position or
having a load-bearing job, any pre-existing MSD history before the
participants entering the hazelnut industry and having joint disease,
gout, diabetes, and trauma during the last one year before data col-
lection as these might display similar symptoms to musculoskeletal
symptoms (Council, 1999). Workers’ medical status was verified by the
occupational physician.
2.2. Research protocol
This cross-sectional study was performed from June of 2018 to
February of 2019. The study was approved by the Ethics Committee of
Ordu University for Clinical Investigations and was conducted in
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International Journal of Industrial Ergonomics 74 (2019) 102838
compliance with the Declaration of Helsinki for medical research in-
volving human subjects. All participants gave their written informed
consent prior to the commencement of the study. This trial was regis-
tered with ClinicalTrials.gov, number NCT03871335.
2.3. Data collection tool
The demographic data (age, weight, height, marital status, educa-
tion years, and employment durations) were recorded via a structured
questionnaire by the principal investigator. Body mass index (BMI) was
calculated as weight in kilograms divided by height in meters squared.
Visual analog scale of 10 cm was used to measure work satisfaction,
stress in the workplace and daily life. The following measures were
performed in the same order by the same examiner in one day. The
Turkish version of the Nordic Musculoskeletal Questionnaire (NMQ)
was used to determine self-reported musculoskeletal symptoms in dif-
ferent body regions (neck, shoulder, elbow, wrist, upper back, lower
back, hip, knee, ankle) in which suffered from aches, pain, or dis-
comfort during the last 12 months before data collection (Kahraman
et al., 2016; Kuorinka et al., 1987). Sick leave obtained from work,
obstructed work, medication taken and visiting a doctor or phy-
siotherapist etc. during the past 12 months regarding work-related MSD
were recorded. The obtained data are presented as percentiles (%). The
pain severity in each region was measured by the last question on the
NMQ which is graded between 0 and 10. The reliability and validity of
NMQ in Turkish was examined (Kahraman et al., 2016).
The work-related risk factors and perceived workload were eval-
uated using the Dutch Musculoskeletal Questionnaire short version in
Turkish (DMQ-TR-s), which is a reliable and valid measurement tool
(Akgöl, 2016). DMQ-TR-s compromises four sections including general
questions, health, perceived workload, and ergonomic environment.
The scores of the three sections apart from general questions were
summed and a total score was obtained. Higher scores indicate more
risky situations (Hildebrandt et al., 2001).
Working posture was evaluated based on the photogrammetry
method which is a reliable and valid tool for postural angle analysis
(Porto and Okazaki, 2018, 2017; Salahzadeh et al., 2014; Singla et al.,
2017; Van Niekerk et al., 2008). Photographs of workers were taken
laterally in working position, which continued on a conveyor belt with
90 cm height, using a digital, professional camera (Canon 4000D,
Japan) from 150 cm distance which is located at the height of the ac-
romion. The workers were sitting on a bench with 60 cm height and
30 cm width without backrest during the working task. The photo-
graphs of all workers were taken two hours after the start of selecting to
represent the real working posture. We did not give any instruction to
the subjects to help them. Craniovertebral angle (CVA), thoracic ky-
phosis and lumbar lordosis angles were measured on the photograph
using the ImageJ program (National Institutes of Health, USA). The
reference anatomical points (C7, tragus, T1, T12, L5) were marked on
the photograph prior to the analysis. For this purpose, first the anato-
mical references points were identified by palpation of the spinous
process of each vertebra, and then the level of these points was marked
on the clothes using a small, sticker. The sticker projections on the
photograph created the reference points for Image J program. CVA was
measured by intersecting the horizontal line with a line which was
drawn from the tragus of the ear to the C7 vertebra and was calculated
as the angle between the lines (Salahzadeh et al., 2014; Singla et al.,
2017). The CVA is the measure of the forward-head position, which is a
useful clinical marker of mid/lower cervical spine posture. Decreasing
CVA represents increasing stress on the cervical spine and is related to
neck pain (Nejati et al., 2015). For thoracic kyphosis assessment, the
angle between the line through the superior endplate of the T1 ver-
tebrae and the line through the inferior endplate of the T12 vertebrae
was used (Leroux et al., 2000; Porto and Okazaki, 2018; Singla et al.,
2017). Lumbar lordosis angle was measured as the angle between the
line through the inferior endplate of the T12 vertebrae and the line
S. Acaröz Candan, et al. International Journal of Industrial Ergonomics 74 (2019) 102838

Fig. 1. Illustration of the postural angles assessment in working position by photogrammetry. Symbols and numbers on photo demonstrates that 1: Tragus of the ear,
2: C7, 3: T1, 4: T12, 5: L5, α: Craniovertebral angle, β: Thoracic kphosis angle, γ: Lumbar lordosis angle.

