HSE

Health & Safety

Executive

Musculo-skeletal disorders, mental health

and the work environment

Prepared by University of Oxford for the

Health and Safety Executive 2005

RESEARCH REPORT 316

 HSE
Health & Safety
Executive

Musculo-skeletal disorders, mental health

and the work environment

Katharine R Parkes MA MSc PhD

Susan Carnell BA, Elly Farmer BA
Department of Experimental Psychology
University of Oxford
South Parks Road
Oxford
OX1 3UD

The prevalence and severity of musculoskeletal disorders (MSD) were assessed in cross-sectional and
longitudinal data obtained from male employees in the UK oil and gas industry. The roles of the
physical and psychosocial work environment, and of individual factors were examined in relation to
reported MSD.
• Assessed by the Nordic Musculoskeletal Questionnaire (MSQ) (N=321), lower back pain showed the
highest 12-month prevalence rate (51%) but, taken together, neck, shoulders and/or upper back MSD
had a similar prevalence rate. Mental health, workload, physical environment stressors, and body mass
index predicted MSD, although their relative importance varied across different body areas.
• In cross-sectional analyses (N=1462), relationships between psychosocial work measures and MSD
in the neck/shoulders/back were mediated by psychological distress, but ‘job activity level (strenuous,
active, and sedentary) and physical stressors remained significant direct predictors. The effect of
‘negative affectivity’ on MSD was also mediated by psychological distress, particularly anxiety.
• In longitudinal analyses (N=321), anxiety and social support were significant factors predicting change
in MSD over the five-year period, 1995-2000. In common with other published findings, the evidence
suggested that the primary causal direction was from anxiety to MSD.
• Factor analysis identified three scales (stress/anxiety, work, and lifestyle) in a set of items assessing
beliefs about MSD causes (N=676). MSD problems were primarily attributed to work and lifestyle
factors. Individual experiences of MSD, including perceived causes and medical consultations, were
also analysed.
This report and the work it describes were funded by the Health and Safety Executive (HSE). Its
contents, including any opinions and/or conclusions expressed, are those of the authors alone and do
not necessarily reflect HSE policy.

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ii

 INDEX

1. INTRODUCTION 1

1.1 Present study 3

2. PREVALENCE OF MUSCULO-SKELETAL COMPLAINTS 5

2.1 Nordic Musculoskeletal Questionnaire 5

2.2 Results 5

2.3 Comparison of present data with literature findings 15

3. ANALYSIS OF MSD SYMPTOMS IN NECK, SHOULDERS AND BACK 17

3.1 Data analysis 17

3.2 Overall prevalence rates and severity ratings 17

3.3 Differences in MSD prevalences across job types 18

3.4 MSD symptom reports in relation to GHQ ‘caseness’ 19

3.5 Multivariate analyses 20

3.6 Severity of reported MSD problems 24

4. CHANGE IN MUSCULO-SKELETAL DISORDERS, 1995 - 2000 27

4.1 Longitudinal analyses 27

4.2 Health-related measures in 1995 and 2000 27

4.3 Change in MSD ratings in relation to age and job type 29

4.4 Change in MSD ratings in relation to environmental and individual factors 29

4.5 Anxiety and MSD symptoms: patterns of change over time 31

4.6 Change in MSD in relation to change in overall health ratings 34

5. GENERAL BELIEFS ABOUT THE CAUSES OF MSD 36

5.1 Assessment of general beliefs about the causes of MSD 36

5.2 Analysis of scale scores 36

6. INDIVIDUAL BELIEFS ABOUT THE CAUSES OF MSD 40

6.1 Data analysis 40

6.2 Identification of particular causes in relation to type of MSD 40

6.3 Comparison of perceived MSD causes across job types 40

6.4 Beliefs about MSD causes as related to personal factors 45

6.5 Medical consultations about MSD problems 46

6.6 Factors perceived to underlie absence of MSD problems 48

7. CONCLUSIONS 49

7.1 MSD prevalences in the present sample 49

7.2 Individual and environmental factors as predictors of MSD 50

7.3 MSD and psychological distress: issues of causal direction 52

7.4 Beliefs about the causes of MSD 53

8. REFERENCES 55

iii
iv

 1. INTRODUCTION

Musculo-skeletal disorders (MSD) are a major cause of disability in the working population.
Government statistics indicate that MSD accounted for one quarter of claims for ‘incapacity benefit’
in the UK in 1996 (Griffiths, 1998). Published research data also confirm the high incidence of MSD.
For instance, in a large-scale survey of a stratified random sample carried out in 1995, MSD accounted
for 57% of the total those reporting work-related illness (Jones, Hodgson, & Osman, 1998). Similarly,
Houtman, Bongers, Smulders, & Kompier (1994), analysing data from a representative sample of the
working population in the Netherlands, found that 25% reported back pain complaints, 8% chronic
back problems, and 24% muscle and joint complaints.

The roles of personal and environmental factors in relation to MSD, particularly lower back pain, have
been widely examined in the medical, epidemiological, and psychological literature. Demographic
variables (gender, age, socioeconomic status); physical work demands (e.g. constrained posture,
lifting, repetitive movements); and psychosocial work conditions (fast work pace, low discretion, role
conflict) have all been implicated (eg. Engels, van der Beek, & van der Gulden, 1998; Leijon, Hensing,
& Alexanderson, 1998; Hagen, Magnus, & Vetlesen, 1998; Palsson, Stromberg, Ohlsson, & Skerfving,
1998). Whilst much research in this area is cross-sectional in design (eg. Friedrich, Cermak, & Heiller,
2000; Hagen et al., 1998; Joksimovic, Starke, von dem Knesebeck, & Siegrist, 2002; Piirainen,
Rasanen, & Kivimaki, 2003; Rasanen, Notkola, & Husman, 1997; Toomingas, Theorell, Michesen,
& Nordemar, 1997), a substantial number of prospective studies have also been reported (e.g. Elders
& Burdorf, 2004; Estlander, Takala, & Viikari-Juntura, 1998; Fredriksson, Alfredsson, Koster,
Thorbjornsson, Toomingas, Torgen, & Kilbom, 1999; Maul, Laubli, Klipstein, & Krueger, 2003;
Viikari-Juntura, Martikainen, Luukkonen, Mutanen, Takala, & Riihimaki, 2001).

Example of two recent prospective studies illustrate typical findings. Thus, Eriksen, Bruusgaard, and
Knardahl (2004) ) studied a large sample of health-care workers over a 15-month period; the findings
showed that “Not only frequent mechanical exposures, but also organisational, psychological, and
social work factors, such as night shift work, perceived lack of support from superior, and perceived
lack of pleasant and relaxing or supporting and encouraging culture in the work unit, are associated
with an increased risk of intense low back pain (LBP) symptoms and LBP-related sick leave in nurses
aides” (p.398). Similarly, in a three-year prospective study of scaffolders, Elders and Burdorf (2004)
found that work-related physical and psychosocial factors influenced both the incidence and recurrence
of low back pain. In particular, high levels of manual handling, together with high work demand and
low control, were associated with cumulative recurrence of back pain.

Particularly valuable in the present context are prospective studies of newly-employed workers that
assess work conditions and health-related factors at baseline and over subsequent years of
employment. In one such study, a cohort of newly-employed workers was followed up over a 24-
month period (Harkness, Macfarlane, Nahit, Silman, & McBeth, 2003); new onset of back pain was
found to be predicted by a combination of physical and psychosocial work factors, including lifting
or pulling heavy weights, kneeling or squatting postures, stressful and monotonous work, and hot
working conditions. In general, psychosocial factors were more significant in predicting new onset of
lower back pain than the mechanical factors.

Consistent with these findings, an extensive review of publications relating to MSD concluded that
good evidence existed for associations of low back disorders with physical work factors (heavy manual
labour, manual material handling, awkward postures, and whole-body vibration), psychosocial factors
(social support and job dissatisfaction), and individual factors (socio-economic status, smoking, and
medical history) (European Agency for Safety and Health at Work, 2000).

However, a recent paper by Hartvigsen, Lings, Leboeuf Yde, and Bakketeig (2004) notes the
discrepant findings of different literature reviews, citing Hoogendoorn, van Poppel, Bongers, Koes,
and Bouter (2000) and Davis and Heaney (2000) as examples of conflicting conclusions. Harvigsen
et al. carried out a systematic review of prospective cohort studies examining psychosocial factors at
work in relation to low back pain. They identified 40 prospective studies of lower back pain (LBP),
ten of which were of high quality, and concluded that “Moderate evidence was found for no
association between LBP and perception of work, organisational aspects of work, and social support
at work. There was insufficient evidence of a positive association between stress at work and LBP”.

Adopting a theoretical approach to the issue of MSD, several models of the pathways by which
organizational, psychosocial, work-related, and individual factors give rise to MSD impairment and
disability have been put forward (e.g . Bongers, de Winter, Kompier, & Hildebrandt, 1993; Buckle,
1997; Sauter & Swanson, 1996; Truchon, 2001). Such models provide conceptual frameworks
representing the processes by which physical, psychosocial, and physiological factors combine to give
rise to MSD. However, whilst characteristics such as age and heavy physical work may play a direct
causal role in MSD, the mechanisms by which psychosocial factors are causally implicated have not
been fully clarified empirically.

Frese (1985) found that ‘objective’ measures of psychosocial stressors at work correlated with self-
reported psychosomatic symptoms, including MSD; having eliminated several alternative explanations
he concluded that the link was a causal one. One possible mechanism is that adverse psychosocial
environments may reduce effective coping behaviour, leading in turn to impaired mental health,
tension, and MSD symptoms (Ursin, Endresen, Svebak, & Tellnes (1993). Other findings also indicate
that MSD symptoms are associated with poor mental health (e.g. Leino & Magni, 1993; Vatshelle &
Moen, 1997); some authors have suggested that mental stress increases psycho-physiological arousal
and muscle activity, and may thus give rise to back, neck and shoulder pain (Lundberg, 1996;
Westgaard & Bjorklund, 1987).

Other researchers take the view that MSD can be at least partially understood as a ‘non-specific health
complaint’ (Engels et al, 1998). Spurgeon, Gompertz and Harrington (1996) note that several
occupational and environmental health concerns arising from events which received widespread
publicity have been characterised by an increase in non-specific symptoms, including MSD.
Furthermore, many employees believe their ill-health to be work-related. Rasanen et al. (1997) found
that at least one harmful factor at work was reported by 94% of survey respondents (N=2744), and half
of them reported more than three such factors. Consistent with the view of MSD as a non-specific
complaint, MSD (reported by 44% of the sample) was the most common of the symptoms perceived
as work-related; mental symptoms being the next most frequent (26%). This finding suggests that the
high incidence of MSD reported by the working population may, at least in part, reflect generalised
discontent with work conditions rather than specific medical disorders.

Spurgeon et al. (1996) set out a model of physical and psychosocial pathways by which a ‘hazard’ may
lead to the generation, amplification and presentation of non-specific symptoms; these authors also
identify a variety of psychological and sociological influences that may intervene along the
psychosocial pathway. Whilst some of these factors have been addressed in published studies, one
reason for the lack of clarity in the current literature on MSD is that many existing findings are based
on cross-sectional survey data which do not allow the nature and direction of causation to be
established. For instance, significant associations between poor mental health and MSD could be due
to the problems and constraints of MSD giving rise to poor mental health, or to psychophysiological
aspects of poor mental health (such as anxiety and muscle tension) leading to MSD, or to one or more
‘third’ factors influencing both mental health and MSD.

Whilst age, gender and physical work conditions are typically taken into account in multivariate
analyses, less attention has been paid to response styles (e.g. ‘negative affectivity’) that may confound
relations between mental health and MSD. In a recent study, neuroticism (a measure of negative
affectivity) was found to relate specifically to diseases of the ‘tension type’, including neck pain
(Johnson, 2003), but other research suggests that NA has a more global effect in relation to the
reporting of MSD symptoms (Watten & Batt, 1996).

A further area of interest is the role of individual beliefs about the causes of MSD, and how such
beliefs relate to the experience and reporting of MSD symptoms. Whilst >stress= (Jamison, 2000) and
exercise (Symonds, Burton, Tillotson, & Main, 1996) are both seen as relevant in this context, beliefs
about the causal role of work conditions are particularly widely held. For instance, Bartys, Tillotson,
Burton, Main, Watson, Wright, and MacKay (2001) found that 50% of a large industrial sample
attributed back pain to work demands. Similarly, Hyytiainen (1994) reported survey data from the
metal industry showing that the great majority of manual workers perceived work conditions
contributed to back pain, either >to some extent= (48%) or >a lot= (45%).

Psychometric scales assessing beliefs that work plays a causal role in MSD pain (e.g. Waddell,
Newton, Henderson, Somerville, & Main, 1993) have been found to predict self-reported MSD
symptoms (particularly low back pain), and related sickness absence (Symonds et al. 1996; Fritz,
George, & Delitto, 2001), although weak or non-significant findings have also been noted (Bartys et
al. 2001; Burton, Symonds, Zinzen, Tillotson, Caboor, Van-Roy, & Clarys, 1997). Disregard of social
context (e.g. organizational attitudes to the reporting of MSD symptoms) may partially explain
discrepancies in findings (Weyman & Boocock, 2001).

A further limitation of research in this area is that, although ‘work conditions’ in general are seen as
risk factors for MSD, beliefs about the causal role of specific work demands and activities have not
been empirically evaluated. Moreover, it is possible that perceptions of particular work risks (e.g.
heavy lifting) may relate differentially to the experience of particular MSD symptoms (e.g. back pain);
identification of these patterns of relationships could potentially enhance the explanatory power of
work beliefs, and allow interventions intended to modify beliefs to be more clearly focused.

In the absence of empirical evidence about specific work beliefs, qualitative studies provide some
relevant information; thus, Bartels, Niederman, and Waters (2000) noted beliefs among farmers that
awkward postures, bending while working, sitting in a cramped position, and long hours of work, gave
rise to MSD. Similarly, Borkan, Reis, Hermoni, and Biderman (1995) identified work overload,
driving, lifting, poorly designed chairs, drafts, and cold working conditions; in this study, non-work
factors (including past injury, hereditary predisposition, stress, and ageing) were also seen to play a
causal role in MSD.

