Kurume Medical Jownal, 52, 199-146, 2005 inal Contribut Musculoskeletal Disorders among Chinese Medical Students DEREK R. SMITH, NING WEI*, TATSUYA ISHITAKE** AND RUI-SHENG WANG Department of Hazard Assessment, National Insitute of Industrial Health, Kawasaki 214-8585, Japan, * Department of Medical Psychology, Hebei Medical University, Shijiazhuang 050051, China and ** Department of Environmental Medicine, Kurume University School of Medicine, Karume 830-001, Japan Received 31 January 2005, accepted 19 October 2005 ‘Summary: We investigated the prevalence and distribution of Musculoskeletal Disorders (MSD) among Chinese medical students, by means of a questionnaire survey. A total of 207 questionnaires were suc- cessfully retuned, giving a high response rate of 92.4%. The MSD period-prevalence at any body site was 67.6% in the previous year and 46.9% in the previous week. Almost one-third of them (31.9%), reported an ‘ongoing MSD. By individual body site, the most commonly affected region was the lower back (40.1% in the last year, followed by the neck (33.8%) and shoulders (21.7%). The 7 day period-prevalence also followed a similar descending patter, being reported by 20.8% at the lower back and 12.1% at both the neck and knees. MSD affected the daily life of students for an average period of 53.8 days, with an average of 6.6 sick days. taken from school. Students reporting high mental pressure were 2.9 times more likely to suffer low back pain inthe previous 12 months (OR 2.9, 95%CI | 4-5.9, P=0.0030), Overall, our study suggests that Chinese ‘medical students are at reasonable MSD risk, although it is probably lower than for working physicians Further investigations are now recommended to elucidate the MSD mechanisms and contributory factors among medical students in China, as elsewhere. A longitudinal study of MSD among a complete group of ‘medical students would be very useful in this regard, Key words me: INTRODUCTION Musculoskeletal Disorders (MSD) represent one of the most common occupational problems in devel- ‘oped countries. Newly developing regions such as China are also beginning to show reasonably high rates of this disease [1-3]. Health Care Workers (HCW) are a regularly-affected occupational sub- group, and this phenomena has been demonstrated among both nurses [4,5] and doctors [6,7] in various parts of the world. MSD are not only confined to the working population however, as they may also affect young people [8] and university students [9-12] on a regular basis. Despite this emerging evidence, no studies have yet investigated MSD prevalence among, Corresponding Author: Dr, Derek R. Smith, Department of Hazard Assessment, National Institute of Indust ical student, musculoskeletal disorder, low back pain, China, risk factor medical students; which is a particularly surprising oversight in the scientific literature. The current dearth of published studies may relate to the fact that investigating MSD among large groups presents methodological difficulties, especially when the sub- jects have no fixed work environment. As such, self- Teported surveys represent a cost-effective and con- venient method for collecting MSD information from Jarge and often dispersed groups [10-12]. Their validity and accuracy has also been shown to be acceptable for both the upper body [13] and lower back regions [14]. As many previous studies of MSD have utilised the Standardized Nordic Questionnaire [15], we considered this instrument appropriate for Chinese research. In recent years, the complicity of Health, 621-1 Nagao, Tama-Ku, Kawasaki 214-8585, Japan, Tel: (+81) 4-858.6111 Fax: 81) $4865.6124 E-mail: smith@nith jp Abbreviations: 9S%CT, 985% Confidence Intervals; MSD, Musculoskeletal Disorders; OR, Odds Ratios, Probability values140 SMITH ET AL various psychosocial factors has been demonstrated with regard to MSD [16,17], and as such, was also deemed worthy of inclusion within our investigation. ‘The aim of this project was therefore, to ascertain the prevalence, duration and risk factors for MSD among a previously understudied group of Chinese medical students. MATERIALS AND METHODS This study involved a retrospective analysis of MSD among a group of Chinese medical students. Data was gathered by means of a self-reporting ques- tionnaire, which was administered to all 4th year stu- dents at a university teaching hospital in Mainland China. The survey instrument was a simple, three- page anonymous form with questions requesting as age, sex, tobacco smoking, alcohol consumption, and