Musculoskeletal Disorders among Dentists in Saudi Arabia
MUSCULOSKELETAL DISORDERS AMONG DENTISTS IN SAUDI ARABIA
*TARIQ ABDULLAH ABDULJABBAR, BDS, MSC, DMSc.
ABSTRACT
The objective of the study was to find out the prevalence and distribution of musculoskeletal
symptoms among dentists in Saudi Arabia. Furthermore, to find possible correlations between these
symptoms and working positions and actions. A questionnaire about musculoskeletal symptoms in
different parts of the body was completed by 140 dentists (63 male, 77 female) from the public dental
service clinics in Dammam and Riyadh cities. Also, a physical ergonomic examination was carried out
during visiting the work places of 60 freshly graduated dentists in King Saud University College of
Dentistry, Dammam Central Hospital and the Military Hospital in Al-Khobar. The following aspects
were investigated: the sitting work posture, the clock-related working position, the use of dental mirror,
active neck mobility and support of the left arm. The descriptive data were analyzed and chi-square test
was used for statistical significance (P<.05). Eighty-three of the responding dentists had pain or
discomfort from the neck, shoulders, lower back or head. Younger dentists had more symptoms than
the older dentists. The female dentists had a significantly higher frequency of pain, headache and
weakness than their male counterparts. Pain and headache were the most commonly reported
symptoms. The dentists who use the mirror more often had less pain or discomfort in the upper
locomotor system than those who do not. The analysis of the ergonomic examination showed that the
most frequently used postures were posture 1 (the whole back bent, the seat straight) and posture 3
(straight lower and upper back, the neck bent, the seat straight) (46.7% and 40.0% respectively). Dentists
who used posture 1 have more neck ache (25%) and lower back pain (57.1%) than those who used posture
3. No significant difference was found between male and female dentists in regard to the presence of
pain (P>.05). The 10 o’clock position was the most frequently used working position by the dentists.
Most of dentists supported their left arm over the left side of the head of the patient. It can be concluded
that the prevalence of musculoskeletal symptoms among dentists in Saudi Arabia is high. A correlation
between back pain and different work actions was observed in this investigation.
Key words: Musculoskeletal disorders, Occupational health, Dentists in Saudi Arabia, Working
positions.
INTRODUCTION
Occupational health hazards are common in many
sectors and are on the increase. Musculoskeletal disorders (MSDs), which are problems of musculoskeletal
system, are significant and costly workplace problems
affecting occupational health, productivity and the
careers of the working population. Musculoskeletal
diseases, including pain, weakness and parasesthesia,
are reported to be associated with wide range of
occupations 1-6. Nearly 2 million workers suffer from
musculoskeletal disorders each year. These problems
are caused by repetitive, awkward, or stressful motions 7. Dental personnel had an increased risk of
developing such disorders 8, 9.
Physically unfavorable load is probably an essential factor in the emergence of symptoms in the upper
locomotor system. However, it should be indicated that
other factors can contribute to the development and
* Assistant Professor, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University,
Riyadh
Correspondence: Dr. Tariq Abdullah Abduljabbar, P. O. Box 60169, Riyadh 11545, Saudi Arabia. Cell: (966)
504413113, Phone: (966) 1- 467 7325, Fax: (966) 1- 465 6663, Email: [email protected]
Pakistan Oral & Dental Journal Vol 28, No. 1
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Musculoskeletal Disorders among Dentists in Saudi Arabia
the experience of pain and discomfort. Later investigations indicated that causes in the psychic working
environment such as work satisfaction, the level of
appreciation, self-confidence, anxiety and worry about
the future can also influence the experience of pain and
discomfort. Rundcrantz et al. 10 emphasized that dissatisfaction with work, demand of performance, anxiety,
psychosomatic sickness (headache, insomnia, stomach
trouble) and concern about the future, can be strong
contributing factors in pain and discomfort perception.
He concluded that these factors together may give rise
unsatisfactory personal harmonity, which probably
increases the risk of pain and discomfort.
