Abstract
Background
In medical settings, lead aprons provide protection from ionising radiation but also result in physical strain that may lead to musculoskeletal complaints (MSCs). These complaints may have an impact on the wearer’s professional or private life. Therefore, we aimed to assess the 12-month prevalence of MSCs among physicians with different exposure times to lead aprons, and to determine the proportion of MSC-related restrictions in work or leisure time. In addition, we investigated potential confounding factors associated with MSC-related restrictions.
Methods
The study population consisted of physicians working full- or part-time. The data were collected between December 2023 and February 2024 using the German version of the Nordic Musculoskeletal Questionnaire. The prevalence of MSCs and MSC-related restrictions was recorded in four body regions: neck and cervical spine, thoracic spine, lumbar spine and lower back, as well as the shoulder joints and upper arms. We conducted a multivariate logistic regression (odds ratio; 95% confidence interval) to identify potential occupational and personal confounding factors.
Results
A total of 461 questionnaires were evaluated. Eighty-seven per cent of participants reported regularly wearing a lead apron for at least one year as part of their work. The prevalence of MSCs varied depending on the body region, ranging from 50 to 82%. Between 21% and 44% of the respondents reported MSC-related restrictions at work or in their leisure time. A significant correlation was identified between awkward postures and MSC-related restrictions in all body regions. Lead apron exposure (more than 20 years) increased the likelihood of experiencing MSC-related restrictions in the shoulder joints and upper arms (OR = 2.3; 95% CI = 1.036–4.943). Performing more than 100 procedures per year increased the likelihood of experiencing MSC-related restrictions in the thoracic spine (OR = 1.6; 95% CI = 1.005–2.670).
Conclusions
This study revealed that MSCs are prevalent among this study population, particularly those affecting the lumbar and cervical spine. Awkward postures at work had a significant impact on MSC-related restrictions in all body regions, whereas wearing a lead apron over several years resulted primarily in MSC-related restrictions affecting the shoulder joints/upper arms. Additional analyses are needed to identify activities that cause physical strain, and determine appropriate, targeted preventive measures.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12891-025-09134-5.
Keywords: Cross-sectional survey, Musculoskeletal disease, Occupational health, Health personnel, Physicians, Vascular surgery, Radiation protection, Back pain
Background
Musculoskeletal complaints are highly prevalent in society and have many different causes. In addition to demographic factors such as age, sex and socio-economic status, physical strain at work also contributes to these complaints becoming more prevalent. A systematic review of the literature of longitudinal studies revealed that repetitive tasks, heavy lifting and awkward postures at work are particularly significant risk factors for the development of MSCs [1]. Lead aprons are required in a number of medical fields (such as radiology, interventional cardiology and vascular surgery) to protect the wearer from ionising radiation. On the other hand, this form of personal protective equipment places physical strain on employees, which may lead to musculoskeletal complaints [2–5]. The weight of a protective lead apron varies depending on its size, and the material and design (one-piece/two-piece) usually ranges from two to eight kilograms [6, 7]. A study by Morrison et al. (2020) reported that 56% of interventional radiologists experienced neck pain, 46% experienced shoulder problems, and 61% experienced lower back pain. Twenty-one per cent of respondents stated that they had not been able to work due to the pain caused by their symptoms [5]. Occupational MSCs deteriorate the quality of life in affected individuals, impairing their ability to work and their well-being outside of work, and may even lead to physical disabilities [8, 9].
In this context, this study aimed to determine the 12-month prevalence of MSCs among physicians with different exposure times to lead aprons, and the proportion of those who experience MSC-related restrictions in their work or leisure time. In addition, we investigated potential confounding factors related to professional, sociodemographic and lifestyle issues associated with MSC-related restrictions.
Methods
This cross-sectional study addressed a target group composed of physicians who wore lead aprons as part of their work. Individuals holding a full-time or part-time position at the time of the survey were included in the study. The participants were recruited between December 2023 and February 2024 by an invitation in the online-newsletter issued by the German Society for Vascular Surgery and Vascular Medicine (DGG). The newsletter was sent to 2,804 potential participants. The participants used a link or QR code to access the website of the University Medical Center Hamburg-Eppendorf. They were provided with the following information about the study: participation was voluntary and anonymous, meaning that it would not be possible to link the collected data to any individual. The data were not shared with third parties. The data collected in the context of this study were collected anonymously, and are therefore not subject to the guidelines of the General Data Protection Regulation (GDPR) on the processing of personal data (Art. 4 and Recital 26 GDPR). Informed consent to participate was obtained from all participants in the study.
Questionnaire/variables
The questionnaire was specifically designed for this study (supplementary file) including the German version of the Nordic Musculoskeletal Questionnaire (NMQ) from the Federal Institute for Occupational Safety and Health (BAuA), in order to collect data on musculoskeletal complaints (MSCs) for the following body regions: neck and cervical spine, thoracic spine, lumbar spine and lower back, as well as the shoulder joints/upper arms [10]. The questionnaire also covered demographic characteristics and lifestyle factors such as sex, age, body mass index (BMI), the amount of time spent exercising every week, the number of years participants have been actively involved in exercise, smoking status and pre-existing conditions and injuries affecting the spine as potential confounders. Professional and workplace-related factors included the number of years in profession, procedures performed per year, hours worked per week, hours per day spent sedentary, standing in a bent posture or in awkward postures (unnatural, uncomfortable and stressful postures.), years for which a lead apron has been worn at work, which design of lead apron the participants used (one-piece apron; vest/skirt), and job satisfaction.
