WORK-RELATED MUSCULOSKELETAL DISORDERS AMONG 
PHYSIOTHERAPISTS AND PHYSIOTHERAPY STUDENTS IN CROATIA 
AND THEIR ASSOCIATION WITH PHYSICAL FITNESS
Marina HORVAT TIŠLAR1,2, Gregor STARC3, Andreja KUKEC4*
1University of Applied Health Sciences, Department of Physiotherapy, Mlinarska cesta 38, 10000 Zagreb, Croatia 
2University of Ljubljana, Faculty of Medicine, Vrazov trg 2, 1000 Ljubljana, Slovenia
3University of Ljubljana, Faculty of Sports, Gortanova ulica 22, 1000 Ljubljana, Slovenia
4University of Ljubljana, Faculty of Medicine, Chair of Public Health, Zaloška cesta 4, 1000 Ljubljana, Slovenia
Received: Apr 20, 2022
Accepted: May 26, 2022
Original scientific article
*Corresponding author: Tel. + 386 1 5437 544; E-mail: andreja.kukec@mf.uni-lj.si
10.2478/sjph-2022-0023 Zdr Varst. 2022;61(3):171-180
171
Z DELOM POVEZANE MIŠIČNO-SKELETNE MOTNJE FIZIOTERAPEVTOV 
IN ŠTUDENTOV FIZIOTERAPIJE NA HRVAŠKEM IN NJIHOVA 
POVEZANOST S TELESNO PRIPRAVLJENOSTJO
© National Institute of Public Health, Slovenia. 
Horvat Tišlar M, Starc G, Kukec A. Work-related musculoskeletal disorders among physiotherapists and physiotherapy students in Croatia and their association with 
physical fitness. Zdr Varst. 2022;61(3):171-180. doi: 10.2478/sjph-2022-0023.
ABSTRACT
Keywords: 
musculoskeletal 
disorders, 
physical fitness, 
physiotherapists, 
physiotherapy students
IZVLEČEK
Ključne besede: 
mišično-skeletne 
motnje, telesna 
pripravljenost, 
fizioterapevti, študenti 
fizioterapije
Introduction: Among physiotherapists, work-related musculoskeletal disorders (WMSDs) are the most common 
health problem. This study aimed to provide evidence for planning evidence-based health promotion programmes 
for ensuring and maintaining adequate physical fitness (PF) to decrease WMSDs among physiotherapists which 
would have started already during the study.
Methods: A cross-sectional study involved the participation of a total of 100 physiotherapy students and 
62 physiotherapists. Observed variables were prevalence of WMSDs in the last 12 months, lasting >3 days 
during physiotherapeutic activities and five PF components: body composition, cardiorespiratory and muscle 
endurance, muscle strength, and flexibility. A chi-square test and binary logistic regression were used as the 
main analytical methods.
Results: Prevalence of WMSDs in physiotherapists was 63.9% (the most common locations: lower back, shoulders, 
neck), while in physiotherapy students it was 46.5% (the most common locations: lower back, neck, upper back) 
(p=0.031). Among the PF components, the results showed statistically significantly worse flexibility among 
students compared to physiotherapists (about two thirds of students had poor or very poor results of flexibility 
testing) (p=0.002) in comparison to physiotherapists. A statistically significant positive association between 
WMSDs and PF was observed only between knee pain and poor cardiorespiratory endurance (OR=4.03 with 95% 
CI 1.12-14.58; p=0.033).
Conclusion: The study showed poor flexibility among students indicating that it is necessary to direct them 
to perform activities that will increase the extensibility of muscles. The awareness of this problem should be 
increased. A specific role should be played by staff involved in clinical practice.
Uvod: Pri fizioterapevtih so z delom povezane motnje mišično-skeletnega sistema (ZDPMSM) najpogostejša 
zdravstvena težava. Namen te študije je bil zagotoviti dokaze za razvoj z dokazi podprtih programov promocije 
zdravja za zagotavljanje in vzdrževanje ustrezne telesne pripravljenosti (TP) fizioterapevtov za zmanjšanje 
ZDPMSM z začetkom že v času študija.