1.1 THE PRESENT STUDY

The study reported here combines analysis of cross-sectional data obtained from male employees in
the UK oil industry in 1995-6 (Parkes & Clark, 1997) with the collection and analysis of follow-up
data relating to physical work conditions, psychosocial factors, individual differences, mental health,
and musculoskeletal symptoms. Information concerned specifically with beliefs about the causes of
MSD was also obtained. The main aims of the work are:

- To determine annual and weekly prevalence rates of MSD symptoms; to compare the levels
observed with those from other occupational groups in the UK and elsewhere; and to examine
the extent to which the MSD symptom profile is related to job types, and to the physical and
psychosocial work perceptions of the job incumbents.

- To enhance understanding of factors underlying self-reports of MSD in an employed sample

by examining (in both cross-sectional and longitudinal data) the combined roles of mental
health, work perceptions, and individual factors (particularly generalised negative biases); and
to examine the relationship between MSD and mental health with particular reference to
causal direction.

- To examine beliefs about the causes of MSD complaints, and to relate these attributions to job
characteristics and psychosocial factors; among those who report experience of MSD
symptoms, to examine individual beliefs about the causes of their MSD problems, and to
relate these factors to personal characteristics; among those who do not report experience of
MSD, to examine the factors to which they attribute their absence of musculoskeletal
symptoms.

 2. PREVALENCE OF MUSCULO-SKELETAL COMPLAINTS

2.1 Nordic Musculoskeletal Questionnaire

The Nordic Musculoskeletal Questionnaire (MSQ) (Kuorinka, Jonsson, Kilbom, Vinterberg, Biering-
Sorensen, et al. 1987) has been widely used to assess the nature and severity of self-rated musculo­
skeletal symptoms. The questionnaire includes items asking about the experience of musculo-skeletal
problems in nine body areas (neck, shoulders, elbows, wrists/hands, upper back, lower back,
hips/thighs, knees, and ankles/feet) over the past week and over the past year. Thus, weekly and annual
prevalences of MSD can be derived.

In addition, a second group of questions requests detailed information about MSD problems relating
to three main body areas; neck, shoulders, and lower back. In these sections, the information obtained
includes the total length of time during the past 12 months that the symptoms have been experienced,
whether work or leisure activities have been reduced because of the problem, the total length of time
that normal work has been prevented, and whether a medical practitioner or other healthcare
professional had been consulted.

The Nordic MSQ was used to assess musculoskeletal problems in the present study. Other information
obtained in this study included age, height and weight, mental health, and perceptions of the work
environment.

2.1.1 Sample

Data were collected from male personnel contacted as part of a 5-year follow-up study of UK oil and
gas industry personnel originally surveyed in 1995. Questionnaires were mailed to participants, and
returned to the research team by mail. Of the 359 personnel who returned completed questionnaires,
321 were still employed in the oil and gas industry (predominantly on offshore installations); the
analyses reported here were carried out on this sample.

2.1.2 Analyses

This chapter focuses on findings obtained from the Nordic MSQ. Descriptive data are presented to
provide an overall picture of the experience of MSD reported by the present sample. Factors associated
with the reporting of particular types of MSD complaints are also examined, as a background to the
more detailed analyses reported in later chapters.

2.2 RESULTS
2.2.1 Sample characteristics

Age distribution. The average age of the analysis sample was 44.7 ± 8.0 years. 26% of the sample
were aged less than 40 years, 45% were in the age range 40-50 years, and the remaining 29% were
aged 50+ years.

Job types. Three broad job categories of jobs were identified in terms of the extent to which they
involved physical activity (see, Parkes, 2003). The percentages of the sample in each of the three
categories, and the specific jobs that were included in each category, are shown in Table 2.1.

 Table 2.1
Percentages of sample in each of three broad job categories

Broad job category % Specific job types %

Construction 6.2
Strenuous 19.6
Drilling 13.5

Maintenance 24.0

Technical/Mechanical 8.2
Active 55.5
Catering 4.4

Production 18.8

Management/Supervisory 16.1
Sedentary 24.9
Administration 8.8

2.2.2 Prevalences of musculo-skeletal symptoms in different body areas

Overall, MSD symptoms were widely reported by the present participants. Thus, 80% of the sample
reported that they had experienced some form of MSD in the past 12 months; 37% reported that they
had experienced one or more problems over the past seven days. Table 2.2 shows the percentages of
the sample experiencing MSD in different body areas during the previous 12 months, and during the
previous seven days. The 12-month prevalence data are shown superimposed on the mannequin which
was used to designate body areas in the survey questionnaire in Figure 2.1.

It can be seen that over both time frames, lower back problems were the most frequently reported, 51%
of the sample had experienced such problems in the past 12 months, and 17% during the past week.
The 12-month prevalence value for lower back problems corresponds closely to the value (50%)
reported by Leboeuf Yde, Klougart, & Lauritzen (1996) in the Nordic population, but it is lower than
the 73% value found by Friedrich et al. (2000) and the similar level reported by Maul et al. (2003).
In the present data, neck and shoulder problems were the next most frequent types of MSD; with
annual prevalences of 42% for neck problems and 30% for shoulder problems.

Table 2.2 also shows 12-month and 7-day prevalence rates for three body areas, upper body (neck,
shoulder, upper back), upper extremities (elbow, wrist/hand), and lower extremities (knee, ankle/ feet).
These data suggest that, when the neck, shoulder and upper back areas are considered together, the
overall prevalence of MSD is comparable to that in the lower back, and is high relative to the rates for
the upper and lower extremities.

 Table 2.2
Observed prevalence rates for musculoskeletal problems

Area of body affected Occurrence in Occurrence in

last 12 months last 7 days

% of sample % of sample

Neck (NCK) 42 12

Shoulder(s) (SHO) 30 15

Elbow(s) (ELB) 13 6

Wrist(s)/hand(s) (WRI) 18 7

Upper back (UPB) 11 3

Lower back (LOWB) 51 17

Hip(s)/thigh(s) (HIP) 10 4

Knee(s) (KNE) 31 9

Ankle(s)/feet (ANK) 10 3

Any upper extremity 27 11

(elbow, wrist, hand)

Any lower extremity 35 11

(knee, ankle, feet)

Any upper body part

(neck, shoulder, upper 51 22
back)

N = 321 (male oil industry employees)

7
 Figure 2.1
Annual prevalence rates for musculoskeletal disorders in different body areas

42%

30%

11%
13%

18%

51%
10%

31%

10%

2.2.3 Prevalence rates in relation to job type and environment

Annual prevalence rates were analysed in relation to job type, as categorised in Table 2.1
(‘sedentary’, ‘active’ and ‘strenuous’), and environment (production platforms vs. drilling rigs)
using a repeated-measures analysis. Age was included as a covariate. Only the environment
factor showed a significantly different pattern of prevalences across the nine body areas for
which MSD was assessed (F=2.56, df=8,2192, p<.01). The MSD profiles across the nine body
areas are shown in Figure 2.2 for each environment.

.7

.6

.5
MSD prevalence

.4

.3

.2

.1

0.0
NCK SHO ELB WRI UPB LOWB HIP KNE ANK

BODY AREA

Production platforms Drilling rigs

Figure 2.2
Prevalences of MSD in different body areas reported by
personnel on production platforms and drilling rigs
(see Table 2.2 for body area codes)

It can be seen from Figure 2.2 that, for those working on production platforms, MSD prevalences
are relatively high for the body areas of neck, shoulders, wrists/hands and knees. Differences in
installation design (there is more need to climb stairs on platforms than on rigs) and in the work
carried out (more work in difficult postures, more manipulation of hand tools on platforms than
on rigs) may both contribute to these results. In contrast, in both work environments, lower back
problems show particularly high MSD rates, most likely reflecting the prominence of manual
tasks, such as lifting and working with heavy machinery, on both production platforms and
drilling rigs.

Multiple musculo-skeletal complaints. A significant proportion of workers in the present sample

reported experiencing more than one musculoskeletal complaint over the last 12 months. For
instance, over this time period, 23% of the total sample reported problems with more than three
of the nine body areas assessed. The cumulative plot shown in Figure 2.3 provides more detailed

information about the frequency of multiple MSD complaints, while Figure 2.4 shows the same
information for two groups differing in mental health (‘cases’ and ‘normals’ identified by the
General Health Questionnaire, GHQ). At each point on the cumulative percent scale (vertical
axis), ‘normals’ report fewer body areas affected by MSD than ‘cases’. Thus, this plot
demonstrates an association between the experience of MSD and mental health; the role of poor
mental health in relation to MSD is further considered later in this report.

100

80
Cumulative percent

60

40

20

0
0 1 2 3 4 5 6 7 8

Number of body areas affected

Figure 2.3
Cumulative plot of number of body areas affected

100

80
‘Normals’
Cumulative percent

60
‘Cases’
40

20

0
0 1 2 3 4 5 6 7 8

Number of body areas affected

Figure 2.4
Cumulative plots of number of body areas affected by
MSD in relation to GHQ-12 caseness

10
2.2.3 Factors associated with MSD as assessed by the Nordic MSQ

The extent to which reported MSD problems over the previous 12 months were associated with a
set of five predictor variables was evaluated using multivariate regression methods. The predictor
variables (chosen on the basis of the existing literature) were age, psychological distress
(‘caseness’ as assessed by the General Health Questionnaire, GHQ), body mass index (BMI),
workload, and physical environment stressors. Using this predictive model, three composite
outcome variables (MSD problems in upper body, upper extremities, and lower extremities) were
examined by means of ordinal logistic regression; for lower back MSD problems, the same
predictive model was used in a binary logistic regression analysis. In each case, the data relating to
12-month prevalences were used.

Overall, the results of these analyses indicated that MSD problems were associated with individual
physical characteristics (age and BMI), with psychological distress (GHQ caseness), and with
work environment variables (physical environment stressors, and workload). As shown in Table
2.3, the predictive model was highly significant in relation to each outcome variable, except the
measure of MSD in the upper extremities for which only a marginal significance level was
obtained. Moreover, the effects of the predictor variables were all in the expected direction, i.e.
higher levels of each measure were associated with higher levels of MSD problems. However, the
pattern of significant predictors was different in each case.

Table 2.3

Factors associated with reported MSD problems in different body areas:

summary of ordinal logistic regression results

Upper Upper Lower Lower back

body extremities extremities
(0-4 scale) (0-4 scale) (0-2 scale) (0-1 scale)

Age ns [p<.06] ns ns

BMI ns ns p<.005 p<.01

GHQ ‘caseness’ p<.005 [p<.10] ns p<.05

Workload p=.005 ns ns p=.05

Physical
environment p<.005 ns p<.025 ns
stressors

Overall model p<.001 [p<.10] p<.01 p<.005

11

BMI was highly significant in relation to MSD problems in the lower extremities and, to a lesser
extent, in the lower back, but not in relation to the upper body or upper extremities. This result is
consistent with the tendency of overweight to put greatest strain on the lower part of the body and
the legs. Lower back MSD was also associated with psychological distress (as identified by GHQ
‘caseness’) and with higher perceived workload, whereas lower extremity MSD was associated
with physical environment stressors. Although age was not significant overall, further analyses
suggested an interaction between BMI and age such that the combination of older age and higher
BMI was particularly likely to give rise to MSD problems in the lower extremities.

MSD problems in the upper body areas (shoulders, neck, and upper back) were strongly predicted
by GHQ caseness, perceived workload, and physical environment stressors, but not by BMI or age.
This finding may be partially attributable to the greater anxiety and muscular tension experienced
by individuals with poor mental health, in addition to strains associated with the physical
environment.

Job type and neuroticism. Job type (sedentary, active, strenuous) did not contribute significantly to
any of the analyses over and above the variables shown; further analyses suggested that physical
environment stressors and perceived workload acted as mediators of the effects of job type on
MSD. Similarly, neuroticism did not predict MSD outcomes over and above the variables already
in the model, with the exception of its significant (p<.02) role in relation to the reporting of MSD
in the lower extremities.

2.2.4 Analysis of profile of nine separate MSD scores

To identify more specific patterns of relations between the predictor variables and MSD outcomes,
the nine single MSD complaints listed in Table 5.2 were examined as a set, and the extent to which
members of the set were differentially related to age, BMI, physical environment stressors, and
anxiety symptoms was evaluated (again using the 12-month prevalence values). The results
showed that BMI and anxiety were significantly associated with particular MSD profiles, whereas
physical environment stressors showed an overall pattern of association with total MSD
complaints.

Anxiety primarily predicted neck, shoulder and upper back complaints (p<.01 in each case); it was
also associated with lower back complaints but only to a marginal significance level (p<.10). In
contrast, BMI was significantly associated with lower back pain, and with MSD problems in knees,
ankles and feet. These more specific profiles are consistent with the results shown in Table 2.3, but
highlight the role of BMI in relation to lower back and weight-bearing joints, and the role of
anxiety and tenseness in relation to neck and shoulder complaints. In contrast, a second specific
mental health measure, social dysfunction (low morale) was not found to be significantly
associated with MSD outcomes..

2.2.5 Duration and consequences of neck, shoulder, and lower back MSD
In addition to the 12-month and 7-day MSD prevalances reported above, further information was
obtained for three particularly frequent MSD problems (those affecting the neck, shoulders, and
lower back). This information included lifetime prevalence, details of the duration of the problem
over the past 12 months, whether it had prevented normal work or leisure activities, duration of
work time lost, and whether or not a medical practitioner or other health care professional had been
consulted. The data are summarized in Table 2.4.

12

 Table 2.4
Duration and consequences of musculoskeletal problems

Area of body affected

Neck Shoulder Lower

back

Sample size 314 313 317

Lifetime prevalence: % of sample who have ever 53% 39% 66%

experienced MSD in the body area shown:

Of those who have ever experienced the

problem:

Total duration of problem over past 12 months:

0 days 12% 25% 19%
1-7 days 46% 22% 34%
8-30 days 20% 27% 24%
> 30 days, but not every day 18% 20% 18%
Every day 4% 6% 5%
[N=165] [ N=121] [N=207]

% having to reduce work activity over past 12 14% 15% 32%

months

% having to reduce leisure activity over past 12 25% 26% 42%

months

Total duration normal work prevented over past

12 months:
0 days 81% 80% 59%
1-7 days 13% 11% 21%
8-30 days 4% 6% 17%
> 30 days 1% 3% 3%

Consultation with medical or other health 26% 26% 32%

professional in past 12 months

It can be seen from Table 2.4 that lower back MSD problems have a higher lifetime prevalence
than either neck or shoulder problems. The 66% lifetime prevalence for lower back MSD found in
the present sample corresponds exactly with the lifetime prevalence value reported by Leboeuf

13
Yde et al. (1996) from five Nordic studies of 30-50 year old men and women (no significant age or
gender differences were found), but it is lower than the 76% age-standardized value for men
reported by the European Agency for Safety and Health at Work (2000).

