Musculoskeletal Disorders in the Teaching Profession

Abstract

Musculoskeletal disorders (MSDs) are among the most common and important occupational health problems in working populations with significant impact on quality of life and a major economic burden from compensation costs and lost income. MSDs decrease productivity at work due to absenteeism, presenteeism and sick leave. During the course of their work, teachers can be subjected to conditions that cause physical and psychosocial illness. Common MSDs among teachers include those affecting the lower back, neck and upper extremities. Research suggests that the aetiology of MSDs is complex and multifactorial in nature. Occupational factors including location of school, carrying heavy loads, prolonged computer use, awkward posture and psychosocial factors such as poor social work environment, high anxiety and low job satisfaction have been found to contribute to development of MSDs. Factors such as high supervisor support and regular physical exercise on the other hand have been found to have a protective effect against MSDs among teachers. The interventions for these conditions need to be contextualized for them to be effective and to take into consideration, the risk factors for these conditions and how they interact with each other.

1. Introduction

Musculoskeletal disorders (MSDs) represent one of the most common and most costly occupational health problems globally [1]. Developing countries are disproportionately affected where working conditions could be poor due to acute lack of awareness on ergonomic issues, education and training [2]. MSDs have also been associated with high levels of health-related presenteeism, absenteeism and sick leave among teachers [3]. MSDs are conditions that affect the body’s muscles, joints, tendons, ligaments, nerves, bones and their local blood supply. Most work-related MSDs develop over time and caused by either work itself or the worker’s working environment [4].

School teachers, in general, have been shown to report a high prevalence of MSDs relative to other occupational groups [5], with prevalence rates of between 40% and 95% according to a systematic review conducted in 2011 [1]. These high prevalence rates among teachers are associated with individual, work-related and psychosocial factors. Some studies have investigated the relationship between MSDs in teachers and their working conditions. The work tasks of teachers involve a wide variety of duties and responsibilities that may involve prolonged sitting and standing, use of inappropriate furniture, awkward postures likely adopted when writing on the board, helping students with their work or when helping students during extracurricular sporting activities. Furthermore, teachers might adopt awkward postures when reading, marking students’ work or preparing lessons. The constant loading of the muscles in the neck, shoulders and the back eventually leads to aches, pains or discomfort [5, 6]. In some instances these activities may be carried out under unfavorable working conditions. Psychosocial risk factors such as poor mental health, low supervisor or colleague support, low job satisfaction, high job stress and high psychological job demands have also been associated with development of MSDs [1]. Preventive programmes are required for management of these disorders and this should ideally be at organizational level rather than individual level [7].

2. Assessment of MSDs among teachers

Historically, evaluation of MSDs has involved use of many different methods ranging from broad approaches to specific techniques. Widely accepted approaches for determining the prevalence of MSD and favoured by researchers include self-developed questionnaires [8, 9, 10] and the Standardized Nordic Questionnaire [11, 12, 13, 14]. Self-developed questionnaires can be structured, semi-structured or unstructured [8] and employ open vs. closed, single vs. multiple responses, ranking, and rating [15, 16]. The Standardized Nordic questionnaire was developed by a Swiss company for analysis of musculoskeletal symptoms. It has both the General the Specific Questionnaire. The General Questionnaire is a graphic in which the human body is split into nine anatomical regions, whereas the Specific Questionnaire focuses on anatomical locations where musculoskeletal problems are more common [9]. The fundamental benefit of using these questionnaires is that they examine the severity of symptoms, their impact on work and leisure activities, the overall duration of symptoms, and sick leave.

Other MSDs evaluation methods include pilot study surveys and questionnaires like the pilot tested surveys, [17, 18, 19], questionnaires such as the Northwick Neck Pain Questionnaire [20], Health Questionnaires [21], Job Content questionnaires [22] and the Subjective Health Complaints Questionnaire [6]. While questionnaires are a cost-effective and manageable method to collect data, they can create recall bias and make follow-up difficult, particularly when anonymous reporting is used [1]. Disregard of physical examination and assessment pervades diagnosis of MSD even though they could likely produce more accurate results. These methods are considered expensive and time consuming and therefore rarely used [1].

The majority of the research used self-reported questionnaires to assess MSDs. Self-reporting has limitations such as participants not being honest, introspective inability, wrong interpretation of questions, recall [23] and sampling bias. The participant recall bias could lead to under or overestimation of MSDs [24]. Additionally, self-reporting could lead to respondents reporting all pain as MSDs [25]. It is also not possible to establish any causal-effect associations through self-reporting [26]. The presence of MSDs is only dependent on the participants' self-reports and not on an objectively validated diagnosis.

