Technologies for Reducing Musculoskeletal Disorders in Nursing Workers: A Scoping Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This article presents a systematic review of the existing literature. The topic is highly topical and has significant practical relevance for improving the working conditions of nurses and preventing musculoskeletal disorders (MSDs). The selection of relevant scientific papers was carried out through reputable databases such as Web of Science, Scopus, ScienceDirect, PubMed, Taylor & Francis and ProQuest. Openly accessible patents were also included in the review. The literature was sorted and evaluated independently by two reviewers. The criteria for inclusion of studies were based on a predefined search string, which focused on technologies intended for the prevention of musculoskeletal disorders in nursing personnel.

The structure of the paper is logical and the review methodology is described in sufficient detail. Overall, the manuscript is well written and contributes to the existing literature in this area.

Within the framework of the presented review, several areas can be identified that could contribute to increasing the overall quality and informative value of work. Although technologies intended for the prevention of musculoskeletal disorders (MSDs) in nursing staff are systematically and clearly categorized, a deeper analysis of their real effectiveness, as well as the specific advantages and limitations of individual technological solutions, is absent. A more detailed comparison, for example, between robotic systems and passive lifting devices, including quantitative data on the reduction of MSDs, would be of significant benefit, which could significantly strengthen the professional discussion.

It would also be beneficial to include more quantitative data where available resources allow. Data such as percentage reduction in MSD incidence or return on investment would provide the reader with a better picture of the effectiveness of individual solutions and would allow for better comparisons between technologies.

I recommend publishing this manuscript after considering and incorporating the above comments. It is a valuable contribution that provides a comprehensive view of an important topic and has the potential to inform practice and future research.

Author Response

REVIEWER 1

We sincerely thank the reviewer for their valuable feedback and constructive suggestions, which have significantly contributed to improving the quality and clarity of our manuscript. We deeply appreciate the time and effort dedicated to providing such insightful comments. Their contributions have enriched our work and strengthened its academic rigor.

Reviewer comments

his article presents a systematic review of the existing literature. The topic is highly topical and has significant practical relevance for improving the working conditions of nurses and preventing musculoskeletal disorders (MSDs). The selection of relevant scientific papers was carried out through reputable databases such as Web of Science, Scopus, ScienceDirect, PubMed, Taylor & Francis and ProQuest. Openly accessible patents were also included in the review. The literature was sorted and evaluated independently by two reviewers. The criteria for inclusion of studies were based on a predefined search string, which focused on technologies intended for the prevention of musculoskeletal disorders in nursing personnel.

The structure of the paper is logical and the review methodology is described in sufficient detail. Overall, the manuscript is well written and contributes to the existing literature in this area.

Comment 1

Within the framework of the presented review, several areas can be identified that could contribute to increasing the overall quality and informative value of work. Although technologies intended for the prevention of musculoskeletal disorders (MSDs) in nursing staff are systematically and clearly categorized, a deeper analysis of their real effectiveness, as well as the specific advantages and limitations of individual technological solutions, is absent. A more detailed comparison, for example, between robotic systems and passive lifting devices, including quantitative data on the reduction of MSDs, would be of significant benefit, which could significantly strengthen the professional discussion.

Response 1

We have incorporated a more detailed analysis of these technologies, comparing approximate costs, typical settings, main preventive effects, scalability, and implementation feasibility, as presented in Table 9. Furthermore, in Section 3.2.2 and in the discussion, we have highlighted several references addressing the benefits of these technologies.

Comment 2

It would also be beneficial to include more quantitative data where available resources allow. Data such as percentage reduction in MSD incidence or return on investment would provide the reader with a better picture of the effectiveness of individual solutions and would allow for better comparisons between technologies.

Response 2

We have highlighted and compared the impact on injury reduction, the cost savings generated through the reduction of MSDs, and the ROI recovery period, as presented in Table 10.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

Congratulations for your work.

I have some concerns regarding your manuscript that you should address in an improved version.