As shown in Table 2.4, lower back MSD is not only more prevalent than shoulder or neck MSD
but also more likely to result in reduced work activity, reduced leisure activity, longer duration of
work incapacity, and greater use of healthcare resources (e.g. medical consultations). Thus,
although the distribution of duration of lower back problems over the past 12 months did not
appear to be markedly different than those for neck or shoulder problems, lower back problems
were more likely to be reported to impact adversely on everyday work and leisure activities. These
findings are consistent with literature which identifies lower back pain as a major cause of lost
work time and incapacity in the working population.

2.2.6 Correlations between Nordic MSD scores and other measures of MSD

In addition to the measures obtained from the Nordic MSQ, ratings of MSD were also obtained
from separate three items which asked if ‘back pain’, ‘shoulder pain’, and ‘neck pain’ had been
experienced over the past six weeks and, if so, how severe it had been on a three-point scale
(mild=1, moderate=2, severe=3) (Vaernes, Knardahl, Romsing, Aakvaag, Tonder, Walther, &
Ursin, 1988). The extent to which these measures correlated with the corresponding Nordic MDQ
measures was determined using the non-parametric Kendall’s tau correlation coefficients. The
correlations are shown in Table 2.5.

Table 2.5
Tau correlations between corresponding self-report MSD ratings

Rating of MSD pain over past 6 weeks (0-3 scale)

Nordic MSQ Time

period Neck pain Shoulder pain Back pain

12 months 0.77 0.39 0.25

Neck
7 days 0.48 0.33 0.18

12 months 0.40 0.73 0.23

Shoulder(s)
7 days 0.34 0.62 0.24

12 months 0.14 0.19 0.56

Upper/lower back
7 days 0.15 0.21 0.51

Values shown in bold face represent correlations between corresponding measures

Two main points arise from the correlational data shown. First, the ratings for the ‘past 6 weeks’
are more closely correlated with the 12-month Nordic MSQ prevalence data than with the 7-day
Nordic MSQ prevalence data, implying that the six-week assessment period used in the

14
comparison questionnaire (Vaernes et al., 1988) taps chronic rather than short-term conditions.
Second, correlations for corresponding ratings are substantially higher than those for non-
corresponding ratings (e.g. neck with back), suggesting that individuals do discriminate between
pain in different areas rather than respond in a generalized manner. Correlations for corresponding
ratings for neck and for shoulder(s) are particularly high (.77 and .73, respectively).

2.2.7 Limitations of Nordic MSQ assessments

The Nordic MDQ provides descriptive information about the experience of MSD and its
implications for work and leisure activities. However, the data are categorical or ordinal in nature,
and the distributions do not lend themselves readily to parametric statistics. Furthermore, in the
present work, no longitudinal data were available for the Nordic MSQ whereas the more limited
items taken from Vaernes et al. (1988) relating to MSD problems were also obtained for the same
sample five years prior to the data analyzed in this chapter. Cross-sectional analyses of these data
are reported in Chapter 3; longitudinal analyses are reported in Chapter 4.

2.3 COMPARISONS 0F PRESENT DATA WITH LITERATURE FINDINGS

Several studies have used the Nordic MSDQ to examine prevalence rates of musculoskeletal
complaints in samples of male employees. It was therefore appropriate to compare the present
Nordic MDQ data with those reported from other studies, taking into account the point made by
Ozguler, Leclerc, Landre, Pietri-Taleb, and Niedhammer (2000) that such comparisons should
include only those studies in which the same questionnaire has been used for assessment purposes.

Table 2.6 shows the demographic characteristics and annual prevalence rates of musculoskeletal
symptoms in the present sample compared with those reported in two studies involving male
samples. These data were obtained from forestry chainsaw operators (Hulse & Gunstone, 1998),
and from sewage workers (Friedrich et al., 2000).

The work of the sewage workers involved frequent stooping and working with hands below knee
level, coupled with frequent heavy lifting. The forestry chainsaw operators carried out repetitive
work involving high levels of physical exertion and exposure to vibration. These groups were
roughly comparable to the present sample in age (mean age 36-45 years) and mean number of
years in the industry (9-13 years).

As can be seen in Table 2.6, the annual MSD prevalence rates are generally greater in the
comparison groups than in the present sample, in spite of similar ages and length of employment in
the current occupation. An exception to this trend is that the annual prevalence rates for neck and
upper back complaints are more prevalent in the present sample as compared to the forestry
chainsaw operator sample. However, the small size of this group (n=36) casts some doubt on the
reliability of the data.

A more complete picture of the disability caused by musculo-skeletal disorders can be obtained by
examining the duration of the problem in addition to prevalence rates. Relatively few studies report
this information, but Table 2.6 also compares (for those respondents who experienced some low
back pain) the present sample with the sewage worker sample in terms of the number of days of
pain experienced in the last 12 months. The number of days low back pain experienced is
substantially greater in the sewage worker sample than in the present sample.

15

 Table 2.6
The demographics, annual prevalence rates, and durations of musculo-skeletal
complaints in the present sample and in comparison groups

Chainsaw Sewage
Present sample
operators1 workers2

Sample size 341 26 255

Age (yrs) 45 (25 - 63) 36 (19 -60) 37 (SD 9.6)
Tenure in the industry (yrs) 11.9 Approx. 10 13
Neck 41 8 52
Shoulder(s) 29 53 ---
Elbow(s) 14 56 ---
Wrist(s)/hand(s) 18 83 ---
Upper back 11 3 55
Lower back 51 72 73
Hip(s)/thigh(s) 10 50 ---
Knee(s) 31 71 ---
Ankle(s)/feet 11 29 ---

Duration (among those with

back pain in the past year)
1-7 days 38.8 --- 11.5

8-30 days 31.8 --- 34.1

>30 days 29.4 --- 54.4

1 2
Hulse & Gunstone, 1998 Friedrich et al., 2000

Overall, the comparisons of the present data with published findings suggest that musculoskeletal
disorders are less prevalent and less severe in the present sample than in other occupational groups
of approximately comparable age. Two factors may contribute to these findings:

• Offshore personnel are an exceptionally healthy worker group required to pass a rigorous
medical examination prior to employment and at regular intervals subsequently. Thus, a
number of medical conditions that may be acceptable in onshore employment are not
accepted for offshore personnel, and the lower rates of musculo-skeletal problems may
reflect this bias towards good health.

• The present sample included a number of management and administrative employees and
other skilled white-collar workers in addition to manual workers; this difference in job
characteristics may also have had the effect of reducing reported musculoskeletal disorders
as compared with groups of manual workers.

16

 3. ANALYSIS OF REPORTED MSD SYMPTOMS

3.1 DATA ANALYSED

The data analysed were obtained from offshore oil industry employees (N=1462) in a wide range of
occupational groups, using a questionnaire developed by Vaernes et al. (1988). The three MSD
measures available related to pain in neck, shoulders, and back, In each case, dichotomous coding
represented whether or not participants had experienced the particular MSD problem concerned
during the previous six weeks (yes = 1, no = 0). Those who had experienced the problem also
indicated its severity on a three-point scale (mild = 1, moderate = 2, severe = 3). In addition to these
separate scores, a total score distinguished between participants who had not reported any MSD
symptoms in neck, shoulders or back, and those who had one or more symptoms. Similarly, among
those who had reported symptoms, an overall mean severity score was calculated.

In analysing these data, overall descriptive statistics for prevalence rates and severity rankings are
presented, and the role of personal and environmental factors as predictors of these MSD measures
is then evaluated.

3.2 OVERALL PREVALENCE RATES AND SEVERITY RATINGS

Table 3.1 shows the 6-week prevalence rates for MSD pain in three body areas (neck, shoulders, and
back), and the distributions of severity ratings for those reporting MSD in these areas. The overall
prevalence (i.e. MSD pain in at least one of the body areas specified) is also shown.

Table 3.1
6-week prevalence rates for MSD in neck, shoulders and back, and severity ratings

6 week prevalence Severity ratings

Mild Moderate Severe

Body area N % of
sample N % N % N %

Neck 333 22.9 169 50.8 142 42.6 22 6.6

Shoulders 253 17.3 110 43.5 115 45.5 28 11.0

Back 439 30.1 238 54.2 162 36.2 39 8.9

One or more of
the three body 673 46.2 451 67.0 146 21.7 76 11.3
areas*

* For overall severity ratings, total scores of 1-2 were coded ‘mild; 3-4 ‘moderate’; 5-9 ‘severe’.

17
Almost half the sample reported MSD problems in at least one of the three body areas specified. The
highest prevalence rate was for back pain, 30.1% of the sample endorsing this item; this percentage
was consistent with the data reported in Chapter 2, in that the six-week prevalence found here was
intermediate between the rates of 51% (annual) and 17% (7 days) obtained from the Nordic MSQ.
Whereas 54.2% of those reporting back pain described it as ‘mild’, shoulder pain (although the least
frequently reported by the present sample) was more likely to be judged ‘moderate’ or ‘severe’.

3.3 DIFFERENCES IN MSD PREVALENCES ACROSS JOB TYPES

As noted in Chapter 2, job types were classified into three categories based on the level of physical
activity involved (see Parkes, 2003, for details). ‘Sedentary’ jobs (e.g. management, administration,
18.1% of the sample) were associated with the lowest levels of physical activity, ‘active’ jobs (e.g.
production, maintenance, catering, 56.5% of the sample) involved moderate regular activity, while
personnel in ‘strenuous’ jobs (e.g. construction, drilling, 25.4% of the sample) were engaged in
physically-demanding tasks during much of the work shift.

For two of the three body areas assessed (back and shoulders), reported prevalance of MSD differed
significantly (p<.001) across job types; for neck problems the difference reached a marginal
significance level (p<.06). The data are shown in Table 3.2, and presented graphically in Figure 3.1.
Personnel in strenuous jobs were the most likely to report MSD; this finding was true of each the
three body areas assessed. Also, in this job group, more than half those concerned (55%) reported
MSD in at least one of the three body areas. Differences between those in sedentary jobs and those
in active jobs were less marked but, overall, with the exception of back problems, those in active jobs
were less likely to report MSD than those in sedentary jobs.

Table 3.2
Proportions of personnel in each of three job types reporting MSD problems

Job type
Body area Significance
Sedentary (N=265) Active (N=824) Strenuous (N=369)
test*
[df=2] n % n % n %

Back P2 = 18.4 66 24.9 230 27.9 143 38.8

p<.001
Neck P2 = 5.8 68 25.7 169 20.5 96 26.0
[p<.06]
Shoulders P2 = 19.8 51 19.2 113 13.7 89 24.1
p<.001

Any of the P2 = 16.0 120 45.3 350 42.6 203 55.0

three areas p<.001

* The P2 test evaluates the significance of the differences in the proportions of individuals in
each job type reporting MSD problems in the three body areas.

18
 Figure 3.1
Percentages of personnel in different job types reporting MSD
problems for three body areas

3.4 MSD SYMPTOM REPORTS IN RELATION TO GHQ ‘CASENESS’

To examine the relationship between MSD and ‘caseness’ as assessed by the General Health
Questionnaire (GHQ), six levels of MSD symptom severity were identified on the basis of the total
score on the three MSD measures (neck, shoulders, and back) each rated on a 0-3 scale. As shown
in Table 3.3, and graphically in Figure 3.2, the percentage of potential GHQ ‘cases’ increased
consistently over the range of increasing MSD severity. Differences in total MSD scores were highly
significant in relation to ‘caseness’. Reflecting the marked increase in ‘caseness’ rates at the highest
level of MSD scores (scores of 5 or more out of a maximum of 9), the relationship had significant
linear (p<.001) and quadratic (p<.001), components.

Table 3.3
GHQ ‘caseness’ in relation to overall level of MSD severity

Total MSD score N Percent of GHQ ‘Cases’

0 782 10%
1 233 11%
2 217 17%
3 82 21%
4 64 27%
5+ 76 47%

19
 .5

Percentages of GHQ 'cases'

.4

.3

.2

.1

0.0
0 1 2 3 4 5+

Level of MSD symptoms

Figure 3.2
Percentage of GHQ ‘cases’ in relation to level of MSD severity

3.5 MULTIVARIATE ANALYSES

The multivariate data analyses reported in this section were designed to answer three questions:

• To what extent are environmental and individual factors predictive of MSD symptoms?

• Are these factors the same for neck/shoulder problems, and for back problems?

• Among those who report MSD problems, what environmental and personal factors predict
severity?

3.5.1 Factors predictive of MSD in any of the body areas: back, shoulders and neck

Binary logistic regression analyses were carried out to determine the extent to which measures of the
physical and psychosocial environment were associated with reported MSD in any of the three body
areas assessed (neck, shoulders, back).
Control variables. At the first step, age, job type, and negative affectivity were entered as control
variables. Age was non-significant, but negative affectivity was highly significant (p<.001) and
positive in effect. Job type was also highly significant (p<.001); those in ‘strenuous’ jobs were more
likely to report MSD problems than those in ‘sedentary’ or ‘active’ jobs, but there was no difference
between those in the latter two categories. The relative risk associated with strenuous jobs as
compared with sedentary jobs was 1.49.
Physical and psychosocial environment (Model 1). Measures of supervisor support, co-worker
support, physical environment stressors, workload, autonomy, and job clarity were entered in a
second step of the analysis. As shown in the first column of Table 3.4 (Model 1), high levels of

20

general physical stressors (e.g. vibration, poorly designed workspace, drafts and cold) and specific
physical stressors (heavy physical workload, working at heights) were both highly predictive of
MSD, while workload played a marginal role. In contrast, autonomy and job clarity were significantly
negatively associated with MSD (p<.01 in each case); thus, higher levels of these work characteristics
were associated with a reduced likelihood of MSD. There was no signficant impact of supervisor or
co-worker support on MSD. For Model 1, the Nagelkerke R2 value (a measure of the extent to which
the independent variables predict the outcome variable) was 0.01.

