Epidemiology of work-related musculoskeletal disorders : Current Opinion in Epidemiology and Public Health

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OCCUPATIONAL EPIDEMIOLOGY: Edited by Alessandro Godono and Yohama Caraballo

Epidemiology of work-related musculoskeletal disorders

Bonfiglioli, Robertaa; Caraballo-Arias, Yohamaa; Salmen-Navarro, Acranb

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Current Opinion in Epidemiology and Public Health 1(1):p 18-24, November 2022. | DOI: 10.1097/PXH.0000000000000003
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It is estimated that approximately 1.71 billion people have musculoskeletal conditions, being the leading contributor to disability and human suffering worldwide. Low back pain is the single foremost cause of disability in 160 of 204 countries analyzed [1].

Musculoskeletal disorders (MSDs) are an umbrella term for several diseases and injuries to muscles, tendons, ligaments, joints, and bones. MSDs could affect the back, the cervical region, as well as upper and lower extremities, resulting in pain and disability. Global prevalence rate of MSDs in 2017 was higher in women than in men and progressively increasing in the older age groups with some inter-country variation [2].

Population growth and aging workforce are important factors, which have elevated the number of subjects with MSDs worldwide. Disability associated with musculoskeletal conditions has also been increasing and is projected to continue this trend in the next decades. Although MSDs are not usually life-threatening conditions, they are typically associated with pain, limited mobility, and dexterity, leading to early retirement from work, lower levels of quality of life, and reduced capability to fully participate in society [3].

MSDs are multifactorial diseases where personal conditions such as age, sex, anthropometry, hereditary background take part in the cause. But most importantly, various modifiable risk factors, including biomechanical overuse, organizational and environmental exposures, psychosocial risk factors and other lifestyle conditions such as smoking and obesity have been implicated in the prevalence of MSDs [4–9].

Over time, psychosocial risks have assumed increasing relevance in the study of determinants of MSDs. However, the mechanism is still being studied, and it is not possible for now to associate a particular psychosocial risk factor to specific MSDs [10].

Occupational risks had the greatest influence on disability-adjusted life-years (DALYs) in middle-Sociodemographic Index (SDI) regions and low-middle-SDI regions, especially in Asian countries. The peak age range of onset of MSDs shifted from to 35–39 years in 1990 to 50–54 years in 2019. Similarly, the burden of DALYs reached a peak in the age range of 50–54 years [11].

Another aspect to be considered is that of migrant workers who are globally known to predominantly work on ‘4-D jobs’ – dirty, dangerous, difficult, and discriminatory. The fourth D was recently added to acknowledge the discriminatory aspect and other social determinants of health migrant workers face in their host country while exposed to precarious work resulting in high prevalence of work-related MSD (WRMSDs) [12,13].

Although it is well known that workplace hazards and biomechanical activity are contributing factors for WRMSD causation resulting in high prevalence rates, research must continue to close gaps, create evidence, and focus resources on primary prevention and adequate workers’ compensation contributing to the future of decent work. 

Box 1:
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As mentioned before, MSDs are highly prevalent and represent a significant worldwide health problem with important socioeconomic consequences affecting about a third of the worldwide population, representing one of the most important causes of chronic disability, sick leave absence, reduced work productivity, and quality of life. Related to ergonomic factors, MSDs are the largest contributors to the occupational disease burden in the workplace [14].

Within low-middle–income countries (LMIC), we find a very high prevalence of MSDs specially in agriculture, manufacturing, and the service industry. In Africa, a recent systematic review of MSDs in Ethiopian working population found that the pooled prevalence of occupational-related elbow pain, wrist/hand pain, knee/leg pain, foot/ankle pain, and hip/thigh pain in the previous 1 year was 19.7% [95% confidence interval (CI) 12.3–30.1], 24.2% (95% CI 17.4–32.7), 25.0% (95% CI 18.5–32.8), 20.2% (95% CI 12.8–30.4), and 15.5% (95% CI 9.9–23.4), respectively [15]. Other studies from Ghana, Nigeria, and South Africa suggest the same in industries such as recycling and driving. [16–18]. In Asia, a large study from Pakistan analyzing the MSD prevalence in sawing machine workers found that of the 200 participants, 91% participants had symptoms of WMSDs in the past 12 months concluding with significant association between personal and occupational factors [19].

