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BMC Musculoskeletal
Disorders
Musculoskeletal pain inhealth professionals
attheend oftheir studies and1year afterentry
intotheprofession: amulti-center longitudinal
questionnaire study fromSwitzerland
Thomas Bucher1*, Thomas Volken1 , Fabian Pfeiffer1 and René Schaffert1
Abstract
Background Musculoskeletal pain, especially back pain, is common among health care professionals (HP). For
prevention purposes, it is important to know whether HP develop their symptoms before or after entering the health
care workforce. Cross-sectional studies among HP cannot answer this question. This follow-up study measures the
prevalence and individual course of musculoskeletal pain among full-time HP students at the end of their studies and
one year after entering the health care workforce.
Method Self-reported one-year prevalence for low back pain, neck/shoulder pain, pain in arms/hands, and pain in
legs/feet was collected at two timepoints from 1046 participating HP using an online questionnaire. Participants were
asked whether their musculoskeletal pain was related to study or work conditions. Generalized estimating equation
(GEE) models of the binomial family with log link were used to estimate adjusted prevalence and corresponding nor-
mal based 95% confidence intervals were derived using the bootstrap method with 1000 replications.
Results The prevalence of low back pain as well as neck and shoulder pain was very high at baseline and follow-up
in all full-time students and later HP. Prevalence for pain in arms/hands, legs/feet was low and there were significant
differences between the professions. HP clearly associated their low back pain and neck/shoulder pain with study and
work conditions; HP strongly associated pain in arms/hands, legs/feet only with work conditions.
Conclusion Many HP suffer from back/neck/shoulder pain already as students before starting their professional
career. The prevention of back/neck/shoulder pain must be part of the education of all health professions at universi-
ties. As an example of best practice, universities should incorporate ergonomic measures and exercises into the daily
routine of training health professionals. The effects of physically demanding professional tasks on the upper and lower
extremities need to be investigated in further studies to take preventive measures.
Keywords Musculoskeletal pain, Back, Neck, Hand, Foot, Health professionals, Longitudinal
Background
Musculoskeletal health is a key factor for human func-
tioning, enabling mobility, dexterity, and the ability to
work [1]. Low back pain, neck pain, and other musculo-
skeletal disorders are the leading cause of years lived with
disability, with low back pain having the greatest impact
worldwide [2]. Compared to other noncommunicable
*Correspondence:
Thomas Bucher
buct@zhaw.ch
1 Zurich University of Applied Sciences ZHAW, School of Health Sciences,
Katharina-Sulzer-Platz 9, CH-8400 Winterthur, Switzerland
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Page 2 of 11
Bucheretal. BMC Musculoskeletal Disorders (2023) 24:518
diseases, musculoskeletal disorders are the leading cause
of years of productive life lost in the workforce [1]. In
order to initiate and promote preventive and mitigat-
ing public health measures, it is important to identify
populations at risk and to understand the causes and
the development of musculoskeletal disorders in these
populations.
Recent studies have reported a high prevalence of mus-
culoskeletal disorders in students [3–6] and in health
professionals (HP) [7–12]. In the absence of long-term
studies in this population, it is uncertain whether HP
develop their musculoskeletal disorders during their
working lives or whether they were preexisting.
erefore, we present this observational, follow-up
study to investigate the prevalence and individual course
of low back pain, neck/shoulder pain, pain in arms/
hands, and pain in legs/feet in full-time HP at the end
of their university studies (HP students) and 1year later,
after working as HP in the health care system. ere are
good reasons to investigate musculoskeletal disorders in
young health professionals at the transition from study to
work.
Given the shortage of qualified HP, it is important to
integrate and retain young HP in the health care work-
force by taking care of their health as early as possible.
Studies show that work-related and chronic musculoskel-
etal disorders may be a reason for HP students to discon-
tinue their studies [13, 14], reduce the ability to perform
job tasks and roles [15, 16], and lead to reduced produc-
tivity when people attend work despite disorders (pres-
enteeism) [17]. Musculoskeletal disorders also predict
burnout [18], lead to sickness absence and often to long-
term absence (absenteeism) [19], and cause HP to change
their specialty or role at work or to leave the profession
[3, 15, 20].
Young HP in the transition from study to work are
predominantly female and between 20 and 30years old.
Low back pain is most prevalent in this age group [3] and
women are more prone to neck pain than men [3]. e
first onset of work-related upper limb symptoms is also
common among HP within the first 5years of work [3].
Research questions
Most studies of HP and HP students measure musculo-
skeletal disorders at only one point in time. As a result,
there is no evidence on whether musculoskeletal disor-
ders are acquired in the health care workplace or occur
before. is information is crucial for the prevention of
musculoskeletal disorders in future HP. erefore, in this
longitudinal study we investigate the following questions:
1) e prevalence and individual dynamics of low back
pain, neck pain, pain in arms/hands, and pain in legs/
feet among full-time HP students at the end of their
studies (baseline) and 1year later after entering the
health care workplace (follow-up).