whether they undertook any regular exercise every week. Regarding classification of variables, alcohol and tobacco consumption were classified as ‘current usage’ or not, without consumption levels. We chose this particular method, as we expected that the Chinese-language translation of ‘current usage’ would be most easily understood. We were also con- cerned that requesting alcohol and tobacco volume might be uncomfortable for students, and may have resulted in non-responses. Information on regular exercise, clinical practice and MSD-related sick eave were more straightforward however, and were requested as the number of hours per week, the num- ber of months at clinical practice and the number of sick days taken, respectively. MSD information was obtained using an updated version of the Standardised Nordic Questionnaire [15], which has been previously used in China for various MSD studies [2,4,5,11]. The survey instru- ment also included other questions adapted from pre- vious MSD studies of adolescents [8,9], as well as various psychosocial factors which have been shown to influence MSD development in recent years [16.17]. Two separate questions focussing on mental pressure and depression were included in this regard. ‘Our Chinese language questions defined high mental pressure and depression as broad categories of symp- toms relating to their studies (i.e. do you often suffer from depressive symptoms relating to your studies as a medical student). Our questionnaire contained a clearly-labelled anatomical diagram for ease of understanding, and defined MSD as an ache, pain or discomfort occurring within the shaded area over the Kurume Medical Journal Vol. 82, previous week, previous year, or whether it was ongoing. The English version was translated by an expert panel of bilingual medical professionals, before being back-translated and checked against the original. Ethical approval was obtained from an insti- tutional ethics committee, and the study was con- ducted in accordance with ethical standards appropri- ate to China. Questionnaires were distributed to all 4th year students during an appropriate lecture period, and collected at the end of each session, Informed consent was implied when students completed and returned their questionnaires. Students in years 1 to 3 were at a different facility to the hospital, and could not be included in our study. As the 5th year students had already begun clinical rotations away from our hospital, they were unable to be located and it was considered unethical t0 contact them individually. Overall, we were able to recruit a complete group of 224 hospital-based students, from whom 207 ques- tionnaires were received, giving a high response rate of 92.4%. Data was coded and entered into a common spreadsheet program before being analysed by statis- tical software. Descriptive statistics were calculated and the results expressed as prevalence rates by gen- der and duration of recall (I year, 1 week or ongo- ing), and also as a prevalence of the entire group. For initial analysis, demographic items were divided into medical students reporting MSD at any body site in the past 12 months (the MSD group) and medical students without MSD at any body site in the past 12 months (the non-MSD group). Statistically signifi- cant differences in MSD prevalence by gender and other demographic variables were investigated using Pearson's chi square test and Fisher's exact test (for discrete variables with cell counts above and below 5, respectively). Statistically significant differences in MSD prevalence for continuous variables were evaluated using one-way analysis of variance. An investigation of possible MSD isk factors was also considered worthwhile, as other investigations of similar student demographics have demonstrated cer- tain correlations in various countries [8-11]. AS Chinese medical students presumably have no occu- pational factors which could be investigated, it was considered that demographic items were the most appropriate alternative. Logistic regression was per- formed to ascertain any such correlations, with the results expressed as adjusted Odds Ratios (OR) and 95% Confidence Intervals (95%C1). We utilised Low Back Pain (LBP) as our variable of primary interest 0, 4, 2005MSD IN MEDICAL STUDENTS. ui during data analysis for a number of reasons. Firstly, the category ‘any MSD’ was found to be too com- mon for accurate statistical calculations. Secondly, although other individual body sites were also con- sidered for regression