Calculating the outcome
The dependent variables (outcomes) used for the regression analyses were MSC-related restrictions, separated by analysed body region. These variables reveal the percentage of all respondents with functional restrictions in their occupational or leisure time for the body regions in question in the 12-month period preceding the survey [10].
Statistical analysis
The categorical variables are presented as frequencies and percentages, whereas the continuous variables are presented as mean values with standard deviations (SD). A chi-square test with a 95% confidence interval (95% CI) was used to evaluate the relationships between the dependent and independent variables; for ordinal variables, we used the Cochran‒Armitage test (linear-by-linear). The odds ratio (OR) was calculated with a 95% CI. We conducted a multivariate logistic regression to analyse the relationships between the independent variables and the dependent variables. Independent variables were included in the multivariate model if a correlation between the independent and dependent variables was proven in the univariate analysis (p < 0.1). The independent variables were analysed for multicollinearity. If two or more independent variables showed a significant association with each other, only one variable was included in the multivariate model. The decision on which variable was included was based on its importance in terms of content. The data analysis was conducted using Version 29 of the Statistical Package of Social Sciences (SPSS). The significance level was set at p < 0.05.
Results
Description of the study population
A total of 481 participants took part in the survey (response rate: 17.2%); 20 questionnaires were excluded from the analysis (95.8% of questionnaires analysed), because they were not completed by a medical professional (n = 16) or the job information section was not filled in (n = 4). Among the 461 respondents evaluated, 95.2% were vascular surgeons, while the remaining 4.8% being physicians from other specialties. The female proportion was 36% (Table 1), and the mean age of the participants was 50 years (SD = 10.5). Half of the respondents had a normal weight, while the other half deviated from the normal weight range (49% overweight or obese, 1% underweight) according to BMI categories [11]. On average, the participants had been actively involved in exercise for 14.5 years (SD = 14.8). The average amount of time spent exercising per week was 3.1 h (SD = 2.9). Fifteen per cent of respondents reported having a spinal condition or having experienced a spinal injury in the past. Almost 40% were either not or less satisfied with their jobs. At the time of the survey, the study population had been working for 19.6 years on average (SD = 9.9) and worked an average of 51.2 (SD = 12.5) hours per week. Eighty-seven per cent of participants had regularly worn a lead apron as part of their work for at least one year. Lead aprons had been used for an average of 14.8 years (SD = 10.4), with an average of 141.8 medical procedures (SD = 135.9) conducted every year. The majority of respondents (68.3%) wore a two-piece lead apron (vest and skirt), with the others wearing a one-piece apron. Respondents spent an average of 2.8 h per day (SD = 2.0) at work in awkward postures, 4.5 h per day (SD = 1.9) standing in a bent posture, and 3.1 h per day (SD = 1.7) in a sedentary position.
Table 1.
Characteristics of the study population (n = 461)
| Variable | Frequency (n)/ mean value (x̄) |
Percentage (%)/ standard deviation (SD) |
|---|---|---|
| Sex (female) | n = 166 | 36.0% |
| Age (yrs) | x̄ = 50.0 | SD = 10.5 |
| BMI (kg/m2) | ||
| < 18.5 (underweight) | n = 6 | 1.3% |
| 18.5–24.9 (normal weight) | n = 223 | 50.0% |
| 25.0–30.0 (overweight) | n = 170 | 38.1% |
| > 30.0 (obese) | n = 47 | 10.5% |
| Exercise (yrs) | x̄ = 14.5 | SD = 14.8 |
| Exercise (hrs/wk) | x̄ = 3.1 | SD = 2.9 |
| Smoking (ever/current) | n = 60 | 13.0% |
| Pre-existing conditions and injuries | n = 68 | 15.0% |
| Job satisfaction (low or no) | n = 183 | 39.7% |
| Years in profession | x̄ = 19.6 | SD = 9.9 |
| Working hours per week | x̄ = 51.2 | SD = 12.5 |
| Lead apron exposure (≥ 1 year) | n = 401 | 87.0% |
| Lead apron exposure (yrs) | x̄ = 14.8 | SD = 10.4 |
| Design of apron | ||
| One-piece apron | n = 82 | 17.8% |
| Two-piece apron (Vest/skirt) | n = 315 | 68.3% |
| Procedures per year | x̄ = 141.8 | SD = 135.9 |
| Awkward postures (hrs/d) | x̄ = 2.8 | SD = 2.0 |
| Standing in a bent posture (hrs/d) | x̄ = 4.5 | SD = 1.9 |
| Sedentary work (hrs/d) | x̄ = 3.1 | SD = 1.7 |
BMI: body mass index; d: day; hrs: hours; kg: kilogram; m2: square meter; SD: standard deviation; wk: week; yrs: years; x̄: mean value
12-month prevalence of musculoskeletal complaints
.