Metode: V presečni študiji je sodelovalo 100 študentov fizioterapije in 62 fizioterapevtov. Opazovane 
spremenljivke so bile prevalenca ZDPMSM v zadnjih 12 mesecih, ki so trajale >3 dni med fizioterapevtskimi 
aktivnostmi in pet komponent TP: telesna sestava, srčno-dihalna vzdržljivost, mišična vzdržljivost, mišična moč 
in prožnost. Glavni analitični metodi sta bili test hi-kvadrat in binarna logistična regresija.
Rezultati: Prevalenca ZDPMSM je bila v skupini fizioterapevtov 63,9-odstotna (najpogostejše lokacije: spodnji 
del hrbta, ramena, vrat), v skupini študentov fizioterapije pa 46,5-odstotna (najpogostejše lokacije: spodnji 
del hrbta, vrat, zgornji del hrbta) (p = 0,031). Med komponentami TP so rezultati pokazali statistično značilno 
slabšo fleksibilnost študentov v primerjavi s fizioterapevti (približno dve tretjini študentov je imelo slabe 
ali zelo slabe rezultate testiranja fleksibilnosti) v primerjavi s fizioterapevti (p = 0,002). Statistično značilna 
pozitivna povezanost med ZDPMSM in TP je bila zaznana le med bolečino v kolenu in slabo srčno-dihalno 
vzdržljivostjo (RO = 4,03 s 95-odstotnim IZ 1,12–14,58; p = 0,033).
Zaključek: Študija je pokazala slabo fleksibilnost študentov, kar kaže, da jih je treba usmerjati v dejavnosti, 
ki bodo povečale raztegljivost mišic. Ozaveščenost o tem problemu je treba povečati. To posebno vlogo mora 
imeti osebje, vključeno v klinično prakso.
1 INTRODUCTION
Musculoskeletal disorders (MSDs), cumulative damage/
dysfunction of the musculoskeletal system caused by 
prolonged and repeated exposure to high- or low-intensity 
loads or as a result of acute trauma (1), are the most 
common cause of severe long-term pain/discomfort 
causing physical disability. Work-related MSDs (WMSDs) are 
MSDs in which the work environment and work contribute 
significantly to the condition and/or the condition worsens/
persists longer due to work conditions (2). They are the 
most common work-related health problem in the European 
Union (EU), with an average prevalence of about 60% (3, 
4), ranging from 40-79% in the Member States in 2015 (3). 
All occupations can be affected, but human health and 
social work occupations more so than others (3). 
In physiotherapists, the WMSDs prevalence is higher 
than average. The 12-month prevalence is estimated at 
58-91% (5-7). Moreover, Glover et al. determined that 
42% of musculoskeletal symptoms persisted for >3 days 
within the past year (5). The leading cause of WMSDs 
among physiotherapists is the performance of repetitive 
movements or intense physical demands (lifting heavy 
patients, manual handling, patient handling, awkward 
positioning, prolonged constrained postures) (6-9). The 
most frequently affected areas are the lower back (6-9, 
10-13), neck and upper back (8, 9), and thumb (6). To carry 
out the physically demanding work of a physiotherapist, it 
is necessary to ensure satisfactory physical fitness (PF).
PF is defined as the capacity for physical activity, which 
is defined as any bodily movement produced by skeletal 
muscles that results in energy expenditure. It consists of 
five components: body composition, cardiorespiratory 
and muscle endurance, muscle strength and flexibility 
(14). The level of PF is partially genetically predetermined 
but is influenced by external factors, such as exercise. 
Although good PF is considered a protective factor for the 
occurrence of MSDs, research to date has not been able to 
show this statistically (15-17). 
The latest available data show that the prevalence of 
WMSDs in Croatia is slightly higher than the average in the 
EU (2015: 62%) (4). Data on PF and the prevalence of WMSDs 
among physiotherapists/physiotherapy students in Croatia 
are very limited. Only recently, studies addressing this 
topic have emerged (18, 19). Sklempe Kokic et al. (2019) 
for example, estimated the last 12-months prevalence of 
MSDs among physiotherapy students at about 80% (18).
Aiming to provide evidence for the development of 
evidence-based health promotion programmes for 
maintaining adequate PF in physiotherapists to decrease 
their WMSDs starting in the years of studying, the objectives 
of this study were a) to assess the differences in self-rated 
WMSDs and PF components between physiotherapists and 
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172
students of physiotherapy and b) to assess the association 
between WMSDs and PF components. 