The physical load among dentists seems to put
them at risk for the occurrence of musculoskeletal
disorders. Muscular imbalance, neuromuscular inhibition, and pain and dysfunction may frequently be
observed among oral health care providers. Repeated
unnatural, deviated or inadequate working postures,
forceful hand movements, inadequate equipment or
workplace designs and inappropriate work patterns are
likely to be the particular risk factors. However, MSDs
are not an avoidable part of the oral health care
providers’ professional lives 11-13.
The high frequency of musculoskeletal disorders
probably reflects the specific work load in dentistry,
with high demands on vision and precision and fine
manipulative hand movements and work with unsupported, elevated arms. The symptoms might impair
work capacity and the future possibility to stay in the
profession. Studies have shown that active leisure and
several psychosocial work factors strongly influence
good general health and well-being. Physical tasks
influence musculoskeletal disorders more than active
leisure and psychosocial work factors 14-17.
The possible pathophysiological mechanism of occupational stress on the neck and shoulders has been
reviewed by Hagberg 18. A mechanical origin for cervical disc degeneration and osteoarthrosis is reported for
a few occupational groups. However, a mechanical
origin for osteoarthrosis is debatable. A work posture
involving elevated arms may accelerate degeneration
of shoulder tendons through impairment of circulation
due to static tension and humeral compression against
the coracoacromial arch. Furthermore, work tasks
with repetitive arm movements may evoke shoulder
Pakistan Oral & Dental Journal Vol 28, No. 1
tendinitis or tendo-vaginitis, probably due to friction.
The three possible routes to neck-shoulder muscular
pain are mechanical failure, local ischemia and energy
metabolism disturbance. The high frequency of symptoms from the neck, shoulders, and upper extremities
of the dentists was probably related to their difficult
work positions with cervical flexion and rotation, abducted arms, and repetitive precision-demanding
handgrips18 .
A high proportion of dental practitioners suffer
from backache 19, 20. A dentist would have approximately
50% chance for partial or complete premature retirement due to ill health. Data collected in the 1940’s
revealed that more than 65 percent of dentists suffered
backache 21. Ever since, many major changes have
occurred in dentistry such as: a change to “sit-down”
technique; improved design of most dental equipments
and increased utilization of motion- economy principles, e.g., four-handed dentistry. Chronic musculoskeletal pain appears early in dental careers, with more
than 70 percent of dental students of both sexes reporting pain by their third year22, 23. MSD was shown to
interfere with daily activities in some cases, while a
considerable proportion of dentists had also sought
medical attention for their symptoms24, 25. The dentists
in the Public Dental Service were found to have a high
prevalence of pain and discomfort in the locomotor
system. Female dentists had a higher prevalence of
pain and discomfort. Younger dentists had pain and
discomfort in the neck, shoulders and headaches than
older dentists. Male dentists, who positioned their
patient carefully to gain a direct view, suffered less
from headache. Furthermore, dentists who used the
mirror reported less headache and pain and discomfort
in the shoulders. The ergonomic examination showed
that dentists without symptoms applied a wedge cushion under the upper part of the patient’s back to obtain
an optimum view. Specialists, both with and without
cervico-brachial symptoms, were more satisfied with
their personal control over their work and the stimulation from their work than were general practitioners. Physiotherapy with a psychosomatic approach
and individual ergonomic instruction gave better relief
from pain and discomfort and an increased feeling of
mental well-being than did ergonomic instruction only.
Personal harmony and age had the highest value for
explaining the number of painful sites in the muscu136
Musculoskeletal Disorders among Dentists in Saudi Arabia
loskeletal system 26. The frequency of lower extremity
complaints was low, and only a few of these complaints
were considered work-related27.
Basic operating posture is considered an important
occupational health issue for oral health care clinicians. It is generally agreed that the physical posture
of the operator, while providing care, should be such
that all muscles are in a relaxed, well-balanced, and
neutral position. Postures outside of this neutral position are likely to cause musculoskeletal discomfort 28.
