International Journal of Occupational Safety and

Ergonomics

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

Job Stress Dimension and Work-related

Musculoskeletal Disorders among Southeast
Nigeria Physiotherapists

Ukachukwu Okoroafor Abaraogu, Charles Ikechukwu Ezema & Chinenye

Kosisochukwu Nwosu

To cite this article: Ukachukwu Okoroafor Abaraogu, Charles Ikechukwu Ezema & Chinenye
Kosisochukwu Nwosu (2016): Job Stress Dimension and Work-related Musculoskeletal
Disorders among Southeast Nigeria Physiotherapists, International Journal of Occupational
Safety and Ergonomics, DOI: 10.1080/10803548.2016.1219476

To link to this article: http://dx.doi.org/10.1080/10803548.2016.1219476

Accepted author version posted online: 03

Aug 2016.
Published online: 03 Aug 2016.

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 Page 1 of 9

Publisher: Taylor & Francis & Central Institute for Labour Protection – National Research Institute
(CIOP-PIB)
Journal: International Journal of Occupational Safety and Ergnomics
DOI: 10.1080/10803548.2016.1219476

Title: Job Stress Dimension and Work-related Musculoskeletal Disorders among Southeast Nigeria
Physiotherapists
Authors: Ukachukwu Okoroafor Abaraogu,* Charles Ikechukwu Ezema, Chinenye Kosisochukwu
Nwosu.
Affiliation (all authors): Department of Medical Rehabilitation, University of Nigeria, Enugu Campus,
Nigeria
* Corresponding author
Correspondence: Ukachukwu Okoroafor Abaraogu, Department of Medical Rehabilitation University of
Downloaded by [Stephen F Austin State University] at 06:04 04 August 2016

Nigeria Enugu Campus, 40006 Enugu Nigeria, ukachukwu.abaraogu@unn.edu.ng (uabaraogu@yahoo.com,

abaraogu01@yahoo.com)
+234(0) 8063582105
Chinenye Kosisochukwu Nwosu Sochima.nwosu@yahoo.com
Charles Ikechukwu Ezema gloryzemas@yahoo.com
Abstract
Background: Although publications describe physical demands of job in the physiotherapy profession,
there is dearth of literature on job stress dimensions (JSDs), and their relationship to work-related
musculoskeletal disorders (WMSDs). Objective: To investigate JSDs and their relationship to WMSDs
among physiotherapists currently practicing in southeast Nigeria. Method: A Cross-sectional study using
items related to the Job Content Questionnaire and the Nordic musculoskeletal questionnaire. Data were
summarized with descriptive statistics, and the relationship between WMSDs and JSDs was analyzed
with the Mann–Whitney U test. Results: A total of 126 physiotherapists responded. There were high
levels of stress in most of all job dimensions investigated. 82.1% and 22.8% of the physiotherapists had
WMSDs in at least one body region in the last 12 months and the last 7 days respectively. The lower back
was the most commonly affected in both periods. No specific domain was related to the development of
WMSDs. Conclusion: Over 80% of physiotherapists in southeast Nigeria have WMSDs. However,
despite high levels of physical demands on the job, the physiotherapists have job control and good social
support. Intervention program aimed at reducing WMSDs in this group should focus on risk factors that
target the physical demands of the job.
Key Words: Job stress, Physiotherapists, Work-related musculoskeletal disorders, Nigeria
1. Background and Rationale
Health care workers, particularly those working in a hospital environment, experience job-related
stress.[1] Many studies of physiotherapists working in the hospitals reveal potential issues in the work
environment that cause job stress. These include the perception of a loss of control regarding job security,
lack of social support, psychological demands, and excessive physical demand.[2] Such issues have been
associated with a wide variety of poor outcomes, including work-related musculoskeletal disorders
(WMSDs).[3,4]
WMSDs are the most common cause of chronic pain and physical disability that affect contemporary
physiotherapy workforce.[5] WMSDs are defined as “musculoskeletal disorders (injuries or disorders of
the muscles, nerves, tendons, joints, cartilage, and spinal discs) in which the work environment and
performance of work contribute significantly to the condition; and/or the condition is made worse or
persists longer due to work conditions”.[6] It can also be seen as pain originating from muscles, tendons,
joint capsule, bursa, and bone lasting more than three days as a result of work. The health care is one of
the essential sectors in southeast Nigeria
Studies have reported that WMSDs significantly affect physiotherapists, causing them to take sick time,
change practice habits, change work settings, or leave the profession. [7] In addition, these studies have
reported a high prevalence of low-back pain as well as neck, neck, elbow, wrist, and hand pain. The
 Page 2 of 9