2 METHODS 
2.1 Study design, setting and time frame
The presented cross-sectional study is a part of 
comprehensive research on WMSDs in physiotherapists 
in Croatia in relation to PF and physical activity. It was 
carried out during the 2017/18 academic year at the 
University of Applied Health Sciences Zagreb (UAHSZ) in 
collaboration with the Faculty of Kinesiology, University 
of Zagreb.
2.2 Subjects
The study involved two groups of subjects. The first 
consisted of physiotherapists involved in the UAHSZ study 
programme (e.g. conducting clinical teaching and clinical 
tutoring). The inclusion criterion was practising the 
profession in the Zagreb area, which was met by 71/80 
physiotherapists. They were invited to participate in the 
study. The second group consisted of the Bachelor of 
Physiotherapy study programme of the UAHSZ students. 
The total population of the third year of 2017/18 (n=107) 
was invited to participate. There were no exclusion criteria.
2.3 Study course
Everyone who was invited to the research was first briefly 
introduced to the purpose and importance of the research 
and its course (filling in the questionnaire and PF testing). 
This was followed by completing a structured self-
completion questionnaire designed by the first author. 
The questionnaire consisted of three sets of questions. 
The first set consisted of questions about WMSDs based 
on selected questions from the Nordic Musculoskeletal 
Questionnaire (NMQ) (20), supplemented by additional 
questions (e.g. questions about the history of symptoms 
and about possible treatment of symptoms). The second 
set consisted of questions of the long version of the 
International Physical Activity Questionnaire (21). The last 
set consisted of questions on socio-demographic data. 
The questionnaire was completed by all who decided to 
participate in this first part of the research. Afterwards, 
the first author demonstrated the performance of PF 
tests. This was followed by a short interview about the 
current self-reported state of health. All those whose 
current state of health did not allow them to perform PF 
tests were excluded from the study.
2.4 Observed variables and study instruments
2.4.1 Musculoskeletal variables
WMSDs status was assessed by questions about WMSDs 
based on selected similar NMQ questions (20). The 
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173
respondents were asked the following: Have you at any 
time during the last 12 months had trouble (ache, pain, 
discomfort) lasting >3 days during physiotherapeutic 
activities (0=no, 1=yes). If yes, they were asked about 
the locations: neck, shoulders, upper back, elbows and 
forearms, lower back, wrist and hands, thumb, hips and 
thighs, knees, and ankles and feet (all 0=no, 1=yes).
2.4.2 Physical fitness components variables
In the PF assessment, the battery of tests proposed by the 
American College of Sports Medicine was used (22). All 
measurements were performed by the study’s first author.
Body composition was assessed by body mass index (BMI) 
(23), which demonstrated high reliability (Cronbach=0.995) 
(24). Body mass was measured using a Seca 700 medical 
personal scale (Seca GmbH, Germany) and body height 
using a Seca 220 stadiometer (Seca GmbH, Germany). The 
original BMI values were transformed into standardized 
categories (1=BMI <18.5: underweight; 2=BMI 18.5-24.9: 
normal weight; 3=BMI 25.0-29.9: overweight; 4=BMI ≥30.0: 
obese) (25).
Cardiorespiratory endurance was assessed with the Harvard 
step test, which demonstrated acceptable reliability 
(Interclass Coefficient-ICC=0.63) (26). Respondents were 
stepping up and down on a step bench (men: 50 cm; women: 
45 cm) for 5 min at the frequency of 30 times per minute 
until exhaustion or up to 5 minutes (27). At one, three, and 
five minutes after the test, pulse rate was recorded. The 
cardiorespiratory fitness index (CRI) was calculated using 
a standard procedure (28). The original CRI values were 
transformed into standardized categories (1=CRI <54(poor), 
2=CRI 54-67(low average), 3=CRI 68-82(average), 4=CRI 83-
96(good), 5=lCRI >96(excellent)) (29). 
Muscle endurance was tested using a curl-up test for 
assessment of the dynamic capacity of the abdominal 
muscles, which demonstrated high reliability (ICC=0.91-
0.96) (30). On the training mat on which two stripes 1 
metre long separated by 10 centimetres were placed 
(UAHSZ, Croatia), the examinee performed the lifting of 
the torso from the lying position on the back, with the 
movement of the arms from the starting to the end marked 
position. The test was conducted for 1 minute in time 
with the metronome (mobile application “Metronome” 
version 1.21). The number of repetitions the subject was 
able to perform was recorded. Considering the sex and 
age of the participants, the number of repetitions was 
transformed into standardized categories (1=poor, 2=low-
average, 3=average, 4=good, 5=excellent) (31).
