LETTER TO THE EDITOR

Sir,

We read with interest the article by [Purohit, M. H. et al., 2023] on an observational study about the risk of developing musculoskeletal disorders (MSDs) by means of the rapid entire body assessment (REBA) among physiotherapists treating paediatric or adult patients with neurological disorders [Purohit, M. H. et al., 2023]. It was found that more than 50% of participating physiotherapists were at medium or high risk of developing MSDs [Purohit, M. H. et al., 2023]. It was concluded that physiotherapists working with neurological patients are at risk of developing MSDs [Purohit, M. H. et al., 2023]. The study is impressive but has several limitations.

We disagree with the notion the MSDs, which can be primary or secondary in general, are only caused by work, as mentioned in the introduction [Purohit, M. H. et al., 2023]. MSDs can be caused by several other conditions, such as genetic disease particularly myopathies and neuropathies (primary MSDs), by trauma, surgery, immunological disease, medications (secondary MSDs), and unusual exercise [Gomez-Galan, M. et al., 2017]. Myopathies and neuropathies not only affect the muscle or the nerves but secondary also the joints, sinews, ligaments, fascias, and joint capsules. Several drugs have musculoskeletal side effects, such as antibiotics (e.g. levofloxacin), lipid-lowering drugs (e.g. statins), osteoporosis medication (e.g. bisphosphonates), asthma inhalers, breast cancer medication (e.g. anastrozole, exemestane, letrozole), isotretinoin, or pregabalin. Exercise-associated MSDs can be caused by bending, crouching or stooping, lifting, pushing, pulling or dragging heavy or bulky loads, stretching, twisting and reaching, repetitive work, particularly using the same hand or arm action, sustained or excessive force, or carrying out a task for a long time. All these differentials need to be ruled out before attributing the risk of MSDs only to work.

We also disagree with the statement that work-related MSDs (WRMSDs) are influenced only by age, gender, type of clinical setting and practice, years of experience, and contact hours with patients as mentioned in the introduction [Purohit, M. H. et al., 2023]. WEMSDs are also dependent on the physiotherapist’s comorbidities, including mood disorders, alcohol consumption, and smoking habits, the physical activity outside the job, current medications, sleep hygiene, the attitude towards the job, the type of treatment applied to the patients, and the severity of the neurological disorder.

Although physiotherapists are commonly quite healthy, they can be chronically ill even from a disorder that affects the musculoskeletal system, such as rheumatoid arthritis. The physical effort needed to treat somebody with tension type headache is completely different to that when treating a patient with transverse syndrome or ischemic stroke with an NIHSS >12. If a physiotherapist has swimming as a hobby his musculoskeletal system will be less stressed than if he is a weight lifter. In summary, the excellent study has limitations that call the conclusions into question. Addressing these issues would strengthen the conclusions and could improve the status of the study. MSDs in physiotherapists treating neurological patients may not only be work-related but due to many other causes. Risk assessment of only work-related MSDs may miss the multicausality of these disorders.