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REVISOES SISTEMATICAS E METANALISE

Risk factors for work-related cardiovascular and musculoskeletal diseases among prehospital urgent care workers: a systematic review

Fatores de risco para doenças cardiovasculares e osteomusculares relacionadas ao trabalho em profissionais do atendimento pré-hospitalar de urgência: uma revisão sistemática

Juliana Adami Sedrez; Ana Paula da Silva Kasten; Fabiana de Oliveira Chaise; Cláudia Tarragô Candotti

DOI: 10.5327/Z1679443520170050

ABSTRACT

BACKGROUND: Studies conducted with prehospital emergency care workers investigated work-related stress and its repercussions on the workers’ mental and physical health.
OBJECTIVE: To identify risk factors for development of cardiovascular (CVD) and musculoskeletal (MSD) work-related diseases among prehospital emergency care workers.
METHODS: We conducted a systematic search in databases PubMed, EBSCO, EMBASE and Science Direct. The inclusion criteria were: risk factors for CVD and MSD among prehospital emergency care workers.
RESULTS:
From 370 articles, 11 were included for review. The included studies identified risk factors for CVD, such as body mass index and sedentary lifestyle, however, with limited level of evidence. For MSD, age and working as first responder were shown to behave as risk factors, with high level of evidence. We were not able to establish which the cardiovascular risk factors are, due to lack of studies that analyzed these aspects.
CONCLUSION:
The most evident musculoskeletal risk factors in the literature are age and working as first responder. Registration PROSPERO: CRD42016042390.

Keywords: cardiovascular diseases; musculoskeletal pain; risk factors; occupational health; emergency care providers.

RESUMO

CONTEXTO: Pesquisas com o trabalhador do atendimento pré-hospitalar de urgências têm investigado o estresse relacionado ao trabalho e suas repercussões na saúde mental e física desses profissionais.
OBJETIVO:
Identificar os fatores de risco para doenças cardiovasculares (DCV) e doenças osteomusculares (DOM) nos trabalhadores do atendimento pré-hospitalar de urgências.
MÉTODOS: Realizou-se uma busca sistemática nas bases de dados PubMed, EBSCO, Embase e Science Direct, com os seguintes critérios de inclusão: abordar fatores de risco para as DCV e DOM e envolver trabalhadores pré-hospitalar de urgências.
RESULTADOS:
Inicialmente, foram encontrados 370 artigos, dos quais 11 foram incluídos na presente revisão. Os estudos considerados identificam fatores de risco para as DCV, como índice de massa corporal e sedentarismo, porém com limitado nível de evidência, bem como para as DOM, entre eles idade e atividade profissional dos socorristas, com forte nível de evidência. Não é possível afirmar os fatores de risco cardiovasculares em virtude da carência de estudos que analisem esses aspectos.
CONCLUSÃO:
Os fatores de risco osteomusculares, mais claros na literatura, referem-se à idade e à atividade profissional dos socorristas. Registro PROSPERO: CRD42016042390.

Palavras-chave: doenças cardiovasculares; dor musculoesquelética; fatores de risco; saúde do trabalhador; auxiliares de emergência.

INTRODUCTION

The aim of the Mobile Urgent Care Service (Serviço de Atendimento Móvel de Urgência - SAMU) is to tend to people with urgent conditions at the place where events occurred to ensure early care delivery and access to the health system1.

In addition to transporting patients to hospitals, prehospital urgent care workers perform low- to medium-complexity procedures, ranging from administration of medications and dressing wounds to cardiopulmonary resuscitation (CPR). The working routine of these workers includes: adult and pediatric trauma cases, insecurity at the site, contact with toxics, violence in poor areas with high social vulnerability, and fires, among others2.

Such high stress situations might be considered as risk factors for cardiovascular (CVD) and musculoskeletal (MSD) diseases. The cardiovascular system must respond to stress, and such response includes: elevation of the heart rate and contractility, blood pressure (BP) and peripheral vascular resistance3.