For muscular strength, the handgrip strength test was 
used (21), which demonstrated high reliability (ICC=0.87) 
(26). Isometric force (kg) was measured with a Jamar 
handgrip dynamometer (Jamar 5030 J1; Sammons Preston 
Inc., USA). Measurements were taken in the seated 
position, with the arm supported leaning against the 
body, elbow bent at 90 degrees, the hand in a neutral 
position holding the dynamometer (22). The participants 
were instructed to squeeze the dynamometer as hard as 
they could (22). The subject performed 3 attempts, each 
hand alternately. The result was the average of the best 
measurements of both hands. Considering the sex and 
age of the participants, basic values were transformed 
into standardized categories (1=poor, 2=low-average, 
3=average, 4=good, 5=excellent) (31). 
As an assessment tool to evaluate posterior muscular chain 
flexibility, which simultaneously implies a requirement 
for balance, the Toe-Touch Test was applied (32), which 
demonstrated high reliability (r=0.97) (33). The respondents 
were standing on a flexometer – a raised platform (UAHSZ, 
Croatia), bending forward with straight knees, touching 
their toes, or reaching further. The distance (in cm) to/
from the ground (point 0) at which the middle index finger 
reaches the lowest was recorded. Measured values were 
divided into seven categories (1=very poor, 2=poor, 3=fair, 
4=average, 5=good, 6=excellent, 7=outstanding) (34).
2.4.3 Other variables
Along with health and PF variables, selected socio-
demographic factors were observed: sex and physical 
workload according to the physiotherapeutic work during 
service or during the practical exercise (1=work in a 
hospital ward, 2=work in an outpatient clinic, 3=work of a 
mixed type) were observed.
2.5 Data processing and statistical analysis
Prior to analysis, the data were prepared so that they were 
suitable for public health purposes. In this procedure, the 
PF variables were dichotomised considering the physical 
workload of the participants in terms of what their PF 
should be in relation to their work as physiotherapists, 
except in body composition. For those working in hospital 
wards, or hospital wards and outpatient clinics, excellent 
and outstanding results were considered satisfactory 
PF achievements. For those working only in outpatient 
clinics good, excellent and outstanding results were 
considered satisfactory PF achievements. For students, 
already average results were considered satisfactory PF 
achievements. A new variable was created for each of 
them: poor cardiorespiratory endurance, poor muscle 
endurance, poor muscle strength and poor flexibility (all 
0=no, 1=yes). A variable for poor body composition was 
also created (0=no (normal weight), 1=yes (underweight/
overweight/obesity)). 
First, differences in WMSDs and PF components between 
physiotherapists and physiotherapy students were 
analysed. The chi-square test was used as a principal 
method, while in the case of low expected frequencies, 
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Fisher exact (in case both variables had two categories) 
and likelihood-ratio tests (in case one variable had more 
than two categories) were used. 
Afterwards, an assessment of the association between 
WMSDs and PF components was performed. Multiple binary 
logistic regression was used as a method of multivariate 
analysis. For each WMSD, a multivariate model was defined 
with the same independent variables: all five components of 
PF, the group of physiotherapy students/physiotherapists, 
and sex. As a method of assessing goodness-of-fit of 
models, the Hosmer-Lemeshow test was used. 
In all statistical tests, p≤0.05 was considered significant. 
The software IBM SPSS for Windows Version 27.0 (SPSS 
Inc., Chicago, IL., USA) was used for computations.
3 RESULTS
3.1 Description of participants
Of the 71 invited physiotherapists, 9 declined to 
participate or had a health condition that did not allow 
the performance of PF tests (pregnancy, neck problems, 
knee problems, multiple sclerosis). Finally, 62 (87.3% of 
invitees) participated in the study. Of 107 physiotherapy 
students 100 agreed to participate in the study (response 
rate of 93.4%). 
The group of students consisted of 31 (31.0%) males and 
69 (69.0%) females. In the group of physiotherapists, the 
distribution by sex was very similar (males: 17, 27.4%; 
females: 45, 72.6%). The mean age of students was 
21.7±1.1 years, while the mean age of physiotherapists was 
42.4±9.0 years. Among the physiotherapists, 28 (45.2%) 
were working in hospital wards and the same number in 
outpatient clinics (28, 45.2%), while 6 of them (9.7%) were 
working in hospital wards and outpatient clinics.
