International Journal of Occupational Safety and

Ergonomics

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Work-related musculoskeletal problems and

associated factors among office workers

Alireza Besharati, Hadi Daneshmandi, Khodabakhsh Zareh, Anahita

Fakherpour & Mojgan Zoaktafi

To cite this article: Alireza Besharati, Hadi Daneshmandi, Khodabakhsh Zareh, Anahita
Fakherpour & Mojgan Zoaktafi (2018): Work-related musculoskeletal problems and associated
factors among office workers, International Journal of Occupational Safety and Ergonomics, DOI:
10.1080/10803548.2018.1501238

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International Journal of Occupational Safety and Ergonomics (JOSE), 2018
https://doi.org/10.1080/10803548.2018.1501238

Work-related musculoskeletal problems and associated factors among office workers

Alireza Besharatia , Hadi Daneshmandib∗ , Khodabakhsh Zareha , Anahita Fakherpourc and Mojgan Zoaktafid
a Occupational Health Unit, Shiraz Health Center, Shiraz University of Medical Sciences, Iran; b Research Center for Health Sciences,
Shiraz University of Medical Sciences, Iran; c Student Research Committee, Shiraz University of Medical Sciences, Iran; d Department of
Ergonomics, Shiraz University of Medical Sciences, Iran

Purpose. The aim of this study was to investigate musculoskeletal disorders (MSDs) and associated factors among Iranian
office personnel. Materials and methods. In this cross-sectional study, 359 Iranian office workers were included. Data were
gathered using a demographic questionnaire, the Nordic musculoskeletal questionnaire, the numeric rating scale, rapid office
strain assessment (ROSA) and the NASA task load index (NASA-TLX). Results. Our findings showed that the highest
prevalence rate of MSDs within the last 12 months and the highest pain/discomfort severity were related to the participants’
necks. The mean performance, mental demand and effort subscale scores of the NASA-TLX were higher than other subscales
(physical demand, temporal demand and frustration level). ROSA scores showed that 53.8% of the participants were in
action level 1 (low MSD risk) and the rest (46.2%) were in action level 2 (high MSD risk). The pain/discomfort severity
in the shoulders, elbows, wrists/hands, thighs and ankles/feet was correlated to the final ROSA score. Age, gender, body
mass index and some NASA-TLX subscales (effort, mental demand and performance) were associated with symptoms of
MSDs in different body regions. Conclusions. Improving workplace conditions (both mentally and physically) is suggested
for reducing and eliminating musculoskeletal problems among office workers.
Keywords: musculoskeletal disorders; NASA task load index; office workers; pain; rapid office strain assessment

1. Introduction cause MSDs and affect people’s well-being and welfare as

Musculoskeletal disorders (MSDs) are among the most
common work-related problems [1]. MSDs are related to
the muscles, joints, tendons and nerves that can affect body
regions such as the neck, upper limbs and back [2].
Work-related musculoskeletal disorders (WMSDs) are
considered the main contributing factor in job absen-
teeism [1], presenteeism [3], reduced quality of life [1],
change of occupation, increased work-related injuries [4]
and increased medical expenses due to disability [5].
In many occupations, people spend long hours in front
of a computer [6]. Office personnel spend most of their
time in offices in a seated position [7]. Use of com-
puters has increased in workplaces, which is associated
with MSD-related symptoms with a prevalence rate of
more than 50%, especially in the upper extremities and
lower back [8]. Also, pain/discomfort caused by MSDs,
in the neck, shoulders and lower back, is common among
office workers due to the time spent in a sitting posi-
tion [9]. Worldwide, MSDs are widespread and have both
socioeconomic and personal consequences [10].
WMSDs and pain/discomfort are related to prolonged
sitting position, fast-paced work, static and awkward pos-
tures, and highly repetitive movements [11]. In addition,
inappropriate and inadequate workplace conditions can
well as reduce productivity [7].
Previous studies indicate that, overall, WMSDs are the
reason for 29% of all workplace-related injuries in the USA
[2]. On the other hand, it is estimated that the costs of
WMSDs and upper extremity and lower back pain com-
prise 0.5 and 2%, respectively, of the European Union’s
gross national product [12].
According to reports, over 77 million people in the
USA [13] and 88 million in the European Union use com-
puters at work [14]. However, the exact statistic about
Iranian computer users is not available.
Office workers perform various activities, such as typ-
ing, writing and reading, that can be linked with prolonged
static and awkward postures, repetitive movements and
high mental workloads [15]. Office personnel as a large
group of employees are exposed to MSDs [16]. As already
stated, MSDs are multifactorial work-related problems.
Therefore, this study was performed to investigate MSDs
and associated factors among Iranian office workers.
2. Method
In this cross-sectional study, 359 Iranian office employ-
ees affiliated to Shiraz University of Medical Sciences