3. Prevalence of MSDs among teachers

Following the systematic review on MSDs among school teachers that was done in 2011 by Erick and Smith [1], substantive research has been carried out on the subject. Globally studies have been conducted among nursery to secondary school teachers on MSDs generally and/or on specific body sites such as neck and/or shoulder, back, upper and/or lower limbs. Recently it was estimated that approximately 1.71 billion people globally have musculoskeletal conditions [27]. A previous systematic review of MSDs among school teachers which was based on papers published between 1981 and 2011 revealed that these conditions affect between 39% and 95% of teachers [1]. The prevalence rates of MSDs among school teachers reported on studies carried out after this review range between 21.1% and 96%.

3.1 Global prevalence of MSDs among teachers

3.1.1 Prevalence of MSDs in Asia

A substantive amount of research on MSDs among teachers has been conducted in the past ten years in Asia. The prevalence rates of general MSDs in the region range between 21.1% and 93.7% with high prevalence rates of 90.7–93.7% reported among school teachers in China [28]. Similarly, 87.3% and 80.1% of secondary school teachers in Saudi Arabia [23] and primary school teachers in Malaysia, respectively [29] reported ever experiencing MSDs. Furthermore, in a study carried out in Pakistan [30] and another study from Saudi Arabia [31], 82.7% and 79.2% female school teachers reported MSDs, respectively. Prevalence rates of MSDs ranging between 60.3% and 74.5% were reported among school teachers in other Asian countries [8, 32, 33, 34, 35]. Low prevalence rates of MSDs have been reported among primary teachers in another study conducted in Malaysia (40.1%) [36] and male secondary teachers in Saudi Arabia [21].

3.1.2 Prevalence of MSDs in South America

Relatively few studies have been carried out to investigate the prevalence of MSDs among teachers South America. In Chile, the 12-months prevalence of MSDs among school teachers was 88.9% [26] while in Bolivia it was 86% [37]. A 7-days MSDs prevalence of 63% was reported among Bolivian school teachers [37]. In a study of chronic musculoskeletal pain among Brazilian teachers in Londrina, 43% reported experiencing chronic pain in the past 12 months [38].

3.1.3 Prevalence of MSDs in Africa

A high prevalence rate of MSDs was reported among Egyptian nursery school teachers (96%) [39]. In Botswana, a 12-months prevalence of MSDs among primary and secondary school teachers was 83.3% [40]. The prevalence rates of MSDs among teachers in two studies carried out in Ogun State [10] and Enugu State, Nigeria [41] were 70.47% and 70.2% [41], respectively.

As reflected above, MSDs appear to be highly prevalent in the teaching profession with the high prevalence reported among nursery schools. MSDs studies carried out in Europe were specific to different body sites.

3.2 Prevalence of MSDs according to different body sites

3.2.1 Neck and/or shoulder pain

Although most of the studies investigated ‘neck pain’ and ‘shoulder pain’ separately, some combined these and reported on them as neck and/or shoulder pain (NSP). In a study conducted in Durban, South Africa a 12-months prevalence of NSP among primary school teachers was 80.4% [42], In Chile, 68.6% of school teachers reported NSP in the last 12 months [26]. Similarly, in two separate studies conducted in Malaysia, 60.1% of secondary [43] and 56.5% of primary [29] school teachers reported NSP. Parallels could be drawn to a study conducted in Ethiopia where 57.3% of teachers reported NSP [13]. In a study conducted in China, almost half (48.7%) of school teachers reported experiencing NSP in the previous 12 months [44]. These studies show that MSDs of the neck/shoulder are highly prevalent.

3.2.2 Neck pain

Even when neck pain is reported separately, there is still evidence that it is a prevalent MSD among school teachers with studies from different countries reporting prevalence rates above 50% with high levels reported in Turin, Italy at 75.6% [45]; followed by Nigeria at 57% [41, 46], Botswana at 50.2% [40] and Bolivia at 47% [37]. Other countries however reported low prevalence rates of neck pain among teachers. Low prevalence of neck pain have been reported among Saudi female teachers (11.3%) [47] and Nigerian teachers (3.2%) [10].