• The title should reflect that the manuscript is a literature review
• I think there is a misunderstanding between caregivers and healthcare professionals. Caregivers can be non healthcare professionals that take care of people. You can read about both definitions, for example, in you reference #58.
• Introduction section, line 56 to 63: the text is confuse and should be rewritten. It starts by addressing MSDs, then moves to other occupational problems and it ends with MSDs.
• The figures captions should indicate the reference (when applicable).
• Overall, the introduction section is big and you repeat the same point a lot of times. You should read the text and try to improve the organization.
• You have many misunderstandings about terminology:
  • risk factors are not always well identified:
    • page 4, lines 19-21, insufficient personnel is not a risk factor is the cause for some risk factors (e.g., task duration, repetition, MMH, ...?). The same for the lack of preventive measures (they contribute to the risk factor, such as inadequate posture, static posture...?
    • page 4, lines 35-39: the 4 factors listed are types of risk factors. the risk factors are well identified in the Figure 4.
    • Table 2: many risk factors are inadequatly identified. Dynamic work is a risk factor? Why? Upper extremities disorders are not a risk factor (they can be the consequence). Uncomfortable postures are not risk factors neither the lack of preventive measures, inadequate conditions and deficit of professionals. All of these are problems derived from different natures but they can not be identified as risk factors.
    • all over the document you mix disorders with symptoms. For exaample, pain is a symptom not a disorder. Fatigue (with insufficient recovery time) is a potential cause of MSD. You must correct these scientific mistakes along the document (page 9, for example but not limited to this page, has a lot of errors regarding this issue).
    • to help you differentiating between MSD risk factors and symptoms, you can read the following documents: 10.1007/978-3-031-38277-2_16 ; 10.1016/j.ergon.2024.103597
    • Neck injury not neck damage
    • words as "optimize" should be replaced by "improve"
• Page 5, line 75-76: you write the main research question; however it does not make sense according to the text that is written in the next lines. After identifying one main research question, you identify 4 other research questions. But only RQ2 and RQ3 are aligned with the main reseach question identified in the first place. I reccomend to delete the part where you describe the main research question.
• What is the objective of the information presented in Table 1? You do not mention anything about the pontuaction in your results.
• Science Direct is included in scopus results so I do not see the need to search on science direct (N=22) if you search on scopus too (N=153).
• Page 8, line 64: do you say that inadequate posture, inadequate equipment and lack of preventive measures are tasks? I suppose it is a translation problem. Perhapes you want to say that these task involve...or are characterized by...
• Figure 6: It does not make sense presenting a figure summarising the contents of the section. All this (not about the section contents but the overall findings) should be described in text.
• I noticed a overuse of the word "ergonomic" as an adjective. Equipments are not ergonomic equipments (it a mistake in daily products due to marketing). Impact is not ergonomic (page 13, line 26). The same for the enviroment (page 13, line 31) and training (page 18, line 87).
• Page 8, line 46: what do you mean by "(...) present risk of musculoskeletal disorders associated with fatigue"?
• Page 9, line 67: falls and slips are related to safety not ergonomics.
• Page 9, lines 84-90: reference is missing
• Page 10, lines 20-37: references are missing
• You have two figures with number 7.
• Page 11, lines 44-56: references are missing
• In the beggining of the 3.2 section, you should explain what kind of technology you considered in each category
• I do not understand why do you present abbreviations if you never use them alone. You always write the complete name followed by the abbreviation between (). It is only necessary to do in the first time. After that, use the abbreviation.
• Page 14, lines 40-47 and figure 9: I do not understand why do you show this information. Regarding the keywords, it seems methodology. The Figure I do not understand at all.
• Page 15, line 74: instead of risk of low back pain, I suppose you want to say the risk of lower back disorders. Pain is a consequence of the disorder.
• Page 17: What do you mean by wearable medical devices? Patients should wear something? I suppose your study was focused on nurses not patients.
• You should present a summary of the answer to each one of the four research question (describing the main findings that address the RQ).
• Future prospects should be after the discussion section

Author Response

REVIEWER 2

We sincerely thank the reviewer for their valuable feedback and constructive suggestions, which have significantly contributed to improving the quality and clarity of our manuscript. We deeply appreciate the time and effort dedicated to providing such insightful comments. Their contributions have enriched our work and strengthened its academic rigor.

Reviewer comments

Congratulations for your work.

I have some concerns regarding your manuscript that you should address in an improved version.

Comment 1

The title should reflect that the manuscript is a literature review.

Response 1

It has been highlighted in the title that the work is a scoping review of the technologies

Comment 2

I think there is a misunderstanding between caregivers and healthcare professionals. Caregivers can be non healthcare professionals that take care of people. You can read about both definitions, for example, in you reference #58.

Response 2

It has been verified that the text clarifies the term health professionals and not caregivers in highlighted places in the text.

Comment 3

Introduction section, line 56 to 63: the text is confuse and should be rewritten. It starts by addressing MSDs, then moves to other occupational problems and it ends with MSDs.

