FAST TRACK ARTICLE

The Healthy LifeWorks ProjectThe Effect of a Comprehensive Workplace Wellness Program on thePrevalence and Severity of Musculoskeletal Disorders in a Canadian

Government Department

Sandra Curwin, PhD, Jane Allt, MPA, Claudine Szpilfogel, MSc, and Lydia Makrides, PhD

Objective: The purpose of this study was to determine the effect of a com-prehensive workplace wellness program on the prevalence and severity ofmusculoskeletal disorders in a Canadian government department. Methods:The Healthy LifeWorks program was developed, implemented, and evalu-ated over a 4-year period. A total of 233 employees completed the NordicMusculoskeletal Questionnaire before and after the program to determinethe prevalence and severity of musculoskeletal disorders. Results: Therewas an approximately 10% decrease in the 12-month prevalence of mus-culoskeletal disorders, ranging from 4% for hip/thigh problems to 12% forlower and upper back problems. The proportion of people reporting that amusculoskeletal disorder interfered with their normal work during the past12 months decreased from 83% to 46%. Conclusions: Comprehensive well-ness, including educational sessions on posture, ergonomics, and joint health,results in improved musculoskeletal health.

M usculoskeletal disorders (MSDs) are among the main causesof activity limitation in workers and account for many long-

term disability costs.1–5 Analysis of the costs associated with specificdiagnostic categories showed that total costs were highest for car-diovascular disease ($18.5 billion), musculoskeletal diseases ($16.4billion), and cancer ($14.2 billion).5 Population surveys have shownthat up to 50% of people report musculoskeletal pain at one or morelocations within the past month.6 The incidence of MSDs seems tobe rising in Canada, the United States, and Europe because of ageand lifestyle factors.7–11 The current burden of MSDs is consider-able, with European and US estimates that MSDs account for nearly50% of all absences from work lasting 3 days or longer and for 60%of permanent work incapacity.2,12 Because most MSDs are non–lifethreatening, the effects on people’s quality of life and the economiccost are often overlooked.13,14

Musculoskeletal disorders include disorders and injuries in-volving muscles, tendons, ligaments, bones, and joints.15 WhenMSDs are considered to be caused by, or related to, work, theyare called work-related musculoskeletal disorders. This category in-cludes repetitive strain injuries, “sprains and strains,” and cumulativetrauma disorders, and injuries affecting muscles and tendons that arethought to be the consequence of overuse, rather than an acute injury.These overuse injuries have become widespread in the workplace and

From Creative Wellness Solutions Inc and School of Physiotherapy(Dr Curwin), Dalhousie University, Halifax, Nova Scotia, Canada; StrategicSupport Services (Ms Allt), Halifax, Nova Scotia Public Service Commission,Canada; Research Power Inc (Ms Szpilfogel), Halifax, Nova Scotia, Canada;and Creative Wellness Solutions Inc (Dr Makrides), Tantallon, Nova Scotia,Canada.

Sponsors (the Nova Scotia Public Service Commission, Pfizer Canada Inc, As-traZeneca Canada Inc, and SunLife Financial) provided funding for this study.

Address correspondence to: Lydia Makrides, PhD, Creative Wellness Solu-tions Inc, P.O. Box 3061, Tantallon, Nova Scotia B3Z 4G9, Canada(lmakrides@wellnesssolutions.ca).

Copyright C© 2013 by American College of Occupational and EnvironmentalMedicine

DOI: 10.1097/JOM.0b013e31829889c1

account for 20% to 25% of all MSDs.12,15 Low back pain is the mostcommon MSD, after neck/shoulder pain.16 It is estimated that up to80% of people report at least one lifetime episode of low back pain,17

although approximately 20% of people surveyed will currently beexperiencing low back pain.18

Risk factors for the development of MSDs are multifacto-rial and include prolonged loading (as in repetitive strain injuries),excessive mechanical loading (as in back pain), vibration, cold, awk-ward working postures, decreased personal strength, increased age,previous injury, obesity, and an overall decline in fitness.15 Lookingahead, the intensification of work, an aging population, and risingrates of obesity are all risk factors for MSDs in the working agepopulation for at least the next 20 years.8

Musculoskeletal disorders are the most common cause ofphysical disability.5,19 They have an enormous socioeconomic cost,the greatest burden coming from back pain, osteoarthritis, andrheumatoid arthritis.5 The majority of the costs are indirectly relatedto social care, pensions, long-term disability, and workers’ com-pensation. Musculoskeletal disorders account for the vast majorityof long-term disability costs in Canada (Health Canada)5 but mostlikely also account for most cases of short-term disability (less than 2weeks) and casual absenteeism. Musculoskeletal disorders comprisethe majority of time-loss claims in health care workplaces.5