2) Differences in the prevalence of musculoskeletal
pain among students/professionals of occupational
therapy, nutritional sciences, midwifery, nursing and
physiotherapy.
3) e causal attributions HP make for their pain.
Methods
Study design
is study is a multi-center, follow-up study with two
measurement points. Baseline data were collected from
full-time HP students (occupational therapy, nutritional
sciences, midwifery, nursing, and physiotherapy) study-
ing at a Swiss university of applied sciences at the end
of their last semester. Follow-up was 1 year later, after
entering the health care workplace.
Population andsample
e target population was all full-time HP students
obtaining a bachelor’s degree at a Swiss university of
applied sciences in 2016, 2017, and 2018. We derived data
from the National Graduate Survey of Health Profession-
als from Universities of Applied Sciences (Nat-ABBE),
a nationwide census survey of final year HP students. A
total of 5197 final year HP students were asked to com-
plete the questionnaire at the end of their sixth semester.
Figure1 shows the response rates and the cases lost and
excluded from the analysis.
We excluded the following groups from this sample:
students who had missing values for all variables used
in the analyses, students of medical radiology because
this subject can only be studied in the French-speaking
part of Switzerland, part-time students because they
were already working in the health care system during
their studies, and HP students who were not working in
the health care sector one year after graduation. We did
not consider the latter as HP because their professional
activity is not known, and they did not answer questions
about their health status. e final sample for this study
included 1046 HP and a total of 2092 observations.
Data collection anddata management
HP students were informed about the National Gradu-
ate Survey of Health Professionals (Nat-ABBE) dur-
ing a class at the end of the last semester. is survey
included questions about education, career expectations
and plans, and questions about health. Subsequently,
the HP students received an email inviting them to par-
ticipate in this online survey; the participation was vol-
untary, and students were assured that their data would
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Bucheretal. BMC Musculoskeletal Disorders (2023) 24:518
be kept confidential. In the baseline survey, partici-
pants were asked to leave an email address where they
could be reached after graduation. Participants gave
informed consent for the use of their data in the online
questionnaire. One year after graduation, the health
professionals were invited by email to participate in the
follow-up survey. e survey was conducted by the Qual-
ity and Evaluation Unit of the Department of Health of
the Zurich University of Applied Sciences. e data were
anonymized and stored in accordance with the univer-
sity’s security regulations. Data collection for the base-
line started in the summer of 2016 for a first cohort of
students and was repeated in 2017 and 2018 for two fur-
ther cohorts. e final survey for the one-year post-grad-
uation follow-up took place between summer 2019 and
ended in May 2020, one year after the last student of the
third cohort graduated.
Measurement ofself‑reported musculoskeletal pain
andattribution tostudies orwork
e Nat-ABBE online questionnaire contained a list of
health problems, including low back pain, neck pain, pain
in arm/hands, and pain in legs/feet. ese items were
taken from the Swiss Health Survey. e Swiss Health
Survey is conducted by the Swiss Federal Statistical
Office and is repeated every 5years (since 1992) based on
the Federal Statistics Act of 1992. Participants were asked
the following question: “In the past year, did you have
one or more of the following health problems?”. Answers
were recorded on a four-point ordinal scale (no, rarely,
occasionally, often). To make the results more compara-
ble to other studies, we derived a subject-specific binary
outcome for low back pain, neck pain, pain in arms/
hands, and pain in legs/feet (yes/no), indicating the pres-
ence of any pain frequency (rarely, occasionally, often) or
the absence of pain, with the category “no”.
If pain was reported in the online questionnaire, an
additional question was asked for the causal attribution
of this pain: “Do you think that these complaints are
related to your studies/ to your work?” e answers were:
no, partly, yes.
Statistical analyses
We used Stata 15.1 (StataCorp, College Station, TX,
USA) for all statistical analyses. Of the 2092 observations
which were included in the analyses, complete data for all
variables were available for 2024 observations (96.75%).
Missing values occurred in 60 cases for a single variable
(2.87%), 5 cases had 2 missing values (0.24%)and 3 cases
had 4 missing values(0.14%). Missing values were most
common in the age variable (n = 22, 1.05%). Visual pat-
tern analysis and cross-tabulation of missing variables
showed no systematic patterns in the missing data. Par-
ticipant characteristics were analyzed using descriptive
statistics with mean values (including standard devia-
tion), minimum and maximum values, or, in the case of
factor variables, with absolute and relative frequencies.