studies have also shown that physiotherapists are more susceptible than other health care providers to
these conditions because of their labor-intensive tasks.[8] The practice of physiotherapy is physically
demanding because it requires the therapist to perform repetitive tasks and use high force manual
techniques on patients. Such techniques exert direct pressure on specific joints of the physiotherapist,
require awkward positioning of the therapist’s joints during certain maneuvers, and demand prolonged,
constrained postures [9].
This study investigated aspects of job stress and their relationship to musculoskeletal disorders (MSDs) in
southeast Nigerian physiotherapists because the very high prevalence of MSDs in this population has
implications for the healthcare system in southeast Nigeria. The purpose of the study was to examine the
relationship between WMSDs and psychological job demands (or work-related stress) in southeast
Nigeria physiotherapists. Findings could guide the characterization of different dimensions of job stress
southeast physiotherapists experience and enabling tailored macro-ergonomic interventions to reduce
WMSDs in the physiotherapists.
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2. Methods
This was a cross-sectional survey conducted in hospitals (teaching, general, private, and government)
across the 5 states of southeast Nigeria. All licensed physiotherapists currently practicing physiotherapy
in southeast geo-political zone of Nigeria were invited to participate. A purposive sampling technique was
used so as to recruit only fully licensed physiotherapists, whether full or part time, working in both the
private and government sectors in southeast Nigeria.

This study used two questionnaires that investigated demographics, job content, and MSDs. The first
questionnaire was the Job Content Questionnaire (JCQ),[10] which was used to measure the dimensions
of job stress. This has been widely used to measure the social and psychological structure of the work
situation, with the reliability index of 0.63–0.86. [11,12] As the questionnaire was intended to be used
among clinical health professionals, 30 relevant items, covering the core set of items, from the full
version of the JCQ [10] were included following example from a previously publish research among
Iranian nurses.[13] The items are grouped into nine scales as follow: decision latitude (9 items),
psychological job demands (5 items), social support (8 items), physical job demands (5 items) and finally
job insecurity (3 items). Each item was scored based on a 4-point scale ranging from 1 = strongly
disagree or never to 4 = strongly agree or often. The scale calculations were performed in accordance to
the JCQ User’s Guide .[12] The second questionnaire was the Nordic questionnaire, designed by
Kuorinka et al., [14] which was used to examine reported cases of WMSDs among the study population.
Ethical approval was obtained from the Ethics and Research Committee of University of Nigeria
Teaching Hospital, Enugu. All participants signed the informed consent form applicable to the research
before being enrolled in the study and receiving the questionnaires.

2.1. Procedure for Data Collection

After obtaining institutional ethical approval, the authors obtained the directories of currently practicing
Nigerian physiotherapists from the secretariat of Nigerian Society of Physiotherapy (NSP). All
Physiotherapists were personally contacted, using the contact information in the directories. After the
authors and/or research assistants provided a detailed explanation of the purpose of the study and
expectations of study participants, all willing participants signed a voluntary written consent form, with
confidentiality assured.
Data were collected between May and June 2014 via hand delivery of questionnaires to physiotherapists
at hospital departments, clinics, and medical centres. Questionnaires were emailed to individuals who
administered them in places where the researchers could not be present. If no email address was available,
questionnaires were couriered to physiotherapy department heads, heads of clinics, or designated contact
physiotherapists. Upon delivery of a questionnaire to a respondent, the respondent’s gender, state, and
phone number were coded into the questionnaire by a research assistant and recorded for follow-up calls.
A reminder was sent to the respondents who did not complete their questionnaires after one week;
respondents were then further reminded by twice-weekly phone calls until the questionnaire was
 Page 3 of 9