Response 3

The wording has been improved for greater clarity and organization of information.

Comment 4

The figures captions should indicate the reference (when applicable).

Response 4

All figures are original and have been drawn using data from sources cited in the text where the respective figures are mentioned. The exact figures were not taken from the sources for inclusion in this manuscript.

Comment 5

Overall, the introduction section is big and you repeat the same point a lot of times. You should read the text and try to improve the organization.

Response 5

The wording has been improved and duplicate parts have been removed from the Introduction section.

Comment 6

You have many misunderstandings about terminology:

risk factors are not always well identified:

        page 4, lines 19-21, insufficient personnel is not a risk factor is the cause for some risk factors (e.g., task duration, repetition, MMH, ...?). The same for the lack of preventive measures (they contribute to the risk factor, such as inadequate posture, static posture...?

        page 4, lines 35-39: the 4 factors listed are types of risk factors. the risk factors are well identified in the Figure 4.

        Table 2: many risk factors are inadequatly identified. Dynamic work is a risk factor? Why? Upper extremities disorders are not a risk factor (they can be the consequence). Uncomfortable postures are not risk factors neither the lack of preventive measures, inadequate conditions and deficit of professionals. All of these are problems derived from different natures but they can not be identified as risk factors..

Responses 6

The lines and sections mentioned have been better written to improve the proper understanding of the risk factors and improve the overall clarity of the text.

Comment 7

all over the document you mix disorders with symptoms. For exaample, pain is a symptom not a disorder. Fatigue (with insufficient recovery time) is a potential cause of MSD. You must correct these scientific mistakes along the document (page 9, for example but not limited to this page, has a lot of errors regarding this issue).

to help you differentiating between MSD risk factors and symptoms, you can read the following documents: 10.1007/978-3-031-38277-2_16 ; 10.1016/j.ergon.2024.103597

Response 7

It has been better written to avoid confusing the reader on all the pages where these aspects are mentioned.

Comment 8

Neck injury not neck damage

words as "optimize" should be replaced by "improve"

Response 8

The wording has been improved and the word “improve” has been used.

Comment 9

Page 5, line 75-76: you write the main research question; however it does not make sense according to the text that is written in the next lines. After identifying one main research question, you identify 4 other research questions. But only RQ2 and RQ3 are aligned with the main reseach question identified in the first place. I reccomend to delete the part where you describe the main research question.

Response 9

The description of the main research question has been removed.

Comment 10

What is the objective of the information presented in Table 1? You do not mention anything about the pontuaction in your results.

Response 10

The description of Table 1 and its contribution to the manuscript have been included.

Comment 11

Science Direct is included in scopus results so I do not see the need to search on science direct (N=22) if you search on scopus too (N=153).

Response 11

We have verified that journals such as “next research (ScienceDirect)” are not listed in the SJR Scimago, which made us think that it is not SCOPUS, for this reason we have searched independently in the ScienceDirect repository, despite this, in the stage of eliminating duplicates, we have made sure not to duplicate these references in our manuscript.

Comment 12

Page 8, line 64: do you say that inadequate posture, inadequate equipment and lack of preventive measures are tasks? I suppose it is a translation problem. Perhapes you want to say that these task involve...or are characterized by...

Response 12

This error has been resolved and we have corrected it for clarity.

Comment 13

Figure 6: It does not make sense presenting a figure summarising the contents of the section. All this (not about the section contents but the overall findings) should be described in text.

Response 13

The findings on technologies have been included in Figure 6 and the content of the section has been removed.

Comment 14

I noticed a overuse of the word "ergonomic" as an adjective. Equipments are not ergonomic equipments (it a mistake in daily products due to marketing). Impact is not ergonomic (page 13, line 26). The same for the enviroment (page 13, line 31) and training (page 18, line 87).

Response 14

The clarity of the elements of this impact section has been improved to avoid confusing the reader according to the proposed comment.

Comment 15

Page 8, line 46: what do you mean by "(...) present risk of musculoskeletal disorders associated with fatigue"?

Page 9, line 67: falls and slips are related to safety not ergonomics.

Response 15

The ideas in the commented lines have been clarified for better understanding.

Comment 16

Page 9, lines 84-90: reference is missing

Page 10, lines 20-37: references are missing

You have two figures with number 7.

Page 11, lines 44-56: references are missing.

Response 16

The mentioned citations and references have been incorporated and the numbering of the manuscript figures has been resolved..

Comment 17.