We used McNemar’s χ2-Test to assess differences in the
pain experience of HP students between baseline and
follow-up. e McNemar’s is used in repeated measures
to test the consistency of responses between two vari-
ables. Generalized estimating equation (GEE) models of
the binomial family with log links were used to estimate
the adjusted prevalence of pain in HP students and the
Fig. 1 Population, return rates, and cases lost / excluded
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Bucheretal. BMC Musculoskeletal Disorders (2023) 24:518
corresponding differences between professional groups.
Corresponding normal-based 95% confidence intervals
and Z-statistic based p-values were derived using the
bootstrap method with 1000 replications. We adjusted
for gender and age, centered on the mean. We also used
cumulative odds models, adjusting for clustering to
assess pain attribution in HP students. Statistical signifi-
cance was set at p < 0.05.
Results
Demographic characteristics ofHP sample
e demographic characteristics of the 1046 participants
are shown in Table1.
Annual prevalence ofmusculoskeletal pain
Figure2 gives an overview of the four types of muscu-
loskeletal pain considered at baseline (1) and follow-up
(2). e results were estimated by bootstrapping, adjust-
ing for gender and age. e white line in the box is the
median bootstrap prevalence estimate. e colored box
shows the interquartile range of bootstrap prevalence
estimates. e whiskers show the bootstrap 95% confi-
dence intervals based on the normal distribution.
At both time points, the prevalence of low back and
neck/shoulder pain is higher than the prevalence of
pain in arms/hands and legs/feet. e prevalence of low
back pain and neck/shoulder pain for the whole cohort
decreases slightly (not statistically significant) but
remains high, with proportions of 73% and72.4% for the
latter, respectively, between baseline and follow-up. e
prevalence of pain in arms/hands and legs/feet in the
whole cohort is higher at follow-up with proportions
of 27.6% and 39.2% respectively for the latter. Midwives
have the highest prevalence for low back pain and neck/
shoulder pain at baseline and follow-up. Occupational
therapists and physical therapists had the highest preva-
lence of arm/hand pain at both time points. Nurses were
most likely to report leg/foot pain at baseline and follow-
up. e largest increase in arm/hand pain was found
among physiotherapists. In the following sections, we
present the detailed results for the types of pain.
Low back pain
Table2 shows the adjusted annual prevalence of low back
pain at baseline and follow-up for health professionals in
Switzerland.
At baseline, midwives show the highest prevalence,
nutritional scientists the lowest. However, differences in
the prevalence of low back pain among full-time HP stu-
dents at baseline were not statistically significant.
At follow-up, there were some differences in prevalence
between different professions with higher prevalence of low
back pain in midwives and nurses compared to the other HP
(midwifery > physiotherapy, p = 0.0005; midwifery > nursing,
p = 0.0008; midwifer y > nutritional sciences, p = 0.0002; mid-
wifery > occupational therapy, p = 0.0065; nursing > nutri-
tional sciences, p = 0.0010; nursing > o ccupational therapy,
p = 0.0308).
Within the HP student groups, the differences between
baseline and follow-up were not statistically significant at
the 5% level. However, the prevalence of low back pain
decreased to near significance between baseline and fol-
low-up for occupational therapy students [-10.1% (-22.7–
1.1), p = 0.0750)].
Neck/shoulder pain
Table3 shows the adjusted annual prevalence of neck/
shoulder pain at baseline and follow-up for health profes-
sionals in Switzerland.
At baseline, all HP show high annual prevalence of
neck/shoulder pain ranging from 82.2% (midwifery
students) to 72.1 (physiotherapy students), but only
the difference between midwifery students compared
to physiotherapy students was statistically significant
(p = 0.0258).
At follow-up, the prevalence of neck pain was signifi-
cantly higher for midwives (84.1%) than for most other
HP (midwifery > nursing, p = 0.0027; midwifery > physi-
otherapy, p = 0.0002).
Within the HP student groups, the differences between
baselineand follow-up were not statistically significant.
Table 1 Demographic characteristics, health professionals in
Switzerland; N = 1046
Characteristic N %
Age at baseline:
Mean: 25.0; Median: 24.0
21–25 775 74.09
26–30 203 19.41
31–35 27 2.58
36–40 10 0.96
41–45 10 0.96
46 -57 10 0.96
missing 11 1.04
Gender:
Men 94 8.99
Women 945 90.34
missing 7 0.67
Professional groups
occupational therapy 112 10.71
nutritional sciences 83 7.93
midwifery 107 10.23
nursing 481 45.99
physiotherapy 263 25.14
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Bucheretal. BMC Musculoskeletal Disorders (2023) 24:518
However, in the total sample of HP students, the preva-
lence of neck pain decreased slightly between baseline
and follow-up [-3.4% (-7.2–0.3)], reaching borderline sig-
nificance (p = 0.0760).
Pain inarms/hands
Table4 shows the adjusted annual prevalence of pain in
arms/hands at baseline and follow-up for health profes-
sionals in Switzerland.