through the inferior endplate of the L5 vertebrae (Fig. 1) (Leroux et al., Table 1
2000; Porto and Okazaki, 2018, 2017) The angle measurements for 30 Demographic characteristics of the female workers in hazelnut factory.
workers were performed by all investigators independently of each Frequency (percent) Mean ± SD
other. The intraclass correlation coefficient of their measurements was
found to be between 0.75 and 0.93. The postural angles of all workers Age (years) 41.0 ± 8.14
< 25 3 (2.65)
were calculated by three investigators and then the three values were
26–40 46 (40.35)
averaged. > 40 65 (57.00)
Education level
İlliterate 4 (3.50)
2.4. Statistical analysis
Literate 1 (0.90)
Primary school 73 (64.00)
All statistical analyses were performed using SPSS for Windows, Middle school 20 (17.50)
version 20.0 (SPSS Inc, Chicago, Illinois). Normal distribution was High school 15 (13.20)
University 1 (0.90)
confirmed using the Shapiro–Wilk test prior to statistical analysis.
Body mass index (kg/m2) 26.87 ± 4.71
Continuous data are presented as mean (SD) and categorical data as a Underweight 0 (0)
percentage. The prevalence of work-related MSD for each body region Normal 43 (37.70)
and the body regions with the highest prevalence of MSD were de- Overweight 45 (39.50)
termined. The ratios of sick leave obtained from work, obstructed work, Obese 26 (22.80)
Duration of employment (years) 8.00 ± 6.75
medication taken and doctor or physiotherapist visits regarding work-
<5 41 (36.00)
related MSD in the past 12 months was determined for each region. The 5–10 38 (33.30)
workers were divided into two groups (with MSD and without MSD) > 10 35 (30.70)
based on the regions with the highest prevalence of MSD. An in- Smoking habit
dependent t-test was used to compare the postural angles (CVA, ky- Non-smokers 88 (77.20)
Smokers 26 (22.80)
phosis, and lordosis) in the working position among these two groups. Exercise habit
The correlation between the working posture, DMQ-TR-s total score, Yes 13 (11.40)
employment duration, stress, work satisfaction and pain severity in the No 101 (88.60)
region with the highest prevalence MSD was determined using
Pearson's correlation coefficient. P < 0.05 was considered statistically
significant. prior to the study. WMSDs most commonly affected the lower back,
neck, shoulder and upper back, with prevalence rates of 61.4%, 57.9%,
53.6% and 45.6%, respectively. The least affected body part was the
3. Results
elbow. A total of 66 (57.9%) of the workers were prevented from doing
activity at home or in the workplace by WMSD affecting one body part.
The total number of female workers included in this study was 114
The most common MSD to cause activity limitations was lower back
with a mean age of 41.0 ± 8.14 years. The mean BMI of workers was
pain (LBP) (37.7%), followed by shoulder pain (24.6%) and neck pain
26.87 ± 4.71 kg/m2. Of the workers, 39.50% and 22.80% were over-
(21.1%).
weight and obese, respectively. The majority (77.20%) of the workers
The pain severities of the female workers who had lower back, neck,
were non-smokers and 11.40% of the workers exercised regularly. The
shoulder and upper back complaints were 6.10 ± 2.29, 5.88 ± 2.00,
mean duration of the employment was 8.00 ± 6.75 years. All em-
6.10 ± 1.49 and 5.67 ± 1.71, respectively. The frequency of pain and
ployees worked for 6 days a week and more than 8 h a day. The de-
the situation of pain relief on holidays were showed in Fig. 3.
mographic characteristics of the participants are summarized in
Fig. 4 reveals the frequency of sick leave taken from work, medi-
Table 1.
cation taken and doctor or physiotherapist visits, etc. due to muscu-
Work-related musculoskeletal disorders were defined according to
loskeletal problems in different body regions during the past 12 months.
whether a worker had pain, numbness, or discomfort in a body part. Of
Eighty (70.2%) workers were seen by a health professional. Of workers,
the hazelnut factory workers, 92.1% had symptoms of WMSDs in at
36.0%, 28.9%, and 27.2% consulted health professionals regarding
least one body part. Fig. 2 presents the prevalence of WMSD symptoms
lower back disorders, neck disorders, and shoulder disorders,
in different body parts and activity limitation during the 12 months

3
S. Acaröz Candan, et al. International Journal of Industrial Ergonomics 74 (2019) 102838

Fig. 2. The prevalence of MSD symptoms in different body regions and activity limitation during the past 12 months.

respectively. The most frequent symptom for medication taken was LBP severity in the lower back and stress in the workplace (p = 0.002), and
(42.1%), neck pain (37.7%), and shoulder pain (34.2%). Disorders of DMQ-TR-s score (p = 0.028); pain severity in neck and CVA
the lower back, shoulder, and neck caused the highest rate of sick leave (p = 0.001), and DMQ-TR-s score (p = 0.042); pain severity in
taken from work. shoulder and employment duration (p = 0.005), and thoracic kyphosis
Table 2 shows the comparison of working posture and work-related angle (p = 0.034); and pain severity in upper back and thoracic ky-
factors (DMQ-TR-s score) among the workers in a hazelnut factory who phosis angle (p = 0.049).
were divided into two groups based on the presence of MSD in the body
part with the highest prevalence. The DMQ-TR-s scores of those with
4. Discussion
WMSDs in the lower back, neck, shoulder and upper back were higher
than those without WMSDs. The working posture was similar among
To our knowledge, the present study is the first investigation about
the groups based on the presence of MSD in the upper back, lower back,
the prevalence of WMSDs and the relationship between pain severity
and shoulder. However, the means of CVA and lumbar lordosis angle
regarding WMSDs and working posture, work-related factors and psy-
among workers who reported MSD symptoms in the neck were sig-
chosocial factors among female workers in a hazelnut factory. The
nificantly lower than those of workers without neck MSD.
findings demonstrated that most of the female workers in this study
The psychosocial factors relating to work satisfaction, stress in the
(92.1%) experienced WMSDs in at least one body part during the last 12
workplace, and stress in daily life were investigated. The mean work
months. For this reason, female workers in hazelnut factories should be
satisfaction was 8.17 ± 1.72. The perceived stress in the workplace
carefully monitored in terms of MSD. In the current study, lower back
and daily life was 5.19 ± 2.52 and 5.03 ± 2.73, respectively.