3.2 Prevalence of WMSDs
The overall 12-month prevalence of WMSDs, lasting >3 days 
during physiotherapeutic activities regardless of location, 
was 53.1%. The results showed that the prevalence in 
physiotherapists was higher except in the lower back, and 
ankle and foot. Among the physiotherapists the prevalence 
was the highest in the lower back, shoulders and neck, 
while among physiotherapy students, it was highest in the 
lower back, upper back and neck (Table 1).
Any location
Neck
Shoulder
Upper back
Elbow and forearm
Lower back 
Wrist and hand
Thumb 
Hip and thigh
Knee
Ankle and foot
Location of pain Physiotherapists (n=62) Students (n=100)
Ncat(%) Ncat(%)
pCategory
22(36.1%)
39(63.9%)
48(77.4%)
14(22.6%)
47(75.8%)
15(24.2%)
49(79.0%)
13(21.0%)
55(88.7%)
7(11.3%)
43(69.4%)
19(30.6%)
52(83.9%)
10(16.1%)
56(90.3%)
6(9.7%)
57(91.9%)
5(8.1%)
55(88.7%)
7(11.3%)
61(98.4%)
1(1.6%)
53(53.5%)
46(46.5%)
88(88.0%)
12(12.0%)
91(91.0%)
9(9.0%)
88(88.0%)
12(12.0%)
97(97.0%)
3(3.0%)
67(67.0%)
33(33.0%)
97(97.0%)
3(3.0%)
100(100.0%)
0(0.0%)
98(98.0%)
2(2.0%)
90(90.0%)
10(10.0%)
94(94.0%)
6(6.0%)
0.031*
0.075*
0.008*
0.125*
0.033#
0.775*
0.003#
0.002#
0.065#
0.795*
0.182#
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Table 1. The 12-month prevalence of pain lasting >3 days due to work-related musculoskeletal disorders.
Legend: *=Chi-square test results, #=Fisher exact test results
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3.3 Physical fitness analysis
Table 2 shows the results of the PF analysis in both 
observed groups, and a comparison between them. The 
results show that more physiotherapists are overweight, 
with poor cardiorespiratory endurance, poor muscular 
endurance, and low average muscular strength, than 
students, except in the case of flexibility. 
Body composition
Cardiorespiratory endurance
Muscular endurance
Muscular strength
Flexibility 
Physical fitness component Physiotherapists (n=62) Students (n=100) pCategory
0(0.0%)
26(41.9%)
31(50.0%)
5(8.1%)
30(48.4%)
0(0.0%)
4(6.5%)
16(25.8%)
12(19.4%)
31(50.0%)
9(14.5%)
8(12.9%)
6(9.7%)
8(12.9%)
7(11.3%)
22(35.5%)
12(19.4%)
13(21.0%)
8(12.9%)
6(9.7%)
20(32.3%)
19(30.6%)
10(16.1%)
5(8.1%)
1(1.6%)
1(1.6%)
4(4.0%)
76(76.0%)
17 17.0%)
3(3.0%)
20(20.0%)
1(1.0%)
16(16.0%)
38(38.0%)
25(25.0%)
11(11.0%)
16(16.0%)
15(15.0%)
16(16.0%)
42(42.0%)
5(15.0%)
25(25.0%)
14(14.0%)
28(28.0%)
18(18.0%)
33(33.0%)
33(33.0%)
25(25.0%)
7(7.0%)
1(1.0%)
1(1.0%)
0(0.0%)
<0.001#
0.003#
<0.001#
0.421*
0.002#
Underweight
Normal weight
Overweight
Obese
Poor 
Low average
Average
Good
Excellent
Poor 
Low average
Average
Good
Excellent
Poor 
Low average
Average
Good
Excellent
Very poor
Poor
Fair
Average
Good
Excellent
Outstanding
Table 2. Physical fitness tests results.
Legend: *=Chi-square test results, #=Likelihood-ratio test results
3.4 Results of analysis of the association between 
WMSDs and PF
Due to the very low frequency, the multivariate analysis 
could not be performed for two pain locations – thumb, 
and ankle and foot. Other results of the analysis of the 
association between WMSDs and PF in physiotherapists 
and physiotherapy students are shown in Table 3.