Table 3.4
Psychosocial and individual predictors of the occurrence of MSD

Model 1 Model 2 Model 3

Control variables Control variables Control variables,
and environment and individual psychosocial and
predictors predictors individual predictors
B Significance B Significance B Significance
Age .01 ns .00 ns .00 ns
Job type -- p<.005 -- p<.001 -- p<.01
Negative affectivity .10 p<.001 .03 ns .02 ns

Workload .11 [p<.10] .04 ns

Autonomy -.15 <.025 -.12 [p<.10]
Clarity -.29 <.02 -.24 p<.05
Physical stressors .18 <.025 .15 [p<.10]
(general)
Physical stressors .19 <.005 .21 p<.005
(specific)
Supervisor support -.03 ns .03 ns
Co-worker support -.02 ns .00 ns

GHQ Anxiety .13 p<.001 .13 p<.001

GHQ Social dysfunction -.06 ns -.06 ns
Job satisfaction .02 ns .08 ns
Job security -.23 p<.01 -.19 p=.05
Subjective physical health -.16 p<.05 -.18 p<.05
Body mass index -.01 ns -.02 ns

Nagelkerke R2 .100 .112 .142

Notes. N=1409. Age, neuroticism, and job type were included in each model. All data shown
relate to simultaneous models in which all predictor variables are adjusted for each other.

21
Job type remained significant (p<.05) when the work environment measures was included in the
model, but the pattern of results was different from that observed when only the control variables
were entered. Thus, in this model, ‘strenuous’ jobs were no longer significantly different from
sedentary jobs; this result suggests that the work environment variables accounted for the difference
in MSD between these job types observed at the first step of the analysis. The results for job type also
showed that, after differences in the work environment had been taken into account, those in ‘active’
jobs were less likely than those in ‘sedentary’ jobs to report MSD problems. The relative risk of those
in active jobs relative to those in sedentary jobs was 0.70.

Individual variables (Model 2). A similar analysis was carried out in which age, negative affectivity,
and job type were again entered into the logistic model as control variables at the first step, and
individual differences (including GHQ measures of anxiety and ‘social dysfunction’, job satisfaction,
job security, self-rated physical health, and body mass index) were entered at the second step. The
significant predictors, over and above job type, were anxiety (p<.001), job security (p<.01), and self-
rated health (p<.05). The effect of negative affectivity was transmitted through anxiety and job
security; thus, negative affectivity was not significant in this model. Body mass index was non-
significant; this result accords with the finding reported in Chapter 2 which showed that body mass
index is implicated in lower body MSD but not in the upper body areas assessed in the present study.
For Model 2, Nagelkerke R2 was 0.112.

Work environment and individual predictors combined (Model 3). When the environmental and
individual variables were combined into a single predictve model (Model 3 in Table 3.4), anxiety was
found to be the most highly significant predictor variable, although individual differences in job
security and subjective health also remained significant. However, with the exception of specific
physical stressors, all the work environment variables showed markedly weaker effects relative to
those apparent in Model 1. This finding suggests that the effects of the psychosocial environment on
MSD are to a large extent mediated by affective distress, particularly high anxiety and low job
security. As shown in Table 3.4, job type remained significant in each of the predictive models
tested. Thus, although the psychosocial and individual predictors partially accounted for differences
in the incidence of MSD associated with different types of jobs, these variables did not fully account
for job differences. Other factors, unmeasured in the present study (e.g. lifestyle variables such as
diet, exercise, and recreational activities) which may also be related to occupational status may also
contribute to differences in MSD among personnel in different types of jobs.

3.5.2 Separate analyses of MSD in the back and in the neck/shoulders

Further analyses were carried out to determine the extent to which the pattern of significant
psychosocial and individual predictors differed for back MSD problems as compared with
neck/shoulder problems. As in the previous section, the dependent variable was dichotomous,
representing only whether or not the problem was reported, without reference to the severity of the
reported problem. For the neck/shoulders outcome, the reported presence of MSD in either or both
of these body areas was considered a positive response. The results for the full model (equivalent to
Model 3 in Table 3.4) are shown in Table 3.5.

For both the outcome variables shown in Table 3.5, GHQ Anxiety was the most highly significant
predictor; thus, anxiety was strongly associated with reports of both neck/shoulder problems and back
problems, separately, as well as with the overall MSD score (see Table 3.4). However, other predictor
variables in Table 3.5 showed different patterns for the two outcomes.

22

 Table 3.5
Psychosocial and individual predictors of MSD in back and neck/shoulders

Back Neck/shoulders

B Significance B Significance

Age -.01 ns .02 ns

Job type -- ns -- p<.005
Negative affectivity .01 ns .02 ns

Workload .11 ns .05 ns

Autonomy -.05 ns -.13 [p<.10]
Clarity -.19 ns -.10 ns
Physical stressors (general) .16 [p<.10] .11 ns
Physical stressors (specific) .35 p<.001 .10 ns
Supervisor support .01 ns .08 ns
Co-worker support .10 ns -.04 ns

GHQ Anxiety .08 p<.001 .14 p<.001

GHQ Social dysfunction -.02 ns -.06 ns
Job satisfaction -.09 ns .04 ns
Job security -.10 ns -.20 [p<.10]
Subjective physical health -.16 p<.05 -.07 ns
Body mass index -.06 p<.01 .02 ns

Nagelkerke R2 .129 .132

Notes. N=1409. All data shown relate to simultaneous models in which all predictor variables
included are adjusted for each other.

Thus, job type was significant only in relation to neck/shoulder problems; personnel in ‘active’ jobs
were significantly less likely (relative risk = .66) to report these problems as compared with those in
sedentary jobs. Two other variables (job security and autonomy) showed marginally significant
effects; in each case, the trend was for higher levels of these characteristics to be associated with
lower risk of neck/shoulder MSD. For reported back problems, the significant predictors (over and
above anxiety) were specific physical stressors, subjective physical health and body mass index.
Higher levels of stressors, poorer general physical health, and lower body mass index were associated
with greater probability of back problems.

23

Height and weight in relation to back MSD. The finding that lower BMI was significantly associated
with a greater likelihood of back MSD problems (see Table 3.5) was unexpected, and contrasted with
findings from the Nordic MSQ reported in Chapter 2 which showed high BMI to be a risk factor for
MSD in the back and lower extremities. To further examine the role of physique in relation to back
problems, BMI was removed from the logistic regression model, and height and weight were entered
as separate terms over and above the other variables in the model.

In this analysis, both height and weight were found to be significant predictors of back MSD. For
height (p<.001), the results showed that taller individuals were more likely to report back problems
than those who were shorter. For weight (p<.025), heavier individuals were less likely to report back
problems than those who were lighter. Taken together, these results suggest that tall/slim individuals
are more likely to report back problems than short/heavy ones, but that height is a more marked risk
factor for back MSD than low weight. However, this finding did not apply to neck/shoulder problems,
for which neither body mass index nor height were significant predictors.

3.5.3 Factors predicting MSD in both back and neck/shoulders, as compared with
MSD in either back or neck/shoulders
The analyses above identified factors associated with the reporting of back problems as compared
with those associated with neck/shoulder problems; however, it was also of interest to determine
which factors identified individuals who reported both back and neck/shoulder problems as compared
with those who reported one or the other type of problem. Logistic regression methods identified
three significant factors associated with the reporting of both problems, rather than either one or the
other. High levels of anxiety (p<.01), workload (p<.05) and specific physical stressors (p<.02) were
characteristic of those who reported both types of problems.

3.6 SEVERITY OF REPORTED MSD PROBLEMS

The extent to which psychosocial and individual variables were implicated in MSD severity ratings
was examined in the sub-sample of participants who reported one or more mild (scored 1), moderate
(scored 2), or severe (scored 3) MSD problems in the particular body area or areas concerned. Those
with no problem in the body area concerned were excluded from these analyses. Ordinal logistic
regression was used to determine the significance of the independent variables in relation to the
severity ratings. The analytic approach adopted was similar to that described above; thus, severity
scores for a combined measure of back, neck and shoulders were examined first; subsequently, the
extent to which severity scores for back problems and for neck/shoulder problems were associated
with different predictor variables was evaluated.

3.6.1 Overall MSD severity

An overall severity score was calculated by summing the severity scores across back, neck and
shoulder problems for all individuals who reported one or more such problem (N=673). As there
were relatively few individuals with high levels of total severity scores, scores of 5 or more were
coded 5+, giving a total of five ordinal categories. The percentages in each category are shown in
Table 3.6. Analysis of these data followed the same approach as the analysis of the incidence data
reported above, that is, the control variables (age, negative affectivity, and job type) were entered into
the regression as control variables at the first step, and two subsequent models tested the separate
effects of work environment variables and individual variables. A final combined model included
both work environment and individual variables

24

 Table 3.6
Distribution of MSD severity ratings

Total severity rating N % of sample

1 234 34.8
2 217 32.2
3 82 12.2
4 64 9.5
5+ 76 11.3
N = 673

Control variables. At the first step, negative affectivity was a highly significant predictor of MSD
severity ratings, but the other control variables were not significant. Individuals higher in negative
affectivity reported higher severity ratings.

Physical and psychosocial environment variables. When variables representing the work environment
were entered, none of them contributed significantly to severity ratings, but negative affectivity
remained highly significant.

Individual variables. When the individual variables were entered jointly with the control variables,
GHQ Anxiety was the strongest predictor (p<.001); in this analysis, negative affectivity ceased to be
significant, indicating that the effect of negative affectivity on severity ratings was mediated through
current anxiety levels. The only other predictor variable significant in this analysis was job type;
those in ‘active’ jobs reported lower severity ratings than those in ‘strenuous’ jobs.

Combined model. When the work environment and individual variables, together with the control
variables were combined into the same model, the results were similar to those noted above, that is,
negative affectivity, mediated by anxiety, made the only significant contribution to the model.

Separate analyses of back pain severity and neck/shoulder pain severity. The separate analyses of
back pain severity and neck/shoulder pain severity reflected the results reported above, that is, the
only variable predictive of severity ratings in each case was negative affectivity mediated by anxiety.

3.7 MODEL OF PSYCHOSOCIAL FACTORS AND MSD

The model shown in Figure 3.3 represents diagrammatically the findings shown in Table 3.4,
showing the mediational pathways by which psychosocial and individual factors impact on the
occurrence of MSD (i.e. the outcome variable is presence or absence of MSD in back, neck or
shoulders). It can be seen that although differences between job types (strenuous, active, and
sedentary) are partially mediated through the perceived psychosocial and physical work environment,
these factors do not entirely account for the impact of job type on MSD. Unmeasured lifestyle and
personal variables have an effect over and above the environmental variables assessed. Moreover,
the effects of psychosocial factors are largely mediated through their impact on measures of affective
distress, particularly anxiety.

25

 Anxiety
Negative Job insecurity
affectivity Low subjective
health

MSD

Job type Psychosocial

work
environment

Physical
work stressors

Figure 3.3
Pathways showing the impact of psychosocial and individual factors
on MSD occurrence

26

 4. CHANGE IN MUSCULO-SKELETAL DISORDERS, 1995 - 2000

4.1 LONGITUDINAL ANALYSES

As many as possible of the oil industry personnel who took part in the 1995-6 survey were followed up
in 2000. The follow-up sample consisted of personnel who had agreed to take part in further work at the
time of the original survey. Many of the individuals concerned could not be traced, and some of those
who were contacted did not return a follow-up questionnaire; however, a total of 359 completed follow-
up questionnaires were received. Of this group, all personnel still employed in the oil industry (N=321)
were included in the longitudinal analyses.

The aim of the longitudinal analyses was to examine changes in reported MSD symptoms over the five-
year interval, and to determine the extent to which changes in measures of the psychosocial work
environment and of psychological well-being predicted the observed changes in MSD. Over this time
period, it would be expected that the normal ageing process would bring about some increase in MSD
symptoms, and in other measures linked to ageing (e.g. BMI), over and above the predicted effects of
changes in the work environment and in psychological well-being. A related issue was the extent to
which changes in MSD symptoms predicted changes in mental health. Thus, the issue of causal direction
between change in MSD symptoms and change in mental health was one focus of the analyses.

4.2 HEALTH-RELATED MEASURES IN 1995 AND 2000

Table 4.1 shows the means and deviations for MSD symptoms, other health-related measures, and work
environment ratings, in 1995 and 2000. The change scores and their significance levels are also shown.

Changes in MSD ratings. It can be seen from Table 4.1 that the total of the MSD scores for back pain,
shoulder pain and neck pain increased significantly between 1995 and 2000, and that each of the separate
components of the total score also showed significant increases over the five-year time interval. The
significance tests shown are paired t-tests, but the significance levels reported corresponded closely to
those obtained by non-parametric methods (Wilcoxon signed ranks test).

Changes in psychological distress and physical health ratings. Mean scores in 1995 and 2000 and the
corresponding change scores for two measures of psychological distress are also shown in Table 4.1;
scores on the measure of anxiety (derived from the General Health Questionnaire, GHQ) increased
significantly over the five-year period, but there was no significant change in scores on the GHQ ‘social
dysfunction’ scale, a measure of low morale. The proportion of GHQ ‘cases’ derived from the GHQ-12
increased from 15.4% to 19.6% but this trend did not reach conventional significance levels (.10<p<.20,
McNemar test). The significant decrease in self-rated physical health indicated that, in general,
participants perceived their health to have deteriorated over the five-year period.

Changes in BMI. Consistent with the tendency for body weight to increase with increasing age, BMI
increased significantly between 1995 and 2000. Corresponding to the increase in mean BMI, the
proportion of the sample in the ‘obese’ category (BMI > 30) increased from 8.3% to 14.1% and the
proportion in the ‘overweight’ category increased from 52.6% to 56.1%; the difference in proportions in
each category from 1995 to 2000 was highly significant (p<.001, Wilcoxon signed ranks test).