(61.4%) was the most prevalent for WMSDs, followed by neck (57.9%),
Table 3 shows the relationship between some variables regarding
shoulder (53.6%) and upper back (45.6%). The least affected body part
working posture, psychosocial factors, work-related risk factors and
was the elbow. Moreover, lower back WMSDs had the highest pre-
pain severity in the lower back, neck, shoulder, and upper back. A
valence in terms of activity limitation, sick leave taken from work,
statistically significant positive relationship was found between pain
medication taken and visits to health professionals. When we measure

Fig. 3. Illustration of a) the frequency of the pain and b) the situation of the pain relief on holidays.

4
S. Acaröz Candan, et al.
Fig. 4. The frequency of the taken sick leave from work, taken medication and seen a doctor or physiotherapist etc. due to musculoskeletal problems in different body
regions during the past 12 months.
head, trunk and back postures during hazelnut selection, we revealed
that hazelnut factory workers have an awkward posture. Furthermore,
for the present population, head posture and work-related factors were
related to neck pain severity, while the trunk posture was related to
shoulder and upper back pain severity. The stress in the workplace and
work-related factors were correlated with the severity of LBP.
Da Costa et al. (2010) described many risk factors for occurrence of
WMSDs including heavy physical work, awkward static and dynamic
working postures, heavy lifting, low level of job control, high psycho-
logical demands, low work satisfaction, younger age, female gender,
smoking, high BMI and comorbidity. During hazelnut selection,
workers sit for a long time in a static, slumped position on a bench and
they must repetitively use their wrists and fingers while the forearm is
supported on the desk. Therefore, we consider that the risk factors for
WMSDs in this department include long-term, static, slumped sitting
position and repetitive use of arms and we also expected a high pre-
valence of WMSD in the wrist and fingers as well as lower back and
neck problems. However, the symptoms in these joints were rarer than
symptoms in the spinal regions. This finding may be attributed to the
majority of the female workers having less than ten years of experience.
We know that the ratio of upper extremity WMSDs increases with ten
years of experience in industries with light manual work (Labbafinejad
et al., 2017). Another reason for the low prevalence of the upper ex-
tremity disorders may be due to the fact that the characteristics of se-
lection task. Although the task of hazelnut selecting includes repetitive
movements for wrist and fingers, it does not include tasks that will force
workers such as the vibratory environment and heavy load (Akbal et al.,
2012; Anderson et al., 1997).
Lower back pain is the most reported WMSD with prevalence rating
between 22.1% and 85.7% (Abaraogu et al., 2015; Pinar et al., 2013;
Saidu et al., 2011) and has the greatest effect on quality of life
(Abaraogu et al., 2015). Consistent with findings from previous studies,
this study showed that LBP was the most common WMSDs and caused
more activity limitations during the past 12 months among hazelnut
factory workers. However, the prevalence rates of WMSDs in this study
was higher than in the previous studies. The difference between the
studies may result from the inclusion of only the female gender in the
current study because we know that WMSDs are more common in the
female population than the overall population (Abaraogu et al., 2015;
Amorim et al., 2017).
Waongenngarm et al. (2016) showed that prolonged sitting in office
workers led to increased complaints in the neck, shoulder, upper back,
lower back and buttock regions. Pinar et al. (2013) also reported that
58.5% and 13.8% of factory workers complained of LBP and neck pain
due to awkward posture, respectively. Kwon et al. (2018) demonstrated
that if slumped sitting is continued for a long time, it may cause pain
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International Journal of Industrial Ergonomics 74 (2019) 102838
and diseases in the cervicothoracic and lumbosacral joints. Consistent
with mentioned studies, the high prevalence of WMSDs of lower back,
neck, shoulders, and upper back in the present study could support that
working in an improper sitting posture without a break is a risk factor
particularly for WMSDs of the spinal regions (Pinar et al., 2013). Be-
cause the workers in the current study had only a break with half hours
(lunch break) in a day which is known that is insufficient for recovery
time of hazelnut workers (Colantoni et al., 2013), and unfortunately, at
the same time they had to work with a supervisor for totally nine hours
in an awkward sitting position which increases stress on the joints. In
other words, as sitting on the bench for a long time during hazelnut
selection involves an excessive amount of hip and back flexion due to
lack of individual working adjustments of the bench and desks, the
workers have to bend their neck and back excessively. In this position,
increased spinal flexion has been linked to increased intradiscal loading
(Nachemson, 1966) and weakened posterior lumbar structure; as a re-
sult, LBP may develop (Corlett, 2006). Another explanation relating to
the cause of LBP is that prolonged, slumped sitting may be associated
with internal oblique and transversus abdominis muscle fatigue which
may impair spinal stability and lead to susceptibility for WMSDs
(Waongenngarm et al., 2016). Thus, the recovery of postural muscle
endurance and improvement of working conditions may be alternatives
to decrease the LBP complaints in the work environment.