completed. After a maximum of 4 weeks, the second authors or the research assistants personally
collected the completed questionnaires.
2.2. Data Analysis
The results were analyzed using SPSS version 20. The prevalence of MSDs was reported in frequency
and in percentages, while the mean and standard deviation of job stress dimensions were reported
according to criteria in the JCQ.[10] The Mann–Whitney U test was used to assess association between
job stress dimensions and reported MSD symptoms. In all tests, p ≤ 0.05 was considered significant at a
95% confidence interval.
3. Results
The records of the five eastern Nigerian state chapters of the Nigeria Society of Physiotherapy indicated
that at the time of the study, 176 fully registered physiotherapists were working in the five southeastern
states. 59 physiotherapists did not participate due to reasons ranging from less than 12 months of work
experience as fully registered physiotherapists (n = 36), on annual leave (14), away from work for a
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training or on maternity leave (n = 9). A further 12 physiotherapists declined to participate, offering no

specific reason. Interns, who did not have a full license to practice at the time of the study, and those who
had not worked for at least 1 year were excluded from the sample.
One hundred twenty-six of 143 eligible physiotherapists participated, yielding a response rate of 88.1%.
Demographic characteristics and baseline working characteristics of the physiotherapists are summarized
in Table 1 and Table 2. The respondents were young and fairly homogeneousregarding age, job
experience, and education.The mean (SD) age of the study population was 31.98(4.96years), and the
majority (65.7%) were male. Mean (SD) BMI was 25.36 (4.29). Over half of the respondents were single
(54.5%), and most (78.2%) had a Bachelor’s degree. Mean (SD) years of job experience was 4.79(4.0
years), mean (SD) number of hours worked per week was 35.78(15.87 h/week). Most held one job
(89.3%), worked full time (91.7%), and had no intention of changing jobs (66.1%). A high percentage of
responders had experienced some kind of MSD symptom during the last 12 months (82.1%), and 22.8%
had experienced MSDs during the last 7 days. The most commonly affected region was the lower back
(57.8% at 12 months and 20.7% at 7-day prevalence respectively).
The mean scores for each job stress dimension (JSD) are shown in Table 3. The minimum and maximum
attainable scores for each scale are also presented for comparison. In this table, lower scores in decision
latitude (control) and social support dimensions indicate higher stress. In contrast, higher scores in
psychological and physical job demands as well as job insecurity dimensions show higher stress. As
shown in this table, mean scores of job control(74.18), social support(24.58), and physical demand(3.63)
were high while mean score of job insecurity was low(4.45). The score for psychological demand was
moderate. Therefore, it can be concluded that job stress is related more to physical than psychological
factors of southeast Nigeria physiotherapists’ work. Mean scores of job stress dimensions in
physiotherapists with and without MSD symptoms within 12 months and 7 days are presented in Table 4.
These showed no significant difference in the mean scores for each of the domains of job stress
dimension scales between the physiotherapists with and without WMSD symptoms (p ≥ 0.05).

4. Discussion
The results showed that southeast Nigeria physical therapists experience high levels of physical demand
of job stress and moderate levels of psychological stress. The 82.1% prevalence of MSD symptoms
reported in this study indicates high prevalence of MSD symptoms. A similar prevalence has been
reported by Adegoke et al. [15] in Nigeria (91.3%), Cromie et al. [16] in Australia (91%), Glover et al. [5]
in the UK (68%), Salik&Ozcan [17] in Turkey (85%), suggesting that physiotherapists in general have a
high risk of MDS.
Lower back pain was the most common MSDs reported, followed neck pain. These findings accord with
the results described by Adegoke et al. in Nigeria.[15] Also, several researchers in the UK, [5] Kuwait,
[18] the USA, [19] Canada [20] also show a higher prevalence of MSDs in the lower back
inphysiotherapists. Based on these findings, one may infer that physiotherapists are exposed to risk
factors more associated with WMSDs affecting the lower back and neck.
 Page 4 of 9

