Musculoskeletal Pain Among Eye Care Professionals

Purpose The purpose of this study is to investigate musculoskeletal pain among eye care professionals. Methods This cross-sectional study was conducted using an electronic detailed questionnaire through Google Forms. The structured questionnaire was distributed through various social media platforms targeting eye care professionals. The study included currently practicing ophthalmologists (Consultants, Specialists, Residents), optometrists, and orthoptists. Results A total of 514 eye care professionals participated in the study. The majority were younger than 30 years old (43.8%), with more than half being males (51.8%) and ophthalmologists (55.2%). The prevalence of eye care professionals who were suffering from musculoskeletal pain was 66.7%. The prevalence was significantly higher among females (76.2%) and those over 50 years old (71.4%). Sixty-eight point three percent (68.3%) of participants who don’t do running exercises and 92.2% of those with comorbidities suffer from pain. The prevalence of pain among eye care professionals who every week examine more than 150 patients is 72.4%, perform more than 20 surgeries is 85.7%, and conduct more than 20 laser treatment sessions is 100%. Conclusion Musculoskeletal pain is highly prevalent among eye care professionals. This is especially true among females and older adults (>50 years). Among different exercises, running is most protective against musculoskeletal pain. Comorbidities contribute significantly to developing pain.


Introduction
Back and neck pains are common problems among the adult population [1,2]. This is also true among medical professionals [3][4][5], especially ophthalmologists and optometrists [6]. This is not strange considering eye care professionals adopt ergonomically awkward sitting positions along with repetitive tasks which strain their bodies [5,6]. The current prevalence of neck and upper back pain among eye care professionals in Saudi Arabia, as reported by a single-tertiary hospital study, is 70% [3].
Ophthalmologists have adopted different approaches to this problem, some have used analgesics [5] and others have used physical exercises as a method to prevent or reduce pain [3]. While it has been shown that physical exercises are beneficial for such pain [3], this has not been adequately investigated. So, we aim to investigate more types of musculoskeletal pain among a larger population of eye care professionals.

Study design and participants
This is a descriptive cross-sectional study that was conducted using an electronic detailed questionnaire through Google Forms. The structured questionnaire consisting of 36 questions was distributed through various social media platforms, including WhatsApp, Twitter, and Telegram targeting eye care professionals in Saudi Arabia. The study included practicing ophthalmologists (consultants, specialists, residents), optometrists, and orthoptists. All individuals who were not currently practicing or retired were excluded. The data variables that were collected were age, sex, occupation, BMI, city/region, exercise routine and type, working pattern, pain analysis, physical stress level, and pain treatment methods used.
The first section of the questionnaire included socio-demographic characteristics (age in years, sex, occupation, BMI), history of trauma, comorbidities, and surgeries related to neck, lower or upper back, wrist, and hand pain. Exercising regularly as yes or no and if yes, participants were asked about the type of exercise they perform. Respondents were asked about the number of patients seen per week, and ophthalmologists were asked about the number of surgeries performed per week and laser sessions per week. They were also asked about physical stress. The second section assesses the frequency and severity of the pain. Participants were asked about the presence of pain, the relation of this pain with work, and any treatment taken for pain.
The questionnaire was distributed to 10 faculty members of King Faisal University, College of Medicine to ensure the clarity and content of the questionnaire. The questionnaire was open for responses for five months from February to July 2021. After collecting the data through Google Forms, it was exported to Microsoft Excel (Microsoft Corporation, Redmond, WA) to process the information and encode open variables. Improvements were made regarding the logic of the answers. Some types of exercises were grouped as Other (such as volleyball, football, swimming, yoga, etc.).