analysis, their respective cell counts (those cells with positive response for that particular item + MSD), were too low for a mean- ingful analysis. Therefore, LBP was chosen as the body site of interest during risk factor calculations. LBP was used as the dependent variable, with demo- graphic items used as the independent variables. The model was run with all variables simultaneously, to account for any potential interactions between them, Continuous variables were evaluated with increasing increments of I yr, 1 cm and 1 kg, respectively. Probability values below 0,05 were regarded as statistically significant throughout all analyses. RESULTS In this study, there were more females than males in the MSD reporting group (55.0% vs. 45.0%). Although alcohol consumption was higher in the MSD group (55.0% vs. 43.3%), tobacco smoking was not (4.3% vs. 7.5%). Average age, height, weight and Body Mass Index (BMI) were very similar between the two groups. Statistical tests indicated that the overall prevalence of MSD was not associated with any demographic items. Refer to Table 1. The MSD period-prevalence at any body site was 67.6% in the previous year and 46.9% in the previous week. Almost one-third of them (31.9%), reported an ongoing MSD. By individual body site, the most commonly affected region was the lower back (40.1% in the last year), followed by the neck (33.8%) and shoulders (21.7%). The 7 day period- prevalence also followed a similar descending pat- tem, being reported by 20.8% at the lower back and 12.1% at both the neck and knees. Refer to Table 2. MSD prevalence (in the past year and past week) varied by body site, when plotted with respect to gender (Figs 1 and 2). Statistically significant differ- ences in 12-month MSD prevalence were noted between male and female students at the neck (P=0.0096) and upper back (P=0.0454). Other correlations were also investigated. Regular exercise was undertaken by 25.0% of medical stu- dents in the MSD group and 35.8% of those in the non-MSD group. Clinical practice had begun for TABLE | Demographic items of medical students No MSD P Value © Percentage ** ‘Male 508% © 45.0% - Female 49.2% 55.0% 0.4382 Alcohol 433% 55.0% 0.1146 Tobacco 13% 43% 03404 ‘Mean Value ** Age (yn) 24 23 0.0827 Height (em) 167.1 1670 0.9471 Weight (ke) 60.1 593 0.5804 BMI (kg/m!) 21.4 213 ae ee Percentage of students in each category Students with any MSD in the previous 12-month « Statistical differences in MSD prevalence by category (calculated using Pearson's chi square test for discrete variables* and one-way analysis of variance for continuous variables **) TABLE2. MSD prevalence among medica students by body site and recall period Ts Ongoing Neck 70 338% 25 121% 18-87% Shoulders 45 217% Mo 68% 10 48% Upper Back 30 ase DR 58% 7 33% Eows Mo 33% 4 19% 4 be Wess Mo 6am 7 82% 4 68% Lower Back 401% 2B 203% 3 119% Upper Lees 35 169% 2B LG 4 68% Kress 37 19% 25 i2t 18 87% eee B IS9e RRR AR ‘Any Body Site” —_—«140—_—67.6% 7 69% 6 39% : Figures are expressed as a percentage of all students (N=207) Any Musculoskeletal Disorder (MSD) at any body site Kurume Medical Journat Vol. 52, No. 4, 2005a2 SMITH ET AL, Fig. 1. MSD among medical students in the past year by gender and body site. * Statistically significant differences in MSD prevalence by gender evaluated using the chi square test and Fisher's exact test (P< 005). Fig. 2. MSD among medical students in the past ‘week by gender and body site. No statistically signfi- ‘cant differences in MSD prevalence by gender when evaluated using the chi square test and Fisher's exact test. TABLE 3. Demographic correlates among medical students by MSD status aie NoMSD* _MSD* : NoMSD* _MSD= e ariables ee eA Wes Mew Pale Regular Exercise (hrs) 358%" 25.0% 0.1066 48h" 40hrs 0.3134 Cinical Practice (mnth) 80.6% 65.0% 0.0219 2thrs — 2.0hrs 0.0975 Mental Pressure (y/a) 179% 29.3% 0.0793, - = = Depression (y/a) 15% 5.7% 0.1635 - 7 ~ MSD Affected Life (dys) O% = 11.6% - Odys — S38dys 045265 MSD Sick Leave (dys) 0% 10.1% - Odys —6.6dys 05240 undertook regular exercise) ‘mean of 4.8 hrs exercise per week) ' Percentage of students expressing each variable in each category (*for example, 35.8% of students with ne MSD : Statistcally-significant differences between categorical variables calculated using Pearson's chi square test. : Percentage of students expressing each variable in each category (** for example, students with no MSD undertook a Statistially-significant differences between continuous variables calculated using one-way analysis of