Ergonomics is the application of a body of knowledge
addressing the interactions between man and the total
working environment, such as atmosphere, heat, light
and sound, as well as all tools and equipment of the
workplace. Work related musculoskeletal injuries,
caused by poor posture, have been discussed in human
dentistry for several years. Neglect of ergonomic principles brings inefficiency and pain to the workplace. An
ergonomically deficient workplace may not cause immediate pain, because the human body has a great
capacity for adapting to a poorly designed workplace or
structured job. However, in time, the compounding
effect of job and/or workplace deficiencies will surpass
the body’s coping mechanisms, causing the inevitable:
physical symptoms, emotional stress, low productivity,
and poor quality of work 29, 30.
Since 1992 the Occupational Safety and Health
Administration (OSHA) has been preparing Federal
legislation concerned with ergonomic hazards in atrisk workplaces 31. Ergonomics is the study of people at
work to understand the complex relationships among
people, machines, job demands, and work methods. As
long as stress is kept within reasonable limits, work
performance will be satisfactory and the worker’s
health and well-being will be maintained. However, if
stress is excessive, undesirable outcomes may result in
the form of accidents and injuries. A variety of musculoskeletal injuries and disorders can be caused by
physical stress in the work environment. Because of
the high medical and compensation costs associated
with these problems, it becomes essential in many
manufacturing situations to implement programs for
controlling physical stress. An important part of any
control program is job evaluation 32, 33.
The epidemiologic data regarding MSDs have been
obtained from many countries and societies14, 16, 34, 35.
Pakistan Oral & Dental Journal Vol 28, No. 1
There is no sufficient information about the spread of
such disorders in Saudi Arabia 36. The purpose of this
research was to study the prevalence and distribution
of symptoms of MSDs among dentists in Saudi Arabia.
Also, the relationship between these symptoms and
work sitting postures of newly-graduated dentists was
to be identified.
MATERIALS & METHODS
I.
Questionnaire
In the first part of the investigation, 300 questionnaires concerning analysis of musculoskeletal symptoms in different parts of the body were randomly
distributed in the Public Dental Service Clinic in
Dammam and Riyadh cities. The questionnaire, as
shown in table 1, was adopted and modified from forms
in previous studies 10, 19. Only 46.7% of dentists (140: 63
male, 77 female) responded by answering the questionnaire.
II. Ergonomic Examination
In the second part of the study, physical examination was carried out during visiting the work places of
60 freshly graduated dentists in KSU Dental College,
Dammam Central Hospital and the Military Hospital in
Khobar. After the physical examination was carried
out, the dentists were asked if they have any of
musculoskeletal symptoms. All dentists were asked to
examine the distal surface of the left maxillary first
molar. The following aspects were investigated:
A. The sitting work postures
The sitting position of the dentist while working on
a simulated case was registered according to Fig 1.
B. The clock-related working position
With the mouth of the patient as the center of a
circle, the dentist’s working positions are described
according to the figures on a clock dial (Fig 2).
Consequently, twelve o’clock corresponds to the
dentist sitting behind the head of the patient.
C. The use of dental mirror
D. Active neck mobility (The mobility was graded
as normal, moderately restricted and very restricted).
137
Musculoskeletal Disorders among Dentists in Saudi Arabia
F. Support of the left arm
The chi-square test was used for statistical analysis. A probability level of P<.05 was accepted as statistically significant.
RESULTS
Results of the questionnaire
The results showed that dentists without symptoms are somewhat older than those with symptoms.
They have also been in the profession for a longer time.
It was found that dentists who have increased the
working-hours per week showed more symptoms. No
significant difference was found between male and
female dentists (Table 2).
A. The whole back bent the seat straight B. Straight
lower and upper back , the neck bent, the seat straight
C. The whole back bent, the seat forward tilted D.
Straight lower and upper back, the neck bent, the seat
forward tilted.
Fig 1: The four sitting work positions
E. Ability to perform active mobility of the shoulders was registered using the following tests;
•
The arm behind the back with the fingertips
touching the opposite inferior angulus of
scapula.
•
The arm over the head with the hand touching
the opposite ear.
Of the 140 dentists who answered the questionnaire, 82.9% dentists (63 male and 77 female) had one
or more symptoms in the musculoskeletal system,
which include pain (59.3%) as the most severe symptom
in the neck and shoulders region followed by headache
(28.6%), then weakness (15.7%). The female dentists
had a significantly higher frequency of pain, headache
and weakness than their male counterparts (Table 3).