Exercise habits significantly affect the health of the musculoskeletal
system. The studies demonstrated that the sedentary lifestyle was as-
sociated with LBP, particularly in females (Abraha et al., 2018; Amorim
et al., 2017). Furthermore, it is known that workers in a similar working
setting with hazelnut selection who had no habit of exercise are nearly
11 times more vulnerable to work-related LBP than those who had
exercise habit (Abraha et al., 2018). A previous study showed that
68.3% of the workers in the hazelnut factory had no exercise habit, 5%
of those had exercise habit, and 26.7% of those is that exercised
sometimes (Avcı and Erdoğan, 2015). In the current study, while 11.4%
of female workers had an exercise habit, particularly in favor of
walking, 88.6% of the female workers had no exercise habit. The dif-
ferences in the ratio among studies may be since our sample group
consists of the only females who are mostly married. Because they also
are responsible for the household work as well as the responsibility in
hazelnut factory. They generally do housework (cooking, dishwashing,
washing, ironing, cleaning, etc.) average 2 h, and some of those help to
do homework of their children after the work. Unfortunately, they must
sit for an average of 15 h per day, including at work and home, and they
have not enough time for exercise. Therefore, another possible reason
for the high prevalence of LBP in this study may be the high proportion
of sedentary behavior. As an additional recommendation to alleviate
LBP complaints, the workers with LBP may be advised to exercise
S. Acaröz Candan, et al. International Journal of Industrial Ergonomics 74 (2019) 102838

Table 2 Table 3
The comparison of CVA, thoracic kyphosis, lumbar lordosis and total score of The relationship between working posture, psychosocial factors, work-related
DMQ-TR-s among groups. factors and pain severity.
Neck MSD N X (SD) CI (%95) p Lower back Neck pain Shoulder Upper back
pain severity severity pain severity pain severity
CVA −8.5/-1.58 0.005 (n = 70) (n = 66) (n = 61) (n = 52)
with 66 28.35 (8.48)
without 48 33.41 (10.24) Employment r = −0.025 r = −0.092 r = 0.352 r = −0.028
Thoracic kyphosis −2.54/3.31 0.796 duration p = 0.839 p = 0.462 p = 0.005 p = 0.844
with 66 36.12 (7.81) Stress in r = 0.365 r = 0.070 r = 0.136 r = 0.262
without 48 35.74 (7.76) workplace p = 0.002 p = 0.576 p = 0.297 p = 0.061
Lumbar lordosis −2.08/-0.15 0.024 Stress in daily r = 0.177 r = 0.017 r = 0.054 r = 0.006
with 66 12.17 (2.46) life p = 0.148 p = 0.891 p = 0.679 p = 0.967
without 48 13.28 (2.72) Work r = −0.095 r = −0.106 r = 0.025 r = −0.077
Total score of DMQ-TR-s 10.51/22.44 < 0.001 Satisfaction p = 0.434 p = 0.399 p = 0.848 p = 0.589
with 66 126.52 (17.99) DMQ-TR-s r = 0.263 r = 0.251 r = 0.112 r = 0.074
without 48 110.04 (12.07) p = 0.028 p = 0.042 p = 0.391 p = 0.601
Shoulder MSD CVA r = −0.051 r = -0.392 r = 0.175 r = 0.115
CVA −4.21/2.93 0.724 p = 0.658 p = 0.001 p = 0.177 p = 0.415
with 61 30.18 (8.66) Thoracic r = 0.175 r = 0.199 r = 0.272 r = 0.274
without 53 30.82 (10.57) kyphosis p = 0.147 p = 0.109 p = 0.034 p = 0.049
Thoracic kyphosis −2.43/3.37 0.748 angle
with 61 36.18 (7.09) Lumbar lordosis r = −0.074 r = 0.161 r = −0.048 r = 0.243
without 53 35.71 (8.52) angle p = 0.542 p = 0.197 p = 0.711 p = 0.082
Lumbar lordosis −1.90/0.02 0.55
with 61 12.20 (2.49) CVA: Cranio-vertebral angle; DMQ-TR-s: Dutch Musculoskeletal Questionnaire
without 53 13.14 (2.69) short version in Turkish.
Total score of DMQ-TR-s 11.22/22.89 < 0.001
with 61 127.51 (16.88)
without 53 110.45 (14.17) the current study. Previous studies associated the neck disorders in
Upper Back MSD workers with static posture, work experience, repetition, awkward
CVA −5.64/1.46 0.247 posture, extended reach, lack of workplace adjustment, and individual
with 52 29.34 (9.51) factors such as age, weight, habits (Ariëns et al., 2000; Berberoǧ;lu and
without 62 31.43 (9.56)
Tokuç, 2013; Labbafinejad et al., 2016). Nonetheless, CVA, which is an
Thoracic kyphosis −1.71/4.07 0.421
with 52 36.60 (8.42) indicator of head position, was also reported as a significant sign of
without 62 35.42 (7.18) neck pain (Afshari et al., 2018; Ariëns et al., 2000; Kocur et al., 2019).