Figure 1 shows the 12-month prevalence of musculoskeletal complaints for the body regions that were analysed, categorised by the frequency of their occurrence during this period. The complaints most frequently reported by the respondents were those affecting the lumbar (82%) and cervical (78%) spine. MSCs in these body regions affected around 25% of respondents for more than 30 days, with over 13% affected (almost) daily. Half of the respondents reported complaints affecting the thoracic spine (51%) and shoulder joints/upper arms (54%). The proportion of respondents experiencing MSCs in these body regions for more than 30 days every year was around 14%, with 5% and 6% of respondents reporting that they had MSCs in these body regions (almost) every day.
Fig. 1.
12-month prevalence of musculoskeletal complaints by frequency of occurrence (n = 461)
MSC-related restrictions in occupational or leisure time
The most common MSC-related restrictions were caused by MSCs affecting the lumbar spine (44%) and cervical spine (36%). MSCs affecting the shoulder joints/upper arms led to restrictions for 26% of the respondents. MSCs affecting the thoracic spine led to restrictions of 21% (Fig. 2).
Fig. 2.
Percentage of individuals with occupational or leisure time restrictions due to musculoskeletal complaints (n = 461)
Several factors were significantly correlated with the outcome of MSC-related restrictions in occupational or leisure time. For cervical spine MSCs, these were awkward postures (p < 0.001) and job satisfaction (p < 0.001) (Table 2). For thoracic spine MSCs, awkward postures (p = 0.003), number of procedures per year (p = 0.002), standing in a bent posture (p = 0.003) and job satisfaction (p = 0.029) were significantly correlated (Table 3). For lumbar spine MSCs, awkward postures (p = 0.001), standing in a bent posture (p = 0.005), number of procedures per year (p = 0.029) and job satisfaction (p < 0.001) were significant (Table 4). For the shoulder joints/upper arms MSCs, there were significant correlations with awkward postures (p = 0.002), lead apron exposure (p = 0.005) and job satisfaction (p = 0.024) (Table 5).
Table 2.
Occupational or leisure time restrictions due to MSCs in the cervical spine (n = 461)
| Variable | Restrictions due to MSCs in cervical spine | Multivariate Analysisb OR [95% CI] |
|||
|---|---|---|---|---|---|
| No (n = 292) n (%) |
Yes (n = 168) n (%) |
p-valuea | |||
| Sex | Male | 184 (63.0) | 108 (37.0) | 0.695 | – |
| Female | 107 (64.8) | 58 (35.2) | |||
| Age (yrs) | ≤ 45 | 109 (62.3) | 66 (37.7) | 0.488 | – |
| 46–60 | 117 (62.6) | 70 (37.4) | |||
| > 60 | 63 (67.0) | 31 (33.0) | |||
| BMI (kg/m2) | < 18.5 | 4 (60.7) | 2 (33.3) | 0.491 | – |
| 18.5–24.9 | 145 (65.0) | 78 (35.0) | |||
| 25.0–30.0 | 104 (61.5)) | 65 (38.5) | |||
| > 30.0 | 29 (61.7) | 18 (38.3) | |||
| Exercise (yrs) | 0 | 61 (57.0) | 46 (43.0) | 0.182 | – |
| 1–10 | 87 (64.0) | 49 (36.0) | |||
| 11–20 | 63 (64.9) | 34 (35.1) | |||
| > 20 | 76 (66.1) | 39 (33.9) | |||
| Exercise (hrs/wk) | 0 | 61 (57.0) | 46 (43.0) | 0.258 | – |
| 1–2 | 76 (66.1) | 39 (33.9) | |||
| 3–4 | 77 (64.7) | 42 (35.3) | |||
| > 4 | 76 (65.0) | 41 (35.0) | |||
| Smoking (ever/current) | No | 258 (64.5) | 142 (35.5) | 0.240 | – |
| Yes | 34 (56.7) | 26 (43.3) | |||
| Pre-existing conditions and injuries | No | 250 (63.8) | 142 (36.2) | 0.736 | – |
| Yes | 42 (61.8) | 26 (38.2) | |||
| Job satisfaction | Yes | 97 (53.0) | 86 (47.0) | < 0.001 | 1 |
| No | 195 (70.4) | 82 (29.6) | 2.0 [1.233–2.778] | ||
| Working hours (hrs/wk) | ≤ 45 | 86 (67.7) | 41 (32.3) | 0.056 | 1 |
| 46–60 | 177 (63.7) | 101 (36.3) | 1.1 [0.667–1.690] | ||
| > 60 | 26 (51.0) | 25 (49.0) | 1.8 [0.885–3.504] | ||
| Lead apron exposure (yrs) | 0 | 42 (70.0) | 18 (30.0) | 0.125 | – |
| 1–10 | 79 (62.7) | 47 (37.3) | |||
| 11–20 | 101 (66.4) | 51 (33.6) | |||
| > 20 | 67 (56.3) | 52 (43.7) | |||
| Design of apron | One-piece apron | 50 (61.0) | 32 (39.0) | 0.810 | – |
| Vest/skirt | 196 (62.4) | 118 (37.6) | |||
| Procedures per year | 0–100 | 167 (66.8) | 83 (33.2) | 0.130 | – |