Eighty-three dentists (59%) had pain and discomfort in
different parts of the locomotor system during the
previous 12 months. The highest percentage of dentists
had pain and discomfort in the neck (67.9%) followed by
the lower back (52.1%). The symptoms were most
pronounced among female dentists (Table 4). The
dentists who reported symptoms during the previous
seven days had the highest frequency of pain and
discomfort in the neck, shoulders, lower back region
and/or headache.
When the operating position of the dentist in
relation to the patient was described as clock face
with the patient’s mouth as the centre of the dial,
67.9% of the dentists reported using a position
between 10 and 12 o’clock. Dentists who used
9 o’clock position reported more symptoms (76.5%),
while dentists who used 10 o’clock position reported
the lowest symptoms (48.3%). Only 17 dentists with
symptoms from neck and lower back used position 12
o’clock.
Fig 2: The working positions according to a clock
figure.
Pakistan Oral & Dental Journal Vol 28, No. 1
Participants were asked to indicate how long they
worked without taking a 10- minute break. Respondents were categorized according to the length of time
138
Musculoskeletal Disorders among Dentists in Saudi Arabia
Please answer by putting a cross in the appropriate box - one cross for each question
(To be answered only by those who have had symptoms).
Have you, at any time during the last
12 months, had symptoms (ache,
pain, discomfort)?
Neck
1. No
At any time during the last
12 months that interferes
with normal work?
2. Yes
At any time during
the last 7 days?
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
Shoulders
1. No.
2. Yes, in the right
3. Yes, in the left
4. Yes, in both shoulders
Elbows
1. No
2. Yes, in the right
3. Yes, in the left
4. Yes, in both elbows
Wrists/hands
1. No
2. Yes, in the right
3. Yes, in the left
4. Yes, in both
Upper back
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
One or both hips/ thighs
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
One or both knees
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
2. Yes
1. No
2. Yes
1. No
2. Ye
Lower back
One or both ankles/feet
1. No
TABLE 1. THE QUESTIONNAIRE USED IN THE STUDY
With symptoms
(mean±SD)
Without symptoms
(mean±SD)
Male (n=45)
Female (n=71)
Male (n=18)
Female (n=6)
Age
42.31±7.61
38.7±5.87
47.44±12.21
39.17±7.88
Years inprofession
15.56±8.14
7.38±4.48
21±10.59
13.17±7.39
Working hours per week
42.30±7.0
34.69±9.23
32.27±15.74
39.5±5.05
TABLE 2. DEMOGRAPHIC DATA OF THE DENTISTS INVOLVED IN THE STUDY.
Pakistan Oral & Dental Journal Vol 28, No. 1
139
Musculoskeletal Disorders among Dentists in Saudi Arabia
Symptoms
Total (n=140)
Male (n=63)
Female (n=77)
No
%
No
%
No
%
Pain
83
59.3
36
57.1
47
61
Headache
40
28.6
8
12.7
32
41.6
Numbness
11
7.9
5
7.9
6
7.8
Weakness
22
15.7
4
6.3
18
23.4
Pins & Needles
5
3.6
1
1.6
4
5.2
TABLE 3. FREQUENTLY REPORTED SYMPTOMS
Total (%)
Male (%)
Female (%)
Pain
59
57.1
61
Neck
67.9
66.7
68.8
Right
25
30.2
20.8
Left
5
7.9
2.6
Both
16.4
3.2
27.3
52.1
52.4
51.9
Right
2.9
3.2
2.6
Left
0
0
0
Both
0
0
0
Right
14.3
11.1
16.9
Left
1.4
3.2
0
Both
3.6
0
6.5
One or both hips/thighs
3.6
4.8
2.6
One or both knees
7.1
1.5
11.6
One or both feet/ankles
0.7
0
1.3
Shoulder
Lower back
Elbow
Wrist/Hand
TABLE 4. MUSCULOSKELETAL PAIN AND DISCOMFORT IN DIFFERENT PARTS OF THE BODY
DURING THE PAST 12 MONTHS AMONG MALE AND FEMALE DENTISTS
Symptoms
Number of dentists
with pain
Number
Percentage
Pain
19
86.4
Neck
Shoulder
17
10
77.3
45.5
Lower back
18
81.8
TABLE 5. CORRELATION OF SYMPTOMS
WITH WORKING WITHOUT A
10-MINUTE BREAK (n=22)
Pakistan Oral & Dental Journal Vol 28, No. 1
Posture
Neck
Pain (%)
Shoulder
Posture A
25
16.7
57.1
Posture B
21
14.3
8.3
Lower back
TABLE 6. THE PRESENCE OF SYMPTOMS IN
RELATION TO THE MOST FREQUENTLY
USED SITTING POSTURES AS SHOWN IN THE
FIGURE #1
140
Musculoskeletal Disorders among Dentists in Saudi Arabia
they worked before taking a 10-minute break into
periods of one hour duration. The most commonly
selected time period was of 1-2 hours duration (Table
5). It was found that increasing the length of working
time without 10-minute break for more than 3 hours is
usually associated with increased pain and discomfort
(86.4%), lower back pain (81.8%), and neck pain (77.3%).