In the beggining of the 3.2 section, you should explain what kind of technology you considered in each category.

Response 17.

Descriptions of the technologies mentioned in section 3.2 have been included.

Comment 18

I do not understand why do you present abbreviations if you never use them alone. You always write the complete name followed by the abbreviation between (). It is only necessary to do in the first time. After that, use the abbreviation.

Response 18

The entire manuscript has been reviewed and verified that the abbreviations are correct and their meaning is stated the first time they are mentioned.

Comment 19.

Page 14, lines 40-47 and figure 9: I do not understand why do you show this information. Regarding the keywords, it seems methodology. The Figure I do not understand at all.

Page 15, line 74: instead of risk of low back pain, I suppose you want to say the risk of lower back disorders. Pain is a consequence of the disorder.

Page 17: What do you mean by wearable medical devices? Patients should wear something? I suppose your study was focused on nurses not patients.

Response 19

The wording has been improved to enhance reader understanding in the commented lines and in the description of Figure 9.

Comment 20

You should present a summary of the answer to each one of the four research question (describing the main findings that address the RQ).

Response 20

A summary of the responses to each of the research questions has been included in the discussion and the findings for each question are addressed and synthesized.

Comment 21

Future prospects should be after the discussion section.

Response 21

The order of the sections has been corrected as discussed.

Reviewer 3 Report

Comments and Suggestions for Authors

This paper presents a literature review on prevention and intervention technologies for musculoskeletal disorders (MSDs) in the workplace, and attempts to categorize and evaluate different technological tools from an engineering control perspective. The authors constructed a three-stage classification framework of “prediction-sensing-intervention” and tried to integrate technologies such as wearable devices, sensor systems, wearable exoskeletons, visual recognition, AI-assisted assessment, etc., which demonstrated good integration thinking and engineering application orientation. Despite the relevance of the selected topic, the current version of the article still suffers from insufficient literature coverage, vague criteria for technology categorization, shallow levels of analysis, and loose logical organization, and it is suggested that the article should be substantially restructured and supplemented before re-review.

1. The objective of the review should be more focused, as it currently covers a wide range of technologies, and it is suggested that it should be clarified whether it is to “systematically categorize existing technologies” or to “propose a new analytical framework”.
2. The three-phase (prediction-detection-intervention) framework proposed in the paper should be further quantified or given clear discriminatory criteria to avoid cross-cutting and ambiguous areas.
3. More technical citations are stuck in 2016-2020, and it is recommended to add cutting-edge research in AI assessment, musculoskeletal modeling, and adaptive workstation systems since 2021. To provide more effective evidence, the authors may consider referring to the following updated relevant studies: Data-Driven Deep Learning for Predicting Ligament Fatigue Failure Risk Mechanisms (https://doi.org/10.1016/j.ijmecsci.2025.110519).
4. There is a lack of evaluation dimensions, and each type of technology is not set up with uniform comparison indicators (e.g., cost, applicable scenarios, preventive effects on different MSDs, etc.), and it is recommended that a comparative analysis table be introduced.
5. The analysis of technologies in the intervention category is weak, and the discussion of the classification and effectiveness of active exoskeletons or feedback sensing systems in particular is shallow; it is recommended that the depth of the discussion be expanded.
6. The structure of many charts and diagrams is loose, and it is recommended to merge the classification framework, technology flow chart, and the distribution of the number of studies, to unify the style of the legend and to improve the visual clarity.
7. Failure to assess practical issues such as scalability, difficulty of deployment, maintenance costs, etc., of various types of technologies in actual working environments.
8. The discussion section failed to rise to a theoretical summary. It could be further refined to summarize the evolutionary trend of MSD prevention technologies and suggest future directions.
9. The concluding section suggests the inclusion of specific research recommendations, such as which areas are yet to be broken through and which links can create technological synergies.

Author Response

REVIEWER 3   

We sincerely thank the reviewer for their valuable feedback and constructive suggestions, which have significantly contributed to improving the quality and clarity of our manuscript. We deeply appreciate the time and effort dedicated to providing such insightful comments. Their contributions have enriched our work and strengthened its academic rigor.

Reviewer comments

This paper presents a literature review on prevention and intervention technologies for musculoskeletal disorders (MSDs) in the workplace, and attempts to categorize and evaluate different technological tools from an engineering control perspective. The authors constructed a three-stage classification framework of “prediction-sensing-intervention” and tried to integrate technologies such as wearable devices, sensor systems, wearable exoskeletons, visual recognition, AI-assisted assessment, etc., which demonstrated good integration thinking and engineering application orientation. Despite the relevance of the selected topic, the current version of the article still suffers from insufficient literature coverage, vague criteria for technology categorization, shallow levels of analysis, and loose logical organization, and it is suggested that the article should be substantially restructured and supplemented before re-review.