Sprains and strains account for more than 50% of time-losswork injuries,20 but many work-related MSDs go unreported. Ac-cording to data from a 1997 study of newspaper office workers, only29% of workers who experienced work-related pain in the neck orupper extremities said they had consulted a health practitioner.21

Nearly two thirds (63%) of workers who reported some degree ofpain in the neck or upper limbs in the previous year said they hadnot mentioned these symptoms to their employers. Many people felttheir symptoms were so mild or fleeting that they did not feel theywere worth mentioning to their employers. Thus, employers oftenunderestimate the existence and effect of MSDs in the workplace.

The purpose of this study was to determine the effect of acomprehensive workplace wellness program, which included educa-tion and interventions aimed specifically at MSDs, on the prevalenceand severity of MSDs in the Department of Justice (DOJ) of the NovaScotia Public Service, Canada.

METHODS

Research DesignThe Healthy LifeWorks (HLW) program, a voluntary com-

prehensive wellness intervention, was developed, implemented,and evaluated over a 4-year period in the DOJ, within the NovaScotia Public Service of the Government of Nova Scotia, Canada. Atotal of 402 DOJ employees participated in a baseline and follow-up (4 years) health risk appraisal (HRA) in 12 sites throughout theprovince of Nova Scotia; 233 employees also completed a muscu-loskeletal pain questionnaire and constitute the study sample. Mainreasons for nonattendance, or attrition, included retirement, changeto other jobs within the Nova Scotia Public Service or to other

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

628 JOEM � Volume 55, Number 6, June 2013

JOEM � Volume 55, Number 6, June 2013 Workplace Wellness and Musculoskeletal Disorders

sites within the DOJ, and work-related difficulties limiting partici-pation in the program. Approximately 10% of DOJ employees whoremained in the study chose not to participate in the final HRAdespite repeated notifications.

Determining the Presence and Severity ofMusculoskeletal Pain—the NordicMusculoskeletal Questionnaire

The presence, location, and severity of musculoskeletal symp-toms were assessed before and after the program using the NordicMusculoskeletal Questionnaire (NMQ)22–25 (see the Appendix). TheNMQ contains questions related to the presence of musculoskeletalpain, aided by a body map illustrating body regions. The followingnine body regions are included: neck, shoulder, upper back, elbow,wrist, lower back, hip/thigh, knee, and ankle/feet. The NMQ has beenused with various populations and shown to be a reliable and validtool for the assessment of the presence of MSDs.25–30 There is anagreement between the questionnaire results and the physical exam-ination, at least for the neck–shoulder region.30 The NMQ assessesthree aspects of musculoskeletal pain: (1) 12-month prevalence, byasking, “Have you at any time during the past 12 months had trouble(ache, pain, and discomfort) in (nine body regions)?”; (2) interfer-ence with work, by asking those with musculoskeletal pain, “Haveyou at any time during the last 12 months been prevented from doingwork (at home or away from home) because of the trouble?”; and (3)current disorders, by asking those with musculoskeletal pain, “Haveyou had any trouble at any time during the last 7 days?” The NMQwas distributed to workers in 12 geographic locations throughoutNova Scotia, and 233 responses were collected before and after theimplementation of the comprehensive wellness intervention.

InterventionsThe comprehensive workplace wellness intervention con-

sisted of programs and policies to support employees in makinglifestyle changes to improve their health including HRAs, work-shops, group presentations, health fairs, competitions, incentivesprograms, various educational materials as well as one-on-one coun-seling via telephone, and computer-based support across lifestylerisk factors. Topics covered a wide range of health issues identifiedby the HRA including nutrition and weight management with a fo-cus on establishing and monitoring healthy eating habits; smokingcessation by telephone and on-site group sessions; physical activitywith a focus on how to exercise safely and effectively to increaseendurance, strength, and flexibility; ergonomics and musculoskele-tal injury prevention with emphasis on train-the-trainer sessions forsustainability; home and work physical activity programs, educationabout posture, sitting techniques to prevent injuries, and the impor-tance of maintaining a healthy weight and improving fitness levelsincluding strength and flexibility.

In addition to interventions aimed at general health risk fac-tors, several interventions focused on MSDs in particular. The latterincluded the following:

• Workshop presentations aimed at educating workers about com-mon MSDs, principles of prevention and treatment, advice onactivity, and common beliefs and misconceptions about MSDs.Presentations were delivered twice at each of the 12 locations andfocused on educating workers about how to reduce the severityof MSDs, the role of exercise in preventing/alleviating MSDs,and the role of the individual in reducing MSDs (eg, work styleand stress management). Emphasis was also placed on changingpeople’s beliefs about the relationships among physical activity,exercise, work, and low back and neck pain.