In the United States, workplace fatalities, injuries, and illnesses cost the country approximately $250 billion every year. Employers that implement effective safety and health programs caused significant improvements to their organization's productivity and profitability [20]. Additionally, The United States Bureau of Labor Statistics (BLS) data reports that the retail trade, manufacturing, and healthcare and social assistance had 50% of all MSD cases in the private sector in 2018. The healthcare sector had the highest incidence rate, with median days away from work for this industry was only 8, while the median days away for MSD cases in the private sector were 12. The transportation and warehousing industry had an incidence rate of 77.1 MSDs cases in 2018. This industry and the information industry had median days away from work for MSD cases of 26 and 33 days, respectively (Fig. 1) [21].

Number, incidence rate and median days away from work of injuries and illnesses involving musculoskeletal disorders by selected industries, U.S., private sector, 2018. Source: U.S. Bureau of Labor Statistics [17▪].

Nursing assistants experienced 10 330 back-related musculoskeletal disorder cases in 2016. Laborers and hand material movers experienced another 10 660 cases. These occupations accounted for 15.6% of all the back-related cases in 2016. The most common body parts affected by musculoskeletal disorders vary by occupation. Among nursing assistants, more than half of their cases in 2016 affected the back. Compared with other occupations, heavy tractor-trailer truck drivers had a greater proportion of injuries that affected the shoulder (19.2%) and leg (16.3%) [22] (Fig. 2).

Work-related musculoskeletal disorders resulting in days away from work in selected occupations by part of body, all ownership, 2016. Source: U.S. Bureau of Labor Statistics [17▪].

These statistics vary by country and occupations. In the United Kingdom, for example, in 2020/2021, there were about 470 000 workers affected by WRMSDs. This represents 1420 per 100 000 workers, and thus accounts for 28% of all work-related illnesses (health issues?) [23].

In the European Union, although the trend over the last few years has indicated a slight decrease in workers complaining MSDs, recent reports by the European Agency for Safety and Health at Work (EU-OSHA) showed that more than half of European workers still face this health problem. Most of these MSDs affect the back 45%, upper limb or neck 39% and the remaining 16% of cases affecting the lower limbs [10]. In Italy, the percentage of the workforce declaring one or more MSDs has significantly decreased from 65% in 2010 to 50% in 2015 [24,25]. These disorders are the most common illness, representing 66.7% of all Italian occupational diseases recognized in 2018 with back pain being the most identified health problem, followed by muscular pain in the upper and lower limbs (51.6%, 46,7 and 29.3%, respectively). Soft tissue diseases and dorsopathies are the two most preponderant WRMSD type in Italy [26–29].

The Covid-19 pandemic brought a few challenges as well in the past 2 years. Overall, the problem was exacerbated for several reasons. First, because of a higher demand for nonhealthcare essential services to keep most of the population working from home, for example, delivery workers, home garbage handlers, utility workers, warehouse workers. Second, the tremendous increase in demand within hospitals where healthcare workers were unexpectedly exposed to several ergonomic hazards. Although a hyper-focus on healthcare workers was the norm, leaving behind other nonhealthcare essential workers, the main preventive interventions were in biosafety looking to avowing coronavirus disease 2019 (COVID-19) infections. Simultaneously, the prevalence of MSDs increased very much, especially in occupations such as ICU nurses, [30] assistant nurses, mortuary workers who perform decedent handling, physiotherapists [31], and cardiac sonographers [32]. Finally, home office work and telework without the appropriate setup and environment affected a large number of the population because of office ergonomic hazards.


Since the last two decades of the 20th century, a large amount of literature indicated an association between MSDs and biomechanical risk factors. Work-related conditions, mainly manual material handling, upper limb repetitive movements, as well as awkward postures, have been recognized as possible causes.

In 1997, the publication entitled ‘Musculoskeletal Disorders and Workplace Factors: a Critical Review of Epidemiologic Evidence for Work Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back’, broadly considered a ‘milestone’ by the National Institute of Occupational safety and Health (NIOSH), concluded that a large body of credible epidemiologic research revealed a consistent relationship between MSDs and certain physical factors, especially at higher exposure levels [33].

Limitations in epidemiological research became evident soon. Various case definitions were adopted in different studies. Several sets of criteria have been applied based on clinical pathology, symptoms, ‘objectively’ demonstrable pathological processes, work disability (i.e. lost work-time status). Therefore, comparisons and pooling of data were hampered, and controversies arisen about the relative importance of various risk factors in the cause of MSDs.