Comment 1

The objective of the review should be more focused, as it currently covers a wide range of technologies, and it is suggested that it should be clarified whether it is to “systematically categorize existing technologies” or to “propose a new analytical framework”

Response 1

It has been emphasized in the title that this is a scoping review to underscore the systematic categorization of the identified technologies. Additionally, this aspect is also highlighted in the methodology section within the stated objectives.

Comment 2

The three-phase (prediction-detection-intervention) framework proposed in the paper should be further quantified or given clear discriminatory criteria to avoid cross-cutting and ambiguous areas.

Response 2

The differences between the three phases have been highlighted on lines 141-162

Comment 3

More technical citations are stuck in 2016-2020, and it is recommended to add cutting-edge research in AI assessment, musculoskeletal modeling, and adaptive workstation systems since 2021. To provide more effective evidence, the authors may consider referring to the following updated relevant studies: Data-Driven Deep Learning for Predicting Ligament Fatigue Failure Risk Mechanisms (https://doi.org/10.1016/j.ijmecsci.2025.110519)

Response 3

Some updated studies and missing citations have been included:

- 10.1016/j.ijmecsci.2025.110519

- 10.1080/21679169.2020.1715473

- 10.1186/s12912-024-01821-3

- https://patents.google.com/patent/EP0773773B1/en

- 10.1097/CIN.0000000000000949

Comment 4

There is a lack of evaluation dimensions, and each type of technology is not set up with uniform comparison indicators (e.g., cost, applicable scenarios, preventive effects on different MSDs, etc.), and it is recommended that a comparative analysis table be introduced.

Response 4

We have incorporated a comparative table that summarizes the most relevant dimensions for each group of technologies, including uniform criteria such as approximate cost, application scenarios, main preventive effects against different types of musculoskeletal disorders (MSDs), and level of scalability. This table aims to provide a clearer and more uniform view of the benefits and limitations of each type of technology, facilitating the interpretation and practical application of the findings..

Comment 5

The analysis of technologies in the intervention category is weak, and the discussion of the classification and effectiveness of active exoskeletons or feedback sensing systems in particular is shallow; it is recommended that the depth of the discussion be expanded.

Response 5

The discussion has been strengthened by considering the aspects discussed. Some findings have been incorporated in lines 821-832.

Comment 6

The structure of many charts and diagrams is loose, and it is recommended to merge the classification framework, technology flow chart, and the distribution of the number of studies, to unify the style of the legend and to improve the visual clarity.

Response 6

This aspect has been improved and the visual clarity of graphs and diagrams has been corrected, as well as highlighting comments that describe some of these graphs.

Comment 7

Failure to assess practical issues such as scalability, difficulty of deployment, maintenance costs, etc., of various types of technologies in actual working environments.

Response 7

Tables 10 and 11 have been included, in which these aspects are compared according to what has been found in scientific literature. In addition, citations that have been used and are updated have been included:

Bogue, R. (2023). Exoskeletons: Developments, applications and future prospects. Industrial Robot: The International Journal of Robotics Research and Application, 50(2), 181–190. https://doi.org/10.1108/IR-10-2022-0207

Öztürk, B., & Eski, M. Z. (2023). Exoskeleton technologies and their integration into healthcare settings: Challenges and opportunities. Technology and Health Care, 31(5), 455–466. https://doi.org/10.3233/THC-236013

Stolt, M., Miettinen, M., & Suhonen, R. (2022). Barriers and facilitators for implementation of assistive health technologies in clinical practice: A scoping review. Journal of Nursing Management, 30(8), 2991–3005. https://doi.org/10.1108/IR-10-2022-0207

Comment 8

The discussion section failed to rise to a theoretical summary. It could be further refined to summarize the evolutionary trend of MSD prevention technologies and suggest future directions.

Response 8

The evolutionary trend has been included in the future directions section, lines 981-995.

Comment 9

The concluding section suggests the inclusion of specific research recommendations, such as which areas are yet to be broken through and which links can create technological synergie.

Response 9

The comments have been included in the conclusions.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The previous concerns were addressed.

Reviewer 3 Report

Comments and Suggestions for Authors

All comments have been addressed.