Stressful work might also cause persistent and significant BP elevation, which is more evident among workers who are required to perform considerable physical effort4. This is a part of the routine of prehospital urgent care providers at the time ofmoving patients, which includes lifting stretchers and other equipment, which is often performed incorrectly, resulting in muscle adjustments and changes in response to the demands imposed by the task. These characteristics are risk factors for MSD.

Studies targeting prehospital urgent care providers investigated work-related stress and its impact on their mental and physical health. Therefore, the literature needs to be reviewed to identify risk factors for CVD and MSD among this population.

 

METHODS

The present review complied with the recommendations formulated in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)5 and was registered at International Prospective Register of Systematic Reviews (PROSPERO) registration number CRD42016042390.

SOURCES OF INFORMATION AND SEARCH STRATEGY

We conducted a systematic search of scientific articles in databases PubMed (Table 1), EBSCO (Medline), Embase and Science Direct on July 2016 with no time limit.

 

 

ELIGIBILITY CRITERIA

The located articles ought to meet the following inclusion criteria: address risk factors for CVD and MSD and consider prehospital urgent care providers. Studies that assessed treatments for the target population, considered single events — as e.g., disasters, or were not written in English, Spanish or Portuguese were excluded.

STUDY SELECTION

Articles were independently selected by two reviewers based on titles and abstracts. The articles that met the eligibility criteria were subjected to full-text analysis. Cases of disagreement were initially solved by consensus; when doubts remained, a third reviewer was called to settle the matter.

DATA EXTRACTION

Data extraction was independently performed by two reviewers, for which purpose they used a standard form to collect the following information: country where study was conducted, population, sample, assessment instruments, aims and risk factors. Instances of disagreement were solved by consensus or a third reviewer.

ASSESSMENT OF THE QUALITY OF THE INCLUDED STUDIES

The quality of the articles was assessed by means of the Critical Appraisal of Studies scale6, which considers 8 items: study design, sampling frame, sample size, outcome measurement, response rate, interpretation of results and applicability of results.

DATA ANALYSIS

First we clustered the collected data per similarity, thus discriminating between cardiovascular and musculoskeletal risk factors. Next we performed a narrative synthesis of the results of the included studies to describe the ratio associated with the identified risk factors. We could not perform a meta-analysis, as a function of the considerable amount of identified risk factors and divergence in the presentation of the results of the analyzed studies, which did not allow for a second statistical analysis. Thus we choose to analyze the strength of the scientific evidence by means of best evidence synthesis (BES) as previously done by the Cochrane Collaboration7. BES is an alternative to meta-analysis that consists in qualitative assessment of studies in which the strength of evidence is established based on the number and quality of studies and the coherence of their results7.

Evidence was thus classified as follows: strong — derived from several high-quality studies; moderate — obtained from one high-quality study and one or more low-quality studies; limited — resulting from one high-quality or several low-quality studies; and none — based on one low-quality study or presence of contradiction among results8.

 

RESULTS

We located 370 articles, as shown in Figure 1. After the various steps of article selection, 11 were included for systematic review.

 


Figure 1. Flowchart representing the process of article selection.

 

The methodological quality of most studies was considered high; 7 out of the 11 analyzed studies exhibited 5 “yes” answers to the items in Critical Appraisal of Studies, and 4 had 4 “yes” answers (Table 2).

 

 

Table 3 describes the characteristics of the studies included for systematic review, to wit, country where study was conducted, population, sample and assessment instruments. Table 4 shows the main results of the articles included for systematic review.

 

 

 

 

DISCUSSION

In the present study we found that 5 articles mentioned risk factors for CVD, which included: body mass index (BMI) corresponding to overweight or obesity9, sedentary lifestyle9, systemic arterial hypertension (SAH)11,12, smoking12, hyperlipidemia12, and work environment13. Analysis of the corresponding strength of evidence showed it was “limited” for BMI and sedentary lifestyle and “none” for all others, the reason being lack of studies on the target population specifically analyzing theses aspects. Therefore, new studies investigating risk factors for CVD among emergency care providers are needed.