Fig. 2 Persistence and change of musculoskeletal pain from baseline to follow-up in Swiss health professionals. Colored box comprises the
interquartile range of bootstrap prevalence estimators. The white line within the box is the median bootstrap prevalence estimator. The whiskers
show the bootstrap 95% normal based confidence intervals. 1 = baseline at the end of studies; 2 = follow up after one year of working in the health
care workforce
Table 2 Low back pain: adjusted annual prevalence; mean (95% CI); N = 1046
Occupational therapy Nutritional Sciences Midwifery Nursing Physiotherapy Full cohort
Baseline 78.4% (70.6–86.1) 71.6% (61.7–81.5 81.3% (74.3–88.8) 76.1% (72.3–80.0) 73.3% (67.9–78.6) 75.8% (73.2–78.5)
Follow‑up 67.6% (58.7–76.5) 60.0% (49.5–70.5) 83.2% (76.1–90.2) 78.4% (74.8–82.0) 66.8% (61.0–72.6) 73.0% (70.7–75.9)
Table 3 Neck/shoulder pain: adjusted annual prevalence; mean % (95% CI); N = 1046
Occupational therapy Nutritional Sciences Midwifery Nursing Physiotherapy Full cohort
Baseline 81.1% (73.7–88.5) 80.2% (71.5–89.0) 82.2% (75.0–89.5) 74.2% (70.4–78.1) 72.1% (66.7–77.5) 75.7% (73.3–78.2)
Follow‑up 74.8% (66.3–83.2) 75.3% (65.3–85.3) 84.1% (77.1–91.1) 71.5% (67.4–75.5) 67.2% (61.5–72.9) 72.4% (69.6–75.1)
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Bucheretal. BMC Musculoskeletal Disorders (2023) 24:518
With a baseline prevalence of pain in the arms/hands
of 34.2% and 27.1%, respectively, occupational therapy
students and physiotherapy students showed a higher
prevalence compared to most other professions (occupa-
tional therapy > midwifery, p = 0.0115; occupational ther-
apy > nursing, p = 0.0028; occupational therapy > nutritional
sciences, p = 0.0009; physiotherapy > nursing, p = 0.0182;
physiotherapy > nutritional sciences, p = 0.0052).
At follow-up, the prevalence of pain in arms/hands
was significantly higher in occupational therapists and
physiotherapists compared to all other HP groups (physi-
otherapy > nurses, p < 0.0001; physiotherapy > nutritional
sciences, p < 0.0001; physiotherapy > midwifer y, p < 0.0001;
occupational therapy > nursing, p = 0.0038; occupational
therapy > nutritional sciences, p < 0.0001; occupational
therapy > midwifery, p = 0.0007).
Within the HP student groups, the adjusted preva-
lence of pain in arms/hands increased in physiotherapy
students [15.3% (7.3–23.2)] as well as in the total sample
of full-time HP students [5.0% (1.3–8.8)] (p < 0.0001 and
p = 0.0080 respectively).
Pain inlegs/feet
Table5 shows the adjusted annual prevalence of pain in
legs/feet at baseline and follow-up for health profession-
als in Switzerland.
On the one hand, nursing students showed a higher
annual prevalence of pain in legs/feet at baseline then
most of the other professions (nursing > physiotherapy,
p = 0.0413; nursing > occupational therapy, p < 0.0001;
nursing > nutritional sciences, p < 0.0001). On the other
hand, the prevalence of pain in the legs/feet at base-
line was significantly lower for nutritional sciences
and occupational therapy students, with proportions
of 19.0% and 22.5%, respectively, compared to most
other professions (nutritional sciences < physiotherapy,
p = 0.0033; nutritional sciences < midwifery, p = 0.0349;
nutritional sciences < nursing, p < 0.0001; occupational
therapy < physiotherapy, p = 0.0120; occupational ther-
apy < nursing, p < 0.0001).
At follow-up, nurses and midwives had the highest annual
prevalence of pain in legs/feet at 52.2% and 39.3%, respec-
tively (nursing > midwifery, p = 0.0111; nursing > physiother-
apy, p < 0.0001; nursing > occupational therapy, p < 0.0001;
nursing > nutritional sciences , p < 0.0001; midwifery > occu-
pational therapy, p = 0.0030; midwifery > nutritional s ci-
ences, p = 0.0009).
Within the HP student groups, the adjusted prevalence
of pain in legs/feet increased significantly in nursing stu-
dents [9.5% (3.1–15.8), p = 0.0040].
Individual dynamics ofpain experience
Depending on the type of pain, full-time HP students in
Switzerland experienced different patterns of change in
pain over time (see Table6).
e patterns for low back pain and neck/shoulder pain
are similar: most students who reported low back or
neck/shoulder pain at baseline still reported them at fol-
low-up. Slightly more students experienced an improve-
ment in their low back or neck/shoulder pain; this overall
change over time was significant only for neck/shoulder
pain (p = 0.0162).