Statistical analysis
Categorical data were presented using numbers and percentages while continuous data were summarized using mean and standard deviation. The frequency of neck, lower or upper back, and wrist and hand pain were compared with different characteristics by using the chi-square test or independent sample t-test. Significant results generated between comparisons were then placed in a multivariate regression model to determine the independent predictors associated with neck, lower or upper back, and wrist and hand pain where the odds ratio as well as the 95% confidence interval were also being reported. The p-value of 0.05 was considered statistically significant. The data were analyzed using Statistical Packages for Social Sciences (SPSS) version 26 (Armonk, NY: IBM Corp.).

Ethical considerations
This study was conducted upon the approval of the research ethics committee of the College of Medicine, King Faisal University. All collected data are confidential and consent was obtained from all participants.

Results
A total of 514 eye care professionals participated in the study. Table 1 demonstrates the socio-demographic characteristics of the participants. The most common age group was less than 30 years old (43.8%) with more than half being males (51.8%) while 45.3% had less than five years in practice. Furthermore, nearly 60% were living in the central region with 43.6% being optometrists and 40.9% being main surgeons. The proportion of participants who were having regular exercise was 38.3%. Fifty-two point one percent (52.1%) had normal BMI while 26.7% were overweight.   Figure 1 shows the type of regular exercise performed by eye care professionals, which demonstrates that the most common exercise performed by the respondents was walking.

FIGURE 1: Type of regular exercise performed by eye care professionals
In Figure 2, the most performed type of surgery was cataract surgery (36.4%), followed by pediatric surgeries (16.3%) and cornea surgeries (14%) while the least performed were vitreoretinal surgeries (8.8%). Table 2 describes the previous history of neck, lower or upper back, wrist, and hand pain. We found that the prevalence of respondents with a previous history of trauma related to neck, lower or upper back, and wrist and hand pain was 17.9% while the prevalence of comorbidities related to pain was 20%. Furthermore, the proportion of respondents with a previous history of surgeries related to trauma was 3.3%. Nearly one-third (32.7%) of the eye care professionals examined 51-100 patients per week while 24.3% indicated that the average number of surgeries performed per week was less than five cases with a similar proportion (<5 cases) performed for laser treatment session per week (28.6%). Nearly half of the respondents (50.2%) reported work-related pain. The most used method for the treatment of pain was oral medicine (32.1%) followed by physiotherapy (21.8%). Additionally, the mean score of physical stress level was 5.74 (SD 2.11) out of 10 points.

Variables N (%)
History of trauma related to the neck, lower or upper back, wrist, and hand pain?

TABLE 4: Pain characteristics of the neck, lower or upper back, and wrist and hand pain among eye care professionals
When measuring the relationship between neck, lower or upper back, and wrist and hand pain among the socio-demographic characteristics of eye care professionals, it was observed that the prevalence of pain was significantly higher among females and older age groups (>50 years) (

