Cath Lab Health

The Prevalence of Low Back Pain and an Evaluation of Prevention Strategies: A Survey of Electrophysiology and Catheterization Laboratory Physicians, Nurses, and Technologists at Two Rural Arkansas Hospitals

Khalid Sawalha, MD1, Principal Investigator; Nicholas Beresic, EdD2; Shoaib Khan, MD1; Gilbert-Roy Kamoga, MD, FACP1

1Internal Medicine Department, White River Health System, Batesville, Arkansas; 2Director of Communications of the Osteoarthritis Action Alliance, University of North Carolina, Chapel Hill, North Carolina

Khalid Sawalha, MD1, Principal Investigator; Nicholas Beresic, EdD2; Shoaib Khan, MD1; Gilbert-Roy Kamoga, MD, FACP1

1Internal Medicine Department, White River Health System, Batesville, Arkansas; 2Director of Communications of the Osteoarthritis Action Alliance, University of North Carolina, Chapel Hill, North Carolina

Healthcare workers are highly susceptible to musculoskeletal disorders due to the regular lifting, positioning, and transporting of patients, combined with a fast-paced work environment and a general collective quality of putting their patients’ health before their own.1 Upon closer review, the electrophysiology (EP)/cardiac catheterization (cath) lab subset of the rural hospital workforce appears to be especially susceptible to the specific musculoskeletal disorder of low back pain. This susceptibility has been attributed to the sustained forward-flexed postures commonly maintained by staff and clinicians while working in the lab,2 combined with a shortage of rural physicians and fewer community-based resources available to rural hospital staff as compared to their urban counterparts.3

As a strategy to address this dilemma, exercise and physical activity routines, health education, and continued management support have been broadly promoted as cost-effective programs that are powerful enough to improve the health of the workforce, yet also produce a positive return on investment.4 In theory, the implementation of these low-cost, low-risk programs is a sound strategy based on evidence-based guidelines. The American College of Physicians strongly recommends nonpharmacologic treatments for chronic low back pain, including exercise and mindfulness-based stress reduction, because the benefits clearly outweigh the risk.5 In practice, however, limited time and the inability to incorporate a program into everyday work routines have been found as the two main reasons why worksite-based fitness programs have failed to produce significant results.6 To overcome these barriers, hospital management must concurrently have the social, financial, and strategic investments in place to complement and support these specific wellness interventions in order to realize significant and lasting reductions in musculoskeletal disorders.7 Unfortunately, the extent to which these investments have been made by hospital management, and thus perceived effective by the EP/cath lab workforce, is unknown. Thus, the objective of this study was to determine the prevalence of low back pain in rural EP/cath labs, and the significance of exercise and physical activity routines, health education, and continued management support as low back pain prevention strategies in the rural EP/cath lab community.

Methods and Data Collection

Individuals who worked in the EP/cath labs of two rural hospitals within the state of Arkansas were eligible to participate in the study. A convenience sample design was used, and all research data were collected through the electronic transmission of a Qualtrics survey. The survey included three general sections: Nordic Musculoskeletal Questionnaire (NMQ), demographics/applicable work practice details, and low back pain prevention strategies.

  • The first section, featuring the NMQ, was used to calculate the prevalence of musculoskeletal symptoms within the study population. The NMQ was developed for the analysis of musculoskeletal symptoms,8 and has been validated and applied to a wide range of occupational groups, including nursing.9 Additionally, the validity and reliability of the NMQ was assessed to be moderate to high and its use appropriate for epidemiological research related to musculoskeletal disorders.10
  • The second section, on demographics/applicable work practice, assessed height, weight, gender, age, number of years worked in an EP/cath lab setting, number of hours per week in a lead apron, and percentage of average shift spent standing in the lab.
  • The third section, on low back pain prevention strategies, assessed exercise and physical activity routines, health education, and continued management support. These questions were developed through the examination of peer-reviewed journal articles, scientific posters, and government websites that promote specific behaviors or actions with the potential to prevent or reduce low back pain.11

A total of 45 participants were invited to participate in the study. Upon receiving IRB approval, the survey was sent to the work email address of all study participants. Data were deidentified and summarized using Microsoft Excel. Analysis showed fifteen individuals either selected they did not want to participate in the study or did not complete the survey in its entirety and thus, were omitted from the final data set. Ultimately, a total of 30 completed surveys were included in the final data set for analysis.


The first section of the survey featuring the NMQ assessed the prevalence of musculoskeletal symptoms in nine different regions of the body. The largest group, 18 (60%), stated they experienced pain in the lower back (L4 to S1) spinal level, while 12 (40%) reported no low back pain. Among the 60% of respondents who have experienced low back pain, eight (26.67%) had trouble in the last week and six (20%) were prevented from doing their normal work (at home or away from home) (Table 1).


Compared to an Occupational Safety and Health Administration (OSHA) study including a population of radiologic technologists who wear lead aprons in a similar fashion,1 the current study shows a higher overall pervasiveness of low back pain (60% to 47.62%, respectively), but fewer low back pain symptoms on a short-term basis (26.67% to 33.33%, respectively). Despite these discrepancies, low back pain was found to be the most prevalent musculoskeletal symptom recorded across both studies. Another significant finding in our study is an increase in the prevalence of low back pain once the threshold of five years of service in an EP/cath lab setting is completed (58% to 61%) (Table 2). Goldstein et al reported a similar upward trajectory in the prevalence of low back pain among interventional cardiologists as the number of years of service increased.12

Finally, the top two prevention strategies reported by those with low back pain were an affirmation that they “regularly complete at least 150 minutes per week of moderate-intensity aerobic physical activity” and responding positively to the question “if a worksite-based fitness program would be offered to you at your department, would you be interested in joining it for at least a year” (Table 3). Motivation to exercise appears to be high among respondents.