Lumbar lordosis −1.52/0.43 0.269 Nejati et al. (2015) indicated that the workers with lower CVA com-
with 52 12.34 (2.70)
plained about increased neck pain. Our results are consistent with these
without 62 12.88 (2.54)
Total score of DMQ-TR-s 4.85/17.49 0.001 studies suggesting that CVA is associated with neck pain severity.
with 52 125.65 (18.53) Moreover, we also demonstrated, in line with Kocur el al.'s study
without 62 114.48 (15.54) (2019), that CVA in the working position was decreased more in the
Lower Back MSD symptomatic group compared to the non-symptomatic group. While
CVA −4.81/2.49 0.530
Yoo and An (2009) explained the neck pain due to diminished CVA by
with 70 30.03 (10.05)
without 44 31.19 (8.76) increased cervical flexion and cervical muscle imbalance, we think that
Thoracic kyphosis −3.25/2.68 0.850 the anterior positioning of the head leads to increased muscle activity of
with 70 35.85 (8.14) cervical erector spina (Caneiro et al., 2009), and delayed, decreased
without 44 36.13 (7.18)
muscle activity of deep cervical flexors (Falla et al., 2011). Conse-
Lumbar lordosis −1.23/0.77 0.646
with 70 12.54 (2.65)
quently, this lesser CVA may increase neck pain in hazelnut factory
without 44 12.78 (2.59) workers due to cervical muscle activation. Interestingly, the lumbar
Total score of DMQ-TR-s 2.57/15.75 0.007 lordosis angle also was more decreased in the workers with neck pain
with 70 123.11 (17.10) than those without neck pain. We attributed the difference in lumbar
without 44 113.95 (17.61)
lordosis among the hazelnut factory workers with neck disorders to the
CVA: Cranio-vertebral angle; DMQ-TR-s: Dutch Musculoskeletal Questionnaire effects of the thoracolumbar spine on the cervical spine due to the
short version in Turkish; MSD: Musculoskeletal disorders. awkward sitting position (Caneiro et al., 2009).
Thoracic kyphosis is another indicator of poor working position.
regularly. We don't know the condition of WMSDs in the group with Singla and Veqar (2017) reported that increased thoracic kyphosis was
exercise habit for this study. We could not investigate the ratio of correlated with forward head posture and also rounded shoulders.
WMSDs for this group because the sample size among groups (n = 13 Additionally, Singla and Veqar (2017) highlighted that they could exist
for the group with exercise habit, and n = 101 for the group without alone or in any combination. In this study, the working posture was
exercise habit) was considerably different for the comparison. Also, characterized by a combined form of decreased lumbar lordosis, in-
even if we have performed such an analysis, we think that depending on creased thoracic kyphosis and forward head posture. Although the
the aerobic exercise preferences of the participants, WMSDs rates will shoulder posture was not assessed in this study, the shoulders of the
be similar, and only pain severity may decrease. For this reason, if it is workers during hazelnut selection were in protraction due to thoracic
intended to prevent or improve WMSDs, we recommend that kyphosis, which adversely influences length-tension relationships of the
strengthening, stretching, and postural correction exercises particularly shoulder girdle muscles and may cause pain. While Otoshi et al. (2014)
specific to work characteristics should be preferred instead of walking. showed the positive relationship between the thoracic kyphosis and
Only in this way, exercise helps to overcome pain through the pain of the shoulder, Griegel-Morris et al. (1992) concluded that in-
strengthening and lengthening of muscles to resist spasm and the in- creased kyphosis is associated with interscapular pain but not with
crease of blood circulation. shoulder or upper arm pain. We found in this study that there was a
Neck-related WMSDs were the second most common complaint in positive relationship between thoracic kyphosis angle and both

6
S. Acaröz Candan, et al.
shoulder, and upper back pain severity. Furthermore, the shoulder pain
severity also increased with employment duration in the present study.
Our finding was in line with those of Labbafinejad et al. (2017) and
Berberoğlu et al. (2013) indicating that long duration of employment
was significantly associated with WMSD of the shoulder.
The work-related musculoskeletal disorders may occur depending
on work posture and work-related factors as well as psychosocial fac-
tors. The association between psychosocial factors and WMSDs is re-
ported by many authors (Berberoǧ;lu and Tokuç, 2013; Costa, 2010). In
the current study, the stress in the workplace and perceived workload
were associated with LBP severity, but there was no correlation be-
tween WMSDs in any body part and stress in daily life and work sa-
tisfaction. Additionally, the present study showed that neck pain se-
verity in hazelnut factory workers was related to the perceived
workload alone. Although including the psychosocial aspect of WMSDs
is a strength of this study, as psychological stress in the workplace or
daily life was measured subjectively based on workers’ perception, in
future studies the use of objective measurements such as job stress
questionnaire may be more beneficial to determine the relationship
between psychosocial factors and pain severity accurately.
The current study has some limitations. First, we studied only fe-
male workers in the hazelnut selection department, as the workers in
this department were mostly female gender. Therefore, the results
cannot be generalized to all hazelnut factory workers. Second, we asked
the participants whether they experienced WMSDs in the past 12
months. Due to recall bias, the participants may have reported the
WMSDs with lower prevalence than in reality. Third, there was a lack of
evaluation of spinal twisting and bending, which are risk factors for
WMSDs. Fourth, the variability of working postures within the same
subject across the time did not evaluate. All limitations may be ad-
dressed in further studies.