The common referring in the scientific literature, as well as by international agencies, to a broad terminology embracing conditions affecting different tissues and multiple body regions has probably slowed down the achievement of a broad consensus on case definitions. The term ‘MSDs’ includes a multiplicity of disorders; diagnostic labels and different approaches have been adopted within the field (different names for the same disorder, labels that vary between different clinical specialties). When legal implications are involved, as in the occupational setting, suffering from a condition labeled as ‘disease’ may bring benefits or negative consequences for the workers, thus affecting their behavior in the reporting of symptoms.

Despite several case definitions for WRMSDs have been proposed and published in the literature, yet they are based on different combinations of symptoms, physical examination findings and instrumental test results. The lack of a unique international consensus for epidemiological research is still a limitation. Indeed, a high heterogeneity in methodology and reporting is resulted from included studies in a recent systematic review and meta-analysis of the prevalence and incidence of WRMSDs in secondary industries of 21st century Europe [34].

Of interest, in 2022, the International Labor Organization (ILO) updated the guidance notes that provide information and criteria to be considered in the diagnosis and prevention of the diseases included in the ILO List of Occupational Diseases (revised 2010). The guidance is intended for the use of competent authorities, social security institutions, workers’ compensation funds, occupational safety and health professionals, physicians, employers and workers, and persons in charge of recording, notification, prevention, and compensation programs for occupational diseases. Even if the main scope of the document is not for research purposes, it constitutes a chapter on some musculoskeletal diseases of the upper and lower limbs [35].

Another important issue regards exposure assessment. Exposure measures of workplace physical hazards can be obtained by self-assessment, observations or video-analysis, and direct measurements. Subjective self-report of workers’ exposure is less accurate (both for under-estimation and for over-estimation). However, it allows the collection of current and retrospective exposure data and can be used to collect information on workplace exposure to psychosocial factors and discomfort by means of structured interviews and questionnaires. It is relatively inexpensive (no technical equipment is needed), and it is suitable for a large sample size. Observational methods are less likely to misclassify exposure status, especially if they are based on a structured approach, which showed good repeatability. However, the influence of experience and subjective judgement of the ergonomist cannot be ruled out. On-site observations are also time-consuming. Finally, instruments that rely on sensors attached directly to the subject for the measurement of exposure variables at work give back objective data and allow for continuous exposure assessment during working activities. Direct measurements make possible objective postural, movement, and force assessment. Some disadvantages could be represented by intrusiveness and by the fact that technologies are expensive and require users’ training [36].

Epidemiological research aimed at identifying the etiologic role of work-related risk factors in the development of MSDs is mainly based on observation in the occupational setting. Numerous studies still adopt cross-sectional design. Cohort and case–control studies, even if less abundant, have contributed to create reasonable evidence for causal relationship between the occurrence of specific MSDs and work-related biomechanical risk factors (lifting, heavy physical work, awkward postures, and repetitive work) as well as organizational and psychosocial factors. Individual factors and lifestyle also play an important role. Because of ethical issues and to established exposure conditions, randomized clinical controlled trials are not feasible in the workplace. Furthermore, blinding participating workers for intervention is not achievable too.


MSDs are still a prevalent condition in workers worldwide. The trend is confirmed by a recent report from EU-OSHA. Across Member States of the EU (EU-28), despite legislation and prevention measures, the levels of WRMSDs remain high, rather increased from 54.2% in 2007 to 60.1% in 2013. Factors that affect the prevalence of MSDs in the workforce include changing ways of working [new formal employment relationships or work patterns, i.e. place of work, working time or use of information and communication technologies (ICT)], age and gender, health behaviors and beliefs, psychosocial factors, and socio-economic differences. Unhealthy lifestyles, physical inactivity and rising obesity rates may also be responsible for musculoskeletal problems. A growing proportion of sedentary jobs results in increased occupational sedentary exposure and musculoskeletal complaints. We need new approaches to prevent MSDs and make recommendations. Among these, a more holistic approach to risk assessment, combining physical and psychosocial risks, both of which put workers at risk of developing MSDs, is advocated [37,38].

General agreed diagnostic criteria are still lacking, and the risk of exposure misclassification is even now under debate. Several ongoing projects are aimed at building agreed criteria to compare results from different epidemiological studies to improve estimates of the burden and natural history of MSDs as well as to understand the role of causal factors.