*Corresponding author. Email: daneshmand@sums.ac.ir

© 2018 Central Institute for Labour Protection – National Research Institute (CIOP-PIB)
2 A. Besharati et al.
with at least 1 year of experience were recruited. Employ-
ees with underlying diseases or accidents affecting their
musculoskeletal system were excluded from the study.
The participants were selected based on simple random
sampling (random number table). All of the respondents
participated in this study voluntarily, and signed a written
informed consent before the study. It should be noted that
the study was performed in accordance with the Helsinki
Declaration of 1964, and as revised in 2008.
2.1. Data gathering tools
2.1.1. Demographic questionnaire
The questionnaire included questions about age, weight,
height, job tenure, daily sitting working time, gender,
marital status and education level.
2.1.2. Nordic musculoskeletal questionnaire
The general Nordic musculoskeletal questionnaire (NMQ)
of symptoms examines the reported cases of MSDs in dif-
ferent body regions among the studied population [17]. In
this study, the reported musculoskeletal symptoms were
limited to the last 12 months. The psychometric proper-
ties of the Persian version of the NMQ were previously
assessed by Choobineh et al. [18].
2.1.3. Numeric rating scale
The numeric rating scale (NRS) is a unidimensional mea-
sure of pain/discomfort intensity [19].
2.1.4. Rapid office strain assessment
Rapid office strain assessment (ROSA) is a picture-based
posture checklist designed to quantify exposure to risk fac-
tors in an office work environment. This technique was
developed by Sonne et al. [20] to determine the level
of MSD risk. The final scores of this technique (ROSA)
showed high inter- and intra-observer reliability (intraclass
correlation coefficients [ICCs] of 0.88 and 0.91, respec-
tively). In this technique, three general parts (A, B and C)
of the office work environment are assessed as follows:
• Part A: chair (height, depth, armrest and backrest).
• Part B: monitor and telephone.
• Part C: mouse and keyboard.
After completing the ROSA checklist, the related tables are
used to calculate the score from each part, and eventually
the final ROSA score is derived. Then, based on the final
ROSA score, each case is interpreted in accordance with
the action levels described below:
• Action level 1 (final score ≤ 4): the level of MSD
risk is low.
• Action level 2 (final score ≥ 5): the level of MSD
risk is high [20].
2.1.5. NASA task load index
The NASA task load index (NASA-TLX) is a subjec-
tive, multidimensional assessment tool [21], which rates
the perceived mental workload in order to assess a task,
a system or a team’s effectiveness or other aspects of
performance. This scale was developed by the human per-
formance group at NASA’s Ames Research Center over
a 3-year development cycle that included more than 40
laboratory simulations [22]. The NASA-TLX originally
consisted of two parts. In the first part, the total workload is
divided into six subscales: (a) mental; (b) physical demand;
(c) temporal demand; (d) performance; (e) effort; (f) frus-
tration. There is a description for each of these subscales
that the participants should read prior to the rating. They
are rated for each task within a range of 100 points with 5-
point steps. The second part of the NASA-TLX intends to
create an individual weighting of these subscales by allow-
ing the subjects to compare them pairwise based on their
perceived importance. In the present study, we used the
first part of this scale (rating/raw NASA-TLX) to assess
the mental workload of the participants.
2.2. Implementation of the study
The participants completed the demographic and Nordic
questionnaires and the NASA-TLX scale at their work-
place. The NASA-TLX scale was completed during their
work shift. In addition, ROSA was used to assess the MSD
risk level for each participant. To assess the intensity of
musculoskeletal pain/discomfort, the subjects were rated
on the NRS on Monday at the start and at the end of their
work shift. Then, the difference between the NRS scores at
the start and at the end of the work shift during their work-
ing day was calculated and regarded as their measure of
musculoskeletal pain/discomfort.
2.3. Factors associated with MSDs in different body
regions
For this purpose, we used multiple logistic regression (for-
ward Wald). In the first step, the association between
variables, such as age, body mass index (BMI), job tenure,
working hours/day, gender, marital status, educational
level, NASA-TLX subscales (mental demand, physical
demand, temporal demand, performance, effort, frustra-
tion level) and ROSA level with MSDs in different body
regions were surveyed via a χ 2 test with a significance
level of p ≤ 0.250. For this purpose, the quantitative vari-
ables were divided into two categories (age ≤ 35 years and
age > 35 years, BMI ≤ 24.9 and BMI > 25.0, job tenure
≤ 10 years and job tenure > 10 years, working hours/day
≤ 8 and working hours/day > 8, NASA-TLX scores ≤
 International Journal of Occupational Safety and Ergonomics (JOSE) 3