5. Conclusions
In the present study, we showed that high prevalence of WMSDs for
at least one body part among workers in a hazelnut factory. The most
common complaints were related to the lower back, neck, shoulder and
upper back, respectively. Ergonomic environment and perceived
workload were related to the severity of LBP and neck pain, while the
head posture during working was associated with neck pain severity.
Moreover, the shoulder and upper back pain severity were correlated
with thoracic kyphosis angle in the working position. Lastly, no WMSDs
were associated with stress in daily life, work satisfaction, and lumbar
lordosis angle, but LBP severity was correlated with stress in the
workplace. These findings are important in determining risk factors of
WMSDs, accessing preventive methods and reducing injuries.
According to the findings in the present study, to alleviate the effects of
WMSDs in hazelnut factory workers, the awkward working posture
could be corrected by postural awareness, exercise or adjustment of the
working environment. In addition, it might be recommended that the
physical activity level is increased and postural exercises performed to
decrease pain severity, along with relaxation exercises to cope with
stress in the workplace.
Conflict of interest
The authors declare that there are no possible conflicts of interest.
Acknowledgment
The authors would like to thank the management of the hazelnut
factory and all employees.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
7
International Journal of Industrial Ergonomics 74 (2019) 102838
doi.org/10.1016/j.ergon.2019.102838.
References
Abaraogu, U.O., Ezeukwu, A.O., Igwe, S.E., 2015. Prevalence of work-related muscu-
loskeletal discomfort and its impact on activity : A survey of beverage factory workers
in Eastern Nigeria. Work 52, 627–634. https://doi.org/10.3233/WOR-152100.
Abraha, T.H., Demoz, A.T., Moges, H.G., Ahmmed, A.N., 2018. Predictors of back dis-
order among Almeda textile factory workers, North Ethiopia. BMC Res. Notes 11,
304. https://doi.org/10.1186/s13104-018-3440-4.
Afshari, D., Mazloumi, A., Nourollahi-darabad, M., Nasl, G., 2018. Effect of neck posture
on cervicothoracic loads in overhead crane operators. Int. J. Occup. Saf. Ergon. 1–7.
https://doi.org/10.1080/10803548.2018.1458436.
Akbal, A., Eroğlu, P., Yılmaz, H., Tutkun, E., 2012. Occupational exposures and muscu-
loskeletal system findings. J. Phys. Med. Rehabil. Sci. 15, 73–76.
Akgöl, A., 2016. Elle taşima yapan işçi ̇ lerde
̇ ergonomik̇ farkindalik oluşturma ve kas is- ̇
̇
kelet sistemi ̇ rahatsizliklarini önlemeye yönelik̇ iki
̇ ̇ farkli eğiti
̇ ṁ yöntemini
̇ ṅ karş-
ilaştirilmasi. Hacettepe University.
Amorim, A.B., Levy, G.M., Pérez-Riquelme, F., Simic, M., Pappas, E., Dario, A.B., Ferreira,
M.L., Carrillo, E., Luque-Suarez, A., Ordoñana, J.R., Ferreira, P.H., 2017. Does se-
dentary behavior increase the risk of low back pain? A population-based co-twin
study of Spanish twins. Spine J. 17, 933–942. https://doi.org/10.1016/j.spinee.2017.
02.004.
Anderson, V., Burt, S., Cole, L., Estill, C., Fine, L., Grant, K., Gjessing, C., Jenkins, L.,
Hurrell, J., Nelson, N., Pfirman, D., Roberts, R., Stetson, D., Haring-Sweeney, M.,
Tanaka, S., 1997. Musculoskeletal Disorders and Workplace Factors. National
Institute for Occupational Safety and Health.
Anyfantis, I.D., Biska, A., 2018. Musculoskeletal disorders among Greek Physiotherapists :
traditional and emerging risk factors. Saf. Health Work 9, 314–318. https://doi.org/
10.1016/j.shaw.2017.09.003.
Ariëns, G.A.M., Van Mechelen, W., Bongers, P.M., Bouter, L.M., Van Der Wal, G., 2000.
Physical risk factors for neck pain. Scand. J. Work Environ. Health 26, 7–19. https://
doi.org/10.5271/sjweh.504.
Avcı, I., Erdoğan, T., 2015. Fındık fabrikasında çalışan işçilerde obezite sıklığı ve sağlıklı
yaşam alışkanlıklarının değerlendirilmesi. TAF Prev. Med. Bull. 14, 364–369. https://
doi.org/10.5455/pmb.1-1429384189.
Berberoǧlu, U., Tokuç, B., 2013. Work-related musculoskeletal disorders at two textile
factories in Edirne, Turkey. Balkan Med. J. 30, 23–27. https://doi.org/10.5152/
balkanmedj.2012.069.
Caneiro, J.P., O'Sullivan, P., Burnett, A., Barach, A., O'Neil, D., Tveit, O., Olafsdottir, K.,
2009. The influence of different sitting postures on head/neck posture and muscle
activity. Man. Ther. 15, 54–60. https://doi.org/10.1016/j.math.2009.06.002.