• Written handouts explaining workstation setup principles (foroffice workers).

• Workplace assessment and modification, and changes in equip-ment setup and behavior (eg, relocating telephones, changes infootwear, different mouse, chair adjustment, posture, and reduc-ing repetitive movements).

• Individual consultations with workers to discuss personal MSDsand make recommendations about appropriate treatment such asphysiotherapy, massage therapy, physician assessment, pedorthicintervention, and dietician referral (no treatment or follow-up wasprovided).

• Strength training programs (part of the physical activity package).• Workshops (6 hours, train-the-trainer) where occupational health

committee members were trained to identify risk factors forMSDs, taught exercises to prevent common MSDs, and advisedon the best treatment principles for MSDs to prevent them frombecoming chronic.

Data AnalysesAll data were analyzed using Statistical Analysis Software

(Version 8.2) (SAS, Inc, Cary, NC). Employees in the study wereassigned a coded ID name (for confidentiality purposes), which ap-peared on all data collection forms. The pre- and post-questionnairedata for each study participant were entered into Statistical AnalysisSoftware Full Screen Product data entry screen using the coded Idname as the identifier. A Cochran–Mantel–Haenszel chi-squared testwas used to compare the frequency and percentages of MSDs in eachbody region. The level of significance was set at P ≤ 0.05.

RESULTS

Overall Prevalence of MSDsThe 12-month prevalence of musculoskeletal pain before and

after the HLW program is shown in Table 1. Nearly 90% (89%;207 of 233) of respondents reported musculoskeletal pain in at leastone body region during the past 12 months at initial assessment,which was reduced to nearly 80% (79%; 184 of 233) after the HLWprogram. The low back (58% pre-HLW vs 46% post-HLW) and theneck (57% pre-HLW vs 48% post-HLW) were the most commonbody regions affected, both before and after intervention, and theelbow the least common location (19% pre-HLW vs 13% post-HLW).The 12-month prevalence of musculoskeletal pain was significantlyreduced (P < 0.05) in all body regions except the hip/thigh regionafter the HLW program. The decreases varied among body regions,ranging from a low value of 6% for the elbow region (19% pre-HLWvs 13% post-HLW) to a high value of 12% for the lower back (58%pre-HLW vs 46% post-HLW) and wrist/hand regions (36% pre-HLWvs 24% post-HLW).

Trouble During the Past 7 DaysThe numbers and percentages of respondents reporting mus-

culoskeletal pain within the past 7 days are shown in Table 1. Thenumbers of people reporting an MSD within the past 7 days de-creased in all body regions postintervention, but the changes weresignificant only for upper back and lower back body regions.

Prevention of Normal WorkThe numbers and percentages of respondents reporting that

musculoskeletal pain interfered with their work during the past 12months are shown in Table 1. Presumably, a more severe MSD willbe more likely to interfere with normal work. The numbers of peoplereporting that an MSD interfered with their normal work decreasedin all body regions, but the changes were significant only for theshoulder and hip/thigh body regions.

Number of Body Regions With Musculoskeletal PainThe percentages of respondents with pain in zero through nine

body regions are shown in Fig. 1. A decrease in the number of body

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

C© 2013 American College of Occupational and Environmental Medicine 629

Curwin et al JOEM � Volume 55, Number 6, June 2013

TABLE 1. Prevalence and Severity of Musculoskeletal Disorders

People Reporting “Yes” to Presence of Musculoskeletal Disorders*

Overall Prevalence Trouble in Past 7 DaysPrevented Normal

Work in Past 12 mo

Body Region Pre Post Pre Post Pre Post

Neck 133 (57) 111† (48) 61 (26) 45 (19) 30 (13) 19 (8)

Shoulder 118 (51) 96† (41) 53 (23) 36 (15) 32 (14) 13† (6)

Elbow 44 (19) 30† (13) 17 (7) 11 (5) 7 (3) 3 (1)

Wrist/hand 85 (36) 56† (24) 33 (14) 16 (7) 16 (7) 11 (5)

Upper back 73 (31) 45† (19) 32 (14) 11† (5) 16 (7) 12 (5)

Lower back 135 (58) 108† (46) 53 (23) 29† (12) 42 (18) 27 (7)

Hip/thigh 61 (26) 52 (22) 29 (12) 24 (10) 18 (8) 7† (3)

Knee 88 (38) 70† (30)† 21 (9) 10 (4) 21 (9) 10 (4)

Foot/ankle 61 (26) 34† (15) 11 (5) 5 (2) 11 (5) 5 (2)

* Values represent numbers of subjects (total n = 233) and percentage (in parentheses).†Significant at P < 0.05 level.