| > 100 | 121 (59.9) | 81 (40.1) | |||
| Years in profession | ≤ 10 | 56 (60.2) | 37 (39.8) | 0.871 | – |
| 11–20 | 113 (67.7) | 54 (32.3) | |||
| > 20 | 120 (61.2) | 76 (38.8) | |||
| Awkward postures (hrs/day) | 0–2 | 170 (73.6) | 61 (26.4) | < 0.001 | 1 |
| > 2 | 120 (52.9) | 107 (47.1) | 2.2 [1.413–3.298] | ||
| Standing in a bent posture (hrs/d) | 0–4 | 159 (67.4) | 77 (32.6) | 0.064 | 1 |
| > 4 | 131 (59.0) | 91 (41.0) | 1.0 [0.630–1.468] | ||
| Sedentary work (hrs/d) | 0–3 | 185 (63.4) | 107 (36.6) | 0.785 | – |
| > 3 | 106 (64.6) | 58 (35.4) | |||
aChi2 test (categorical variables: Pearson; ordinal variables: linear by linear); bold number means statistically significant (p < 0.05)
bVariables p < 0.1 were included in the multivariate regression. Age and Years in profession were not included as they showed multicollinearity with each other and with lead apron exposure (yrs)
BMI: body mass index; CI: confidence interval; d: day; hrs: hours; kg: kilogram; m2: square meter; MSCs: musculoskeletal complaints; OR: odds ratio; wk: week; yrs: years
Table 3.
Occupational or leisure time restrictions due to MSCs in the thoracic spine (n = 461)
| Variable | Restrictions due to MSCs in thoracic spine | Multivariate Analysisb OR [95% CI] |
|||
|---|---|---|---|---|---|
| No (n = 366) n (%) |
Yes (n = 95) n (%) |
p-valuea | |||
| Sex | Male | 225 (77.1) | 67 (22.9) | 0.089 | 1 |
| Female | 139 (83.7) | 27 (16.3) | 0.6 [0.361–1.035] | ||
| Age (yrs) | ≤ 45 | 134 (76.1) | 42 (23.9) | 0.445 | – |
| 46–60 | 154 (82.4) | 33 (17.6) | |||
| > 60 | 74 (78.7) | 20 (21.3) | |||
| BMI (kg/m2) | < 18.5 | 5 (83.3) | 1 (16.7) | 0.227 | – |
| 18.5–24.9 | 183 (82.1) | 40 (17.9) | |||
| 25.0–30.0 | 128 (75.3) | 42 (24.7) | |||
| > 30.0 | 37 (78.7) | 10 (21.3) | |||
| Exercise (yrs) | 0 | 83 (76.9) | 25 (23.1) | 0.428 | – |
| 1–10 | 110 (80.9) | 26 (19.1) | |||
| 11–20 | 72 (74.2) | 25 (25.8) | |||
| > 20 | 96 (83.5) | 19 (16.5) | |||
| Exercise (hrs/wk) | 0 | 83 (76.9) | 25 (23.1) | 0.779 | – |
| 1–2 | 92 (80.0) | 23 (20.0) | |||
| 3–4 | 98 (82.4) | 21 (17.6) | |||
| > 4 | 91 (77.8) | 26 (22.2) | |||
| Smoking (ever/current) | No | 322 (80.3) | 79 (19.7) | 0.213 | – |
| Yes | 44 (37.3) | 16 (26.7) | |||
| Pre-existing conditions and injuries | No | 313 (79.6) | 80 (20.4) | 0.749 | – |
| Yes | 53 (77.9) | 15 (22.1) | |||
| Job satisfaction | Yes | 136 (74.3) | 47 (25.7) | 0.029 | 1 |
| No | 230 (82.7) | 48 (17.3) | 1.4 [0.882–2.320] | ||
| Working hours (hrs/wk) | ≤ 45 | 112 (88.2) | 15 (11.8) | 0.202 | – |
| 46–60 | 206 (73.8) | 73 (26.2) | |||
| > 60 | 45 (88.2) | 6 (11.8) | |||
| Lead apron exposure (yrs) | 0 | 51 (85.0) | 9 (15.0) | 0.461 | – |
| 1–10 | 102 (81.0) | 24 (19.0) | |||
| 11–20 | 113 (73.9) | 40 (26.1) | |||
| > 20 | 97 (81.5) | 22 (18.5) | |||
| Design of apron | One-piece apron | 66 (80.5) | 16 (19.5) | 0.638 | – |
| Vest/skirt | 246 (78.1) | 69 (21.9) | |||
| Procedures per year | 0–100 | 212 (84.5) | 39 (15.5) | 0.002 | 1 |
| > 100 | 147 (72.8) | 55 (27.2) | 1.6 [1.005–2.670] | ||
| Years in profession | ≤ 10 | 77 (82.8) | 16 (17.2) | 0.740 | – |
| 11–20 | 125 (74.4) | 43 (25.6) | |||
| > 20 | 161 (82.1) | 35 (17.9) | |||
| Awkward postures (hrs/day) | 0–2 | 197 (84.9) | 35 (15.1) | 0.003 | 1 |
| > 2 | 167 (73.6) | 60 (26.4) | 1.7 [1.036–2.897] | ||
| Standing in a bent posture (hrs/d) | 0–4 | 200 (84.7) | 36 (15.3) | 0.003 | 1 |
| > 4 | 164 (73.5) | 59 (26.5) | 1.5 [0.879–2.437] | ||
| Sedentary work (hrs/d) | 0–3 | 231 (78.8) | 62 (21.2) | 0.676 | – |
| > 3 | 132 (80.5) | 32 (19.5) | |||
aChi2 test (categorical variables: Pearson; ordinal variables: linear by linear); bold number means statistically significant (p < 0.05)
bVariables p < 0.1 were included in the multivariate regression. Age and Years in profession were not included as they showed multicollinearity with each other and with lead apron exposure (yrs)
BMI: body mass index; CI: confidence interval; d: day; hrs: hours; kg: kilogram; m2: square meter; MSCs: musculoskeletal complaints; OR: odds ratio; wk: week; yrs: years
Table 4.