Choobineh, A., Tabatabaee, S.H., Behzadi, M., 2009. Musculoskeletal problems among
workers of an Iranian sugar-producing factory musculoskeletal problems among
workers of an Iranian sugar-producing factory. Int. J. Occup. Saf. Ergon. 15, 419–424.
https://doi.org/10.1080/10803548.2009.11076820.
Colantoni, A., Cecchini, M., Monarca, D., Bedini, R., Riccioni, S., Dafne, E., 2013. The risk
of musculoskeletal disorders due to repetitive movements of upper limbs for workers
employed in hazelnut sorting. J. Agric. Eng. XLIV, 649–654. https://doi.org/10.
4081/jae.2013.s2.e130.
Corlett, E.N., 2006. Background to sitting at work: research-based requirements for the
design of work seats. Ergonomics 49, 1538–1546. https://doi.org/10.1080/
00140130600766261.
Costa, B.R., 2010. Risk factors for work-related musculoskeletal Disorders : a systematic
review of recent longitudinal studies. Am. J. Ind. Med. 53, 285–323. https://doi.org/
10.1002/ajim.20750.
Council, N.R., 1999. Work-related Musculoskeletal Disorders: Report, Workshop
Summary, and Workshop Papers. The National Academies Press, Washington.
https://doi.org/10.17226/6431.
Falla, D., Oleary, S., Farina, D., Jull, G., 2011. Association between intensity of pain and
impairment in onset and activation of the deep cervical flexors in patients with
persistent neck pain. Clin. J. Pain 27, 309–314. https://doi.org/10.1097/AJP.
0b013e31820212cf.
Griegel-Morris, P., Larson, K., Mueller-Klaus, K., Oatis, C.A., 1992. Incidence of common
postural abnormalities in the cervical, shoulder, and thoracic regions and their as-
sociation with pain in two age groups of healthy subjects. Phys. Ther. 72, 425–431.
Hildebrandt, V., Bongers, P., van Dijk, F., Kemper, H., Dul, J., 2001. Dutch
Musculoskeletal Questionnaire : description and basic qualities. Ergonomics 44,
1038–1055. https://doi.org/10.1080/00140130110087437.
Kahraman, T., Genç, A., Göz, E., 2016. The Nordic Musculoskeletal Questionnaire: cross-
cultural adaptation into Turkish assessing its psychometric properties. Disabil.
Rehabil. 38, 2153–2160. https://doi.org/10.3109/09638288.2015.1114034.
Kim, E., Nakata, M., 2014. Work-related musculoskeletal disorders in Korea and Japan : a
comparative description. Ann. Occup. Environ. Med. 26, 1–7. https://doi.org/10.
1186/2052-4374-26-17.
Kirkhorn, S.R., Earle-Richardson, G., Banks, R.J., 2010. Ergonomic risks and muscu-
loskeletal disorders in production agriculture: recommendations for effective re-
search to practice. J. Agromed. 15, 281–299. https://doi.org/10.1080/1059924X.
2010.488618.
Kılıç, O., Alkan, I., 2006. The developments in the world hazelnut production and export,
the role of Turkey. J. Appl. Sci. 6, 1612–1616.
Kocur, P., Wilski, M., Lewandowski, J., Lochynski, D., 2019. Female office workers with
moderate neck pain have increased anterior positioning of the cervical spine and
stiffness of upper trapezius myofascial tissue in sitting posture. PM&R 11, 476–482.
https://doi.org/10.1016/j.pmrj.2018.07.002.
S. Acaröz Candan, et al.
Kuorinka, I., Jonsson, B., Kilbom, A., Vinterberg, H., 1987. Standardised Nordic
Questionnaires for the Analysis of Musculoskeletal Symptoms. pp. 233–237.
Kwon, Y., Kim, J., Heo, J., Jeon, H., Choi, E., 2018. The effect of sitting posture on the
loads at cervico-thoracic and lumbosacral joints. Technol. Health Care 26, 409–418.
https://doi.org/10.3233/THC-174717.
Labbafinejad, Y., Danesh, H., Imanizade, Z., 2017. Assessment of upper limb muscu-
loskeletal pain and posture in workers of packaging units of pharmaceutical in-
dustries. Work 56, 337–344. https://doi.org/10.3233/WOR-172495.
Labbafinejad, Y., Imanizade, Z., Danesh, H., 2016. Ergonomic risk factors and their as-
sociation with lower back and neck pain among pharmaceutical employees in Iran.
Work Health Saf. 64, 586–595. https://doi.org/10.1177/2165079916655807.
Leroux, M.A., Zabjek, K., Simard, G., Badeaux, J., Coillard, C., Rivard, C.H., 2000. A
noninvasive anthropometric technique for measuring kyphosis and lordosis: an ap-
plication for idiopathic scoliosis (Phila. Pa. 1976). Spine 25, 1689–1694. https://doi.
org/10.1097/00007632-200007010-00012.
Merino, G., Mattos, D., Guimarães, B., Merino, E., 2019. International Journal of
Industrial Ergonomics Ergonomic evaluation of the musculoskeletal risks in a banana
harvesting activity through qualitative and quantitative measures , with emphasis on
motion capture ( Xsens ) and EMG. Int. J. Ind. Ergon. 69, 80–89. https://doi.org/10.