Most full-time HP students had no pain in arms/hands,
but more students experienced a change for the worse
over time compared to students who had no pain in
arms/hands at follow-up (p = 0.0034).
No pain in legs/feet at both times was the most com-
mon pattern, with the overall burden of pain in legs/feet
increasing over time (borderline significance: p = 0.0536).
Attribution ofpain
Figure 3 shows whether HP associate their pain com-
pletely, partially or not with study/work. e upper part
of the Figure (A) shows the estimated percentage by
response category (yes, partially, no) at baseline (1) and
follow-up (2) with 95% confidence intervals; the lower
Table 4 Pain in arms/hands: adjusted annual prevalence; mean (95% CI); N = 1046
Occupational therapy Nutritional Sciences Midwifery Nursing Physiotherapy Full cohort
Baseline 34.2% (25.1–43.4) 13.9% (6.1–21.7) 19.2% (12.1–26.4) 19.5% (15.9–23.1) 27.1% (21.9–32.3) 22.5% (20.0–25.1)
Follow‑up 37.8% (28.4–47.3) 11.1% (4.1–18.2) 16.8% (9.8–23.8) 22.2% (18.4–26.0) 42.4% (36.3–48.4) 27.6% (24.8–30.3)
Table 5 Pain in legs/feet: adjusted annual prevalence; mean (95% CI); N = 1046
Occupational therapy Nutritional Sciences Midwifery Nursing Physiotherapy Full cohort
Baseline 22.5% (14.8–30.3) 19.0% (10.1–27.9) 33.0% (24.0–42.0) 42.8% (38.3–47.2) 34.8% (29.0–40.7) 35.6% (32.9–38.5)
Follow‑up 20.9% (13.1–28.8) 18.5% (10.0–27.1) 39.3% (30.2–48.4) 52.2% (47.7–56.8) 29.9% (24.5–35.3) 39.2% (36.2–42.1)
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Bucheretal. BMC Musculoskeletal Disorders (2023) 24:518
part (B) shows the estimated percentage difference
between baseline (1) and follow-up (2) by response cat-
egory with 95% confidence intervals.
Low back pain in the HP study cohort in Switzerland
is mainly attributed to work or studies. Only a minor-
ity of full-time HP students reported that low back pain
was not related to either their studies at baseline [26.8%
(23.8–29.7)]or to work at follow-up [19.0% (16.6–21.4)]. In
addition, there was a significant and substantial increase at
follow-up of 10.3% (6.6–14.0) in those who attributed low
back pain to study/work, while the percentage of HP stu-
dents who did not attribute low back pain to work or who
attributed low back pain partly to work decreased by 7.8%
(4.9–10.6) and 2.5% (1.4–3.7) respectively.
As with low back pain, neck pain is mainly attributed to
work or studies by full-time HP students in Switzerland.
Only a minority of HP students did not attribute neck
pain to studies at baseline [19.7% (17.2–22.3)] or to work
at follow-up [20.5% (17.9–23.1)]. With 35.7% (33.1–38.3)
and 36.1% (33.5–38.7), respectively, more than a third
attributed neck pain partly to work at baseline or follow-
up, and a majority attributed neck pain to study/work
at both times [44.6% (41.1–48.0) and 43.4% (40.0–46.7),
respectively]. In contrast to low back pain, the attribution
of neck pain did not change significantly over time.
As shown in Fig.2 above, pain in the arms/hands is less
common than low back pain and neck pain, but this form
of pain is also mainly attributed to work or study by the
HP of our cohort, with a significant increase between
baseline and follow-up. At baseline, around a third of
full-time HP students reported pain in the arms/hands
as not related to their studies, partly related to their
studies or related to studies [34.3% (28.0–40.5), 31.5%
(27.2–35.8), and 34.3% (28.2–40.4), respectively]. At fol-
low-up, the percentage of HP students attributing pain in
the arms/hands to work increased by 17.9% (10.6–25.3),
Table 6 Individual dynamics of pain experience between baseline and follow-up; N = 1046
Pain symptoms low back neck/shoulder arms/hands legs/feet
yes at baseline—yes at follow-up 62.1% 61.4% 9.8% 20.6%
no at baseline—no at follow-up 13.4% 13.3% 59.5% 45.6%
yes at baseline—no at follow-up 13.4% 14.5% 12.8% 15.1%
no at baseline—yes at follow-up 11.2% 10.8% 17.9% 18.6%
McNemar’s χ2(1); p 2.07; 0.1498 5.78; 0.0162 8.56; 0.0034 3.72; 0.0536
Fig. 3 Causal attribution of musculoskeletal pain. LBP: lower back pain; NP: neck/shoulder pain; AHP: pain in arms/hands; LFP: pain in legs/feet
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Bucheretal. BMC Musculoskeletal Disorders (2023) 24:518
while those attributing pain in the arms/hands to work
partly or not at all decreased by 3.6% (1.6–5.6) and 14.3%
(8.0–20.6) respectively.