This study, the first study in Nigeria that examines different psychosocial job dimensions associated with
WMSDs among physiotherapists, showed that although job demand, particularly physical job demand, is
high among the physiotherapists, psychological stress is moderate. The southeast Nigeria physiotherapists
felt they had the control over their job, enjoyed good social support, and therefore had low levels of job
insecurity. Because no national data concerning psychosocial job dimensions among occupational groups
in Nigeria exists, it is not possible to compare the results from this study to a national average. That
notwithstanding, Ibikunle et al.[21] reported that about 40% of Nigerian physiotherapists see their jobs as
stressful but did not provide dimensions for stress factors. Okwaraji and Aguwa[22] reported a high level
of burnout and psychological stress among Nigerian nurses, but this is not a fair comparison with our
research due to the dissimilarity of studies in tool and design used as well as population studies. However,
the results of this study show that compared with their counterparts in the USA, physiotherapists in
southeast Nigeria had higher physical demands but similar job control.[23] Similar to the physiotherapists
we studied, Iranian nurses reported high levels of physical and psychological demands; however they had
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low job security, job control and social support [13] unlike our respondents. The high level of physical
job demand in these workers is a concern because of its established relationship to poor health and work
outcomes. [3,4] Interestingly, the southeast Nigeria physiotherapists studied had good job control and
security as well as social support. The implication is that job control and security as well as the social
support enjoyed by the physiotherapists compensates for the physical stress associated with the
profession. Therefore, the results suggest that job stress in southeast Nigeria physiotherapists is related
more to physical than psychological factors.
In this study, a high level of physical demand was not associated with WMSDs. This is a rather surprising
finding because physical demand has been well documented as responsible for WMSDs in many
occupational groups, [24,25] including physiotherapists .[23] We had expected this association in the
light of the high prevalence of WMSDs in the physiotherapists. Perhaps another factor, not considered in
this study, is confounding the expected association between physical demand and WMSDs. Regardless,
the inability to compare our group of physiotherapists with a group of healthcare providers whose job
entails high physical load (such as nurses) who did not have WMSDs or reported low physical demand
makes it difficult to draw conclusions from these data.
The results showed no association in physiotherapists between psychological demand and WMSDs in any
of the body regions. This is also surprising because psychological job demands have been found to be
significantly associated with WMSDs among many occupational groups. [13, 24,26] This finding may
suggest higher than usual tolerance to psychological stress in physiotherapists in southeast Nigeria who
constantly face harsh psychological situations, as shown by their psychological stress score. It could also
mean that because WMSDs are very prevalent among this group, the possible association may have been
obscured.
Jones and Bright [27] described job control as employees' control over their tasks and how those tasks are
executed. High levels of decision latitude (job control) had no association with MSDs among the
physiotherapists. This contrasts with the results of Bugajska et al. [26] in which increased control showed
a statistically significant decrease in the risk of carpal tunnel syndrome ((p = 0.037). Campo et al.,[23]
Brazideh et al.,[13] and Skov et al.,[28] also reported that among physical therapists in America, nurses in
Iran, and sales people in Denmark respectively low levels of decision latitude (job control) were related to
WMSDs. The high decision latitude (job control) reported among physiotherapists in our study indicates
that southeast Nigeria physiotherapists have excellent control in execution of work related tasks.
Levels of job insecurity had no association with WMSDs among the physiotherapists, a finding which
disagrees with the reports of Lee et al.[24] among long-haul international female flight attendants, in
which showed an association between high levels of job insecurity and lower-back WMSDs. The low
level of job insecurity reported among southeast Nigeria physiotherapists may suggest a decreased burden
among this group and the may explain the dissociation between WMSDs and job insecurity.
5. Limitation
The particular limitation of the present study is the same size in light that no scientific derivation was
employed in determining the minimum sample. This was not possible in light of the not too large
 Page 5 of 9