Eighty-nine percent of the sample reported that
they practice four-handed dentistry, with 57%
complaining of one or more of the musculoskeletal
symptoms. The symptoms had been decreased with
dentists who used the dental mirror all the time.
According to the patient position, about 72.1% dentists
use the supine position as the preferred patient position. Sixty-eight percent of them had pain in the neck
and shoulders.
Results of the Ergonomic Examination
During the examination of the left maxillary first
molar by 60 recently graduated dentists (30 female, 30
male), the results showed that the most frequently
used postures were posture 1 (46.7%) and posture 3
(40.0%) in both groups (Fig 2). Dentists who used
posture 1 have more neck ache (25%) and lower back
pain (57.1%) than those who used posture 3 (Table 6).
No significant difference was found between male and
female dentists in regard to the presence of pain
(P>.05). The 10 o’clock position was the most frequently used working position by the dentists. Most of
dentists used the dental mirror during the examination
of the left maxillary first molar. Most of dentists
supported their left arm over the left side of the head
of the patient.
Moderate restricted mobility was found only in a
few dentists without significant differences between
groups and restriction was most common during flexion of the neck. However, no significant difference was
found between dentists with and without pain and
discomfort concerning the neck mobility. All dentists
were able to perform the active mobility tests of the
shoulders without difficulty.
DISCUSSION
The dentists were asked to note the occurrence of
pain and discomfort over the past twelve months and
the previous seven days. The questionnaire gives
answers only with respect to the occurrence of sympPakistan Oral & Dental Journal Vol 28, No. 1
toms and not to the frequency and intensity of pain and
discomfort. Furthermore, the results are based on a
visit to the workplace of 60 newly-graduated dentists
and on a structural interview.
The investigation showed that the frequency of
headache and also pain and discomfort in the neck,
shoulders and lower back, was relatively high. This
corresponds with earlier investigations from different
parts of the world 22, 24, 26, 27. Only 24 dentists, out of the
140 who answered the questionnaire, were completely
without pain and discomfort in the locomotor system.
The female dentists had a significantly higher frequency of pain, headache and weakness than their
male counterparts. This could be explained because
female usually has lower threshold of tolerance than
male. Furthermore, the results showed that the frequency of pain and discomfort had tendency to decrease
with age and with the number of year in practice. The
low occurrence of pain and discomfort among older
dentists may be due to the “healthy workers effect” and
due to the ignorance of ergonomics in the new dental
curriculum. In addition, older dentists have been taught
to more frequently use the dental mirror for directly
inaccessible areas in the patient’s mouth. While older
dentists are more specialized with less load of patients,
younger dentists are mainly practicing general dentistry or enrolled in postgraduate training that put
them under more pressure. Instead of using the dental
mirror, younger dentists work more often with a direct
view and with the use of wedge cushion to improve the
view. However, there was no correlation between the
frequency of symptoms and the age. It appeared from
the results that the dentists who position their patients
in a appropriate position for direct view had a significantly lower frequency of pain. In agreement with
previous study the results showed that dentists who
usually use the dental mirror in positions where a
direct view is difficult had significantly less pain and
discomfort 37.