A similar pattern of a significantly increased propor-
tion of HP attributing their pain to work at follow-up
appears for pain in the legs/feet. At baseline, most full-
time HP students did not attribute pain in the legs/feet to
their studies [46.4% (41.4–51.3)], 27.7% (24.3–31.2) partly
attributed pain in legs/feet to their studies, and only a
minority of 25.9% (21.8–30.0) reported pain in the legs/
feet to be related to their studies. At follow-up, however,
a substantial majority attributed pain in the legs/feet to
work [45.9% (41.2–50.6)], 27.8% (24.4–31.2) partly attrib-
uted pain in legs/feet to work, and only 26.2% (22.2–30.3)
did not attribute pain in the legs/feet to work. In sum-
mary, the percentage of students who did not attrib-
ute pain in the legs/feet to work decreased significantly,
while the percentage of students who attributed pain in
the legs/feet to work increased.
Overall, we found that, except for neck pain, the per-
centage of HP students attributing pain to work had sig-
nificantly increased by follow-up (Fig.3).
Summary ofmost important results
Table7 presents the most important results of this study.
Pain in the lower back and neck/shoulder was common
among HP, with midwives being most susceptible to this
pain. Individual experiences of pain in the lower back and
neck/shoulder were often constant over time, and more
HP experienced a change for the worse than an improve-
ment. Most HP attributed some or all the causes of lower
back pain and neck/shoulder pain to their studies or work
(Table7). Pain in arms/hands and legs/feet was less com-
mon. Physiotherapists and occupational therapists were
more likely to report pain in arms/hands than other pro-
fessional groups; nurses and midwives were more likely to
report in legs/feet than other HP with significant increase
after one year of working in the health care sector. e
attribution of the causes of pain in arms/hands and legs/
feet was ambiguous at baseline; after working one year in
the health care sector, HP attributed their pain in arms/
hands and legs/feet more often to their work.
Discussion
In this follow-up study, we investigated the prevalence
and individual course of musculoskeletal pain in HP at
the transition from study to work in Switzerland. Full-
time HP students reported their pain using an online
questionnaire at the end of their studies and one year
after entering the healthcare workforce. We were particu-
larly interested in the question of whether musculoskel-
etal pain in HP is already present during studies or only
occurs in professional life.
e results strongly suggest that low back pain and
neck/shoulder pain in HP already occur during their
studies: 75% of the participants reported low back pain
and or neck/shoulder pain at baseline; low back pain and
neck/shoulder pain were present in 62% and 61%, respec-
tively, at both time points (see Table7: Overall preva-
lence and individual change over time). is was true for
all professional groups in our study.
In contrast, the prevalence of pain in arms/hands and
legs/feet is generally lower: 22.5% and 35.6% respectively.
e prevalence of pain in arms/hands increased signifi-
cantly at follow-up, especially among physiotherapists.
e prevalence of pain in legs/feet increased significantly
among nurses after they started working. is suggests
that work-related factors are responsible for this pain
in physiotherapists and nurses. is is supported by the
attributions that physiotherapists and nurses make for
their pain: ey associate their pain more strongly with
their professional life at follow-up than with their studies
at the baseline.
Table 7 Summary of major results for musculoskeletal pain in Swiss health professionals; N = 1046
low back neck/shoulder arms/hands legs/feet
Overall prevalence baseline/
follow-up 75.8% / 73.0% 75.7% / 72.4% 22.5% / 27.6% 35.6% / 39.2%
Substantial differences in
prevalence between professional
groups
highest for midwives
(83.2%) and nurses
(78.4%) at follow-up
highest for midwives (84.1%) at
follow-up highest for physiotherapists
(42.4%) and occupational thera-
pists (37.8%) at follow-up
highest for nurses
and midwives at
follow-up
Individual change of pain experi-
ence over time little change, most
common is pain at
both time points
(62.1%)
little change, most common is
pain at both time points (61.4%) substantial increase in physiother-
apists (27.1%—> 42.4%) significant
increase in nurses
(42.8%—> 52.2%)
Partial or total causal attribution of
pain to studies at baseline/ to work
at follow up
73.2% / 81.2% 80.3% / 79.5% 65.8% / 80.1% 53.6% / 73.7%
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 11
Bucheretal. BMC Musculoskeletal Disorders (2023) 24:518
Dierences betweenprofessional groups
Midwives and nurses have the highest prevalence of low
back and neck pain. ese two professions perform unfa-
miliar and physically demanding tasks such as bending
and lifting during internships and after graduation, which
may explain the difference compared to the other HP
groups.