3.2.3 Shoulder pain

High prevalence rates of shoulder pain were reported by teachers in China (73.4%) [44]. Parallels could be drawn to the results of a study that was conducted in Nigeria where 62.3% of teachers reported shoulder pain. Most of the studies reported prevalence rates ranging between 41% and 57.5% [12, 21, 23, 30, 32, 33, 34, 46, 48, 49]. However, low prevalence rates were reported in studies conducted among female teachers in Malaysia (22.2%) [36] and Saudi Arabia (20.6%) [47] and primary school teachers in Egypt (15%) [50] and Ogun State, Nigeria (11.7%) [10]. Lessons could be learnt from these places on factors associated with these low rates of shoulder pain.

3.2.4 MSDs in the upper extremities

When compared to other MSDs, upper extremities appear to be less prevalent. A study that was conducted in Brazil reported that 14% of teachers experienced upper limb pain [38]. Wrist/hand pain was reported by 26% teachers in Chuquisaca, Bolivia [37], 23.4% in Turkey [51] and 16.2% secondary female teachers in Saudi Arabia over 6 months [31] and 7.4% in another study conducted among female teachers in Saudi Arabia over 3 months [47]. Elbow pain on the other hand was reported by between 5.6% and 16% of teachers in studies carried out in Italy [45], Turkey [51], and Malaysia [36]. Although prevalence rates for MSDs of the upper extremities were generally low across most countries, there were a few countries where prevalence rates could go above 40% as was the case among primary school teachers in Kota Kinabalu, Malaysia who reported hand/fingers pain in the last 6 months [29].

3.2.5 Low back pain

In this section, the prevalence of back pain among school teachers is discussed. Limited studies reported general back pain whilst majority separated low back pain and upper back pain. The prevalence of general back pain was reported in studies conducted in Qassim, Saudi Arabia (74.4%) [11], Minas Gerais, Brazil (58%) [52], Turkey (42.7%) [34] and Iran (39%) [12].

When compared to other MSDs among school teachers, low back pain (LBP) appears to have been the most studied. High prevalence rates of low back pain have been reported in studies conducted in Spain [53], Jordan [54] and Ekpoma State, Nigeria [46] where 96.5%, 92.3% and 85% school teachers reported low back pain respectively. Almost three-quarters of teachers in Turkey (74.9%) [34], Northern Ethiopia (74.8%) [55], Putrajaya Malaysia (72.9%) [9] and Italy (70.6%) [45] reported experiencing LBP in the past 12 months. Most of the studies reported prevalence rates between 35.3% and 68% [14, 23, 24, 31, 32, 42, 47, 56, 57]. However, some studies reported low prevalence rates. One quarter of female teachers in Terengganu, Malaysia [36] and school teachers in Kanpur, India [58] reported LBP in the previous 12 months. In Abha City, Saudi Arabia [21] and Ogun State, Nigeria [10], one fifth of teachers reported LBP while in Brazil 13% of them also reported LBP [38]. LBP is common among teachers regardless of the geographical location. This is a concern as LBP is a leading cause of disability in both developing and developed countries [44].

3.2.6 Upper back pain

Upper back pain does not appear to have been studied as much as LBP. Although 84% of preschool teachers in Turin, Italy reported experiencing upper back pain [45] it appears this pain is not as prevalent as LBP. This is evidenced by prevalence rates reported in studies carried out in Enugu State in Nigeria [41], Peshawar, Pakistan [30] and Thailand [33] where 47.4%, 43.3% and 36.1% of school teachers reported upper back pain, respectively. In Terngganu, Malaysia, one quarter of female primary school teachers reported upper back pain experienced in the previous 12 months [36]. Lower prevalence rates were reported among female Saudi teacher (17.7%) [47] and teachers in Ogun State in Nigeria (1.1%) [10].

3.2.7 MSDs of the lower extremities

Several studies have investigated MSD in the lower extremities such as the knees, leg, hips, ankles and feet. In a study conducted in Kota Kinabalu, Malaysia, almost half of the primary school teachers reported lower extremities pain in a period of 6 month [29]. However, a lower prevalence of 13% was reported in a study of Brazilian teachers [38]. The prevalence rates of knee pain among different school levels ranged between 26.3% and 49%. About 49% of nursery school teachers in Ekpoma State in Nigeria reported knee pain [46] while it was reported by 41% of secondary school teachers in Hail, Saudi Arabia [23]. Parallels could be drawn to the results of studies conducted in Enugu State of Nigeria [41] and Turin, Italy [45] where 39.3% and 38.7% of teachers and nursery school teachers reported knee pain respectively. One third of teachers in Turkey [34] and Terengganu, Malaysia [36] reported knee pain in the last 12 months while in Saudi Arabia one quarter reported the same condition in the past 3 months [47].