Changes in work perceptions. In contrast to the tendency for the health-related measures shown in Table
1 to show unfavourable trends over the five-year follow-up period, changes in the work perceptions
measures presented a more ambiguous picture. Perceived exposure to physical stressors decreased and
control over work tasks increased significantly, but job clarity decreased. No significant changes were
found in the measures of workload and of social support.

27

 Table 4.1
Health-related and environment measures 1995/2000, and significance of change scores

1995 2000 Change from Significance

Measure Mean (s.d.) Mean (s.d.) 1995 to 2000 of difference
(2000 - 1995 scores)

MSD symptom ratings:

t = 4.69,
Neck, shoulders, back (total) 1.08 (1.53) 1.58 (1.90) 0.50 (1.53) df = 304,
(0 - 9 scale) p<.001

Neck .40 (.72) .55 (.85) .15 (.92) p<.01

Shoulder .27 (.65) .47 (.84) .20 (.86) p<.001

Back .41 (.76) .57 (.80) .16 (.96) p<.01

Psychological distress (GHQ)

t = 3.21
Anxiety 4.19 (3.47) 4.82 (3.76) 0.63 (3.48) df = 311
(0 - 21 scale) p<.001

Social dysfunction 6.92 (1.80) 7.04 (2.01) 0.12 (2.13) t<1

(0 - 21 scale) ns

Proportion of GHQ ‘cases’ 15.4% 19.6% 4.2% Z = 1.54

(0 - 1 scoring) ns

Subjective physical health rating t = !3.46

(1 - 5 scale) 3.63 (.82) 3.46 (.81) !0.17 (.85) df = 311
p<.001
t = 9.51
Body mass index (BMI) 25.95 (2.75) 26.66 (2.93) 0.71 (1.31) df = 311
p<.001

Physical environment stressors 1.80 (.85) 1.59 (.84) !0.21 (.70) t = !5.24
p<.001

Psychosocial environment
t = 2.55
Control 2.35 (.70) 2.45 (.70) 0.10 (.70) p<.02

t = !6.02
Clarity 2.59 (.58) 2.39 (.54) !0.20 (.58) p<.001

t = 1.35
Workload 2.37 (.85) 2.44 (.74) 0.07 (.88) ns

t<1
Supervisor support 1.63 (.66) 1.65 (.70) 0.02 (.76) ns

t = !1.84
Co-worker support 2.01 (.59) 1.94 (.62) !0.07 (.68) [p<.10]

Based on N= 305 - 312 (depending on missing data)

28
4.3 CHANGE IN MSD RATINGS IN RELATION TO AGE AND JOB TYPE

A repeated-measures analysis of variance (with year, 1995/2000, as the repeated-measures factor) was
carried out to determine the extent to which age and job type (sedentary, active, or strenuous) determined
the extent of change in MSD symptoms. Job type was unrelated to change in MSD, but age showed a
marginal effect (p<.06) whereby the increase in MSD symptoms over the five-year interval was greater
among older personnel than among their younger counterparts. This pattern of results was not changed
by the inclusion of negative affectivity, which was non-significant in relation to MSD change.

4.4 CHANGE IN MSD: EFFECTS OF ENVIRONMENTAL AND INDIVIDUAL FACTORS

The repeated-measures analysis model was extended to examine the extent to which changes in work
perceptions, and in measures of mental health, between 1995 and 2000 contributed to change in MSD
symptoms. Over and above age, only one aspect of the environment was found to be significant; increase
in supervisor support was associated with a decrease in MSD symptoms (F=11.4, df=299, p<.001).
Changes in other work environment measures did not contribute to change in MSD. Similarly, among
the individual measures of mental health (GHQ anxiety and GHQ social dysfunction measures), affective
well-being (job satisfaction, job security), and body mass index, only changes in GHQ anxiety were
significantly related to change in MSD. A combined model in which age in 1995, change in supervisor
support and change in anxiety (from 1995 to 2000) were evaluated in a simultaneous analysis was
therefore carried out. The results for the ‘within-subjects’ analysis are shown in Table 4.2; there were
no significant ‘between-subjects’ effects.

Table 4.2
Factors predicting change in MSD symptoms, 1995 to 2000

df F Significance

Year (2000 vs 1995) 1 24.3 p < 0.001

Year x Age (1995) 1 3.93 p < 0.05

Year x change in Supervisor Support 1 8.13 p < 0.005
Year x change in Anxiety 1 21.1 p < 0.001
Error term 298

Analysis based on N = 302

The effects of age and of change in supervisor support were evaluated using the B regression coefficients
for 1995 and 2000 levels from the repeated-measures analysis. These effects are represented graphically
in Figures 4.1 and 4.2. In these diagrams, age is evaluated at the mean level of change in support, and
change in support is evaluated at the mean level of age (consistent with the additive nature of these two
effects). It can be seen that there is a general increase in MSD scores between 1995 and 2000. Moreover,
although age is unrelated to MSD in 1995, it does have a significant effect in 2000. Thus, age is directly
related to the extent of the increase in MSD scores over the five-year period.

29

 Figure 4.1
Age in 1995 in relation to MSD scores in 1995 and 2000

Figure 4.2
MSD symptoms in 1995 and 2000 in relation to change in
supervisor support

30
The effect of supervisor support is shown graphically in Figure 4.2. The increase in MSD symptoms is
most marked in those who experienced a decrease in supervisor support over the five-year follow-up
period. Thus, the results suggest that reduced supervisor support acts to accentuate increases in MSD
between 1995 and 2000, over and above those due to other factors, particularly age-related changes.
Conversely, increased support over this period mitigates the observed increase in MSD symptoms.
Anxiety change was also significant in this analysis; the role of anxiety in relation to MSD is considered
in more detail in the following section.

4.5 ANXIETY AND MSD SYMPTOMS: PATTERNS OF CHANGE OVER TIME

In view of the interest in relations between anxiety and MSD, particular attention was given to patterns
of change in MSD and anxiety over time in the longitudinal data analysis. The analysis reported above
demonstrated that the difference score representing change in anxiety between 1995 and 2000 was
significant in relation to change in MSD symptoms (treated as the repeated-measures factor). The analyses
reported in this section, examines the relationships between the 1995 and 2000 measures of anxiety and
MSD in more detail. The analysis was carried out in two parts.

Anxiety in 1995 and 2000 as predictors of MSD change. In this analysis, instead of using a difference
score (i.e. score in 2000 minus score in 1995) to represent change in anxiety, Anxiety (1995) and Anxiety
(2000) were treated as two separate predictor variables in relation to MSD scores in 1995 and 2000. These
two variables were included in the model in addition to the two variables found to be significant in the
earlier analyses (age and change in supervisor support). The interaction between Anxiety (1995) and
Anxiety (2000) was also evaluated in the predictive model. This interaction term allowed a test of whether
the cross-sectional relationship between anxiety in 2000 and MSD in 2000 was influenced by the prior
anxiety level assessed in 1995. The results are shown in Table 4.3, and the corresponding regression
estimates are shown in Table 4.4.

Table 4.3
Repeated-measures analysis of change in MSD symptoms, 1995 to 2000

df F Significance

Year (2000 vs 1995) 1 33.2 p < 0.001

Year x Age (1995) 1 3.04 [p < 0.10]

Year x change in Supervisor Support 1 8.24 p < 0.005
Year x (Anxiety 1995) 1 6.98 p < 0.01
Year x (Anxiety 2000) 1 23.3 p < 0.001
Year x (Anxiety 1995) x (Anxiety 2000) 1 9.08 p < 0.005
Error term 296

Analysis based on N = 302

31

 Table 4.4
The prediction of MSD from anxiety: Regression coefficients

Prediction of MSD in 1995 Prediction of MSD in 2000

B t p B t p

Intercept 1.056 11.6 < 0.001 1.698 15.32 <.001

Age (1995) -.066 <1 ns .110 1.10 ns
Change in Supervisor Support .070 <1 ns -.222 -2.19 <.05
Anxiety 1995 .504 4.87 < 0.001 .169 1.33 ns
Anxiety 2000 .071 <1 ns .660 5.43 < 0.001
Anxiety 1995 x Anxiety 2000 .074 1.01 ns -.196 -2.20 <.05

Note. Standardized scores were used for the predictor variables

It can be seen from Table 4.3 that there is a highly significant interaction between Anxiety (1995) and
Anxiety (2000) in predicting MSD in the repeated-measures analysis. The regression coefficients in
Table 4.3 show the predictors of MSD ratings in 1995 and 2000. MSD in 1995 is predicted only by the
Anxiety in 1995; in contrast, MSD in 2000 is predicted by the interaction between Anxiety in 1995 and
Anxiety in 2000. Thus, MSD in 2000 depends not only on the concurrent level of anxiety but also on the
prior 1995 level of anxiety. The data are plotted in Figure 4.3 for high (+1SD) and low (-1SD) levels of
MSD in 1995 and 2000.

Figure 4.3
MSD ratings in 1995 and 2000 as related to changes in anxiety

32
MSD in 1995 and 2000 as predictors of Anxiety change. A similar analysis was carried out to determine
the extent to which MSD scores in 1995 and 2000 predicted anxiety in the repeated-measures analysis.
This analysis is shown in Tables 4.5, and the corresponding regression coefficients in Table 4.6. The
pattern of results in Table 4.5 differs from that in shown Table 4.3 in that there is no significant
interaction between MSD in 1995 and MSD in 2000 in predicting Anxiety (2000). It can be seen from
the corresponding regression coefficients shown in Table 4.6 that MSD in 1995 predicts Anxiety in 1995,
and MSD in 2000 predicts Anxiety in 2000; thus, only concurrent effects are observed in this analysis.
The data are plotted in Figure 4.4.

Table 4.5
Repeated-measures analysis of change in anxiety, 1995 and 2000

df F Significance

Year (2000 vs 1995)

1 10.40 p < 0.001

Year x Age (1995) 1 <1 ns

Year x change in Supervisor Support 1 2.08 ns
Year x MSD 1995 1 12.89 p < 0.001
Year x MSD 2000 1 17.22 p < 0.001
Error term 297
Analysis based on N = 302. The interaction term, Year x (MSD 1995) x (MSD 2000) was non-
significant (F<1), and was not included in the model.

Table 4.6
The prediction of anxiety from MSD: Regression coefficients

Prediction of Anxiety 1995 Prediction of Anxiety 2000

B t p B t p

Intercept 4.134 22.61 p<.001 4.76 23.73 p<.001

Age (1995) .277 1.51 ns .10 <1 ns
Change in Supervisor Support -.038 <1 ns -.32 -1.58 ns
MSD score 1995 1.166 5.74 p<.001 .40 1.77 ns
MSD score 2000 .250 1.21 ns 1.16 5.10 p<.001

Notes. Standardized scores were used for the predictor variables

33
 Figure 4.4
Anxiety in 1995 and 2000 in relation to changes in MSD

Taken together the two sets of results are consistent with the view that MSD and anxiety are correlated
in cross-sectional concurrent analyses, but also that anxiety plays a causal role in the development of
MSD symptoms over time. In contrast, there is no evidence to suggest the reverse causal path applies.

4.6 CHANGE IN MSD IN RELATION TO CHANGE IN OVERALL HEALTH RATINGS

The present data also allowed evaluation of the extent to which change in MSD status from 1995 to 2000
contributed to change in self-ratings of overall health. In this analysis, change in MSD status was
classified in four groups: no reported symptoms in 1995 or 2000 (n=92), reported symptoms in both 1995
and 2000 (n=109, onset of MSD between 1995 and 2000 (n=71), and remission of MSD between 1995
and 2000 (n=38). These four categories were examined in a multivariate analysis in which change in self-
rated health (controlled for self-rated health in 1995) was treated as the dependent variable; other
predictors included for control purposes were age (ns), BMI in 1995 (ns) and change in BMI between
1995 and 2000 (p<.01).

Change in MSD was found to be a significant predictor in this analysis (p<.05). As shown in Figure 4.7,
significant deterioration in self-rated health was found among those with continuing MSD and those with
MSD onset between 1995 and 2000, as compared with small and non-significant change among those
with no MSD or with MSD remission. This finding, which highlights the significant role played by
changes in MSD symptoms over time in relation to changes in overall subjective health evaluations, is
important in that decreases in subjective health perceptions are predictive of subsequent sickness absence
(Moreau, Valente, Mak, Pelfrene, de Smet, De Backer, & Kornitzer, 2004), and other adverse outcomes
(Idler & Benyamini, 1997; Mantyselka, Turunen, Ahonen, & Kumpusalo, 2003).

34
 0.0

Change in self-rated health from 1995 to 2000

-.1

-.1

-.2

-.2

-.3

-.3
No MSD Continuing MSD MSD onset MSD remission

MSD status in 1995 and 2000

Figure 4.7

Change in self-rated health in relation to change in MSD status

between 1995 and 2000

35

 5. GENERAL BELIEFS ABOUT THE CAUSES OF MSD

5.1 ASSESSMENT OF GENERAL BELIEFS ABOUT THE CAUSES OF MSD

5.1.1 Scale development

The initial aim of the work described in this chapter was to develop a list of items to assess the
extent to which individuals attributed MSD problems to a range of personal, work-related and
stress/health factors and to establish the psychometric properties of the scale. Table 5.1 shows the
items used, which were identified from the relevant literature (eg. Haerkaepaeae, Jaervikoski &
Estlander, 1996; Rasanen et al., 1997; Symonds et al., 1996; Waddell et al., 1993). Participants
(N=676) were asked to rate, for each item, to what extent they considered it likely that the cause
described contributed to MSD among personnel in their type of job. Thus, the question was
general, rather than focused specifically on the individual’s experience of MSD. A three-point
scale (0 = unlikely; 1= possible; 2= very likely) was used. Separate ratings were obtained for MSD
in relation to three body areas (neck/shoulders; lower back; and hips/knees/ankles). For
psychometric purposes, these three ratings were summed across the three body areas for each item,
giving an overall range of 0-6. Data were obtained from 676 male offshore personnel, mean age
44.2 years (SD 8.5 years).