Occupational or leisure time restrictions due to MSCs in lumbar spine (n = 461)
| Variable | Restrictions due to MSCs in lumbar spine | Multivariate Analysisb OR [95% CI] |
|||
|---|---|---|---|---|---|
| No (n = 257) n (%) |
Yes (n = 201) n (%) |
p-valuea | |||
| Sex | Male | 154 (52.7) | 138 (47.3) | 0.057 | 1 |
| Female | 101 (62.0) | 62 (38.0) | 0.5 [0.319–0.828] | ||
| Age (yrs) | ≤ 45 | 100 (57.8) | 73 (42.2) | 0.378 | – |
| 46–60 | 104 (55.6) | 83 (44.4) | |||
| > 60 | 49 (52.1) | 45 (47.9) | |||
| BMI (kg/m2) | < 18.5 | 5 (83.3) | 1 (16.7) | 0.068 | 0.4 [0.046–4.022] |
| 18.5–24.9 | 125 (56.6) | 96 (43.3) | 1 | ||
| 25.0–30.0 | 99 (58.6) | 70 (41.4) | 0.7 [0.417–1.076] | ||
| > 30.0 | 18 (38.3) | 29 (61.7) | 1.8 [0.876-3.500] | ||
| Exercise (yrs) | 0 | 54 (50.9) | 52 (49.1) | 0.501 | – |
| 1–10 | 82 (60.3) | 54 (39.7) | |||
| 11–20 | 52 (53.6) | 45 (46.4) | |||
| > 20 | 67 (58.3) | 48 (41.7) | |||
| Exercise (hrs/wk) | 0 | 54 (50.9) | 52 (49.1) | 0.879 | – |
| 1–2 | 70 (61.4) | 44 (38.6) | |||
| 3–4 | 71 (59.7) | 48 (40.3) | |||
| > 4 | 62 (53.0) | 55 (47.0) | |||
| Smoking (ever/current) | No | 226 (56.8) | 172 (43.2) | 0.457 | – |
| Yes | 31 (51.7) | 29 (48.3) | |||
| Pre-existing conditions and injuries | No | 222 (56.9) | 168 (43.1) | 0.404 | – |
| Yes | 35 (51.5) | 33 (48.5) | |||
| Job satisfaction | Yes | 83 (45.6) | 99 (54.4) | < 0.001 | 1 |
| No | 174 (63.0) | 102 (37.0) | 1.7 [1.209–2.762] | ||
| Working hours (hrs/wk) | ≤ 45 | 78 (61.4) | 49 (38.6) | 0.138 | – |
| 46–60 | 150 (54.3) | 126 (45.7) | |||
| > 60 | 26 (51.0) | 25 (49.0) | |||
| Lead apron exposure (yrs) | 0 | 38 (63.3) | 22 (36.7) | 0.185 | – |
| 1–10 | 69 (55.6) | 55 (44.4) | |||
| 11–20 | 87 (57.2) | 65 (42.8) | |||
| > 20 | 61 (51.3) | 58 (48.7) | |||
| Design of apron | One-piece apron | 44 (53.7) | 38 (46.3) | 0.812 | – |
| Vest/skirt | 172 (55.1) | 140 (44.9) | |||
| Procedures per year | 0–100 | 152 (60.8) | 98 (39.2) | 0.029 | 1 |
| > 100 | 101 (50.5) | 99 (49.5) | 1.3 [0.826–1.909] | ||
| Years in profession | ≤ 10 | 54 (59.3) | 37 (40.7) | 0.402 | – |
| 11–20 | 94 (56.3) | 73 (43.7) | |||
| > 20 | 106 (54.1) | 90 (45.9) | |||
| Awkward postures (hrs/day) | 0–2 | 146 (63.5) | 84 (36.5) | 0.001 | 1 |
| > 2 | 109 (48.2) | 117 (51.8) | 1.6 [1.032–2.447] | ||
| Standing in a bent posture (hrs/d) | 0–4 | 147 (62.3) | 89 (37.7) | 0.005 | 1 |
| > 4 | 108 (49.1) | 112 (50.9) | 1.4 [0.903–2.129] | ||
| Sedentary work (hrs/d) | 0–3 | 160 (55.2) | 130 (44.8) | 0.570 | – |
| > 3 | 95 (57.9) | 69 (42.1) | |||
aChi2 test (categorical variables: Pearson; ordinal variables: linear by linear); bold number means statistically significant (p < 0.05)
bVariables p < 0.1 were included in the multivariate regression. Age and Years in profession were not included as they showed multicollinearity with each other and with lead apron exposure (yrs)
BMI: body mass index; CI: confidence interval; d: day; hrs: hours; kg: kilogram; m2: square meter; MSCs: musculoskeletal complaints; OR: odds ratio; wk: week; yrs: years
Table 5.