FIGURE 1. The number of subjects reporting a musculoskele-tal disorder in zero to nine body regions before (pre) andafter (post) the HLW program. The number of subjects re-porting no musculoskeletal pain increased from 11% prein-tervention to 21% postintervention. Sixty percent of subjectshad zero to two regions of pain postintervention, versus 43%preintervention. This shift represents a median decline of onepain location after the HLW program (x = 0.76; P ≤ 0.0001).

regions with pain means that some areas of pain have disappeared.There are decreases in the number of subjects reporting four to ninebody regions with pain (92 pre-HLW vs 51 post-HLW), althoughthe numbers of respondents with three or fewer locations of pain in-creased (141 pre-HLW vs 182 post-HLW). This represents a generalshift downward in the number of musculoskeletal problems reportedby each participant. The largest change was observed in the “zero”category, where 23 additional respondents had no musculoskeletalpain after the HLW program. Prior to the HLW program, only 11%subjects reported no musculoskeletal pain, which increased to 20%after the HLW program.

DISCUSSIONThe results of this study are consistent with previous reports

that the low back region is the most common location for work-related MSDs.18 The 12-month prevalence of low back pain of 58%was within the range of 22% to 65% reported in a systematic review,

higher than the 1-year prevalence of 39% reported in a later system-atic review,17 but similar to previous estimates of 60% in Africa,31

40% to 47% in Sweden and Norway,32 and 67.6% in Australia,33 aswell as a reported 6-month prevalence of 48.9% in Saskatchewan,Canada.34 The 7-day prevalence of 23% in this study is consistentwith an estimated point prevalence of 20% for low back pain.16

We observed higher rates of neck pain in our initial surveyresults (57%) than the 12-month prevalence of 15% to 45% reportedby others,35–37 although similar rates of 60% have been reported in agroup of medical secretaries.38 A large survey of a British populationfound 12-month and 7-day prevalence of neck pain of 34% and 20%,respectively, although we observed 57% of subjects reporting a his-tory of neck pain within the past 12 months and 26% within thepast 7 days.28 This may reflect differences in the population becausemany of the workers we surveyed worked in office conditions, whereneck pain is more common. The proportion of subjects reportingthat neck pain interfered with their work was similar to previousreports (13% in this study vs 11% in another study28). Neck paindecreased 9% after the HLW program, and a similar decrease wasobserved in upper back pain (12%) and shoulder pain (10%), whichoften accompany neck pain. More than 51% of respondents initiallyreported pain in the shoulder region (one or both), slightly higherthan the 1-year prevalence rates of 46.7% reported in the literature,39

which declined significantly to 41% postintervention. We observeda significant decline in the 12-month prevalence of musculoskeletalpain in all body regions except the hip/thigh region. We also sawa one-point reduction in the number of pain locations reported bysubjects; that is, each subject, on average, had one fewer pain loca-tion after the HLW program. The decrease in 12-month prevalence,7-day prevalence, and number of pain locations suggests an overallimprovement in musculoskeletal health after the HLW program; in-deed, an additional 23 people reported no musculoskeletal pain inthe past 12 months (26 pre-HLW vs 49 post-HLW).

The results of the pre-program NMQ were used to plan the ed-ucational sessions delivered; these focused on neck/shoulder/upperback and lower back problems because these areas accounted forthe largest proportions of MSDs. Lower extremity problems wereless prevalent and seemed to be more pronounced among correc-tional officers. This may be because these workers, mostly guards,are required to spend large amounts of time walking and standing,including considerable stair climbing. We observed decreases in allreported lower extremity problems, but this was significant onlyfor the foot and ankle (12-month prevalence) and hip/thigh regions

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

630 C© 2013 American College of Occupational and Environmental Medicine

JOEM � Volume 55, Number 6, June 2013 Workplace Wellness and Musculoskeletal Disorders

(prevented normal work during the past 12 months). The smallernumbers of subjects reporting hip/thigh, foot/ankle, or knee painmay mean that a larger sample size may have been required to showchanges in the prevalence of MSDs in these body regions. Alterna-tively, interventions more specifically tailored to the lower extrem-ity and the corrections work environment may be required, such asfootwear modifications, specific lower extremity exercises, or modifi-cations in job performance (especially decreasing the amount of stairclimbing).