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Neck pain
Shoulder pain
Upper back pain
Elbow and forearm pain
Health outcomes Category OR(95% CI limits) pV pHLPF and socio-demographic factors
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
Students
Physiotherapists
Males
Females
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
Students
Physiotherapists
Males
Females
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
Students
Physiotherapists
Males
Females
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
Students
Physiotherapists
Males
Females
1.00
0.76(0.28-2.09)
1.00
0.50(0.17-1.50)
1.00
2.30(0.77-6.86)
1.00
0.55(0.17-1.83)
1.00
0.65(0.17-2.49)
1.00
3.16(0.80-12.41)
1.00
1.04(0.37-2.90)
1.00
0.72(0.24-2.12)
1.00
0.27(0.08-0.90)
1.00
2.37(0.70-8.00)
1.00
0.50(0.13-1.84)
1.00
1.02(0.18-5.65)
1.00
6.96(1.55-31.09)
1.00
2.41(0.68-8.54)
1.00
0.72(0.26-1.99)
1.00
0.79(0.27-2.32)
1.00
1.98(0.65-6.00)
1.00
1.40(0.42-4.66)
1.00
1.30(0.25-6.90)
1.00
1.34(0.34-5.35)
1.00
1.65(0.54-5.03)
1.00
1.05(0.22-4.98)
1.00
0.63(0.10-3.60)
1.00
2.80(0.45-17.03)
1.00
0.58(0.09-3.41)
1.00
0.17(0.03-0.92)
1.00
5.09(0.56-45.88)
1.00
0.59(0.12-2.84)
 
0.599
0.218
0.134
0.331
0.531
0.099
0.938
0.554
0.033
0.164
0.297
0.981
0.011
0.172
0.531
0.668
0.227
0.581
0.752
0.678
0.380
0.953
0.601
0.265
0.547
0.040
0.147
0.514
0.529
0.706
0.851
0.822
Poor body composition
Poor cardiorespiratory endurance
Poor muscular endurance
Poor muscular strength
Poor flexibility
Group
Sex
Poor body composition
Poor cardiorespiratory endurance
Poor muscular endurance
Poor muscular strength
Poor flexibility
Group
Sex
Poor body composition
Poor cardiorespiratory endurance
Poor muscular endurance
Poor muscular strength
Poor flexibility
Group
Sex
Poor body composition
Poor cardiorespiratory endurance
Poor muscular endurance
Poor muscular strength
Poor flexibility
Group
Sex
Table 3. Results of multiple binary logistic regression analysis of the association between pain associated with work-related 
musculoskeletal disorders, and physical fitness and socio-demographic factors.
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Lower back pain
Wrist and hand pain
Hip and thigh pain
Knee pain
Health outcomes Category OR(95% CI limits) pV pHLPF and socio-demographic factors
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
Students
Physiotherapists
Males
Females
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
Students
Physiotherapists
Males
Females
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
Students
Physiotherapists
Males
Females
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
No 
Yes 
Students
Physiotherapists
Males
Females
1.00
0.51(0.23-1.16)
1.00
1.21(0.52-2.81)
1.00
1.86(0.81-4.28)
1.00
0.72(0.28-1.83)
1.00
0.97(0.31-2.96)
1.00
0.92(0.30-2.75)
1.00
0.59(0.28-1.30)
1.00
1.11(0.29-4.15)
1.00
1.62(0.37-6.98)
1.00
1.53(0.31-7.45)
1.00
1.49(0.29-7.48)
1.00
0.75(0.12-4.52)
1.00
2.91(0.40-21.04)
1.00
0.89(0.22-3.54)
1.00
0.76(0.10-5.69)
1.00
0.19(0.02-1.86)
1.00
0.59(0.08-4.03)
1.00
2.69(0.28-26.14)
1.00
0.06(0.01-0.54)
1.00
7.23(0.50-103.64)
1.00
1.85(0.22-15.18)
1.00
0.88(0.27-2.86)
1.00
4.03(1.12-14.58)
1.00
0.66(0.19-2.35)
1.00
0.44(0.10-1.97)
1.00
0.66(0.15-2.94)
1.00
1.19(0.23-6.14)
1.00
0.82(0.26-2.64)
0.109
0.656
0.141
0.486
0.953
0.877
0.190
0.874
0.520
0.599
0.627
0.756
0.291
0.869
0.796
0.157
0.588
0.394
0.013
0.145
0.567
0.833
0.033
0.525
0.287
0.583
0.835
0.742
0.441
0.272
0.113
0.377
Poor body composition
Poor cardiorespiratory endurance
Poor muscular endurance
Poor muscular strength
Poor flexibility
Group
Sex
Poor body composition
Poor cardiorespiratory endurance
Poor muscular endurance
Poor muscular strength
Poor flexibility
Group
Sex
Poor body composition
Poor cardiorespiratory endurance
Poor muscular endurance
Poor muscular strength
Poor flexibility
Group
Sex
Poor body composition
Poor cardiorespiratory endurance
Poor muscular endurance
Poor muscular strength
Poor flexibility
Group
Sex
Legend: OR=odds ratio; CI=confidence interval; pV=p-value of a variable; pHL=p-value of the Hosmer-Lemeshow test 
4 DISCUSSION
The study showed two unexpected results, both regarding 
physiotherapy students. First, they had pain in the lower 
back and knees essentially as often as physiotherapists; 
second, two thirds of them had poor/very poor flexibility. 