variance TABLE 4, Correlations between demographic items and LBP among modical students Proportion Correlates z = Male Gender * 38 18.4% Mental Pressure © 30 145% Depression * 6 29% ‘Aleohol Drinker © 48 23.2% ‘Tobacco Smoker 4 1.99% Regular Exercise © 2 10.6% Clinical Practice * 52 25.1% Increasing Age 207 100% Increasing Height * 207 100% Increasing Weight = 207 100% ic Regression” OR (@5%CD P Value 06 02-16) 0.3089 29 (1.4.5.9) 0.0030 La 03-75) 0.7087 16 (0.83.2) 0.1765 09 023.6) 0.8779 09 (05-18) 0.8016 06 03-11) 0.0981 os (0.043.6) 0.4179 07 (0.05-8.2) 0.7620 Ll (0.07-18.9) 0.9615 ‘Expressed as adjusted Odds Ratios (OR) with 95% Confidence Intervals (95%CD, »: Percentage of students in each subcategory ( « Caleulated as dichotomous variables (no: OR 207) 0) % Calculated as dichotomous variables (do not or have not: OR 0) * Caleulated as continuous variables, with increasing increments of I yr, 1em and 1 kg. Kurume Medical Journal Vol, 62, No, 4, 2005MSD IN MEDICAL STUDENTS. a3 65.0% of students in the MSD group and 80.6% in the non-MSD group (P=0.0219). High mental pres- sure and depression was reported by 29.3% and 5.7% of the MSD group, and 17.9% and 1.5% of the non- MSD groups, respectively. Neither of these items were correlated with MSD. Because we collected data on regular exercise and MSD-related sick leave in two ways (discrete: yes / no, and continuous: if yes, how long), statistically significant differences were evaluated separately. The average period of regular exercise conducted per week was 4.0 to 4.8 hrs, and the average period of clinical practice was 2.0 to 2.1 months. MSD affected the daily life of students for an average period of 53.8 days (the median value was however, only 4 days). The aver- age number of sick days taken for an MSD was 6.6 days (median 3.0 days) (Table 3). Logistic regression revealed no risk factors for any MSD in either of the 3 categories (last year, last week or ongoing MSD). We therefore conducted a logistic regression analysis of risk factors for the most commonly affected body site (low back). In this regard, Table 4 shows the risk factors for Low Back Pain (LBP), where a statisti- cally significant correlation was found. Students reporting high mental pressure were 2.9 times more likely to suffer LBP in the previous 12 months (OR 2.9, 95%CI 1.4-5.9, P=0.0030).. DISCUSSION ‘As our study was the first MSD investigation conducted among Chinese medical students, there is very little data with which to directly compare it Nonetheless, physicians who have already graduated may be a reasonable referent group, as their age and experiences would presumably be similar to the student group, particularly when considering senior ‘medical students. In this regard, there appear have been two MSD studies conducted among working physicians in Japan [6] and the Netherlands [7]. In these investigations, it was revealed that Japanese orthopaedic surgeons and general surgeons reported MSD most frequently at the lower back region (affecting 50% and 36.5% of them, respectively) [6] Although our Chinese medical students reported MSD most commonly at the lower back, their 12 month period-prevalence (40.1%) was less than that reported by Japanese orthopaedic surgeons (50%) [6]. Interestingly, in the Netherlands, van Doom [7] documented how physicians were at the lowest risk for claiming low-back disability insurance, when compared to veterinarians, dentists and physical therapists. A previous survey of LBP among young Australians also documented a lower LBP rate, being reported by only 34% of them at some point in the previous year [8]. Other research conducted among nursing students has also revealed lower rates of LBP in China (28.1%) [11] and Japan (13.5%) [12]. On the other hand, Australian nursing students seem to suffer from LBP at higher rates than their Chinese medical counterparts (59.2%) [10] Differences in MSD prevalence rates between medical students in our study and those of others, is difficult to explain conclusively. Nevertheless, idio- syncratic differences in health-promoting behaviour may have influenced the results. For example, Najem et al. [18] documented how graduate nursing students had the highest prevalence of tobacco smoking when compared to medical and dental undergraduates. In the same study, the authors also showed that medical students exercised more frequently than either the dental students or nursing students. Similarly, Coe et al. [19] also found that medical students engaged in more regular health-promoting behaviour