Previous reports on workplace interventions to reduce MSDshave shown mixed results,40 and a recent systematic review suggeststhat such interventions aimed at MSDs may reduce absence fromwork but do not improve overall musculoskeletal health.41 Mostworkplace interventions, however, have focused solely on MSDs,rather than also including a broader approach to health improvement,and have measured time lost from work due to MSDs, rather thanexamining the presence and severity of MSDs. Because most peopleremain at work, even while experiencing musculoskeletal pain, mea-suring work absence probably only captures the worst MSDs, ratherthan overall musculoskeletal health.21 The HLW program examinedthe overall musculoskeletal health status, rather than work presenceor absence, and included interventions specific to MSDs as wellas interventions aimed at general health and lifestyle. Because theexact causes of MSDs such as low back pain are unknown, recent re-search and recommendations for improving musculoskeletal healthsuggest an integrated approach aimed at improving lifestyle, includ-ing increasing physical activity, maintaining a healthy body weight,smoking cessation, balanced use of alcohol, prevention of accidentsand musculoskeletal injuries, and specific interventions for those athighest risk or with existing musculoskeletal conditions.1,4,42 Ourresults suggest that such an integrated approach can indeed improvemusculoskeletal health.

Education about the causes of low back pain and other MSDsdoes not seem to be effective in preventing work-related low backpain;43 however, evidence suggests that information aimed at chang-ing people’s attitudes and beliefs about back pain may be moresuccessful.44,45 Although workers should be aware of conditions thatcan cause or aggravate MSDs, too much emphasis on risk factors inthe workplace can lead people to believe that work is the sole causeof their musculoskeletal pain, and that further activity may maketheir condition worse. The musculoskeletal education component ofthe HLW program incorporated these findings, explaining the ubiq-uitous nature of low back and neck pain, and how exercise shouldbe embraced, rather than avoided, by those experiencing low backpain,46,47 Appropriate rest intervals, shown to reduce musculoskele-tal pain,48 were incorporated. Individual consultations between theHLW physiotherapist (S.C.) and those experiencing musculoskele-tal problems enabled us to address specific concerns, as well asidentify those individuals who might need further evaluation andtreatment (no physical examinations or treatments were conducted).The education sessions related to neck/shoulder and upper backproblems also emphasized work breaks, use of armrests, equipmentsetup, work style, and strength training for the upper extremities.The overall goal of the education sessions was to enable workers to(1) reduce risks; (2) pace themselves during the workday; (3) adapt,rather than avoid, exercise to decrease MSDs; and (4) improve overallhealth.46,47

The relationship between MSDs and workplace productivityhas been established.49 Musculoskeletal disorders not only are re-sponsible for many of the costs related to absenteeism and disabilitybut also account for much of the cost of presenteeism (productivityloss due to working while sick). Presenteeism due to musculoskeletalpain has been estimated to cost from 0.8 hr/wk50 to 5.2 hr/wk for lowback pain,51 although exact numbers are difficult to establish. Pre-senteeism has not been measured in this study but may be inferredfrom the numbers of workers reporting that an MSD prevented their

normal work in the past 12 months. Taking low back pain as anexample, and assuming 3.4 hr/wk, per person, productive time losteach week because of back pain (a value midway between 1.6 and5.2 hr/wk), if 42 people reported that back pain interfered with theirwork during the past 12 months (pre-HLW), and 53 people reportedback pain in the past 7 days (pre-HLW), we can estimate that between143 hr/wk (3.4 hr/wk × 42 = 142.8 hr/wk) and 177 hr/wk (3.4 hr/wk× 52 = 176.8 hr/wk) of work productivity were lost, in the samplestudied, before the HLW program started. For each fewer personwith back pain, 3.4 hr/wk of productivity is gained (or somewherebetween 1.6 and 5.2 hr/wk, depending on the work population). TheHLW program resulted in 27 fewer people experiencing low backpain during the previous 12 months (11 fewer in the past 7 days;11 fewer reporting low back pain interfered with their work). Thus,somewhere between 37.4 hr/wk (3.4 hr/wk × 11 fewer people withlow back pain in the past 7 days) and 91.8 hr/wk (3.4 hr/wk × 27fewer people with low back in the past 12 months) of productivework can be estimated to have been gained by reducing low backpain alone as a result of the HLW program.

We observed a decline in these numbers for all nine body re-gions, with 86 fewer people (83% preintervention vs 46% postinter-vention), reporting that musculoskeletal pain had prevented normalwork during the past 12 months. Cost savings through preventing lossof productivity could thus be estimated using numbers between a lowvalue of 38 hours50 to a high value of 250 additional work hours peryear.51 Work-related MSDs are associated with higher costs relatedto absenteeism, workers’ compensation claims, disability costs, andoverall health care use.52 We did not relate absenteeism or healthcare costs directly to the prevalence or severity of MSDs amongthe subjects in this study, but we have previously shown that absen-teeism and health care costs decrease as overall health improves.53

Because MSDs account for most cases of short-term disability, adecrease in the prevalence and severity of MSDs should result inlower absenteeism and health care costs.