Occupational therapists and physiotherapists had the
highest prevalence of pain in the hands/arms and a sig-
nificant increase between baseline and follow-up. is
may be explained by the higher demands on the arms
and hands, for example from manual therapies, which are
common in these professions.
Nurses and midwives were most affected by pain in the
legs/feet with a significant increase between baseline and
follow-up. is is probably related to prolonged standing
and walking, which is common in the daily routine of these
professions. In Switzerland, about 78% of nurses spend at
least half of their working time standing, and 65% must
do so for at least three-quarters of the time. ese rates
are higher than in other professions: only 46% of medi-
cal doctors and 59% of other health professionals spend
at least half of their work time in a standing position [12].
Although many nurses experience leg/foot pain, it receives
little attention compared to other musculoskeletal disor-
ders. In a recent systematic review of interventions to pre-
vent musculoskeletal injuries in nurses [3], none of the 20
included studies focused on the lower limbs. Most of the
interventions were aimed at preventing back pain. Almost
ironically in this context, an intervention study investigat-
ing the effects of unstable footwear focused on low back
pain and disability as outcome variables [3].
Causal attribution ofpain
It is not possible to deduce the causes of low back/neck
pain from the available data. However, the majority of
HP attribute their low back pain and neck/shoulder pain
completely or at least in part to their studies/work. In the
last year of their studies, students write their bachelor’s
thesis, which involves long hours of computer/laptop
work, and they are often in an internship.
Full-time HP students did not associate their pain in
arms/hands and legs/feet as clearly with their studies as
they did with low back pain and neck/shoulder pain. is
changed after one year of work: 80.0% associated pain in
arms/hands and 73.7% associated pain in legs/feet fully
or at least partly with their work.
e stronger association of these pains with work in the
health sector corresponds to the increase in these com-
plaints after starting work in the health sector. e work
of physiotherapists and occupational therapists requires
the use of hands and arms. e lower back, shoulders/
neck and legs/feet of midwives and nurses are exposed to
high levels of strain in their professional lives. It is under-
standable that HP, after their office-based studies, asso-
ciate the causes of these complaints with the strenuous
work in hospitals or outpatient clinics.
Comparison ofprevalences withprevious studies
Previous studies have reported the following one-year
prevalences of musculoskeletal pain in HP:
low back pain: 55.0% to 73.1% [19–22]
neck/shoulder pain: 13.0% to 96.0% [3, 19–22]
pain in arms/hands: 14.0% to 33.6% [19, 20, 22]
pain in leg/feet: 36.0%–65.7% [20, 22]
A direct comparison of our results with other studies
is not possible because of different measurement meth-
ods and more heterogeneous age groups in other studies.
Also, the range of prevalence in the studies found is very
wide, especially for neck/shoulder pain. Nevertheless, our
results are within the range of previous studies, which we
take as an indication of the trustworthiness of our data.
Recommendations
For most health professionals, low back pain and neck/
shoulder pain start during their studies and continue into
the first year of work, and these symptoms are mainly
attributed to study or work. e prevalence of low back
pain and neck/shoulder pain is alarmingly high, consider-
ing that this study mainly examined young health profes-
sionals at the beginning of their careers. Moreover, if we
consider the results of clinical follow-up studies [23–28],
which mostly suggest a chronic or intermittent course for
low back pain and neck/shoulder pain, this gives a poor
prognosis for the future if so many health professionals
start their career with low back pain and neck/shoulder
pain. Low back pain and neck/shoulder pain are there-
fore not only a burden on the individual, but also a pub-
lic health problem in two ways: First, the high prevalence
represents a risk and burden for the general public in
terms of health insurance costs, occupational insurance
costs, and increasing tax transfers. Second, in view of
the shortage of health professionals, it is a threat to the
health care system: the premature retirement of qualified
health professionals due to health problems compromises
the provision of health care for the whole population, i.e.
a potential shortage of essential health services.
In addition to this, full-time HP students and HP
strongly associate their low back pain and neck/shoul-
der pain with study and work, respectively. is negative
connotation can prevent positive feelings about the job
and reduce motivation to continue working for as long as
possible. It is therefore important to avoid this negative
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 11
Bucheretal. BMC Musculoskeletal Disorders (2023) 24:518
connotation. Computer work and physically demanding
tasks cannot be avoided in the health professions. ere-
fore, health self-care for these known risks must become
an integral part of the training of health professional. e
period of study has great potential for the prevention of
these health problems. Universities have the know-how
and the infrastructure to integrate the prevention of low
back pain and neck pain into their curricula and to imple-
ment preventive measures during the studies.
Pain in arms/hands and pain in legs/feet are more com-
mon at work than at university and are mainly attributed
to work. ere are differences between different profes-
sions and more research is needed to better understand
the causes and to develop interventions to reduce pain in
legs/feet for nurses and midwives and pain in arms/hands
for physiotherapists and occupational therapists.