The prevalence rates of leg pain among teachers ranged between 38.7% and 65.2%. The highest prevalence rate was reported by school teachers in Ogun State in Nigeria [10] while the lowest was reported by preschool teachers in Turin, Italy [45]. Hip pain was reported by between 15.4% and 45.3% of teachers in Enugu State in Nigeria [41], nursery schools in Ekpoma State in Nigeria [46], female teachers in Saudi Arabia [47] and teachers in Turkey [34]. Some studies combined hip and thigh pain and was reported by 49.6% preschool teachers in Italy [45] and 18.4% of teachers in Terenggamu, Malaysia [36] in the past 12 months.

The prevalence of ankle pain was relatively common among teachers ranging between 12.3% and 48.4%. Female teachers in Pakistan reported the highest prevalence rate of this pain (48.4%) [30]. Although nursery school teachers have been thought to be at increased risk of ankle pain due to activities which require sustained periods of kneeling, stooping, squatting or bending [59], only 31% of nursery school teachers in Ekpoma State, Nigeria reported ankle pain [46]. Some studies studied ankle and feet pain combined and the highest prevalence (85.5%) was reported in a study conducted among school teachers in Abha City, Saudi Arabia [60]. However, relatively low prevalence was reported in studies carried out in Terenggamu, Malaysia [36] and preschool teachers in Italy [45] where this pain was reported by 32.5% and 16.8% of the study population, respectively.

MSDs have been previously reported to be more prevalent among nursery school teachers because of the kind of work they do. This chapter confirms the previous findings because when compared to other school teachers, high numbers of nursery teachers reported general MSDs, upper back pain, neck and/or shoulder, knee and elbow pain. This has been attributed to that nursery school teachers perform a wide variety of tasks and combine basic health childcare and teaching duties, and those that require sustained mechanical load and constant trunk flexion [59, 61]. Furthermore, nursery school teachers have been found to have elevated prevalence of MSDs due to activities which require sustained periods of kneeling, stooping, squatting or bending [59]. The high prevalence of MSDs of different body sites among teachers is a concern as this population consists of high numbers of members of the society. Teachers ill-health does not only affect them but high likely to affect learners. Therefore, it is crucial to establish work-related factors that affect this population to put in place control measures that will reduce prevalence and progression of these conditions. The following section discusses work-related factors associated with teachers reporting MSDs.

4. Work-related risk factors for MSDs among teachers

A large proportion of MSDs have been associated with adverse work conditions. Increased risk of these disorders have been reported in occupations with repetitive work tasks, awkward postures and heavy lifting as well as psychologically demand work environments. The section will discuss work-related factors associated with MSDs among school teachers.

4.1 Location of school

In a study carried out in both rural and urban areas of Bolivia, teachers working in rural areas were more than two to almost four times more likely to report any work limiting musculoskeletal pain during the last 12-months and for work limiting pain in at least three parts of the body than teachers in urban areas. The study also found that work limiting pain in ankles was higher in rural than urban school teachers [37]. These findings have been attributed to that apart from the teaching responsibilities, teachers in rural areas work closely with the rural communities which could be both physically and psychologically demanding. For this reasons, there is often concentration of professionals in urban areas as opposed to rural areas which in turn impacts on the quality of education and increased inequalities between the two areas [37].

4.2 Carrying heavy loads

Carrying heavy loads have also been associated with MSDs among school teachers. Brazilian teachers in Londriana region who reported carrying didactic materials were almost two times more likely to report upper limbs pain than those who did not report carrying heavy materials [38]. Lifting loads with hands was also associated with LBP among secondary school teachers in Putrajaya, Malaysia. Teachers who reported lifting loads with hands were at increased risk of developing LBP than those who did not report so [9]. Carrying weight has also been significantly associated with MSDs among secondary school teachers in Fiji [62].