Regarding the prevalence, the results could only be 
compared with the results of the study of Glover et al. 
(5) in which the question about experiencing WMSDs was 
most similar to the question in our study (symptoms that 
lasted >3 days); the observed prevalence in their study 
was 42%. As the composition of the studied group was to 
a certain extent also similar (94% of the studied group 
consisted of physiotherapists and physiotherapy students, 
and 6% physiotherapy assistants), we can conclude that the 
problem in Croatia seems to be slightly greater than in the 
UK. Comparison with other studies was not possible due 
to differences in the question about WMSDs, which in our 
study focused only on WMSDs prevalence of longer duration 
(>3 days) in the previous 12 months, while other studies 
were focused on the previous 12-month prevalence of 
WMSDs without specifying the duration (7, 18), or lifetime 
prevalence of WMSDs (6, 9). A comparison regarding the 
location of the pain was less problematic. Studies in this 
area have shown that our results are very similar: the 
most common pain locations were the lower back, neck, 
and shoulders (5, 35, 36). For students, the location 
could also be compared to a recent study conducted in 
Croatia (18). The results were very similar: the highest 
prevalence was observed, as in our study, in the lower 
back, neck, and upper back. As expected, the prevalence 
of WMSDs in our study was higher in physiotherapists in 
comparison to students in general, as well as in many 
individual locations.  Although the prevalence of low 
back pain between students and physiotherapists has not 
been significant, it is important to note that this finding in 
students is worrying, which may be related to an increased 
sedentary lifestyle, and it should be investigated further. 
Similar, though less pronounced, is the problem in two 
other locations – knees and upper back. The latter was 
revealed only by multivariate analysis.
The body composition of physiotherapy students was 
within the normal range, similarly to other recently 
published studies (15, 28, 36-38), and was statistically 
significantly better than in physiotherapists, although 
it was still within acceptable limits, which is consistent 
with the study of Ramanadi et al. (16). Cardiorespiratory 
endurance was also statistically significantly better 
in students than in physiotherapists, for whom it was 
surprisingly poor. The situation was similar in muscular 
endurance, which was scored as excellent for students. 
The results were similar to those of Juhkam et al. (37). The 
first PF component of concern in students was muscular 
strength. The isometric handgrip strength is one of the 
important components of PF, indicating the strength of 
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10.2478/sjph-2022-0023 Zdr Varst. 2022;61(3):171-180
the upper limb and, indirectly, the whole body (39). We 
expected students to do better than physiotherapists, 
but the two groups were quite similar. A similar result 
was shown by Juhkam et al. (37). It would make sense 
to direct students to a physical activity requiring more 
involvement of the upper limbs and handgrip. Unexpected 
was the result of the flexibility test in which as many as 
two thirds of students demonstrated poor or even very 
poor flexibility. Consequently, students should be directed 
to perform activities that will increase the extensibility of 
the dorsal muscle chain of the boot and hip (40). Again, a 
similar result was observed in another study (41). 