than law students at the same university. It is conceivable therefore, that increased health-promoting behaviour among medical students may offer a protective affect against MSD at various body sites. In this regard, we found that a greater proportion of medical students without MSD (35.8% of them) exercised regularly, when compared to those with MSD (where only 25% exercised regularly). Differences in MSD prevalence rates between medical students and working physi- cians were also noted in our current study, and prob- ably reflect the occupational stressors of medical work. Although Kant et al. [20] suggested that work- postures of ear-nose-throat surgeons or general sur- geons in the Netherlands were probably not harmful, some still needed improvement. The recognised MSD risk among working surgeons probably relates to static work postures in the operating theatre (20). Other ergonomic studies conducted among hospital nurses have also shown elevated MSD rates within surgical departments [21]. However, as medical stu- dents would presumably being undertaking only a limited amount of surgical work (if any at all) these biomechanical factors may not be applicable in our study. Nevertheless, the importance of manual handling and MSD has been documented among Chinese health care workers in Taiwan (22], suggest- ing that the complicity of these factors cannot be completely dismissed during Asian student investiga- tions, such as ours. Suboptimal health behaviours may also be an Kurume Medical Journal Vol. 52, No. 4 2005important consideration for medical students, as previous researchers have described how young Australian doctors tend to give their healthcare a low priority [23]. On the other hand, medical students probably spend more time on computers and doing deskwork than physicians, which may have influ- enced the distribution or severity of their reported MSD symptoms. In this regard, previous research has suggested that studying ‘Computer Science’ may be associated with an increased MSD risk among university students [9]. Chinese medical stu- dents in the current study reported a 12-month peri- ‘od-prevalence of neck-related MSD (33.8%) which was similar to the rate documented among Japanese physicians (between 20.6% and 38.9%) [6]. This was lower than a previous study of American college stu- dents, where more than half of them (53%) reported MSD of the upper-body, particularly after using a computer (9]. On the other hand, previous research con-ducted among Australian nursing students found a very similar 12-month period-prevalence as ours (34.6%) [10]. Interestingly, shoulder-related MSD was reported by 21.7% of our medical students, which was lower than that reported by Japanese orthopaedic surgeons (31.5%) [6] and Australian nursing students (23.8%) [10]. It was however, higher than the rate reported by and Japanese general surgeons (17.5%) [6]. Again, the reasons for these differences and similarities are difficult to explain conclusively, and will need to be ascertained with more extensive research. Statistical analysis of our data provided some interesting findings. Basic investigation with Pearson's chi square and Fisher's Exact tests showed that most demographic items did not differ signifi- cantly between those students reporting MSD and those who did not. This is contrary to some previous studies of university students. An Australian study of nursing students for example, revealed statistically significant differences in MSD prevalence rates between males and females, with males having the highest rates [10]. Similarly, research conducted upon American college students also found that females incurred an elevated risk for MSD of the upper body [9]. Age showed no relationship MSD, which is contrary to a previous study of Japanese doctors, where junior orthopaedic surgeons were at higher risk of MSD at certain body sites [6]. Alcohol and tobacco consumption was not related to ‘an increased risk of any MSD among our Chinese students, despite previous research suggesting a strong association between musculoskeletal-related SMITH ET AL, injury and smoking within certain occupational groups [24]. Clinical practice was shown to be associated with MSD reporting among our students, which may suggest the complicity of manual medical work. Participation in regular exercise showed no relationship with MSD, which is contrary to a pre- vious study of American university students, where participation in athletics offered a protective effect against MSC of the upper body [9]. It