Study LimitationsA number of issues particular to the workplaces involved

affected the study results. Some recommendations were not possiblein all settings. For example, office staff and lawyers may be ableto take appropriate rest breaks, but this is not usually possible forcourt stenographers during long court sessions. Twelve geographiclocations, ranging from courthouses to correctional facilities andincluding everyone from prison cooks to judges, meant that theneeds of a very diverse group of workers in various settings had tobe addressed. Union requirements to make all interventions availableto all workers, rather than just study participants, and to maintainanonymity among workers, made it impossible to compare studyparticipants with the rest of the workforce, or to know whether studyparticipants completed all the interventions. However, the use ofsuch a diverse and challenging “real-life” work setting may meanthat the results are likely to be more generalizable, and a similarmultifaceted approach with a more homogeneous workforce mayyield even better results.

CONCLUSIONSThis study reported the effects of a comprehensive work-

place wellness program, including education and interventions aimedspecifically at MSDs, on the prevalence and severity of MSDs inworkers in the DOJ of the Nova Scotia Public Service, Canada. The12-month and 7-day prevalence of MSDs was reduced in seven ofnine body regions; the number of locations of musculoskeletal painwas reduced, and fewer people reported that musculoskeletal painhad affected their work during the past year. The results suggestthat integrated workplace wellness approaches aimed at improvingoverall health, in addition to targeted interventions for MSDs, candecrease the prevalence and severity of MSDs in a diverse workforce.

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

C© 2013 American College of Occupational and Environmental Medicine 631

Curwin et al JOEM � Volume 55, Number 6, June 2013

ACKNOWLEDGMENTSThe authors thank the participants, staff, and senior man-

agement at the Nova Scotia DOJ. Without their support and coop-eration this study would not have been possible. The assistance ofDr Pantelis Andreou, Dalhousie University, in the data analyses isespecially acknowledged. Special thanks are also due to the staff ofCreative Wellness Solutions and particularly Jean Petrie, Cardiovas-cular Nurse, for expert, professional guidance and untiring effortsthroughout all aspects of the project. This study was made possibleby our sponsors: the Nova Scotia Public Service Commission, PfizerCanada Inc, AstraZeneca Canada Inc, and SunLife Financial.

REFERENCES1. Akesson K, Woolf A. How to develop practical strategies for improving mus-

culoskeletal health. Best Pract Res Clin Rheumatol. 2007;21:5–25.

2. Bevan S, Quadrello T, McGee R, Mahdon M, Vavrovksy A, BrahamL. Fit for work? Musculoskeletal disorders in the European workforce. Avail-able at http://www.fitforworkeurope.eu/Default.aspx.LocID-0afnew009.RefLocID-0af002.Lang-EN.htm. Published September 30, 2009. AccessedDecember 1, 2009.

3. Colman R. Cost of chronic disease in Nova Scotia. Available at http://www.gpiatlantic.org/pdf/health/chronic.pdf . Published 2002. Accessed December1, 2009.

4. European Commission. European Action Towards Better MusculoskeletalHealth. ISBN 91-975284-0-4. Lund, Sweden: Bone & Joint Decade. Avail-able at http://ec.europa.eu/health/ph projects/2000/promotion/fp promotion2000 exs 15 en.pdf . Published 2004. Accessed December 1, 2009.

5. Health Canada. The economic burden of illness in Canada. Available athttp://www.phac-aspc.gc.ca/ebic-femc/ebic-femc98/pdf/ebic1998.pdf . Pub-lished 1998. Accessed December 1, 2009.

6. Parsons S, Breen A, Foster NE, et al. Prevalence and comparative trouble-someness by age of musculoskeletal pain in different body locations. FamPract. 2007;24:308–316.

7. Health Canada. Arthritis in Canada. An Ongoing Challenge. Ottawa, Ontario,Canada: Health Canada; 2003.

8. Human Resources and Skills Development Canada. Challenges of an agingworkforce: an overview of the issue. Available at http://www.sdc.gc.ca/asp/gateway.asp?hr=/en/lp/spila/wlb/aw/02overview.shtml&hs=. Published 2002.Accessed December 1, 2009.

9. Lyons R, Langille L, Gardner P. The Midlife Bulge: Promoting Health inCanada’s Expanding Midlife Population. Halifax, Nova Scotia, Canada: At-lantic Health Promotion Research Centre; 2005.