To identify diagnostic criteria for specific MSDs to be used in occupational healthcare programs, surveillance, or research, van der Molen et al. conducted a scoping review. Case definitions available in peer-reviewed journals for WRMSDs and diseases were summarized. In addition to a considerable heterogeneity in defining all MSDs except low back disorders, results indicated a lack of standardization and reporting of the consensus criteria applied for case definition. Furthermore, for prevention purposes, authors suggested that case definitions on WRMSDs should also include work-related exposure [39▪].

To support the development of the WHO and ILO estimates of work-related burden of disease and injury, a systematic review and meta-analysis of the prevalence of occupational exposure to physical ergonomic risk factors for osteoarthritis and other musculoskeletal diseases produced pooled effect estimates. However, even recent studies of working age populations are affected by important source of bias because of subjective exposure data from self-reported ergonomic risk factors concerning characteristics, frequency, and intensity [17▪].

Job Exposure Matrix (JEM) that links job titles with indices of exposure to one or more factors has been proposed as an alternative. On the basis of workers’ job title, JEMs can give back an exposure estimate and infer more complex information for epidemiological studies. When selecting a JEM, users should carefully assess the development and validation process and should be aware of possible limitations, since JEMs represent an ‘average’ level of exposure. Several JEMs are available for various applications in public health research as well as in studies assessing the association between workplace exposure and health outcomes, including WRMSDs [40].

Another area of improvement is sensors-based exposure assessment. The application of wearable devices in ergonomics has received a growing interest in the last few years, mainly for the assessment of physical factors. Single components or platforms that combine information obtained from multiple devices are applied for real-time tracking of movements and the assessment of awkward postures; muscle activity and physical load can be recorded as well. To date, many of the studies concern experimental designs based on simulation; others regard real-context applications [41].

At the same time, artificial intelligence and machine learning techniques have been introduced for the exploration of large datasets to identify potential biomechanical, social, and psychological risk factors, to monitor real-time WRMSD risk or predict, which workers may sustain a WRMSD. According to a recent scoping review, machine learning techniques provided the greatest contributions to the development of interventions, followed by risk factor identification, underlying mechanisms, incidence of MSDs, and evaluation of interventions [42▪].

To sum up, a novel approach is rising for the prevention of chronic conditions potentially caused or influenced by several factors along the life span, including individual, environmental, occupational, and socio-economic conditions as well. To extend our knowledge beyond the traditional framework based on ‘one exposure, one disease’, which fits well with a high single occupational exposure in relation to a specific health end point, new concepts able to represent the multifactorial nature of diseases together with the complexity of the relationship between environmental and occupational exposure, with its related nonoccupational conditions (lifestyle, behavior, and socio-economic status) are proposed. An example is the European Union Exposome Project for Health and Occupational Research (EPHOR) (https://www.ephor-project.eu/), which aims to apply the exposome concept to working life health research to improve the evidence base for developing cost-effective preventive actions and reducing the burden of noncommunicable diseases (NCDs), such as musculoskeletal diseases. A harmonized JEM (EuroJEM) including physical, ergonomics, and psychological exposures, will be developed and applied to existing large cohorts; wearable sensors, smart technologies, and noninvasive biomonitoring will integrate the exposome assessment. This approach is also expected to fill the gap of knowledge on vulnerable life stages and subgroups or more complex exposure interactions in heterogeneous working life exposure patterns [43].


Scientific evidence of new forms of employment, changes in working environment, sedentary work, obesity, and other chronic diseases are strongly emerging their impact on musculoskeletal health and affects the entire world of human factors and ergonomics. Therefore, conventional forms of epidemiological research in MSD prevention, needs to be adapted.

In a postpandemic era, the impact of new technologies, remote work, telework and the ‘gig economy’ have broken the traditional boundary between work and life and workplace/environmental exposure. They bring new challenges that should be addressed appropriately.

Together with ongoing harmonization policies, new perspectives for exposure and clinical assessment are required. Strategies for monitoring large cohorts of individuals along the working day and the lifespan, to study the interaction between new forms of technologies and the environment, as well as to promote interventions to prevent MSDs and support groups that need special attention are desirable.



R.B.: ORCID No. 0000-0003-4248-4448.

Y.C.-A.: ORCID No. 0000-0001-7105-0441.

A.S.-N.: ORCID No. 0000-0001-9391-4589.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


Papers of particular interest, published within the annual period of review, have been highlighted as:

▪ of special interest

▪▪ of outstanding interest


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epidemiology; ergonomics; experts’ opinion; musculoskeletal disorders; occupational diseases; occupational health

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