Occupational or leisure time restrictions due to MSCs in shoulder joints/upper arms (n = 461)
| Variable | Restrictions due to MSCs in shoulder joints/upper arms | Multivariate Analysisb OR [95% CI] |
|||
|---|---|---|---|---|---|
| No (n = 339) n (%) |
Yes (n = 120) n (%) |
p-value | |||
| Sex | Male | 125 (75.3) | 41 (24.7) | 0.664 | – |
| Female | 213 (73.4) | 77 (26.6) | |||
| Age (yrs) | ≤ 45 | 133 (76.4) | 41 (23.6) | 0.323 | – |
| 46–60 | 136 (72.7) | 51 (27.3) | |||
| > 60 | 67 (71.3) | 27 (28.7) | |||
| BMI (kg/m2) | < 18.5 | 4 (66.7) | 2 (33.3) | 0.166 | – |
| 18.5–24.9 | 170 (76.2) | 53 (23.8) | |||
| 25.0–30.0 | 121 (72.0) | 47 (28.0) | |||
| > 30.0 | 31 (66.0) | 16 (34.0) | |||
| Exercise (yrs) | 0 | 80 (74.1) | 28 (25.9) | 0.466 | – |
| 1–10 | 100 (74.6) | 34 (25.4) | |||
| 11–20 | 76 (78.4) | 21 (21.6) | |||
| > 20 | 79 (86.7) | 36 (31.3) | |||
| Exercise (hrs/wk) | 0 | 80 (74.1) | 28 (25.9) | 0.475 | – |
| 1–2 | 88 (76.5) | 27 (23.5) | |||
| 3–4 | 87 (73.7) | 31 (26.3) | |||
| > 4 | 82 (70.7) | 34 (29.3) | |||
| Smoking (ever/current) | No | 297 (74.3) | 103 (25.8) | 0.617 | – |
| Yes | 42 (71.2) | 17 (28.8) | |||
| Pre-existing conditions and injuries | No | 288 (73.7) | 103 (26.3) | 0.816 | – |
| Yes | 51 (75.0) | 17 (25.0) | |||
| Job satisfaction | Yes | 124 (68.1) | 58 (31.9) | 0.024 | 1 |
| No | 215 (77.6) | 62 (22.4) | 1.7 [0.996–2.457] | ||
| Working hours (hrs/wk) | ≤ 45 | 97 (76.4) | 30 (23.6) | 0.061 | 1 |
| 46–60 | 211 (76.2) | 66 (23.8) | 0.9 [0.527–1.532] | ||
| > 60 | 30 (58.8) | 21 (41.2) | 2.0 [0.973–4.303] | ||
| Lead apron exposure (yrs) | 0 | 48 (80.0) | 12 (20.0) | 0.005 | 1 |
| 1–10 | 99 (79.2) | 26 (20.8) | 0.9 [0.380–1.978] | ||
| 11–20 | 113 (74.3) | 39 (25.7) | 1.2 [0.560–2.677] | ||
| > 20 | 76 (63.9) | 43 (36.1) | 2.3 [1.036–4.943] | ||
| Design of apron | One-piece apron | 56 (86.3) | 26 (31.7) | 0.319 | – |
| Vest/skirt | 231 (73.8) | 82 (26.2) | |||
| Procedures per year | 0–100 | 189 (75.3) | 62 (24.7) | 0.429 | 1 |
| > 100 | 144 (72.0) | 56 (28.0) | 1.0 [0.628–1.576] | ||
| Years in profession | ≤ 10 | 68 (73.9) | 24 (26.1) | 0.306 | – |
| 11–20 | 132 (78.6) | 36 (21.4) | |||
| > 20 | 137 (70.3) | 58 (29.7) | |||
| Awkward postures (hrs/day) | 0–2 | 185 (80.1) | 46 (19.9) | 0.002 | 1 |
| > 2 | 152 (67.3) | 74 (32.7) | 1.9 [1.232–3.054] | ||
| Standing in a bent posture (hrs/d) | 0–4 | 179 (75.8) | 57 (24.2) | 0.291 | – |
| > 4 | 158 (71.9) | 63 (28.5) | |||
| Sedentary work (hrs/d) | 0–3 | 218 (74.9) | 73 (25.1) | 0.583 | – |
| > 3 | 119 (72.6) | 45 (27.4) | |||
aChi2 test (categorical variables: Pearson; ordinal variables: linear by linear); bold number means statistically significant (p < 0.05)
bVariables p < 0.1 were included in the multivariate regression. Age and Years in profession were not included as they showed multicollinearity with each other and with lead apron exposure (yrs)
BMI: body mass index; CI: confidence interval; d: day; hrs: hours; kg: kilogram; m2: square meter; MSCs: musculoskeletal complaints; OR: odds ratio; wk: week; yrs: years
The results of the multivariate regression analysis are presented in Tables 2, 3, 4 and 5, separated by analysed body region. Awkward postures for more than two hours a day significantly increased the odds of MSC-related restrictions in occupational or leisure time in all four analysed body regions: by 120% for cervical spine MSCs (OR = 2.2; 95% CI = 1.413–3.298), by 70% for thoracic spine MSCs (OR = 1.7; 95% CI = 1.036–2.897), by 60% for lumbar spine symptoms (OR = 1.6; 95% CI = 1.032–2.447) and by 90% for shoulder joints/upper arms MSCs (OR = 1.9; 95% CI = 1.232–3.054). The number of procedures performed per year was associated with thoracic spine MSC-related restrictions. The likelihood of MSC-related restrictions increased by 60% among respondents performing more than 100 procedures each year (OR = 1.6; 95% CI = 1.005–2.670). Wearing a lead apron for more than 20 years increased the odds of MSC-related restrictions in shoulder joints/upper arms by a factor of 2.3 (OR = 2.3; 95% CI = 1.036–4.943).
A lower level of job satisfaction doubled the likelihood of restrictions in the cervical spine related to the MSC (OR = 2.0; 95% CI = 1.233–2.778) and increased MSC-related restrictions in the lumbar spine by 70% (OR = 1.7; 95% CI = 1.209–2.762). Biological sex had a protective effect. The likelihood of lumbar spine MSCs causing restrictions was 50% lower for female respondents (OR = 0.5; 95% CI = 0.319–0.828). We did not identify any correlations between MSC-related restrictions and the variables of age, BMI, exercise, smoking status, pre-existing conditions and injuries the spine, number of years in profession, hours worked per week and hours spent sedentary.