4.3 Prolonged computer use

Prolonged computer use has previously been associated with MSDs of different body sites among school teachers. Brazilian teachers in Minas Gerais region who reported using computer or tablet within 5 h and for 6 or more hours during the COVID -19 pandemic were 1.12 times and 1.27 times more likely to report back pain compared to those who did not report computer or tablet use [52]. Primary school teachers in Samsun Turkey who reported daily computer use were at increased risk of neck pain when compared to those who did not indicate daily computer use [34]. Prolonged computer use leads to prolonged sitting. Activities of prolonged sitting and computer use are unsafe acts favorable for the development of neck/shoulder pain, back pain and upper limb pain among teachers [44]. This may also be attributed to a sustained forward head posture and/or constant neck flexion which cause static overload of neck and shoulders muscles. When combined with repetitive movements associated with a mouse, touchpad or keyboard can increase the likelihood of shoulder and/or neck pain [48].

4.4 Awkward postures

Awkward postures have been found to contribute to reporting of MSDs. This is evidenced by the results of a study among primary school teachers in Cairo, Egypt where awkward posture was associated with MSDs [50]. Furthermore, teachers who reported awkward arm position at work in a study conducted in Botswana were 1.4 times more likely to report LBP than those who did not report awkward arm position [63]. In another study conducted in Botswana, teachers who had reported awkward arm position when working were at risk of shoulder pain, upper back pain and wrists/hands pain [40]. Teachers in Gondar town of Ethiopia who had reported static head down posture and elevated arm over shoulder were 2.26 times and 2.71 more likely to report shoulder/neck pain than those who did not report the awkward postures [13]. Similarly, Chinese teachers who reported prolonged static posture were more likely to develop NSP and LBP than those who did not report static posture. Teachers who reported that they acquired posture characterized by twisting were also at increased risk of LBP than those who did not report so [44]. Bending has been significantly associated with MSDs among secondary school teachers in Fiji [62].

Stretching to write on the board placed school teachers in Thailand at increased risk of repetitive strain injuries [33]. Writing on the board has also been strongly associated with MSDs of different anatomical areas such as upper limbs pain, LBP and lower limbs pain among Brazilian teachers in Londrina region [38]. Forward-bending and backward bending of the head for a prolonged time when writing on the board has been significantly associated with NSP among primary school teachers in South Africa [42]. Shoulder pain may occur as a result of working with raised arms unsupported for a considerable time, a characteristic synonymous with teachers’ work as they write on the board. Awkward postures caused by sustained muscle stretching particularly overhead are likely to induce neck and/or upper limbs pain in teachers. Awkward postures affect MSDs of different body areas. This is so because the broad activities which teachers participate in such as reading, marking, lesson preparation lead to prolonged sitting periods, bending to assist students at student level, writing on and reading from the board put strain on different body areas.

Prolonged sitting and standing have been associated with MSDs of different body area. A study of Chinese teachers in Guang dong Province, found that those who reported prolonged sitting were at risk of reporting NSP and LBP than those who did not report prolonged sitting. NSP was also experienced by those teachers who reported prolonged standing than those who did not [44]. Prolonged standing has also been associated with LBP among Egyptian teachers [55] and general MSDs among male secondary school teachers in Saudi Arabia [32]. Prolonged sitting has also been significantly associated with NSP among Gondar teachers in Ethiopia [13], with LBP among secondary school teachers in Putrajaya, Malaysia [9] and among primary school teachers in Durban, South Africa [42] and foot pain among Saudi teachers in Abha Sector [60]. Prolonged standing and sitting were also significantly associated with MSDs among female school teachers in Pakistan [30] and secondary school teachers in Fiji [62]. Standing and sitting for a long period, working in a head down posture for long periods, bending/twisting upper body have been significantly associated with MSDs among preparatory government school teachers in Cairo, Egypt. The study further found that prolonged working in the same posture, helping students into flexing posture and repeating the same movement of arms or hands many times per minute were also significantly associated with MSDs [39].

4.5 Inappropriate furniture

Previous research indicates that inappropriate furniture contributes to development of MSDs. A significant association has been found between MSDs and school furniture among school teachers in two separate studies carried out in Egypt [39, 50]. Uncomfortable work chair/table was significantly associated with MSDs among female school teachers in Pakistan [30]. In China, school teachers who reported uncomfortable back support were about two times more likely to report NSP and LBP compared to those who did not report so [44]. Women teachers, nurses and sonographers in Sweden who reported that they were dissatisfied with computer workstation arrangements were 1.2 times more likely to report neck pain and shoulder pain respectively than those who reported that they were satisfied [64].