66 and NASA-TLX scores > 66 for all of the subscales). Table 2. Frequency of reported MSD symptoms in
Subsequently, all of the independent variables that had different body regions among office workers during the
last 12 months (N = 359).
significant association were included in the multivariate
logistic regression model. MSDs Severity of pain
Body region N % M ± SD
2.4. Statistical analysis Neck 216 60.16 2.36 ± 2.39
In this study, data were analyzed using SPSS version 16.0 Shoulders 194 54.03 2.07 ± 2.48
using the χ 2 test, multiple logistic regression and Spear- Elbows 49 13.64 1.31 ± 2.31
Wrists/hands 174 48.46 1.75 ± 2.64
man correlation. Since the data did not appear to follow Upper back 175 48.74 1.67 ± 2.01
a normal distribution, the Spearman correlation coeffi- Lower back 205 57.10 2.02 ± 2.71
cient was used to evaluate the correlation between mus- Thighs 63 17.54 1.53 ± 2.23
culoskeletal pain/discomfort and the final score of ROSA. Knees 176 49.02 1.57 ± 2.40
Also, the Kolmogorov–Smirnov test was used to test the Ankles/feet 125 34.81 1.62 ± 2.17
data’s normality. Note: MSD = musculoskeletal disorder.

3. Results
Table 3. Rating score for the NASA-TLX
Table 1 summarizes the personal details of the office subscales of the participants (N = 359).
workers participating in the study.
Table 2 presents the prevalence rate of the reported NASA-TLX subscale M ± SD
MSD symptoms in different body regions among the office
Mental demand 73.53 ± 24.06
workers during the past 12 months. In addition, this table Physical demand 54.64 ± 28.46
shows the mean ± SD of pain/discomfort in different body Temporal demand 69.88 ± 23.40
regions among the studied participants. As shown in this Performance 74.84 ± 20.65
table, the mean pain/discomfort score in the neck, shoul- Effort 73.32 ± 21.89
ders and lower back was higher than in the other body Frustration level 60.06 ± 30.19
NASA total 67.68 ± 15.52
regions.
Table 3 presents the mean ± SD rating score of the Note: TLX = task load index.
NASA-TLX subscales. As shown in this table, mean scores
for the performance, mental demand and effort subscales of
the NASA-TLX scale were higher than for the other sub- Table 4. Assessment of physical exposure to
scales (physical demand, temporal demand and frustration musculoskeletal risks with ROSA among office
level). workers (N = 359).

Section Result of ROSA

Table 1. Personal details of the studied office
workers (N = 359). Chair, M ± SD 4.41 ± 1.66
Monitor and telephone, M ± SD 2.46 ± 1.06
Variable Value Mouse and keyboard, M ± SD 3.01 ± 1.22
Action level, N (%)
Quantitative, M ± SD 1 193 (53.8)
Age (years) 34.54 ± 7.41 2 166 (46.2)
Weight (kg) 66.52 ± 15.27
Height (cm) 164.08 ± 13.53 Note: ROSA = rapid office strain assessment.
BMI 25.29 ± 13.65
Job tenure (years) 3.80 ± 1.85
Working hours/day 8.13 ± 1.88
Qualitative, N (%) Table 4 presents the results of physical exposure assess-
Gender –
Male 70 (19.5)
ment to musculoskeletal risks with ROSA among the
Female 289 (80.5) surveyed office workers.
Marital status – Table 5 presents the correlation between the pain/
Single 130 (36.22) discomfort score in different body regions and the final
Married 229 (63.78) ROSA score. As shown in this table, the pain/discomfort in
Educational level –
the shoulders, elbows, wrists/hands, thighs and ankles/feet
Associate degree and lower 77 (21.44)
Bachelor of science and higher 282 (78.56) were correlated with the final ROSA score. Based
on the rule of thumb in interpreting the size of
Note: BMI = body mass index. correlation coefficient, these values (correlation coef-
4 A. Besharati et al.