is possible that this lack of association may have related to our broad categorization of the term ‘exercise’, rather than dividing it into separate levels such as walking, jogging, running and so on. As such, future longitu- dinal studies of MSD should now be conducted among Chinese students, and ones which may care- fully consider the exact type of exercise undertaken. Other psychosocial factors, such as high mental pressure and regular depression were not related to MSD during simple statistical tests. However, a com- prehensive regression model did reveal that high ‘mental pressure was a significant MSD risk factor at the lower back. Students were almost 3 times as likely to report LBP if they experienced high mental pressure at school. This finding reflects an increasing body of research, implicating psychosocial factors as MSD tisk correlates [4,5,16,17]. Nevertheless, the reasons for these statistical associations are difficult to ascertain conclusively, as not all of our identified MSD correlates were consistent with previous esearch, One issue may relate to temporality, particularly with respect to depression and mental pressure. Although we showed that mental pressure ‘was a statistically-significant correlate for MSD and may thus be a risk factor, itis also possible that stu- dents already suffering MSD would experience high mental pressure. Another issue may relate to the relative homogeneity of student sample. As we only surveyed a single grade, many of their intrinsic and extrinsic influences were probably very. similar. Medical school usually takes 5 years in China, and for the current study, we could only gain access to a single year. ‘On the other hand, our sample size (N=207) and response rate (92.4%) were both quite high, suggest- ing a reasonably accurate capture of information. It is also interesting to consider whether our sample size was adequate 10 establish statistical significance. Ina previous study of college students, Katz et al. [9] showed that between 3% and 7% of their sample suffered MSD following computer usage of various durations. Assuming that our Chinese students were roughly comparable and that between 10% and 15% Kurume Medical Journal Vol. 52, No.4, 2005MSD IN MEDICAL STUDENTS. Mas of them might report similar symptoms, a power cal- culation can be established. Using the methodology proposed by Naing [25] and adopting a confidence interval of 95%, the required sample size to reach statistical significance would be 138 (if the preva- lence was 10%) and 196 (if it were 15%). Therefore, with 207 students, we believe that our methodology would have been adequate to accurately detect differ- ences in many of the tests. As some of the reported prevalence rates were over 15% however, further research with larger sample sizes would be appropri- ate among medical students in China, as elsewhere. Another consideration when interpreting our data is the intrinsic limitation of self-reporting. surveys, and the fact that what people report may differ from their actual situation. Nevertheless, we believe that ‘medical students would be in ideal position to under- stand not only the definitions we used, but also the value of accurately and truthfully answering ques- tionnaire-based health surveys. They would also be in a reasonably good position to determine when rest or medical treatment is required, due to their acquired medical knowledge. A final consideration is survey validity, although we were careful to utilize a well- established instrument (the Nordic Questionnaire) [15], which has previously been used in a variety of international investigations. The recall periods in the current study (I week, 1 year and ongoing) were also consistent with other student investigations [8-11]. As such, we feel that our research offers a reasonably accurate assessment of MSD among Chinese medical students, and one which may now be used as a base- line for future international investigations of similar cohorts. CONCLUSION Overall, our study suggests that Chinese medical students are at reasonable MSD risk, although it is probably lower than for working medical doctors. Further investigations are now recommended to elu- cidate the MSD mechanisms and contributory factors among medical students in China, as elsewhere. A longitudinal study of MSD among a complete group of medical students would be very useful in this regard. ACKNOWLEDGMENTS: We are grateful to all the medical students who completed our questionnaire. 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