Similarly, school teachers in Enugu State of Nigeria who reported using teaching board with height of 180–190 cm and more than 190 cm were 3.5 times and 4.6 times more likely to report neck pain, respectively than those who used teaching board that was less than 180 cm. Furthermore, those who reported using a teaching board with height of 180–190 were also at increased risk of pain in one or both elbows [41]. These heights may lead to adoption of prolonged neck extension positions when writing on or reading from the board and ultimately contribute to neck pain.

4.6 Workload

Although it is assumed that physically school teachers’ work is varied and relatively light [64], research on this study population has demonstrated that they are exposed to high workloads. Rapid physical activity has been significantly associated with shoulder pain, wrists/hands pain and hips/thighs pain among school teachers in Botswana [40]. Similarly, primary school teachers in Samsun, Turkey who reported physical activity were two times at risk of neck pain when compared to those who did not report physical activity [34]. Walking up and down stairs was associated with LBP among secondary school teachers in Putrajaya, Malaysia [9].

High workload has been significantly associate with MSDs among preparatory teachers in Egypt [39]. Addis Ababa teachers who reported high work load were four times increased risk of reporting LBP than those who were not [14]. This is consistent with results of primary school teachers in Egypt where job demand was significantly associated with MSDs [50]. Physical workload has also been associated with feet pain among women teachers, nurses and sonographers in Sweden [64]. In Londrina, Brazil, high number of students in a classroom were associated with upper limbs pain [38].

The association between high job demand and MSDs might be due to the nature of teachers’ work which by its nature is physically demanding. When the physical work load is reduced, the impact of job demand and onset of MSDs is reduced [65]. Apart from teaching students, teachers are also involved in lesson preparation, assessments of students’ work and being involved in the extracurricular activities such as sports. Teachers also participate in different school committees. These may cause teachers to suffer adverse mental and physical health issues due to the variety of job functions [1].

4.7 Psychosocial factors

School teachers are considered to experience high level of psychological stress [64]. High psychological job demands have been associated with LBP [63], upper back pain and shoulder pain among school teachers in Botswana [40]. Similar results have been reported among secondary school teachers in Malaysia where those who reported high psychological job demands were at increased risk of developing LBP compared to those who reported low psychological job demands [43]. Psychological job demands have been associated with neck, shoulder, hands, lower back and feet pain among women teachers, nurses and sonographers in Sweden [64]. It has been suggested that the more psychological demands needed for a particular task, the greater the possibility to develop any kind of MSDs regardless of the body area [66].

The study of teachers working in governmental primary schools in Addis Ababa, Ethiopia found that those who reported a poor or fair work social environment were at increased risk of LBP than those who had good work environment [14]. Similarly teachers in another study conducted in Gondar town in Ethiopia, who reported to have stress were more likely to report LBP than those who did not report stress [57]. Mild to moderate and severe to extremely severe stress have been associated with experiencing LBP and NSP among secondary school teachers in Malaysia [43].

High anxiety and very low colleague support have been associated with MSDs among preparatory teachers in Egypt [39]. Parallels could be drawn to results of Malaysia secondary school teachers who were found to be at increased risk of LBP and NSP due to mild to moderate and severe to extremely severe anxiety [43].

Teachers in Tehran, Iran who reported low job satisfaction were more likely to develop low back when compared to those who reported high job satisfaction [56].

Low skill discretion and low supervisor support have been significantly associated with reporting low back and neck and/or shoulder pain among Malay teachers, respectively [43].

5. Protective factors

Some factors have shown a protective effect against MSDs among school teachers. These include factors such as workplace support, regular physical exercise and perceived better health.

5.1 Workplace support

A protective effect was demonstrated for Botswana teachers who reported high supervisor support. These teachers were less likely to report neck, upper back pain and hip/thigh pain as compared to those who reported low supervisor support [40]. High supervisor support was also a protective factor against LBP among Kenyan teachers [24]. Ethiopian teachers in Amhara region who reported satisfaction with work environment and culture were showed decreased odds for reporting LBP and those who had an office were also less likely to report LBP [57].

Nursery and primary school teachers who reported that there were three of them per class were less likely to report upper back, low back pain and pain on one or both ankles or feet [41].

In a study carried out among women teachers, nurses and sonographers, those who reported high job control were less likely to report shoulder, hands, lower back and feet pain. The study further demonstrated that those in leadership were less likely to report neck, shoulder and lower back pain [64].