Table 5. Correlation between pain/discomfort severity ficients) were in the negligible correlation category
score in different body regions and final ROSA score. (0–0.3) [23].
Body region r p Table 6 presents the multiple logistic regression output
for detecting the potential risk factors for MSDs in different
Neck 0.009 0.874 body regions.
Shoulders 0.116 0.032
Elbows 0.187 0.001
Wrists/hands 0.128 0.018 4. Discussion
Upper back 0.093 0.133
Lower back 0.054 0.322
This study was carried out to investigate MSDs and their
Thighs 0.139 0.010 related factors in Iranian office workers. The mean ± SD
Knees 0.076 0.165 of age and job tenure were 34.54 ± 7.41 and 3.80 ± 1.85
Ankles/feet 0.179 0.001 years, respectively. 19.5% of the participants were men and
80.5% were women.
Note: Significance level, α = 0.05. ROSA = rapid
office strain assessment. Our results showed that the highest prevalence rates
of MSD symptoms in the last 12 months were related to
Table 6. Modeling of association between potential risk the neck (60.16%), lower back (57.10%) and shoulders
factors and MSDs in different body regions of participants (54.03%). In a previous study, it was reported that the
using multiple logistic regression (N = 359). prevalence rate of MSD symptoms among office person-
Association between potential risk factors and nel ranged from 40 to 80% [24]. Choobineh et al. [25]
MSDs reported that the highest prevalence rates of MSD symp-
toms among Iranian office workers in the past 12 months
Body region Potential risk factor OR 95% CI p
were related to the lower back (45.1%), neck (41.7%) and
Neck Age (years) 2.03 [1.27, 3.24] 0.003 upper back (36.6%). Another study showed that the high-
≤35: reference est prevalence rates of MSD symptoms among Iranian
>35 office workers were linked to the neck (42%), lower back
Age (years) 1.62 [1.03, 2.56] 0.035
≤35: reference (42%) and shoulders (41%) [26]. Other researchers found
>35 that the neck, lower back and upper back had the highest
Gender 2.15 [1.24, 3.74] 0.006 prevalence rates of MSDs among office workers [27]. The
Male reference findings of our study and other previous studies on Iranian
Female office workers showed that the neck, lower back and shoul-
Effort 1.75 [1.11, 2.77] 0.016
≤66: reference der regions of this working group are at risk of MSDs. The
>66 risk factors for MSDs in these body regions (neck, lower
Elbows – – – – back and shoulders) can be attributed to static and awkward
Wrists/hands Age (years) 1.56 [1.01, 2.42] 0.045 postures, inappropriate workstation design and repetitive
≤35: reference movements [28].
>35 Our findings showed that the highest scores of muscu-
Mental demand 2.83 [1.16, 2.87] 0.009
loskeletal pain/discomfort were related to the neck (2.36),
≤66: reference
>66 shoulders (2.07) and lower back (2.02). This shows that
Upper back Performance 1.99 [1.22, 3.24] 0.006 the reported symptoms of MSDs are in accordance with
≤66 the perceived musculoskeletal pain/discomfort among the
>66 reference participants.
Effort 1.89 [1.16, 3.08] 0.010 We found that the mean scores of the performance,
≤66 mental demand and effort subscales of the NASA-TLX
>66: reference
were higher than the other subscales (physical demand,
Lower back – – – –
temporal demand and frustration level). Bridger and
Thighs Performance 1.97 [1.11, 3.48] 0.019
≤66 Brasher [29] inferred that the NASA-TLX can be used to
>66: reference measure the cognitive demands of office workers. Safari
Knees BMI 2.10 [1.34, 3.27] 0.001 et al. [30] showed that office workers had the lowest men-
≤24.9 reference tal workload among the studied working groups (spinning,
>25 weaving, repair, supervisor, office, doubling). The find-
Ankles/feet BMI 1.90 [1.21, 2.99] 0.005 ings of Darvishi et al.’s [27] study revealed that effort,
≤24.9 reference mental demands and temporal demands had the highest
>25
mean score in the NASA-TLX scale between office work-
Note: Significance level, α = 0.05. BMI = body mass ers. Also, the results of this study showed that the mean
index; CI = confidence interval; MSD = musculoskeletal scores for all of the subscales of the NASA-TLX among
disorder; OR = odds ratio. the participants with MSD symptoms were significantly
 International Journal of Occupational Safety and Ergonomics (JOSE)
higher than the other groups (subjects without MSD
symptoms) [27].
The results of the ROSA technique showed that the