Interestingly, no positive responses were recorded when respondents were asked if their worksite-based fitness program occurred on company time, or if low back pain and other musculoskeletal symptoms were periodically evaluated. In addition, only one positive response was recorded when asked if ergonomic-related topics were discussed during team meetings. These findings suggest it is the cultural norm of the EP/cath lab community to believe that addressing the widespread low back pain present in the workforce is the personal responsibility of the employee rather than a shared responsibility of the employee and hospital (EP/cath lab) management. This was emphasized by only 36.67% of respondents reporting that “hospital management believes improvements in physical conditioning will help to prolong my career.”


The primary goal of our study was to illustrate the prevalence and generalized characteristics of back pain among EP and cath labs in rural hospital settings. The prevalence of low back pain demonstrated within this study was consistent when compared to available studies. Low back pain is a common condition among EP and cath lab employees, and several low-cost, low-risk preventative strategies for reducing musculoskeletal symptoms in the workforce are not currently being completed by those who participated in the study. Further studies to evaluate the extent of low back pain in a rural settings and hospital policies regarding preventive strategies may be beneficial. 

Disclosure: The authors report no conflicts of interest regarding the content herein.

Authors can be contacted via Khalid Sawalha, MD, at



Marsha Holton, CCRN-K, RCIS, FSICP, Cardiovascular Orientation Programs, Mechanicsville, Maryland

Cath lab professionals have been talking about and researching the occupational health risks our team members may experience for many years.

Historical studies have demonstrated that the damage from repetitive-use tasks we perform daily does indeed have an impact. Six papers are identified below, ranging in time from 2003 to the Society for Cardiovascular Angiography and Interventions (SCAI) Position Statement published in 2020.

This article by Sawalha et al brings those concerns to us again.

I believe this article, in combination with the historical data sets, reflects the awareness of these problems, and, as cath lab professionals, the goal is to continue to identify ways and means to decrease the wear and tear on our people.


  1. Holton M. Ergonomics in the cath lab (or how to save staff backs, necks, wrists…). Cath Lab Digest. 2003; 11(5): 1-14. Accessed March 22, 2021. Available online at:
  2. Moglia A. Cath lab ergonomics. Cath Lab Digest. 2006; 14(2). Accessed March 22, 2021. Available online at
  3. Holton M. An ergonomic survey of cath lab repetitive stress injuries. Cath Lab Digest. 2008; 16(1). Accessed March 22, 2021. Available online at Repetitive-Stress-Injuries
  4. Chambers CE. Occupational health risks in interventional cardiology: expected inherent risk or preventable personal liability? JACC Cardiovasc Interv. 2015 Apr 20; 8(4): 628-630. doi: 10.1016/j.jcin.2015.01.015
  5. Andreassi MG, Piccaluga E, Guagliumi G, et al. Occupational health risks in cardiac catheterization laboratory workers. Circ Cardiovasc Interv. 2016 Apr; 9(4): e003273. doi: 10.1161/CIRCINTERVENTIONS.115.003273
  6. Klein LW, Goldstein JA, Haines D, Chambers C, Mehran R, Kort S, Valentine CM, Cox D. SCAI multi-society position statement on occupational health hazards of the catheterization laboratory: shifting the paradigm for healthcare workers’ protection. J Am Coll Cardiol. 2020 Apr 14; 75(14): 1718-1724. doi: 10.1016/j.jacc.2020.02.015
  1. OSHA. Caring for our caregivers: facts about hospital worker safety. September 2013. Accessed January 19, 2021. Available online at
  2. Johnson DD. Efficacy of a novel thoracopelvic orthosis in reducing lumbar spine loading and muscle fatigue in flexion: A study with weighted garments (doctoral dissertation). Accessed January 19, 2021. Available online at
  3. Jaret P. Attracting the next generation of physicians to rural medicine. Association of American Medical Colleges. February 3, 2020. Accessed April 27, 2021. Available online at
  4. Goetzel R, Roemer E, Liss-Levinson R, Samoly D. Workplace health promotion: policy recommendations that encourage employers to support health improvement programs for their workers. A Prevention Policy Paper Commissioned by Partnership for Prevention. December 2008. Accessed April 27, 2021. Available online at
  5. Qaseem A, Wilt TJ, McLean RM, et al; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017 Apr 4; 166(7): 514-530. doi: 10.7326/M16-2367
  6. Christenssen W. Stretch exercises: reducing the musculoskeletal pain and discomfort in the arms and upper body of echocardiographers. Journal of Diagnostic Medical Sonography. 2001;17(3):123-140. doi:10.1177/87564790122250318
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  8. Kuorinka I, Jonsson B, Kilbom A, et al. Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl Ergon. 1987 Sep;18(3):233-237. doi: 10.1016/0003-6870(87)90010-x
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  10. Lenderink A, Zoer I. Review on the validity and reliability of self-reported work-related illness. Health and Safety Executive. 2012. Accessed April 27, 2021. Available online at
  11. Beresic N. Examining low back pain prevention strategies in the electrophysiology and catheterization lab (Doctoral dissertation). 2019. Accessed April 27, 2021. Available online at
  12. Goldstein JA, Balter S, Cowley M, eta l; Interventional Committee of the Society of Cardiovascular Interventions. Occupational hazards of interventional cardiologists: prevalence of orthopedic health problems in contemporary practice. Catheter Cardiovasc Interv. 2004 Dec;63(4):407-411. doi: 10.1002/ccd.20201