5.2 Regular physical exercise

Physical exercise of more than 5 h per week was associated with reduced odds of reporting upper back pain [40] and LBP [63] among school teachers in Botswana. This was in comparison to teachers who reported five or less hours of weekly exercise. Similarly, teachers in Amhara region in Ethiopia who exercised were less likely to report LBP compared to those who did not exercise [57]. Chinese school teachers who reported exercising for seven or more hours per week were less likely to experience NSP compared to who exercise for less than 7 h per week [44]. Parallels could also be drawn to the results of a study conducted among Ethiopian teachers where those who exercised reported decreased odd of NSP compared to those who did not exercise [13]. Physical exercise was also associated with decreased odds of reporting neck pain among Iranian teachers [67], and upper back pain and LBP among school teachers in Enugu State, Nigeria [41]. Exercise habits also had a protective effect against neck and upper extremity pain among teachers in Turkey [51]. Saudi teachers who reported that they were involved in sports were less likely to report foot pain [60].

5.3 Perceived better health

Teachers who were generally healthy in a study conducted in Iran, were found to be less likely to experience neck pain [67]. Better self-perceived mental health reported by Malay teachers demonstrated a protective effect against LBP and NSP [43].

6. Management of MSDs

As reflected above, MSDs are common among teachers with different contributing factors. This means that management of these need to evaluate risk factors for MSDs carefully before coming up with interventions to address them. The interventions for disorders need to be contextualized for them to be effective and to take into consideration, the risk factors for these conditions and how they interact with each other. MSDs disproportionately affect females compared to their male counterparts among school teachers in Saudi Arabia [23]. Aging and improper postures have also contributed to experience of MSDs among teachers in Punjab [68].

6.1 Workplace preventative programmes

Preventive programmes are required for management of these disorders and this should ideally be at organizational level rather than individual level [7] and also use health promotion approaches to them prevent repetitive strain injury (RSI) [33]. Previous research speak to prevention measures to reduce back pain [24]. In a study conducted among Chinese teachers, there was a statistically significant improvement in attitudes, awareness, symptoms on neck and back pain after 6 and 12 months post intervention. Researchers had administered a multi-faceted workplace intervention comprising of health education through lectures, workplace ergonomic training and public awareness materials using posters and brochures and assessed pre and post intervention effects of the workplace programme [28]. Similar findings were reported among nursery school teachers who underwent an Extension oriented exercise programme to prevent LBP in nursery school teachers. The programme was found to alleviate LBP among teachers who received brochure and exercise programme done by a physiotherapist compared to those who received only the brochure [33]. Preventive interventions focusing on posture have also been shown to work including reducing amount of time on awkward postures such as knee bending among pre-school teachers in Germany [69].

6.2 Individual coping strategies

Individual coping strategies are an important consideration for managing MSDs among teachers. This is because teachers may engage or prefer certain self-help therapies which may not necessarily be effective in prevention and management of MSDs as reported in one study where teachers used thermal spring therapy and/or painkillers to cope with their MSD pain [70]. Coping mechanism used by people suffering from MSDs can be influenced by gender and social class. This has been shown in one study where men in lower social class were found to prefer avoidant coping mechanisms compared to female counterparts while females in low social class used less problem solving methods to cope with MSDs [71]. Maintaining regular physical activity both at work and at home has demonstrated benefits for physical education teachers in terms of experiencing MSDs and their overall health and wellbeing especially their cardiovascular health [72] indicating a need to approach management of MSDs using a comprehensive risk based approach.

6.3 A comprehensive model of MSDs at work

The importance of a comprehensive multi-faceted programme to tackle MSDs is underlined by findings from a systematic review which demonstrated that massage therapy alone, a common mode of treatment for MSDs had limited benefits among patients with neck and back pain and no statistically significant benefits when compared to other treatments [73]. Additionally, patients diagnosed with MSDs commonly have other medical conditions including mental health and gastrointestinal conditions with those patients more likely to report a severe form of MSDs [74]. These patients may benefit from a holistic approach to the MSDs. A model of managing MSDs therefore requires further exploration and consideration. This is the bio-psychosocial (BPS) model of pain management.

6.3.1 The bio-psychosocial model

The model consists of three factors operating in the patient’s life which are the environment, biological and cognitive factors [75]. The model posts that biomedical approaches alone have not been effective in managing pain especially MSDs and therefore a more holistic approach consisting of managing the patient biological factors, their environment and the way they think about pain, cognitive factors is key.