10. Murray CJL, Lopez AD, eds. The Global Burden of Disease: A ComprehensiveAssessment of Mortality and Disability From Diseases, Injuries and RiskFactors in 1990 and Projected to 2020. Cambridge, MA: Harvard UniversityPress; 1996. (Global Burden of Disease and Injury Series, Vol. 1).

11. Stafinksi T, Menon D. The burden of osteoarthritis in Canada: a reviewof current literature. Canada: Institute of Health Economics. Available athttp://www.ihe.ca/working papers.html?EK=47. Published 2004. AccessedDecember 1, 2009.

12. United States Bone and Joint Decade. The Burden of Musculoskeletal Diseasesin the United States. Rosemount, IL: American Academy of OrthopaedicSurgeons; 2008.

13. Woolf AD, Akesson K. Understanding the burden of musculoskeletal condi-tions. The burden is huge and not reflected in national health priorities. BMJ.2001;322:1079–1080.

14. Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull WorldHealth Organ. 2003;81:646–656.

15. National Institute for Occupational Safety and Health. Musculoskeletal Disor-ders and Workplace Factors: A Critical Review of Epidemiologic Evidence forWork Related Musculoskeletal Disorders of the Neck, Upper Extremity, andLow Back. U.S. Department of Health and Human Services: Public Health Ser-vice Centers for Disease Control and Prevention. Cincinnati, OH: NationalInstitute for Occupational Safety and Health; 1997.

16. Cote P, Cassidy JD, Carroll L. The Saskatchewan health and back pain survey.The prevalence of neck pain and related disability in Saskatchewan adults.Spine. 1998;23:1689–1698.

17. Loney PL, Stratford PW. The prevalence of low back pain in adults: a method-ological review of the literature. Phys Ther. 1999;79:384–396.

18. Walker BF. The prevalence of low back pain: a systematic review of theliterature from 1966 to 1998. J Spinal Disord. 2000;13:205–217.

19. Statistics Canada. A profile of disability in Canada, 2001. Available athttp://www.statcan.ca/bsolc/english/bsolc?catno=89-577-X. Published 2001.Accessed December 1, 2009.

20. Worker’s Compensation Board of Nova Scotia. 2010 Annual Report. Availableat http://www.wcb.ns.ca. Accessed June 16, 2011.

21. Polanyi MF, Cole DC, Beaton DE, et al. Upper limb work-related mus-culoskeletal disorders among newspaper employees: cross-sectional surveyresults. Am J Ind Med. 1997;32:620–628.

22. Kuorinka I, Jonsson B, Kilbom A, et al. Standardised Nordic questionnairesfor the analysis of musculoskeletal symptoms. Appl Ergon. 1987;18:233–237.

23. Crawford J. The Nordic Musculoskeletal Questionnaire. Occup Med.2007;57:300–301.

24. Deacon J, Stevenson J, Vail G, Nelson J. The use of the Nordic questionnairein an industrial setting: a case study. Appl Ergon. 1994;25:182–185.

25. Dickinson CE, Campion K, Foster AF, Newman SJ, O’Rourke AMT, ThomasPG. Questionnaire development: an examination of the Nordic Musculoskele-tal Questionnaire. Appl Ergon. 1992;23:197–201.

26. MacDonald F, Waclawski E. Upper limb disorders among coopers in theScotch whiskey industry. Occup Med. 2006;56:232–236.

27. Palmer K, Smith G, Kellingray S, Cooper C. Repeatability and validity of anupper limb and neck discomfort questionnaire: the utility of the standardizedNordic questionnaire. Occup Med. 1999;49:171–175.

28. Palmer KT, Walker-Bone K, Griffin MJ, et al. Prevalence and occupationalassociations of neck pain in the British population. Scand J Work EnvironHealth. 2001;27:49–56.

29. Tezel A. Musculoskeletal complaints among a group of Turkish nurses. Int JNeurosci. 2005;115:871–880.

30. Perrault N, Brisson C, Dionne CE, Montreuil S, Punnett L. Agreement be-tween a self-administered questionnaire on musculoskeletal disorders of theneck-shoulder region and a physical examination. BMC Musculoskeletal Dis-ord. 2008;9:34. Available at http://www.biomedcentral.com/1471-2474/9/34.

31. Louw QA, Morris LD, Grimmer-Somers K. The prevalence of low back painin Africa: a systematic review. BMC Musculoskeletal Disord. 2007;8:105–119.

32. Ihlebaek C, Hansson TH, Laerum E, Brage S, et al. Prevalence of low backpain and sickness absence: a “borderline” study in Norway and Sweden. ScandJ Public Health. 2006;34:555–558.