There are few published studies on the relationship 
between WMSDs and PF, and comparison with other 
results is difficult. The only similar study by Mirza and 
collaborators showed very similar results - the association 
between PF and WMSDs could not be confirmed (15). A 
statistically significant positive association was observed 
only between knee pain and poor cardiorespiratory 
endurance, while other statistically significant results 
were debatable (in the shoulder, the elbow/forearm, and 
the hip/thigh pains). Poor cardiorespiratory endurance 
and poor flexibility in our study seemed to be protective 
factors for pain as a contradictory result; however, as 
previously stated, the available literature thus far has not 
shown a statistical relationship between PF and WMSDs.
The study has some limitations. First, the observed group 
was too small, which, given the low frequency of some 
observed WMSDs, did not allow for more in-depth analyses, 
although the size of the participants was estimated 
in accordance with the theory and was expected to be 
large enough (42). However, we still obtained some very 
important results. Representativeness was also not an 
issue, as all identified physiotherapists at the time of the 
study and all students in the academic year were invited, 
and the response rate was on average more than 90%. 
Next, there is a time mismatch of the variables in the 
multivariate models. However, as in similar studies, we 
asked about the symptoms of WMSDs in the previous 12 
months, and this could be at any time during the past 
12 months and quite distant in time, while in a cross-
sectional design the PF measurements could only be 
performed at the time of the study. Next, one could argue 
that the original general NMQ, whose reliability proved 
to be moderate to high in the majority of questions 
with kappa coefficients above 0.50 (43), was not used. 
However, some parts have been used, although slightly 
modified or supplemented. First was the question on the 
occurrence of troubles at any time during the last 12 
months, which was modified in the sense that the focus 
in our study was only on troubles lasting >3 days occurring 
during physiotherapeutic activities. All locations of 
troubles listed in the original NMQ were also used (in all 
yes or no regardless of the body side), while the thumb 
location was added. Other parts of the original general 
NMQ were omitted. Next, one could also argue that the 
Physical Workload Questionnaire was not used in judging 
workplace workload. Finally, the applied fitness tests 
have rather low sensitivity. For each component of PF, it 
is possible to use several different tests, focusing more 
on the examination of the upper or lower part of the 
body. However, we believe that the application of other 
tests would not significantly contribute to a change in the 
obtained results of measuring the parameters of PF. 
Nevertheless, the study has some important strengths. 
First, this is the first study showing the level of PF and 
the problem of WMSDs among physiotherapists in Croatia 
in relation to physiotherapy students. Next, one very 
important strength is that it is a study on a population with 
very high responsiveness. This allows a reliable estimate 
of prevalence. Finally, the results could be useful in other 
social environments as well, especially in those where the 
transition took place in a similar way and, consequently, 
the values of the younger generations of the population 
are subject to similar changes in values.
The results provide very important implications in terms of 
where to direct efforts to prepare future physiotherapists 
physically for their future profession. The educational 
institution should be actively involved, as should the 
physiotherapists from whom students receive practical 
training. It would make sense, for example, to direct 
students to organised physical exercise, which would be 
useful not only during their studies, but could also be 
performed in late adulthood to prevent frailty (44). An 
appropriate exercise, which is also popular among young 
people, could be yoga (45).
In the continuation of research in this field, it would first 
be necessary to increase the sample size, while choosing 
fitness tests appropriate for the individual location of 
WMSDs due to greater sensitivity. In addition, it would 
be sensible to construct a questionnaire that puts the 
phenomena in which we observed the relationship in 
the right place in terms of chronological order and 
simultaneity.
5 CONCLUSIONS
The study showed two important unfavourable results. The 
first is that physiotherapy students have pain in the lower 
back even more often than their older senior colleagues, 
and the second is that an extremely high percentage of 
physiotherapy students have poor flexibility. Both results 
are issues of great concern and indicate where action is 
needed – in promiting physical activity for the preservation 
and improvement of the health of physiotherapy students. 
UAHSZ should be more involved in introducing them to this 
problem. This role should be played by staff involved in 
clinical practice, who by their example, and work activities, 
can improve their attitude to PF and physical activity.
CONFLICT OF INTEREST
No conflict of interest.
FUNDING
No funding.
ETHICAL CONSIDERATIONS
Participation in the study was voluntary and anonymous. 
Participants were provided informed consent. The 
research protocol was approved by the UAHSZ Ethics 
Committee (KL:602-04/16-18/410, URBR:251-379-1-17-04; 8 
November 2017).
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