5.1.2 Factor analysis

Factor analysis with varimax rotation was applied to the raw data. As shown in Table 5.1, three
factors were identified, designated ‘stress/anxiety’ (including poor health behaviours), ‘work-
related causes’, and ‘lifestyle’, on the basis of their main content areas. These scales had 10, 9, and
6 items, respectively; the corresponding coefficient alpha values were .88, .82. and .70. The three
factors together accounted for 46.1% of the variance. Six items did not load on any of the scales;
these items were dropped in creating the sub-scale scores.

5.2 ANALYSIS OF SCALE SCORES

The mean item scores on the three scales differed significantly (p<.001) overall. Scores on the
‘stress/anxiety’ scale (mean value, 1.64) were significantly lower than those on the other two
scales, indicating that participants perceived these items as less likely to be causes of MSD than
those on the ‘work-related’ and ‘lifestyle’ scales (mean values 3.67 and 3.75 respectively).

5.2.1 Patterns of scores in relation to age, neuroticism and experience of MSD

Patterns of scores for items on each of the three scales (stress/anxiety, work-related, and lifestyle
factors) were examined in relation to neuroticism and whether or not individuals had reported
MSD in at least one body area. Age was included as a control variable. Figure 5.1 shows the mean
item scores for the groups who did or did not report experience of MSD. Lifestyle items were
unrelated to the predictor variables.
Stress/anxiety items. Neuroticism was significantly and positively associated with overall scores on
the stress/anxiety scale (p<.01), but did not relate differentially to items on the scale. In contrast,
experience of MSD was differentially related to items on this scale (p<.025 in each case).
Individuals reporting MSD (as compared with those who reported no MSD) had higher scores on
Items #6, #9, #17, #20, and #26. Thus, over and above the effect of neuroticism, experience of
MSD was associated with scores on several ‘beliefs’ items reflecting stress and anxiety.

Work-related items. Overall, scores on this scale were positively related to the experience of MSD
(p<.05). Age did not show an overall effect, but the age x item interaction was significant (p<.025);
beliefs that heavy workload (#1) and general work demands (#4) were associated with MSD were
significantly and positively related to age. These items, together with long work hours (#28), were
also significantly related to high neuroticism.

36

 Table 5.1
Items assessing MSD causal attributions, and factor loadings for the three subscales

Factor
Item # Item wording I II III
‘Stress’ ‘Work’ ‘Lifestyle’
1 Heavy workload .68

2 Inherited problem / runs in the family .48

3 Poorly designed/uncomfortable chairs -- -- --

4 General work demands .67

5 Smoking .58
6 Anger/annoyance .70
7 Non-work activities (sport/DIY/gardening) .56
8 Unhealthy food .60
9 Stressful situations at home .78
10 Poor ventilation in work area .66
11 Low morale .77
12 Inadequate rest breaks during work hours .54
13 Physical problem (past injury/illness) .63
14 Poorly designed/cramped work space .51
15 Working in cold conditions .54
16 Noise/vibration in work area -- -- --
17 Irregular eating patterns .69
18 Lack of fitness/exercise .62
19 Normal process of ageing .63
20 Depression/low mood .74
21 Inadequate job training or experience -- -- --
22 Working in hot conditions -- -- --
23 Being overweight .64
24 Frequent use of steep stairs .62
25 Lifting heavy/awkward objects at work .61
26 Anxiety/tension .65
27 Lack of support from work colleagues -- -- --
28 Long work hours .64
29 Lack of control over work tasks .54
30 Work involving night shifts -- -- --
31 Alcohol intake .51
32 Frequent/prolonged use of telephone -- -- --

37
 5.0

4.0

Mean item score

3.0

2.0

1.0

0.0
#5 #6 #8 #9 #10 #11 #17 #20 #26 #31

'Stress/anxiety' items

5.0

4.0
Mean item score

3.0

2.0

1.0

0.0
#1 #4 #12 #14 #15 #24 #25 #28 #29

'Work-related' items

5.0

4.0
Mean item score

3.0

2.0

1.0

0.0
#2 #7 #13 #18 #19 #23

'Lifestyle' items

No MSD reported (n=138)

One or more MSD symptoms reported (n=531)

Figure 5.1
Scores on measures of beliefs about causes of MSD in relation to symptom reports

38
5.2.2 MSD beliefs in relation to psychosocial work characteristics

Multivariate analysis of the three ‘beliefs’ scales in relation to psychosocial work characteristics
(workload, control, autonomy, and job clarity) and job type (sedentary, active, strenuous) with control
for age and neuroticism showed that workload and job type were significant, but the other work
characteristics were unrelated to scores on the ‘beliefs’ scales. Workload was highly significantly
(p>001) and positively related to stronger beliefs that stress/anxiety and work conditions were causes of
MSD. Job type was significantly related only to the scale assessing beliefs about work causes of MSD;
those in strenuous jobs had higher scores on this scale than those in active jobs, who had higher scores
than those in sedentary jobs.

5.2.3 MSD beliefs in relation to different body areas

The analyses reported above were based on total ‘beliefs’ scores summed over the three different body
areas (neck/shoulders, lower back, and hips/knees/ankles). To determine the extent to which the
different body areas were associated with different patterns of beliefs, mean scores were calculated for
each of the three body areas separately for the three scales representing different beliefs about the
causes of MSD (stress/anxiety, work-related, and lifestyle). The possible range of these item mean
scores was 0-2 in each case. A repeated-measures analysis with two within-subjects factors (body area
and belief scale), each with three levels, was carried out on these scores.

The results showed that both body area and the nature of the beliefs (stress/anxiety, work-related, and
lifestyle) significantly predicted mean scale scores; moreover there was a highly significant interaction
between these two factors (p<.001). The mean scores are shown in Figure 5.2. Scores on the
stress/anxiety scale showed the most marked differences across body areas; they were highest for
neck/shoulders, and lowest for hips/knees/ankles with lower back showing an intermediate score.

Mean item scores on the other belief scales were higher than those for the stress/anxiety scale for all
body areas; these mean item scores on these scales also differed across body areas. The work-related
scale was high for lower back MSD relative to the other body areas, while lifestyle scores were high for
both lower back and lower extremities (hips/knees/ankles) relative to neck/shoulders.

1.4
Mean score on MSD beliefs items

1.2

1.0

.8
Stress/anxiety

.6
Work-related
.4

.2
Lifestyle
Neck/shoulders Lower back Hips/knees/ankles

BODY AREA

Figure 5.2
Mean item scores on scales assessing beliefs about
the causes of MSD for three body areas

39

 6. INDIVIDUAL BELIEFS ABOUT THE CAUSES OF MSD

6.1 DATA ANALYSIS

The analyses presented in this section differ in two ways from those in Sections 5. First, the data
examined relate to respondents’ causal beliefs about their own experience of MSD, rather than their
beliefs about the causes of MSD in general. Thus, the analyses are carried out on data obtained from
those who had actually experienced MSD problems over the previous year in the specified body area
(neck/shoulders, lower back, or hips/knees/ankles). It was therefore necessary to examine data for the
sub-samples reporting each of the three MSD problems separately, as the size and composition of the
group concerned differed in each case. Second, the data focus on the specific items identified by the
individuals concerned as being the main causes of their MSD problem. Thus, participants who reported
that they had experienced MSD in the body area concerned over the past year were asked to indicate
which four items (from the list of 32 items in Table 5.1) were most relevant to themselves.

The data analysis was carried out in a similar way for each of the three body areas concerned. First,
the frequencies with which each of the 32 items were identified as one of the four main causes
specified by each participant was determined. These frequencies varied widely from zero for some
items to almost 40% for others. For example, 39% of the sample concerned (N=274) identified
‘Frequent climbing of steep stairs’ (Item #24) as one of the four most important causes of the
hips/knees/ankles MSD problem they had experienced. In analysing the data, items identified by less
than 10% of the sample were disregarded. In each of the three data sets (corresponding to the three
different body areas), 12 items out of the 32 listed met the 10% frequency criterion.

6.2 IDENTIFICATION OF PARTICULAR CAUSES IN RELATION TO TYPE OF MSD

As shown in Table 6.1, of the total of 14 items identified as having a frequency of at least 10% of the
sample concerned for any particular type of MSD problem, nine causes were common to each body
area (ie. they were perceived as major causes of MSD in neck/shoulders, lower back, and
hips/knees/ankles). Considered in terms of the three scales identified in Section 5.1, seven of the 14
items fell on the ‘work-related’, five on the ‘lifestyle’ scale, and one on the ‘stress/anxiety’ scale.

However, as shown in Table 6.1, there was variation across the three body areas in the frequencies
with which the 14 individual items were reported to be causes of MSD. In relation to neck/shoulder
MSD, ‘poorly designed workspace’ was the most frequently identified cause, 28% of the sample
experiencing MSD in this body area perceiving this factor to be important. ‘Poorly designed
workspace’ was also seen as important in relation to lower back MSD complaints (by 27% of those
concerned), but a higher proportion (36%) perceived ‘lifting heavy objects at work’ as a major causal
factor in relation to lower back problems. A different pattern was observed for MSD complaints
affecting hips/knees/ ankles; in this case, the two most frequently identified factors were ‘normal
process of ageing’ (by 31% of the sample) and ‘frequent use of steep stairs’ (by 39% of the sample).

6.3 COMPARISON OF PERCEIVED MSD CAUSES ACROSS JOB TYPES

The data shown in Table 6.1 were further examined in relation to age and job type (sedentary, active,
and strenuous). These analyses were carried out separately for the three MSD measures as the samples
were different for each body area. In each analysis, job type and age both interacted significantly
(p<.001 in each case) with the within-subjects factor (items), indicating that the pattern of responses
across items differed with age and for different types of jobs. The results are shown graphically in
Figure 6.2 - 6.4.

40

 Table 6.1
Causes of MSD as identified by individuals experiencing particular MSD problems

Body area
Item
Item Perceived MSD cause type1 Neck/ Lower Hips/knees/
shoulders back ankles
N = 386 N = 348 N = 274
% % %

1 Heavy workload W 24 21 20
3 Poorly designed chairs --- 22 25 ---
4 General work demands W 22 21 21

7 Non-work activities L 20 23 22

13 Physical problem (eg past injury) L 15 22 28

14 Poorly designed workspace W 28 27 18
15 Working in cold conditions W 12 10 11
18 Lack of fitness/exercise L 11 18 18
19 Normal process of ageing L 22 23 31
23 Being overweight L --- 11 13
24 Frequent use of steep stairs W --- --- 39
25 Lifting heavy objects at work W 22 35 17
26 Anxiety/tension S 18 --- ---
28 Long work hours W 19 16 12

The values shown in the table are the overall percentages of those experiencing MSD in
particular body areas who identify the specified cause as important in their case. Items identified
by less than 10% of the relevant sample were omitted.

1
‘Item type’ refers to the scale on which the item fell in the factor analysis shown in Table
5.1. W = Work-related L = Lifestyle S = Stress/anxiety

Neck/shoulders MSD. As shown in Figure 6.2, there was considerable variation across job types in the
profiles of frequencies with which the items were identified as major causes of neck/shoulder MSD.
Individuals in sedentary jobs were most likely to attribute their neck/shoulder MSD problems to poorly
designed chairs, with anxiety/tension and long work hours the next most frequent attributions. In
contrast, for those in strenuous jobs, heavy workload, general work demands, lifting heavy objects at
work, and poorly designed workspace were the most frequently noted causes. Those in active jobs also
identified poorly designed workspace and lifting heavy objects as main causes of neck/shoulder MSD.

41

 40
NECK/SHOULDER MSD

% of sample reporting each item 30

20

Job type

10 Sedentary

Active

0 Strenuous
1 3 4 7 13 14 15 18 19 25 26 28

ITEM NUMBERS

Figure 6.2
Perceived causes of neck/shoulders MSD identified by those
experiencing this MSD problem (N=386)

Perceived causes of Job type

Item #
neck/shoulders MSD Sedentary Active Strenuous
% % %

1 Heavy workload 24 18 37
3 Poorly designed chairs 35 19 14
4 General work demands 16 20 36
7 Non-work activities 24 21 11
13 Physical problem (e.g. past injury) 17 15 12
14 Poorly designed workspace 15 33 30
15 Working in cold conditions 6 15 10
18 Lack of fitness/exercise 13 11 8
19 Normal process of ageing 22 24 20
25 Lifting heavy objects at work 3 27 33
26 Anxiety/tension 25 16 13
28 Long work hours 25 14 23

42

 50

LOWER BACK MSD

% of sample reporting each item

40

30

20
Job type

Sedentary
10
Active

0 Strenuous
1 3 4 7 13 14 15 18 19 23 25 28

ITEM NUMBER

Figure 6.3
Perceived causes of lower back MSD identified by those
experiencing this MSD problem (N=348)

Perceived causes of Job type

Item #
lower back MSD Sedentary Active Strenuous
% % %

1 Heavy workload 11 21 34
3 Poorly designed chairs 38 25 14
4 General work demands 14 20 31
7 Non-work activities 32 20 20
13 Physical problem (e.g. past injury) 32 20 16
14 Poorly designed workspace 15 30 32
15 Working in cold conditions 3 10 18
18 Lack of fitness/exercise 20 21 9
19 Normal process of ageing 20 27 17
23 Being overweight 14 11 11
25 Lifting heavy objects at work 14 40 44
28 Long work hours 16 11 25

43

 50

HIPS / KNEES / ANKLES MSD

% of sample reporting each item

40

30

20
Job type

Sedentary
10
Active

0 Strenuous
1 4 7 13 14 15 18 19 23 24 25 28

ITEM NUMBER

Figure 6.4
Perceived causes of hip/knees/ankles MSD identified by those
experiencing this MSD problem (N=274)

Perceived causes of Job type

Item #
hip/knees/ankles MSD Sedentary Active Strenuous
% % %

1 Heavy workload 14 18 29
4 General work demands 14 22 26
7 Non-work activities 37 21 9
13 Physical problem (e.g. past injury) 37 28 22
14 Poorly designed workspace 7 20 23
15 Working in cold conditions 3 12 17
18 Lack of fitness/exercise 26 18 8
19 Normal process of ageing 38 32 23
23 Being overweight 18 11 12
24 Frequent use of steep stairs 36 41 40
25 Lifting heavy objects at work 4 19 26
28 Long work hours 13 8 21
Lower back MSD. For individuals in active or strenuous jobs, the frequencies with which the item

44
‘lifting heavy objects at work’ was identified as a cause of lower back MSD were particularly high,
(40% and 44% respectively), whereas the corresponding value for those in sedentary jobs was only
14%. This latter group were more likely to note poorly designed chairs, non-work activities, and
physical problems such as past injuries, as causes of lower back problems.