Discussion
This study investigated physicians, most of whom specialise in vascular surgery, who wear lead aprons to protect themselves from ionising radiation during their work. It examined MSCs and MSC-related restrictions in various regions of the spine, shoulder joints and upper arms. We calculated the 12-month prevalence of musculoskeletal complaints in four body regions and MSC-related restrictions in the occupational or leisure time of the respondents. To our knowledge, this is the first publication to address MSC-related restrictions in this target group.
The results of the study show that physicians, most of whom wear lead aprons as part of their work, experience musculoskeletal complaints, with the highest prevalence occurring in the lumbar and cervical spine of the examined body regions. This is in line with the results of a study by König et al. (2024) [12]. Furthermore, our results show that musculoskeletal complaints affect the well-being of the study population and are associated with various occupational and non-occupational factors.
It is well documented that awkward postures are a risk factor for musculoskeletal complaints in various professions [1, 13–16]. Our results confirm this: awkward postures were determined to significantly influence the likelihood of MSC-related restrictions in all body regions covered by the study. This appears to be the main influencing factor for MSCs in this professional setting. The inconsistent association between wearing a lead apron for several years and MSC-related restrictions in the shoulder joints and upper arms, but not in the spine, should lead to the results being interpreted with caution. The design of the apron, on the other hand, had no influence on the likelihood of MSC-related restrictions in any of the body regions investigated. However, other studies have described correlations between wearing lead aprons and MSCs affecting the spine [2–4, 17], as well as differences in weight pressures exerted by different designs [18]. The number of hours spent working per week did not have a significant impact on the occurrence of MSC-related restrictions. While the variable had an increased odds ratio for respondents working more than 60 h per week for the cervical spine and shoulder joints/upper arms, this association was just under the significance level. Our data did not confirm the hypothesis that long working hours are associated with MSC-related restrictions. This may be due to the healthy worker effect, whereby physicians with restricted work ability may avoid long working hours. This would dilute any potential association between exposure and MSC. Low or no job satisfaction was associated with increased odds on the outcomes for the cervical and lumbar region. This finding is consistent with the results of a study by Dauer et al., which investigated MSC-related restrictions in childcare workers (2025) [19]. However, it is not clear whether job satisfaction has a causal relationship with MSC-related restrictions or whether it is influenced by them. Female sex was shown to be a protective factor against restrictions caused by MSCs affecting the lumbar spine. Research has indicated that females are more likely to experience MSCs than males [20, 21]. The protective effect of being female is, to some extent, surprising. Whether this observation can be explained by the smaller and therefore less heavy aprons for females, should be studied. In our study population, neither age nor the number of years in profession were associated with MSC-restrictions. One potential explanation is that we only included working respondents in the study, meaning that older employees would only be able to work if they had mild or no MSCs. Due to the healthy worker effect, older employees who no longer work in this occupational field due to MSC may not have been included in the study. The age effect may therefore have been underestimated. In addition, these variables showed multicollinearity with each other and with lead apron exposure in years. Therefore, age and years in profession were not included in the multivariate regression.