According to some studies, 48% of paramedics exhibited high or very high risk of CVD10; 49% of workers under 40 years old and 83% of the ones over 40 exhibited two or more risk factors for CVD, which denote significantly higher odds of CVD in this population12.

According to Studnek et al.9, obese individuals are more prone to report a history of disease. Prevalence of over 50% of obesity/overweight was described for emergency medical service (EMS) workers10,12. Also individuals with sedentary lifestyle are more prone to report a history of disease, while the prevalence of sedentary lifestyle was high among the target population (30%)12.

We should observe that a large part ofthe studies included in the present systematic review were performed in the United Stable; perhaps the aspects related to obesity and sedentary lifestyle do not apply to other countries.

None of the other analyzed risk factors exhibited any strength of evidence. Thus being, new studies are needed to conclude on this subject. For now, in regard to SAH Boreham et al.12 found that EMS workers exhibited significantly higher BP compared to the overall male population. The prevalence of HAS was also high among the target population, 11%10, while the systolic (SAP) and diastolic (DAP) arterial pressure was respectively 30% and 41% above the recommended levels12.

Hyperlipidemia, i.e., a well-known risk factor for CVD, was described as the most prevalent condition among the reported diseases9, its prevalence varying from 11.5% to 71%9,10,12. Among the relevant findings of the present study, we might mention the significant reduction of the average high-density lipoprotein (HDL) levels by comparison to the overall population12. The incidence of smoking was higher among EMS workers compared to the overall population12, with prevalence of 19% among paramedics10.

A much discussed risk factor is the professional activity of emergency care providers and their work environment. In their study, Jamner et al.13 found higher SAP, DAP and heart rate (HR) when professionals were “at the scene” (i.e., in action) compared to the time of waiting at the station. However, Weiss et al.11 reported opposite results, i.e., the mean arterial pressure (MAP) did not exhibit post-shift changes, and in some individuals HR decreased after the shift. These authors observe that their results do not support the hypothesis that intervention is needed for management of cardiovascular risk factors among paramedics. Given that the results are thus contradictory, new studies investigating the influence of professional activity and work environment of emergency care providers on BP and HR are needed to establish whether this population is exposed to higher risk of CVD.

Six studies mentioned risk factors for MSD, including: age14,18, sex14, educational level17, physical fitness18, professional activity14,18,19, night shift15,16, working hours, consecutive shifts and recovery period15, self-reported general health17 and job satisfaction18.

Analysis ofthe strength ofevidence showed it was “strong” for age and professional activity, “limited” for educational level, physical fitness, general health and job satisfaction, and “none” for the remainder of the risk factors.

Relative to the factors for which strong evidence I currently available, increasing age was associated with higher relative risk of reporting musculoskeletal injuries14 and also higher odds of back complaints18.

The studies that analyzed the influence of emergency care providers’ professional activities found this population exhibits higher odds of low back injury compared to others14,18. For most emergency care providers, musculoskeletal injuries are associated with handling of patients, and most of them involve the upper limbs and back15,16. A probable reason for such higher risk is patient transport, which tasks poses heavy physical demands. For instance, bed—to-stretcher transfer was described as posing high risk for low back injury, especially as a function of extreme reach and degree of anterior flexion, being even more serious for professionals who lift patients from the head, which demands lifting a heavier weight, and the resulting moment on the spine19.

In addition to the physical effort demanded by patient handling, emergency care providers are subjected to other adverse conditions, such as emotional stress and work in ergonomically inappropriate locations. Examples are the scene of accidents, which was mentioned as the most common site where injuries and MSD occur (51.7%) or the ambulance during patient transportation, which accounted for 29.2% of injuries15.