33. Walker BF, Muller R, Grant WD. Low back pain in Australian adults: preva-lence and associated disability. J Manipulative Physiol Ther. 2004;27:238–244.

34. Cassidy JD, Carroll LJ, Cote P. The Saskatchewan health and back pain survey.The prevalence of low back pain and related disability in Saskatchewan adults.Spine. 1998;23:1860–1866.

35. Cagnie B, Danneels L, van Tiggelen D, De Loose V, Cambier D. Individualand work related factors for neck pain among office workers: a cross sectionalstudy. Eur Spine J. 2007;16:679–686.

36. Cote P, van der Welde G, Cassidy JD, et al. The burden and determinantsof neck pain in workers. Results of the Bone and Joint Decade 2000–2010Task Force on neck pain and its associated disorders. Eur Spine J. 2008;17(suppl 1):S60–S74.

37. Hush JM, Michaleff Z, Maher CG, Refshauge K. Individual, physical andpsychological risk factors for neck pain in Australian office workers: a 1-yearlongitudinal study. Eur Spine J. 2009;18:1532–1540.

38. Kamwendo K, Linton SJ, Moritz U. Neck and shoulder disorders in medicalsecretaries. Part I. Pain prevalence and risk factors. Scand J Rehabil Med.1991;23:127–133.

39. Luime JJ, Koes BW, Hendriksen IJ, et al. Prevalence and incidence of shoulderpain in the general population; a systematic review. Scand J Rheumatol.2004;33:73–81.

40. Linton SJ, Van Tulder MW. Preventive interventions for back and neck painproblems: what is the evidence? Spine. 2001;26:778–787.

41. van Oostrom SH, Driessen MT, de Vet HCW, et al. Workplace interventionsfor preventing work disability. Cochrane Database Syst Rev. 2009:CD006955.doi: 10.1002/14651858.CD006955.pub2.

42. European Agency for Safety and Health at Work. Work-related mus-culoskeletal disorders: prevention report. Available at osha.europa.eu/en/publications/reports/en_TE8107132ENC.pdf. Published 2008.Accessed June 16, 2011.

43. Heymans M, van Tulder MW, Esmail R, Bombardier C, Koes BW. Backschools for non-specific low-back pain. Cochrane Database Syst Rev.2004:CD000261. Doi: 10.1002/14651858. CD000261. pub2.

44. Buchbinder R, Jolley D, Wyatt M. 2001 Volvo award winner in clinical studies:effects of a media campaign on measurement of low back pain in generalpractice. Spine. 2001;26:2535–2542.

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

632 C© 2013 American College of Occupational and Environmental Medicine

JOEM � Volume 55, Number 6, June 2013 Workplace Wellness and Musculoskeletal Disorders

45. Woby SR, Roach NK, Urmston M, Watson PJ. Outcome following aphysiotherapist-led intervention for chronic low back pain: the importantrole of cognitive processes. Physiotherapy. 2008;94:115–124.

46. Frost H, Klaber Moffett JA, Moser JS, Fairbank JCT. Randomized controlledtrial for evaluation of fitness programme with patients with low back chroniclow back pain. BMJ. 1995;310:151–154.

47. Frost H, Lamb SE, Klaber Moffett JA, Fairbank JCT, Moser JS. A fitnessprogramme for patients with chronic low back pain: 2-year follow up of arandomized controlled trial. Pain. 1998;75:273–279.

48. McLean L, Tingley M, Scott RN, Rickards J. Computer terminal work andthe benefit of microbreaks. Appl Ergon. 2001;32:225–237.

49. Escorpzio R. Understanding work productivity and its application to work-related musculoskeletal disorders. Int J Ind Ergon. 2008;38:291–297.

50. Zhang W, Gignac MA, Beaton D, Tang K, Anis AH. Productivity loss due topresenteeism among patients with arthritis: estimates from 4 instruments. JRheumatol. 2010;37:1805–1814.

51. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productivetime and cost due to common pain conditions in the US workforce. JAMA.2003;290:2443–2454.

52. Koehoon M, Cole DC, Hertzman C, Lee H. Health care use associated withwork-related musculoskeletal disorders among hospital workers. J OccupRehabil. 2006;16:411–424.

53. Makrides L, Smith S, Allt J, et al. The Healthy LifeWorks project: a pilot studyof the economic analysis of a comprehensive workplace wellness program ina Canadian government department. J Occup Environ Med. 2011;53:799–805.

APPENDIX

Nordic Questionnaire

From Dickinson et al.25

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

C© 2013 American College of Occupational and Environmental Medicine 633