population of the physiotherapists studied. Therefore a total sampling was deemed a best fit for a better
representation. Secondly, our design being cross-sectional could not establish causality between job stress
dimensions and WMSDs. Future studies should explore prospective design in studying this relationship in
this population.
6. Conclusions
The prevalence of work related MSDs among physiotherapists in southeast Nigeria is high. Physical and
psychological job demands are prevalent among these physiotherapists, but job stress is related more to
physical than psychological factors. In any case, the job stress dimensions are not associated with MSDs
among the physiotherapists. Interventional programs should be organized to prevent MSD symptoms in
the study population, and efforts made to reduce psychological and physical job demands at the
workplace. Importantly, there is a need for ergonomic guidelines for the clinical practice of physiotherapy
in Nigeria. Such guidelines can contribute to a reduction to of risk factors for MSDs and reduce the
prevalence of this condition. Further studies with a larger sample size, and more encompassing variables
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assessment including analysis of specific task variables are recommended. Although our respondents are
representative of Nigeria in terms of gender distribution of physiotherapists,[29] future studies should
include the entire country so that wider age and years of practice distribution could give a more inclusive
evidence regarding all physiotherapists in Nigeria.
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 Page 7 of 9

Table 1: Personal characteristics of participants (n = 126)

Age M(SD) 31.98(4.96)
Job experience M(SD) 4.79(4.03)
Work h/week M(SD) 35.78(15.87)
BMI M(SD) 25.36(4.29)
Gender n (%)
Male 76(65.7)
Female 49(34.3)
Marital status n (%)
Single 67(54.5)
Married 55(44.7)
Separated 00(0.0)
Other 1.0(0.8)
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Educational level n (%)

Degree 97(78.2)
Postgraduate 28 (21.8)
Second job n (%)
Yes 13(10.7)
No 108(89.3)
Working status n( %)
Full time 111 (91.7)
Part time 10 (8.3)
Intention to change job (n %)
Yes 40 (33.9)
No 78 (66.1)
Note: missing values are evident as physiotherapists did not respond to certain items. BMI = body mass
index.

Table 2: Prevalence of work-related musculoskeletal disorders among participants

12-month prevalence 7-day prevalence
Body region n % n %

At least one body region 101 82.1 28 22.8

Neck 49 41.9 11 15.5

Shoulder 34 30.1 9 14.3

Elbow 12 10.8 3 4.9
Wrist/hands 32 28.3 4 6.1
Upper back 34 29.8 11 16.2
Lower back 67 57.8 17 20.7
Hip/thigh 18 16.1 3 4.9
Knees 23 20.7 4 6.2
Ankle/foot 11 10.0 3 5.1
 Page 8 of 9
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Table 3: Mean scores of the prevalent job stress dimensions among the physiotherapists(n = 126)
Job stress dimension M (SD) Range Range attainable
Physical demand 3.63 (0.55) 1–4 1–4
Decision latitude 74.18(11.53) 28–92 24–96
Skill discretion 37.16(5.91) 16–48 12–48

Decision authority 37.02(7.75) 12–48 12–48

Psychological demand 32.52(5.18) 12–46 12–48
Social support 24.58(3.94) 12–32 8–32
Co-worker support 11.95(2.12) 6–16 4–16
Supervisor support 12.66(2.28) 5–16 4–16
Job insecurity 4.45(1.44) 3–11 3–12
 Page 9 of 9

Table 4: Association between job stress dimensions and musculoskeletal disorders in at least one body
region.
12-month prevalence 7-day prevalence
Yes No (n = 22) p ≤ 0.05 Yes (n = 28) No p
(n = 101) (n = 95)
Job stress dimension Mean rank scores Mean rank scores
Physical demands 60.83 59.05 0.791 64.44 59.35 0.414
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Decision latitude 61.67 60.73 0.910 63.67 60.88 0.718

Psychological 61.16 63.05 0.820 59.67 62.02 0.759

demands
Social support 60.36 64.05 0.659 54.35 62.91 0.261

Job insecurity 63.47 49.24 0.079 55.46 62.59 0.334

Note: Missing values are evident as physiotherapists did not respond to certain items.
p ≤ 0.05 was considered significant