All the other aforementioned risk factors with limited strength of evidence were analyzed by one single study, which does not allow for a more thorough discussion of aspects such as job satisfaction, physical fitness, educational level and general health. Shortly, according to the currently available data, dissatisfied workers18, the ones with poor physical fitness18 and those who reported poor general health17 were significantly more prone to reporting back complaints. In turn, workers with higher educational level were less prone to reporting backache17.

The strength ofevidence for the remainder ofthe analyzed risk factors was categorized as “none” As a rule, these factors were related to work. One example is shift length, which was associated with reporting occupational injury or disease. Shifts of 8 hours or shorter reduced the risk of injury or disease by 30%, shifts of12 hours or longer increased such risk by 49%, and risk of injury or disease increased 4% per each additional hour. Yet, working consecutive shifts and recovery period were not associated with reporting injury or disease15. Relative to the night shift, the studies described divergent results15,16, and thus we cannot draw any conclusion at this moment.

To summarize, the studies included in the present systematic review did not adequately elucidate the risk factors for CVD and MSD. In addition, the vast majority of the studies were conducted in the United States, and the results perhaps might not be extrapolated to other countries. Therefore, we suggest that future studies should investigate these risk factors in other countries, including the Latin American ones. Such studies are relevant, because accurate knowledge about the risk factors for CVD and MSD among prehospital urgent care providers is necessary to implement actions and strategies aiming at promotion and maintenance of the workers’ health, reaffirming to managers the relevance of health care and of the right to health.

 

CONCLUSION

The risk factors for CVD found in the present review were high BMI and sedentary lifestyle, but both had only limited strength of evidence. The strength of evidence for the remainder of the analyzed risk factors for CVD was categorized as “none”, and thus no conclusion may be drawn on this subject. As a function of the lack of studies analyzing this aspect, we are not able to state which the cardiovascular risk factors are.

In regard to the musculoskeletal risk factors, the evidence for age and professional activity exhibited was strong. In turn, job satisfaction, physical fitness, educational level and general health had limited strength of evidence. Therefore, although several studies addressed risk factors for disease among emergency care providers, the literature is still poor in analyses of risk factors for CVD and MSD in this population. As a result, the currently available evidence on the effective risk factors for CVD and MSD is inconclusive.

 

REFERENCES

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13. Jamner LD, Shapiro D, Goldstein IB, Hug R. Ambulatory blood pressure and heart rate in paramedics: effects of cynical hostility and defensiveness. Psychosom Med. 1991;53(4):393-406.

14. Roberts MH, Sim MR, Black O, Smith P. Occupational injury risk among ambulance officers and paramedics compared with other healthcare workers in Victoria, Australia: analysis of workers’ compensation claims from 2003 to 2012. Occup Environ Med. 2015;72(7):489-95.

15. Weaver MD, Patterson PD, Fabio A, Moore CG, Freiberg MS, Songer TJ. An observational study of shift length, crew familiarity, and occupational injury and illness in emergency medical services workers. Occup Environ Med. 2015;72(11):798-804.

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17. Studnek JR, Crawford JM, Wilkins JR, Pennell ML. Back problems among emergency medical services professionals: the LEADS health and wellness follow-up study. Am J Ind Med. 2010;53(1):12-22.

18. Studnek JR, Crawford JM. Factors associated with back problems among emergency medical technicians. Am J Ind Med. 2007;50(6):464-9.

19. Lavender SA, Conrad KM, Reichelt PA, Johnson PW, Meyer FT. Biomechanical analyses of paramedics simulating frequently performed strenuous work tasks. Appl Ergon. 2000;31(2):167-77.

Recebido em 27 de Junho de 2017.
Aceito em 22 de Agosto de 2017.

Trabalho realizado na Universidade Federal do Rio Grande do Sul (UFRGS) – Porto Alegre (RS), Brasil.

Fonte de financiamento: nenhuma


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