Pre-existing conditions and injuries affecting the spine did not significantly affect the outcomes. We therefore do not expect any distortion of the results in this regard, increasing the validity of our results.
Strengths and limitations
One of the strengths of this study is that it involved a homogeneous study population, with 95% of respondents working in vascular surgery. Another strength is the standardised recording of MSCs using the NMQ. This approach has proven to be a reliable tool for objective data collection and facilitates comparisons with other studies investigating MSCs [22]. However, the results of our study must be interpreted in light of the following limitations. One limitation of the study is its design. A cross-sectional study provides results for a snapshot in time and therefore does not allow conclusions to be drawn about a causal relationship between the variables examined. Another limitation is the absence of a separated comparison group. This means that it was not possible to compare the prevalence and significant effect measures for this study population with those of an unexposed group. However, 13 per cent of our study population reported not wearing lead aprons, which enabled a comparison within the study population between exposed and unexposed individuals. This study did not distinguish between different types of procedure. These may differ across specialties and impact physical strain. We cannot rule out selection bias, since participation in this study was voluntary and the response rate of 17.2% was relatively low. The prevalence of MSCs may have been overstated in this study, as respondents with MSCs may have been more motivated to take part than those without MSCs. The fact that this was a questionnaire-based study means that the data were collected retrospectively. As a result, we cannot rule out the possibility of recall bias, whereby participants provide inaccurate information due to their unreliable memories when taking part in retrospective studies. Furthermore, the information provided by participants is based on their subjective assessments. This means that information may be reported differently from one person to the next, particularly in regard to MSCs or MSC-related restrictions.
Conclusions
Overall, the study revealed that MSCs are prevalent in various body regions in physicians with different exposure to lead aprons. The results show this occupational group most frequently experiences MSCs in the body region of the lumbar and cervical spine. Awkward postures in particular had a consistently significant effect on MSC-related restrictions in all analysed body regions. Wearing a lead apron for several years was associated with increased odds of restrictions affecting the shoulder joints/upper arms. Although our study revealed no differences in the prevalence of complaints by design of the apron, physicians should use aprons that minimise physical strain (e.g., two-piece aprons to distribute weight across the shoulders and hips, or suspended aprons). The time spent wearing aprons should be reduced to the minimum required for protection purposes. Additional studies are needed to identify activities that cause physical strain, and determine appropriate, targeted preventive measures that will protect the quality of life and general well-being of employees in this occupation, while also maintaining their ability to continue working.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We would like to thank the Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW) for supporting the study, and the German Society for Vascular Surgery and Vascular Medicine (DGG) for enabling the data collection.
Abbreviations
- BAuA
Institute for Occupational Safety and Health
- BMI
Body mass index
- CI
Confidence interval
- d
Day
- DGG
German Society for Vascular Surgery and Vascular Medicine
- e.g.
For example
- GDPR
General Data Protection Regulation
- hrs
Hours
- kg
Kilogram
- m2
Square meter
- MSCs
Musculoskeletal complaints
- NMQ
Nordic musculoskeletal questionnaire
- OR
Odds ratio
- SD
Standard deviation
- wk
Week
- yrs
Years
Author contributions
Conceptualisation: C.H., H.G., J.H., A.N.; Methodology: C.H., H.G., J.H., A.N.; Validation: C.H., H.G., J.H., A.N.; Formal Analysis: C.H.; Data Curation: C.H., Writing—Original Draft: C.H., Writing—Review and Editing: C.H., H.G., J.H., A.N.; Visualisation: C.H.; Project Administration: A.N.
Funding
This study was funded by the Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW), which did not influence the study design, data collection, analysis, or publication of the results.
Data availability
The datasets analysed during the current study are not publicly available due to privacy restrictions. Participants have been assured that their information will not be disclosed to third parties. Requests should be addressed to the corresponding author.
Declarations
Ethical approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki. All data in this study were collected and analysed anonymously, and are therefore not subject to the guidelines of the General Data Protection Regulation (GDPR) on the processing of personal data (Art. 4 and Recital 26 GDPR). All necessary data protection and data security measures were applied. As the survey was completely anonymous, no ethical committee approval was required. This is based on the (Model) Professional Code for Physicians Practicing in Germany – MBO-Ä 1997 –*) in the version of the resolution of the 128th German Medical Conference on May 9, 2024, in Mainz, Germany. Before the actual survey began, the participants were made aware of the anonymised form of the data collection and the data protection regulations applicable to the CVcare. Informed consent to participate was obtained from all participants in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets analysed during the current study are not publicly available due to privacy restrictions. Participants have been assured that their information will not be disclosed to third parties. Requests should be addressed to the corresponding author.