Discussion
Musculoskeletal pain is a common issue among ophthalmologists. It is reported that more than half of ophthalmologists experience at least one type of pain, either in the lower back (39%) or neck (32.6%) [4].
Several factors have been reported that may have contributed to causing this issue among ophthalmologists. For example, working in the same posture for a long period of time, awkward posture, and bending the back [6]. Al-Ruwaili' and Khalil' have noted that the prevalence of lower back pain was high among ophthalmologists and healthcare professionals, which is due to sitting for a long time that ultimately increases the chance of lower back pain by 1.5 times [7][8][9].
Lower back pain is associated with low productivity and absenteeism [10]. Also, there is an association between work disability and musculoskeletal disorders [11]. Back pain and stress at work are related to each other [12]. Vinstrup et al. have noted that there is a positive association between stress, musculoskeletal pain, and poor quality of sleep [13], which makes us believe that the cause of pain is a cumulative effect of several known and unknown risk factors. The increased musculoskeletal pain experienced by the participants in our study may be associated with stress, anxiety, and fewer break times in the work period [14,15].
Al Shammari et al. reported that the prevalence of musculoskeletal pain increases with older age [16]. In our study, the prevalence of musculoskeletal pain was 66.7%. Among them, 47.9%, 40.3%, 35.6%, and 24.1% were experiencing neck pain, lower back pain, upper back pain, and wrist and hand pain, respectively. When looking at the demographic data of our sample, we also found that pain is more prevalent in older age (>50 years). It is also interesting that the pain was more prevalent in females. Some justify the difference by low muscle tone and strength, hormonal changes, and a higher incidence of osteoporosis among females [17]. Female dentists and nurses have shown more prevalence of neck, shoulder, and upper and lower back pain as compared to males [17,18]. Both working environments (Dentistry and Eyecare) have similarities in working conditions in the clinic where you must lean down and forward to examine or treat a patient. It was shown that there is a gender difference in the perception of pain, which may be attributed to differences in the level of psychological stress and somatic and visceral perception [19]. We think females are more likely to be sensitive to pain than males, which makes the rate of musculoskeletal pain in females higher than in males.
Prudhvi and Murthy noted that obesity is related to lower back pain among dentists [20]. In our study, we also found an association between obesity and lower back pain.
We found that the prevalence of pain was higher in cornea and glaucoma surgeons. Venkatesh et al. also found that general ophthalmologists, cataract, cornea, refractive, and glaucoma surgeons, and medical retina specialists are more at risk to have back pain than pediatric ophthalmologists, neuroophthalmologists, oculoplastic surgeons, and retina surgeons [21]. We believe that this is also true due to the fact that pediatric ophthalmologists, neuro-ophthalmologists, oculoplastic surgeons, and retina surgeons are more dynamic in the clinic and the operating theater than other ophthalmologists. They use various types of examination equipment and methods interchangeably and are less dependent on slit lamps and surgical microscopes, which may demand a more rigid posture. Assistant surgeons are assumed to have more pain because of their awkward sitting position; however, we didn't find a significant difference in pain between main surgeons and assistant surgeons. We found that when more patients are seen each week, there is an association with a higher prevalence of pain. However, Schechet et al. noted that there was no relationship between reported pain and how many patients are seen per week [22].
To minimize the prevalence of musculoskeletal pain, several studies have recommended: moving and stretching every 10 to 15 minutes during surgery, maintaining a relaxed neutral posture, distributing the pressure equally on both foot pedals, placing the patient in a comfortable position, being closer to the bed during surgery, taking a break every 10 to 15 minutes after using the microscope, using a backrest, and having an ergonomic workplace [22,23].
Oral medicine and physiotherapy were the most common treatment options that our participants used to relieve pain. Also, they are commonly used by other healthcare providers such as otolaryngologists [24]. It was shown that using manual therapy, a form of physical therapy, along with exercising is better for neck pain than exercising or manual therapy alone [25]. A systematic review study of European back and neck pain clinical guidelines has recommended oral treatment for neck pain, however, they didn't recommend it for lower back pain [26]. Also, correction of false posture can be important to prevent neck and arm pain [27]. Pain in our participants could be partly due to the wrong posture. There are several studies that confirm that exercise has a huge effect on lower back pain. Al Gadeeb et al. found that the prevalence of musculoskeletal pain decreases with physical activity and increases with physical inactivity [28]. Alnaami et al. noted that exercising regularly can be helpful for lower back pain, and exercising can result in a significant long-term improvement in shoulder, neck, and lower back discomfort [29,30]. In our study, participants who were not running have shown a higher prevalence of pain.
There are a few limitations in our study. We have not asked if the pain is better or relieved during vacations, which may signify more that the pain is due to work. We also should have asked surgeons if they experienced more pain after surgery as compared to the clinic. We have not included shoulder, thigh, and knee pain in the questionnaire. Other risk factors that may have contributed to pain like psychosocial factors and smoking were not asked in the questionnaire. We suggest further studies be done to investigate if there is a relationship between high working hours a week, emotional stress, and pain. The cross-sectional design of the study limits the finding of other potential risk factors.