1016/j.ergon.2018.10.004.
Nachemson, A., 1966. The load on lumbar disks in different positions of the body. Clin.
Orthop. Relat. Res. 45, 107–122.
Nejati, P., Lotfian, S., Moezy, A., Nejati, M., 2015. The study of correlation between
forward head posture and neck pain. Int. J. Occup. Med. Environ. Health 28,
295–303. https://doi.org/10.13075/ijomeh.1896.00352.
Nordander, C., Ohlsson, K., Balogh, I., Hansson, G., Axmon, A., Persson, R., Skerfving, S.,
2008. Gender differences in workers with identical repetitive industrial tasks : ex-
posure and musculoskeletal disorders. Int. Arch. Occup. Environ. Health 81,
939–947. https://doi.org/10.1007/s00420-007-0286-9.
Otoshi, K., Takegami, M., Sekiguchi, M., Onishi, Y., Yamazaki, S., Otani, K., Shishido, H.,
Kikuchi, S., Konno, S., 2014. Association between kyphosis and subacromial im-
pingement syndrome: LOHAS study. J. Shoulder Elb. Surg. 23, e300–e307. https://
doi.org/10.1016/j.jse.2014.04.010.
Pinar, T., Cakmak, Z.A., Saygun, M., Akdur, R., Ulu, N., Keles, I., Saylam, H.S., 2013.
Symptoms of musculoskeletal disorders among ammunition factory workers in
Turkey. Arch. Environ. Occup. Health 68, 13–21. https://doi.org/10.1080/
19338244.2011.627893.
Porto, A.B., Okazaki, V.H.A., 2018. Thoracic kyphosis and lumbar lordosis assessment by
radiography and photogrammetry: a review of normative values and reliability. J.
International Journal of Industrial Ergonomics 74 (2019) 102838
Manip. Physiol. Ther. 41, 712–723. https://doi.org/10.1016/j.jmpt.2018.03.003.
Porto, A.B., Okazaki, V.H.A., 2017. Procedures of assessment on the quantification of
thoracic kyphosis and lumbar lordosis by radiography and photogrammetry: a lit-
erature review. J. Bodyw. Mov. Ther. 21, 986–994. https://doi.org/10.1016/j.jbmt.
2017.01.008.
Punnett, L., Wegman, D.H., 2004. Work-related musculoskeletal disorders : the epide-
miologic evidence and the debate. J. Electromyogr. Kinesiol. 14, 13–23. https://doi.
org/10.1016/j.jelekin.2003.09.015.
Saidu, I.A., Utti, V.A., Jaiyesimi, A.O., Rufa’i, A.A., Maduagwu, S.M., Adezieonuwe, H.,
Jajere, A.M., 2011. Prevalence of musculoskeletal injuries among factory workers in
kano metropolis, Nigeria. Int. J. Occup. Saf. Ergon. 17, 99–102. https://doi.org/10.
1080/10803548.2011.11076874.
Salahzadeh, Z., Maroufi, N., Ahmadi, A., Behtash, H., Razmjoo, A., Gohari, M.,
Parnianpour, M., 2014. Assessment of forward head posture in females: observational
and photogrammetry methods. J. Back Musculoskelet. Rehabil. 27, 131–139. https://
doi.org/10.3233/BMR-130426.
Singla, D., Veqar, Z., 2017. Association between forward head, rounded shoulders, and
increased thoracic kyphosis: a review of the literature. J. Chiropr. Med. 16, 220–229.
https://doi.org/10.1016/j.jcm.2017.03.004.
Singla, D., Veqar, Z., Hussain, M.E., 2017. Photogrammetric assessment of upper body
posture using postural angles: a literature review. J. Chiropr. Med. 16, 131–138.
https://doi.org/10.1016/j.jcm.2017.01.005.
Thetkathuek, A., Meepradit, P., Sa-ngiamsak, T., 2018. A cross-sectional study of mus-
culoskeletal symptoms and risk factors in Cambodian fruit farm workers in eastern
region , Thailand. Saf. Health Work 9, 192–202. https://doi.org/10.1016/j.shaw.
2017.06.009.
Tous, J., 2005. Hazelnut production in Spain. Acta Hortic. (Wagening.) 686, 659–664.
https://doi.org/10.17660/ActaHortic.2005.686.87.
Van Niekerk, S.M., Louw, Q., Vaughan, C., Grimmer-Somers, K., Schreve, K., 2008.
Photographic measurement of upper-body sitting posture of high school students: a
reliability and validity study. BMC Muscoskelet. Disord. 9, 1–11. https://doi.org/10.
1186/1471-2474-9-113.
Waongenngarm, P., Rajaratnam, B.S., Janwantanakul, P., 2016. Internal oblique and
transversus abdominis muscle fatigue induced by slumped sitting posture after 1 hour
of sitting in office workers. Saf. Health Work 7, 49–54. https://doi.org/10.1016/j.
shaw.2015.08.001.
Yoo, W.-G., An, D.-H., 2009. The relationship between the active cervical range of motion
and changes in head and neck posture after continuous VDT work. Ind. Health 47,
183–188. https://doi.org/10.2486/indhealth.47.183.