The model brings together an appreciation of how the risk factors already alluded to can all be incorporated effectively in a workplace programme for prevention and management of MSDs. The risk factors can seem to be too many and overwhelming to tackle for both patient and healthcare providers. However by designing a programme consisting of biological risk factors relating to the person and disease itself, cognitive factors and the environment in which illness occurs. The BPS model emphasizes the importance of making health within the patients’ context taking into consideration the patients’ sociocultural beliefs about illness, worries and concerns they may have about the meaning of the illness for their job and them as a person and possible coping mechanism that they have which may enhance or detract from effective interventions. Likely benefits of the bio-psychosocial model are echoed by Waddell who estimates that incapacity and sickness absence from these disorders could be reduced by up to 50% [76] and expounds on the key components of the BPS model of disability.

7. The impacts of MSDs on teachers

An important question to consider is why the public, the employers and employees must be concerned about effective prevention and management of MSDs in general and more importantly among teachers. There are bound to be costs encountered by the employee, the employer and the public because of the employees’ inability to perform their duties effectively. The costs can be both tangible and intangible, direct and indirect. Assessing the impact of MSDs must therefore take a 360° view of who is affected and how are they affected. The impact can be felt at individual level and societal level.

7.1 Individual level impact

MSDs present with symptoms of pain, fatigue and functional limitations [71]. They have also been shown to adversely affect the physical and emotional components of quality of life and a likely cause of future ill health and disability [26]. Work performance is another impact of MSDs shown to affect academic teachers due to lack of adequate mental and physical rest from work even while at home [77]. A study among teachers in Botswana also noted that the effect of MSDs included functional limitations and at times career change with important implications for limited resources [40]. Increased sick leave among female teachers as well as rising levels of depression were found to be associated with having MSDs in Turkey [70]. It is clear that with symptoms experienced from these disorders, individual teachers are likely to experience functional limitations at home and at work.

7.2 Economic impact

Treatment of MSDs in general has been shown to provide economic benefits in terms of keeping people employed and earning an income in addition to reducing sickness absence from work. A study done among adults with MSDs in the UK, where 54% were employed, it showed that an average of 3.8 days were lost due to work absenteeism. The study further found that reduced functional limitations led to a reduction in the patients’ ability to remain in employment, higher chances of claiming disability benefits and sickness absence [78], which all add to the economic costs of MSDs. Patients experiencing MSDs in another UK study reported that their MSDs contributed significantly to their inability to work (74%) with a quarter reporting inability to find a suitable job because of the MSDs, low job satisfaction (68%) and half experiencing limited career choices and similar proportion experiencing reduced household income [74]. These were however not all teachers but it is likely that even teachers would experience similar challenges given the physical and psychological demands of their role as teachers and the nature of MSDs. These economic cost of MSDs has long been established. Canada reported an estimated economic cost due to MSDs as early as two decades ago at 26 billion Canadian dollars with the bulk of the costs being due to healthcare resource utilization and disease sequelae [79].

7.3 Societal level impact

The impact of MSDs among teachers on other aspects of the society are not well studied. For example, the impact on the pass rates of their students, career choices of their students and psychological wellbeing of the students. It is expected that students will experience some anxiety related to sickness absence of their teacher or having a temporary teacher to replace their substantive teacher. It is also possible that the temporary teacher may not have the same qualifications and experience as the substantive teacher, they may also not have the organizational context or institutional memory which would help them to navigate the school environment and the so called difficult students effectively. This is an important area of future research.

8. Conclusion

Although self-administered questionnaires have recall biasness, introspective inability and may be subject to wrong interpretation of questions, they have been commonly used to investigate MSDs. This chapter demonstrated that MSDs are common among teachers despite of their geographical location. Additionally, MSDs are a cause of pain and suffering for teachers globally. Some countries have higher than average prevalence rates for all MSDs. Physical and psychosocial risk factors have been associated with MSDs of different body regions. Factors such as high supervisor support, high job control and regular physical exercise have been shown to have a protective effect against MSDs. Due to the effects of MSDs on individual life, work attendance and productivity it is important to manage these. Because MSDs tend to affect more than one body site and are mediated by multiple factors, a workplace approach to managing these should be holistic and as comprehensive as reasonably practicable. Future research using longitudinal study designs should be conducted to establish the casual effect of work-related and psychosocial factors in development of MSDs. Research is also needed to identify innovations that can reduce the prevalence of these disorders.

Conflict of interest

The authors declare no conflict of interest.