Hips/knees/ankles MSD. For this body area, the pattern of item responses again showed a different
profile. Individuals in all job groups tended to perceive ‘frequent use of steep stairs’ as a major
cause of MSD in lower extremities (hips/knees/ankles), but the frequency with which other items
were noted depended on job type. For those in sedentary jobs, lifestyle factors such as ‘non-work
activities’ and ‘normal process of ageing’ had high frequencies, whereas work-related factors
featured more prominently among those in active or strenuous jobs.

6.4 BELIEFS ABOUT MSD CAUSES AS RELATED TO PERSONAL FACTORS

The information in Section 6.3 indicates that individuals in different types of jobs perceive different
patterns of main causes of the MSD problems they experience. In general, the frequencies with
which particular items were identified by individuals as specific causes of their MSD problems
corresponded with the findings from the psychometric analyses of item ratings obtained from the
sample as a whole, irrespective of whether they experienced any MSD problems themselves. Thus,
the items most frequently identified by individuals as causes of their particular MSD problems also
tended to have relatively high mean scores in the analyses in Chapter 5.

To examine whether an individual’s identification of the particular causes of his MSD problems
reflected a generalised perception of MSD causal factors, or whether they actually reflected his own
personal situation, further analyses were carried out using relevant information from the survey data,
specifically, age, body mass index and GHQ ‘caseness’ status. The questions that could be examined
in this way were:

• Are older individuals more likely than younger ones to identify ‘normal process of ageing’
as a main cause of their MSD problems?

• Are obese/overweight individuals more likely than those of normal weight to identify ‘being
overweight’ as a main cause of their lower back and hips/knees/ankles MSD?

• Are individuals identified as potential GHQ ‘cases’ more likely than ‘normals’ to indicate
‘Anxiety/tension’ as a main cause of their neck/shoulder MSD problems?

‘Normal process of ageing’. Among individuals who experienced neck/shoulders MSD, age was
a highly significant and positive predictor (p<.001) of identifying ‘normal process of ageing’ as one
of the four most important causes of their MSD. Similarly, in the group who reported lower back
MSD, and in the group who reported hips/knees/ankles MSD, age was also highly significant
(p<.001 in each case) and positive predictor of noting ageing as a main causal factor.

‘Being overweight’. This item was among the ten most frequently reported in relation to lower back
problems and hips/knees/ankles MSD (see Table 6.1). A chi-square test was used to examine
whether the proportion of individuals who identified ‘being overweight’ as a cause in relation to
their lower back MSD differed across normal weight, overweight (BMI 25-30), and obese (BMI
>30) groups. A significant chi-square value was obtained (P=26.7, df=2, p<.001); in the normal
weight group, 2% noted overweight as a cause of their lower back MSD, as compared with 12% of
the overweight group, and 31% of the obese group. The corresponding analysis for the group
reporting hips/knees/ankles MSD gave very similar results.

45

‘Anxiety/tension’. This item was among the ten most frequently reported in relation to neck/shoulder
MSD (see Table 6.1). For the group concerned, a chi-square test was used to determine whether the
proportion of individuals who identified ‘anxiety/tension’ as a main cause of their MSD was higher
for GHQ ‘cases’ than ‘normals’. Among GHQ ‘cases’, 29% identified ‘anxiety/tension’ as a main
cause of their neck/shoulder MSD, as compared with 15% of GHQ ‘normals’ (P=8.5, df=1, p<.005).

Literature findings demonstrate the roles of age, BMI, and anxiety as correlates of MSD problems
(e.g. BenDebba, Torgerson, & Long, 1997; Estlander et al., 1998; Leino-Arjas, 1998; Manninen,
Heliovaara, Riihimaki, & Makela, 1997; Mannion, Dolan, & Adams, 1996; Power, Frank, Hertzman,
Schierhout, & Li, 2001). The present findings suggest that individuals with experience of particular
MSD problems are also aware of these factors. In each of three respects, individuals’ perceptions
of the causes of their MSD problems tended to reflect relevant personal factors. Thus, rather than
responding in a generalised way to the questions asking about their experience of MSD, a significant
proportion of the sample identified specific relevant causal factors. However, although the findings
were statistically significant, not all of those potentially concerned noted the relevant cause as
applying to their MSD problem. For instance, although 31% of the obese group included ‘being
overweight’ as a main cause, 69% of the group did not mention this cause.

6.5 MEDICAL CONSULTATIONS ABOUT MSD PROBLEMS

In addition to reporting which factors they considered to be the main causes of their MSD problems,
participants indicated which sources of medical advice they had contacted in connection with the
problem. Overall, 57% of those reporting MSD problems had not sought any medical advice, 14%
had consulted their General Practitioner, 9% had consulted the Occupational Health Department
(usually the offshore medic) of the employing company, 7% had consulted some other health
professional, and 13% had sought advice from more than one source. Tables 6.2 - 6.4 show the
sources of consultation cross-tabulated with the degree of pain/discomfort reported for each of the
three MSD problems considered. It can be seen that the majority of respondents indicated that they
had not consulted anyone about the MSD problem they reported, irrespective of which body area
was affected. Across body areas, 10-20% of those concerned had consulted general practitioners,
while approximately similar proportions had consulted more than one health professional.

Table 6.2

Cross-tabulation of reported MSD pain and source consulted: Neck/shoulders

Neck/shoulders
Mild Moderate Severe Overall
% % % %

None 82 58 14 64

General Practitioner 8 8 25 10

Occupational Health Department 6 13 9 9

Other health professional 3 11 11 8

More than one source 1 9 41 9

Sample size 177 172 44 393

% of total sample 45% 44% 11% 100%
P2 = 112.9, df=8, p<.001

46
 Table 6.3
Cross-tabulation of reported MSD pain and source consulted: Lower back

Lower back

Mild Moderate Severe Overall

% % % %

None 76 50 9 54

General Practitioner 8 15 23 14

Company Occupational
11 16 7 12
Health Department

Other health professional 3 10 11 8

More than one source 4 9 50 12

Sample size 121 160 44 325

% of total sample 37% 49% 14% 100%
P2 = 102.5, df=8, p<.001

Table 6.4
Cross-tabulation of reported MSD pain and source consulted: Hips/knees/ankles

Hips/knees/ankles

Mild Moderate Severe Overall

% % % %

None 80 44 13 54

General Practitioner 8 25 33 19

Company Occupational
7 6 5 6
Health Department

Other health professional 3 8 5 5

More than one source 3 17 45 16

Sample size 105 98 40 243

% of total sample 43% 40% 17% 100%

P2 = 76.5, df=8, p<.001

47
However, for each type of MSD problem, these proportions varied significantly with the degree of
pain reported. Thus, 70-80% of those with mild pain had not consulted anyone about it; these figures
compared with the 40-50% of those with severe pain who had consulted more than one health
professional about the problem. Analyses were also carried out to determine whether beliefs about the
causes of MSD in general, and specifically in relation to the MSD problems experienced by the
individuals concerned, were related to source of consultation, but there were no significant findings.

6.5.1 Role of ‘Occupational Health’ personnel

In view of the perceived importance of work-related causes in relation to MSD problems, further
analyses were carried out to examine whether there was an association between reporting work-related
factors as major causes of individual MSD problems and reporting consultation with Occupational
Health departments. Using a multivariate analysis, a significant overall relationship (p<.01) was found
between reporting consulting with Occupational Health personnel about neck/shoulder, lower back,
or hips/knees/ankles MSD, and identifying work-related causes of these problems; the two causes most
strongly related to Occupational Health consultations were ‘Heavy workload’ and ‘Working in cold
conditions’, while ‘Lifting heavy objects at work’ reached a marginal significance level.

6.6 FACTORS PERCEIVED TO UNDERLIE THE ABSENCE OF MSD PROBLEMS

In addition to asking those who did report MSD problems about factors seen as playing a causal role
in their case, those who did not report experience of MSD were asked in an open-ended question to
what they attributed their favourable musculo-skeletal health. More than half the responses to this
question referred to exercise, maintaining fitness, and/or keeping active.

The next most frequent category was diet and food, with a few also noting multi-vitamin intake and/or
moderate wine drinking; avoiding obesity may have been an underlying factor in motivating exercise,
fitness, and awareness of diet, but was only rarely specifically mentioned.

Explanations concerned with genetic/inheritance factors were also given by several respondents.
Interestingly, inclusion of ‘young age’ was rare as an explanation for absence of MSD in spite of the
fact that approximately one-third of the sample were aged under 40 years. The only work-related
explanations to be noted were ‘commonsense when lifting’, ‘good manual handling procedures’, and
‘regular breaks from repetitive work’.

In addition to the specific factors identified in the open-ended responses, a range of comments such
as ‘health lifestyle’, ‘good attitude’ ‘good living’, ‘a sound approach to all tasks undertaken’, and
‘being happy with life’, all tend to suggest a generally optimistic and adaptable approach to life,
consistent with low levels of negative affect.

48

 7. CONCLUSIONS

The present work combined several data sets, both cross-sectional and longitudinal, in examining
the nature, severity, and predictors of reported MSD in a male >healthy worker= sample; particular
attention was given to determining the extent to which demographic, individual and environmental
characteristics were associated with reported MSD, to the role of mental health in relation to MSD;
and to attributions and beliefs about the causes of MSD.

7.1 MSD PREVALENCES IN THE PRESENT SAMPLE

As assessed by the Nordic musculo-skeletal questionnaire, the annual MSD prevalences found in
the present study were consistent with other publications highlighting the widespread occurrence
of musculo-skeletal disorders in representative population samples (e.g. Leboeuf Yde et al., 1996;
Power et al., 2001), in particular industries (e.g. Estlander et al, 1998; Leino-Arjas, 1998; Morken,
Riise, Moen, Bergum, Hauge, et al., 2002), and in particular employee groups, such as
supermarket cashiers (Mackay, Burton, Boocock, Tillotson, & Dickinson, 1998), farmers
(Manninen et al., (1997), nurses (Maul et al., 2003); and lock assemblers (Williams & Dickinson,
1997).

Offshore workers, the participants in the present work, are required to pass regular medical
examinations, and can therefore be regarded as a particularly ‘healthy worker’ group. Although the
observed MSD prevalences observed in the present study were lower than those recorded in two
comparison studies of male employees, they were nonetheless well within the ranges reported in
the current literature.

In common with findings from other studies (e.g. Friedrich et al., 2000; Maul et al., 2003), the
body area most frequently affected by MSD was the lower back; more than half (51%) of the
present sample reported back pain in the previous year, and the corresponding lifetime prevalence
was 66%. However, the occurrence of MSD in the neck, shoulders or upper body was also widely
reported, with an overall annual prevalence of 51% in the present sample.

In addition to being particularly prevalent, lower back pain was also reported to be more likely to
result in reduced work and leisure activity, longer duration of work incapacity, and greater use of
healthcare resources (e.g. medical consultations) than other forms of MSD. Thus, although the
reported duration of lower back problems was not markedly different from that for the neck or
shoulders, lower back MSD does appear to impact particularly adversely on everyday activities.
These findings are consistent with literature that identifies lower back pain as a major cause of lost
work time and incapacity in the working population (European Agency for Safety and Health at
Work, 2000).

Responses to the Nordic musculo-skeletal questionnaire were examined in relation to data from a
short three-item scale assessing the occurrence and severity of MSD in the neck, shoulders and
back (Vaernes et al., 1988). Whilst there is no normative data for this short assessment instrument,
it was possible to examine correlations between corresponding measures. The results showed good
agreement between the Nordic questionnaire data and scores on the short Vaernes et al. scales, particularly
for neck and shoulder complaints. In general, the data from the short scales (which related to the previous six
weeks) agreed more closely with the12-month Nordic questionnaire prevalence data than with the 7-day
prevalence data; this finding suggests that the short assessment instrument tends to assess chronic rather than
acute conditions.

49

7.2 INDIVIDUAL AND ENVIRONMENTAL FACTORS AS PREDICTORS OF MSD

7.2.1 Environmental factors

Objective work characteristics. There were two main findings relating objective work
characteristics to MSD reports. First, the profile of MSD prevalences across the nine body areas
identified by the Nordic MSQ was differed significantly between production platforms and drilling
rigs. These differences appeared to reflect differences in the design of platforms and rigs, and
differences in work patterns. However, in this analysis, job activity level (strenuous, active,
sedentary) did not differentially influence the pattern of MSD symptom reporting. In contrast, job
activity level was significant in relation to MSD in the three body areas (neck, shoulders, back)
assessed by the Vaernes et al., (1988) questionnaire. The most marked effect was the high level of
back problems reported by personnel in strenuous jobs; this group also had a high frequency of
shoulder problems relative to other job groups. Active jobs had fewest neck/shoulder problems.

Perceived work environment. Several dimensions of the perceived work environment predicted
the incidence of MSD in one or more of the three body areas assessed by the Vaernes et al., (1988)
questionnaire; thus, perceived autonomy, clarity,and physical stressors all contributed significantly
to the logistic regression model (after control for age, job type and negative affectivity). Low
autonomy, low clarity, and high physical stressor levels were all associated with increased
likelihood of MSD. These results are consistent with those reported by Toomingas et al., 1997)
who particularly emphasized the effects of work demands on muscular tenderness in the neck and
low back. However, contrary to the results of Toomingas et al., social support was not a significant
predictor in the cross-sectional data analysis.

The significance of physical environment stressors was also demonstrated in the analysis of the
Nordic MSQ data in relation to environmental and individual factors; in this analysis, the physical
environment measure was significant in relation to MSD in the upper body and in the lower
extremities, while workload was a significant predictor of upper body MSD and lower back MSD.

In contrast to the non-significant results obtained for social support in relation to MSD in the cross-
sectional data set, the results of the longitudinal analysis showed that supervisor support was a
highly significant predictor of change in MSD symptoms over the five years from 1995 to 2000.
Among those who reported decreased supervisor support, MSD symptoms showed a significantly
more marked increase than among those who reported increased support. This finding is consistent
with evidence that social support plays a protective role in relation to MSD outcomes, including
pain (Torp, Riise, & Moen, 2001) and severity of symptoms (Polanyi, Cole, Beaton, Chung, et al.,
1997), and MSD-related sickness absence (Hemingway, Shipley, Stansfield, & Marmot, 1997).