mean score of the chair section was higher than that of
the other sections (mouse and keyboard, and monitor and
telephone). This shows that the parameters associated with
the chair section should be considered as a priority, and
should be corrected. In addition, our findings showed that
53.8% of the participants were in action level 1 (low MSD
risk) and the other workers were in action level 2 (high
MSD risk).
Our study showed that the severity of musculoskele-
tal pain/discomfort in the shoulders, elbows, wrists/hands
and ankles/feet had a low correlation with the final ROSA
score. Sonne and Andrews [31] found a high correlation
between the final ROSA score and total body discomfort.
4.1. Factors associated with MSDs in different body
regions
Our findings showed that age had a significant associ-
ation with MSD symptoms in the neck, shoulders and
wrists/hands with odds ratios (OR) ranging from 1.56 to
2.03. This means that as age increased, the chance of
MSDs increased [32,33]. Gender had a significant associ-
ation with MSD symptoms in the shoulders with OR of
2.15. This meant that the incidence of MSDs in female
workers was 2.15 times more than their male counterparts,
and this result was in line with a World Health Organi-
zation (WHO) report [34,35]. BMI was significant for the
knees and ankles/feet regions with OR ranging from 1.90
to 2.10. This means that with increased BMI, the chance
of MSD symptoms rose as well, which is consistent with
other studies [36,37]. The effort subscale of the NASA-
TLX was associated with the presence of MSDs in the
shoulders and upper back of the participants with OR rang-
ing from 1.75 to 1.89. The mental demand subscale of the
NASA-TLX was associated with the presence of MSDs in
the wrists/hands of the participants with OR of 2.83. The
performance subscale of the NASA-TLX was associated
with the presence of MSDs in the upper back and thighs
of the participants with OR ranging from 1.97 to 1.99.
In this context, the findings of previous studies showed
that different dimensions of mental workload can affect
the prevalence of MSDs among office workers and other
occupational groups [38–41]. The results for the elbows
and lower back showed that no variables were associated
with these regions (no variables remained in the multiple
logistic regression model).
4.2. Limitations of the study
Due to the cross-sectional nature of this study and the
self-report method for data gathering, our findings have to
be interpreted cautiously. Since this study was carried out
5
among office workers, the results cannot be generalized to
other working groups.
5. Conclusion
Work-related musculoskeletal discomfort/pain and symp-
toms mainly occur due to physical (static and poor pos-
tures, repetitive movements, non-ergonomic workstation
design, etc.), psychological (stress, mental workload, etc.)
and organizational (improper work–rest cycle, lack of job
enrichment, etc.) factors in workplaces. Improvement in
working conditions, proper design and layout of workplace
by organizations and effective ergonomics interventions in
the work environments are recommended. Workplace anal-
ysis, controlling the related risk factors, medical manage-
ment and training people to prevent and eliminate WMSDs
are necessary.
6. Suggestions
The following solutions are recommended to reduce the
adverse effects of computer use among office personnel:
• Improving general working conditions, such as the
layout of equipment, housekeeping and environmen-
tal features (e.g., lighting, noise and temperature).
• Using ergonomic peripheral devices, such as mouse
and keyboard, to prevent awkward postures.
• Using prompting software, such as Stretch Break
version 6.6, and COMPU Stretch version 2.0.
• Using active workstations, such as sit–stand, in lieu
of traditional desks.
• Using an appropriate work–rest schedule.
• Walking to a colleague’s desk instead of telephoning
or emailing.
Acknowledgements
Hereby, the authors would like to thank those office personnel
who participated in this study. The authors wish to thank Mr H.
Argasi from the Research Consultation Center (RCC) at Shiraz
University of Medical Sciences for his invaluable assistance in
editing this manuscript.
Disclosure statement
No potential conflict of interest was reported by the authors.
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