Strengths, weaknesses, andlimitations ofthis study
e longitudinal design is a major strength of this study,
with its two repeated intra-individual measures of pain.
is allowed us to show that many HP suffer from low
back pain and neck pain during their studies and that
these complaints are not acquired during their working
lives. However, there are several limitations to the study.
Firstly, our study only looked at the presence of pain.
Other relevant factors, such as pain intensity and chro-
nicity, could not be considered because they were not
part of the questionnaire. Second, the dropout rate was
relatively high, i.e. more than 50% of the students who
completed the baseline questionnaire did not attend the
follow-up and were not included in the study. Conse-
quently, selective response bias due to missing data may
have influenced our results. Although our sensitivity
analyses, in which we assessed pain at baseline between
participants and non-participants at follow-up (adjusted
for age, gender, and type of health profession), did not
show significant differences, selective response bias may
still be present. ird, all data are self-reported. As such,
they may be subject to recall bias, social desirability bias,
or may depend on social and professional experiences
and meanings derived from the respondents’ social envi-
ronment (“Lebenswelt”).
Conclusions
Musculoskeletal pain is a major issue among students
and young HP. Low Back and shoulder–neck pain already
occurs during studies, while pain in arms/hands and legs/
feet tend to occur after entering professional life. e
results call for research into the causes of these com-
plaints so that empirically based preventive measures can
be taken. Further research on the incidence and course of
musculoskeletal pain in students of other fields of study,
and working adolescents is warranted to gauge the scope
of this problem.
Abbreviations
HP Health professionals
HP students Students of health professions
Nat-ABBE National Graduate Survey of Health Professionals
Acknowledgements
The Authors would like to thank participating Swiss Universities of Applied
Sciences, and namely their representatives in the planning committee of the
National Graduate Survey (Nat-ABBE) for their collaboration in planning the
survey, collecting, and sharing the data: Berner Fachhochschule BFH: Andrea
Mahlstein, Fachhochschule Ost: Heidi Zeller, Scuola universitaria professionale
della Svizzera italiana SUPSI: Luca Scascighini, and Haute Ecole Spécialisée
de la Suisse occidentale; HES-SO: Blaise Guinchard, and Zurich University of
Applied Sciences ZHAW: Godela Dönnges.
Informed consent
Students were informed about the aims of the Nat-ABBE survey, as well as the
processing and storage of the data, during a session at the end of the semes-
ter. When completing the online questionnaire, they gave their informed
consent to participate in the study.
Authors’ contributions
TB was responsible for the study design, the data collection, and the manu-
script draft. TV was responsible for the data analysis and the editing of the
results. All authors contributed to the literature search, the manuscript draft,
the discussion of the results, revising and editing the manuscript. All authors
approved the final version of the manuscript.
Funding
Open access funding provided by ZHAW Zurich University of Applied Sci-
ences. This study received funds from the federal government of Switzerland
(federal project contributions for the program “Strategy to Combat Lack of
Qualified Workers in the Healthcare Industry”).
Availability of data and materials
The dataset analyzed during the current study is available online: https://
zenodo. org/ record/ 71234 25.
Declarations
Ethics approval
At the time the survey providing the data for this article was planned, the
national business management system for ethics committees that now exists
in Switzerland did not yet exist. In addition, there were no forms available at
the time for studies that did not require approval, so it was not possible to
apply for a waiver of ethical approval. The procedures and forms in place at that
time were mainly focused on clinical trials and were not suitable for a study
investigating the transition from studies to work of HP. Against this background,
the planning committee for the National Graduate Survey of Health Profession-
als decided that ethics approval was not required for this survey, based on the
criteria on the website of the Ethics Committee of the Canton of Zurich (https://
www. zh. ch/ de/ gesun dheit/ ethik- human forsc hung/ zusta endig keit- kanto nale-
ethik kommi ssion. html). The criteria were: questionnaire study with anonymized
data, voluntary participation of health care students, consent of participants for
use of the data, and use of standardized questionnaire items adopted from the
Swiss Health Survey of the Swiss Federal Statistical Office based on the Federal
Statistics Act of 1992 (https:// www. bfs. admin. ch/ bfs/ de/ home/ stati stiken/ gesun
dheit/ erheb ungen/ sgb. html). In addition, the participating universities gave
their permission to use the data for this study and all methods were carried
out in accordance with their relevant guidelines and regulations. Data from the
survey were anonymized and stored by the Quality and Evaluation Unit of the
Department of Health Professions at the ZHAW Zurich University of Applied Sci-
ences in accordance with university regulations. The researchers analyzing the
data are not able to trace the selected data back to the participating students.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 11 of 11
Bucheretal. BMC Musculoskeletal Disorders (2023) 24:518
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Competing interests
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Received: 7 December 2021 Accepted: 14 June 2023
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