7.2.2 Individual factors

Age. As an overall predictor of MSD, age played a surprisingly small part in the cross-sectional
analyses; it was found to be non-significant in relation to the data from both the Nordic and the
Vaernes et al. (1988) assessment instruments. However, in the longitudinal analysis of change in
MSD between 1995 and 2000, age in 1995 was a significant predictor, older individuals
(represented by +1SD above the mean, equivalent to age 48 years) showing greater increase in
MSD symptoms over the five-year period. This finding suggests that increase in MSD with age
may not be a linear process but one that progresses relatively slowly at younger ages, but
accelerates with increasing age.

50

Mental health. Affective measures explained more of the variance in MSD outcomes than
demographic variables. Thus, mental health, as assessed in terms of GHQ ‘caseness’ or in terms of
the more specific measure of anxiety, was highly significant in relation to both the Nordic and
Vaernes et al., (1988) measures of upper body and lower back MSD. In particular, both the linear
and quadratic components of the relationship between GHQ ‘caseness’ and the total MSD scores
were significant, reflecting a disproportionate increase in the percentage of GHQ ‘cases’ among
those with high levels of MSD symptoms.

However, mental health was not significant in relation to MSD in the upper or lower extremities
(i.e. arms, elbows, wrists, and hips, knees, ankles). Thus, MSD in the neck, shoulders and back
appears to be more directly tension-related than MSD in the arms and legs which shows closer
relationships to physical work characteristics. Manninen et al. (1997) also notes the particularly
strong link between psychological distress and MSD in the low back and neck/shoulder areas,
speculating that psychological factors can change the perception of MSD pain or induce
physiological changes (such as increased muscle tension) that might result in MSD pain.
Consistent with these cross-sectional findings, change in anxiety between 1995 and 2000 was
found to be a highly significant predictor of change in neck, shoulder and back MSD symptoms.
The relationship between mental health and MSD is considered in more detail below.

Body mass index and height. The Nordic MSQ included measures of back pain and pain in the
lower extremities (i.e. hips, knees, ankles); both these measures were more strongly predicted by
body mass index (BMI) than by mental health. Higher BMI levels were directly associated with
greater likelihood of MSD as assessed by the Nordic MSQ. This was especially true of MSD in the
lower extemities; moreover, this effect appeared to be particularly marked at older ages. However,
consistent with the view that BMI affects MSD by putting strain on the weight-bearing parts of the
body, BMI was unrelated to the Nordic measures of upper body and upper extremity MSD.

The analysis of data obtained from the Vaernes et al. (1988) questionnaire threw a different light
on the role of physique on MSD. In this analysis, low BMI was found to be significantly related to
the occurrence of back pain, a result consistent with the finding of Power et al. (2001) that BMI
values in the lowest 15% of the range were associated with greater likelihood of developing low
back pain as compared with those in the middle BMI ranges. Further analyses showed that height
was the main predictor; the positive relationship between height and the occurrence of back pain
was highly significant, while weight played a less significant and negative role. Thus, tall, low-
weight individuals are at particular risk of back pain, possibly because environments (especially
seating) tend to be designed to suit a normative height range, and low body weight may be
associated with lack of muscle fitness.

Negative affectivity. Whilst there is evidence that negative affectivity (NA) is associated with
reports of musculoskeletal symptoms associated with work conditions (Watten & Batt, 1996), in
the present study, neuroticism (a trait measure of negative affectivity) did not predict the
occurrence of MSD over and above the mental health measures; thus, this evidence suggests that
NA impacts on prevalence rates by increasing the tendency to experience psychological distress
rather than by directly affecting reports of MSD. There was little evidence to support the view that
the reported occurrence of MSD symptoms was no more than an expression of non-specific
distress associated with generalised negative perceptions. Rather, specific environmental and
individual factors were found to be associated with the occurrence of MSD.

When the sample of individuals reporting one or more MSD problems was analysed, NA was
found to be a highly significant predictor of reported MSD severity, but this effect was also found
to be mediated by current anxiety levels. Indeed, the effect of NA, mediated by anxiety, was the
only significant predictor of severity ratings, suggesting that this dispositional variable plays a

51

large part in perceived MSD severity. Thus, when examining demographic and work-related
predictors of MSD, scores which assess only the occurrence of MSD in one or more body parts are
more likely to be informative than scores which combine occurrence with severity ratings.

7.2.3 Mediational effects

Models of work-related stress, such as the Michigan model (e.g. Israel, Baker, Goldenhar, Heaney,
& Schurman, 1996), represent the effects of the perceived work environment as influencing
chronic health impairment through their effect on short-term outcomes, including affective states.
In the present context, this model suggests that when perceived work measures and affective
measures are included in the same predictive model, the significance of the work environment
measures will be eliminated or reduced as compared with their direct effects assessed in the
absence of affective measures.

This result was observed in the cross-sectional analysis of MSD (see Table 3.4, and Figure 3.3);
the affective measures which predicted MSD in the final model were anxiety (positively), and job
security and subjective health (negatively), while job type and physical stressors were the only
remaining predictors to show highly significant direct effects over and above the affective
measures. More detailed analysis in which each body area was considered separately demonstrated
that the direct effect of job type was related to the reporting of neck/shoulder MSD problems,
while the direct effect of physical work stressors was related to the reporting of back problems.

Thus, the overall picture presented by the findings relating to environmental and individual factors
was consistent with a mediational process whereby the perceived work environment influenced
psychological distress, which in turn influenced the reporting of MSD, although in the present case
the mediation partially (rather than fully) accounted for the direct effects. These results accord with
the conclusions of Davis and Heaney (2000), and with the suggestion of Ursin et al. (1993) that
adverse psychosocial environments may impair coping behaviours, leading in turn to impaired
mental health, tension, and consequent MSD symptoms. The specific effects found for back, neck
and shoulder pain are also consistent with the view that increased psychophysiological arousal and
muscle activity associated with anxiety and mental stress plays a causal role in the occurrence of
MSD pain in these body areas (Lundberg, 1999; Westgaard, 1999).

7.3 MSD AND PSYCHOLOGICAL DISTRESS: ISSUES OF CAUSAL DIRECTION

Significant associations between poor mental health and MSD, such as those noted in Section
7.2.2, could be due to the problems and constraints of MSD giving rise to poor mental health, or to
psycho-physiological aspects of poor mental health (such as anxiety and muscle tension) leading to
MSD, or to one or more ‘third’ factors influencing both mental health and MSD. Longitudinal data
allows more detailed examination of the issue of causal direction than data collected only at one
point in time.

In the present study, this issue was addressed by examining patterns of change in anxiety and MSD
symptoms over the five-year period, 1995 to 2000. Two separate repeated-measures analyses were
carried out (see Tables 4.3 and 4.5). In the first analysis, the dependent variables were MSD scores
in 1995 and 2000, while the corresponding anxiety measures were used as predictors; in addition to
the main effects of anxiety at these two time points, the interaction between these variables was
found to be significant in predicting MSD in 1995 and 2000.

Closer examination of the results showed that, whereas MSD in 1995 was predicted only by
anxiety in 1995, MSD in 2000 was significantly predicted by anxiety in 2000 and by the

52

interaction between 1995 anxiety and 2000 anxiety. Thus, prior anxiety (i.e. in 1995) significantly
affected the concurrent relationship between anxiety in 2000 and MSD in 2000. When the reverse
analysis was carried out (in which anxiety in 1995 and 2000 was the dependent measure and the
corresponding MSD measures were treated as predictors), no such interaction was found. Rather,
only the two cross-sectional associations were found to be significant; MSD in 1995 was
associated with anxiety in 1995, and MSD in 2000 was associated with anxiety in 2000.

Taken together these two analyses suggest that the primary effect is from anxiety to MSD rather
than in the reverse direction although, concurrently, it is likely that a two-way reciprocal effect
occurs. This view is consistent with the findings of two other prospective studies, both of which
adopted a dual analysis approach similar to that used in the present work, but applied to larger
samples and with 10-year follow-up periods (Leino & Magni, 1993; Manninen et al., 1997). Both
these studies also had the advantage of independent diagnoses of MSD problems; both studies, also,
focused on examining the role of psychological distress as a causal factor in relation to MSD
problems in the neck/shoulder areas and the lower back.

Similarly, a study by Mannion et al. (1996), which sought to circumvent a number of

methodological problems frequently encountered in studies of psychological factors and MSD,
concluded that ‘abnormal’ scores on a measure of psychological distress preceded, rather than were
affected by, episodes of back pain. In addition, a prospective UK cohort study with a 10-year
follow-up period found that psychological distress at baseline (23 years) more than doubled the later
risk of low back pain at age 33 years (Power et al., 2001). Thus, the present results add to the
increasing number of studies to conclude that, although reciprocal effects may occur concurrently
between the two variables, psychological distress is a primary cause, rather than an outcome, of
MSD pain. However, it is also possible that different aspects of psychological distress may play
different roles in relation to MSD; thus, while anxiety appears to be a causal factor, depression may
be a result of MSD (Andersson, 1999).

7.4 BELIEFS ABOUT THE CAUSES OF MSD

The development of a measure to assess beliefs about the causes of MSD led to the identification of
three scales designated, respectively, stress/anxiety (e.g. low morale, anxiety/tension, smoking),
work-related factors (e.g. lack of control over work tasks, lifting heavy objects, poorly designed
workspace), and lifestyle factors (e.g. lack of fitness/exercise, normal process of ageing, hereditary
influences, being overweight, sport and other non-work activities). Each of the three scales
described potential causes of MSD identified in the literature (e.g. Bongers et al., 1993; Davis &
Heaney, 2000; Leino-Arjas, 1998; Manninen et al., 1997; Viikari-Juntura et al., 2001).

Both the work-related and the lifestyle scales had relatively high scores indicating that participants
considered these factors to be likely causes of MSD. These results are consistent with other
published findings (e.g. Bartys et al. 2001; Borkan et al., 1995; Waddell et al. 1993) which identify
work and lifestyle factors as causes of MSD as perceived by employees. In general, therefore,
participants appeared to appropriately attribute MSD to work and/or lifestyle factors, but were less
likely to identify psychological and behavioral aspects of stress/anxiety as potential MSD causes
(c.f. Jamison, 2000). However, scores on the stress/anxiety scale were significantly predicted by NA
(high NA being associated with greater beliefs in stress/anxiety causes); this finding may reflect the
actual experience of high NA individuals.

Age was associated with beliefs that heavy workload and general work demands were causal factors
in MSD. Workload was the only psychosocial work variable associated with scores on the beliefs
scales; high workload significantly predicted beliefs that work conditions and stress/anxiety were

53

causes of MSD, but was unrelated to the lifestyle scale. Job type (strenuous, active, sedentary) was
also related to beliefs about work-related causes; consistent with the findings of {Hyytiainen, 1994),
those in strenuous jobs were more likely to attribute MSD to work causes. Thus, both individual and
environmental characteristics were associated with specific beliefs about the causes of MSD.

When beliefs were examined in relation to reported MSD, the work-related and the lifestyle scales
were found to be significantly related to MSD problems in the neck, shoulder and back; those with
stronger beliefs in work and lifestyle causes were more likely to report these MSD problems.
However, the stress/anxiety scale was not associated with MSD outcomes.

The link between beliefs about specific MSD causes and individuals’ experiences of particular
MSD problems was examined in more detail in additional data collected from participants who had
experienced MSD over the past year. Individuals identified the four causes they perceived to be
most important in relation to their own experience of MSD. Analysis of these data demonstrated a
strong consistency across individuals, and across body areas in which MSD was experienced, in the
causes considered to be most important.

Thus, as described in Section 6.2, a sub-set of 14 of the 32 specific causes listed covered the great
majority of causes identified by individuals; almost all of this subset of 14 items related to work or
lifestyle factors, anxiety/tension being the only exception. Some items were noted by more than
one-third of all those concerned; for instance, 39% identified ‘frequent use of steep stairs’ as a
cause of their MSD in hips/knees/ankles, while 35% identified ‘lifting heavy objects at work’ as a
cause of their lower back MSD. Only slightly less frequent,‘poorly designed workspace’ was noted
to be a cause by 28% of the sample experiencing neck/shoulder MSD, and by 27% of those
experiencing lower back MSD.

Differences in the profiles of perceived causes across the different body areas for which assessments
were made were relatively small, but job type (strenuous, active, sedentary) did significantly affect
these profiles. Those in sedentary jobs tended to emphasize ‘poorly designed chairs’, ‘anxiety/
tension’, and ‘long work hours’, while those in active or strenuous jobs were more likely to identify
‘lifting heavy objects’ or ‘poorly designed workspace’.

Further analyses carried out on these data sought to determine whether individuals recognized
relevant personal characteristics, such as age, BMI and psychological distress as causal factors in
their MSD problems. The evidence suggested that the relevant factors were identified significantly
more often by the individuals affected than by those for whom the factor was less salient. Thus, for
instance, among those of normal weight (BMI<25), only 2% identified ‘being overweight’ as a
causal factor in their back pain, while the corresponding figures for the overweight (BMI 25-30)
and obese (BMI >30) groups were 12% and 31%. Similarly, the ‘normal process of ageing’ was
more likely to be noted by older individuals, and ‘anxiety/tension’ was more likely to be recognized
by individuals who were identified as potential ‘cases’ by the GHQ.

It was also of interest to contrast the factors that were reported to be perceived causes of MSD with
those that were identified by participants not experiencing MSD (in response to an open-ended
question) as factors accounting for their favorable musculoskeletal health. The majority of
responses referred to exercise, maintaining fitness, and/or keeping active, with causes related to diet
and food intake being the next most frequent category. Work-related causes were much less likely
to be mentioned, although some responses indicated factors such as ‘commonsense when lifting’ and
‘regular breaks from repetitive work’. Largely conspicuous by their absence were explanations such
as young age, and good environmental conditions, although causes reflecting an optimistic and
adaptable approach to life, consistent with low levels of negative affect, were quite frequently
mentioned.

54

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