In regard to the ergonomic examination, the left
maxillary first molar was chosen because it is difficult
to obtain a direct view in such area from the mouth
without bending the neck into an unfavorable way. The
direct view may be improved by putting the wedge
cushion under the upper part of the back of the patient.
Also, it is important to support the arms to reduce the
static work of the muscles of the neck and shoulders. If
141
Musculoskeletal Disorders among Dentists in Saudi Arabia
the dentist works with direct vision, it is probably
appropriate for him to sit in the 9 o’clock position when
working in the upper jaw to reduce the stress on the
neck. In the working position 11 or 10 o’clock, the
dental mirror should be used to reduce the load on the
neck.
The appearance of musculoskeletal symptoms
among dental students, even after a relatively short
clinical training period, suggests that ergonomics should
be covered in the educational system to reduce risks to
dental practitioners 38. Valachi et al 39 showed that there
are deficiencies in operator position, posture, flexibility, strength and ergonomics. Education and additional
research are needed to promote an understanding of
the complexity of the problem and to address the
problem’s multifactorial nature. A comprehensive approach to address the problem of MSDs in dentistry
represents a paradigm shift in how operators work.
New educational models that incorporate a multifactorial approach can be developed to help dental operators
manage and prevent MSDs effectively. Physiological
changes that accompany these disorders can be related
to practices used by today’s operators-primarily being
seated for prolonged periods. Studies associated such
postures with increased disk pressures and spinal
hypomobility, which are factors that may lead to degenerative changes within the lumbar spine and low back
pain or injury. There is a relationship shown between
prolonged, static (motionless) muscle contractions and
muscle ischemia or necrosis. Weak postural muscles of
the trunk and shoulder may lead to poor operator
posture. As muscles adapt by lengthening or shortening to accommodate these postures, a muscle imbalance may result, leading to structural damage and
pain. A significant number of today’s dental operators
experience musculoskeletal pain and are at risk of
developing serious MSDs. A thorough understanding of
the underlying physiological mechanisms leading to
these problems is necessary to develop and implement
a comprehensive approach to minimize the risks of a
work-related injury.
Work-related musculoskeletal disorders are of serious concern to many organizations, including industry, insurance, and health care. They are also of
immediate concern to the workers and their families
who are adversely affected by these disorders. Workrelated musculoskeletal disorders are a substantial
Pakistan Oral & Dental Journal Vol 28, No. 1
source of economic drain to these organizations. Sources
of this drain include economic losses incurred from lost
or decreased productivity as well as medical treatment
and indemnity costs. Therefore, it is within the best
interest of these organizations to prevent work-related
musculoskeletal disorders from occurring, before they
manifest into serious issues of medical, social, and
economic concern. The dental teams need functionally
designed dental equipment and proper training in
ergonomic methods 40-42. Therefore it is useful to take
again a closer look at the preventive measures that can
contribute to less physical and psychological strain in
the daily practice 43. The use of ergonomic design and
appropriate selection of hand tools can reduce exposure to cumulative trauma. Remember, tissues of each
individual have a threshold of resistance, and if that
threshold is crossed too many times by a defective or illfitting tool, pathologic changes can occur. The proper
tool design, rotating work schedules, work pacing,
scheduling, and exercise programs can, in combination, improve productivity and promote human wellness14, 44-47. Although there have been considerable
advances in dental equipment, the introduction of
such technology has often been piecemeal and “rushed
to market.” As a result there has been insufficient
attention paid to ergonomic considerations and a systematic approach to dental ergonomics have not yet
emerged 48.
Dentists can recognize and identify their own
postures, practicing positions, and the equipment usage patterns that are associated with increased risks of
experiencing musculoskeletal pain and discomfort.
Such recognition is the first critical step to avoiding or
neutralizing ergonomic habits and work environment
layouts that might otherwise unnecessarily shorten
professional clinical careers 49. Further studies are
required to identify the factors, which will reduce the
prevalence of the musculoskeletal symptoms among
Saudi dentists.
CONCLUSIONS
Within the limitations of the present research, the
following conclusions can be drawn down:
1
The results suggested that the prevalence of
musculoskeletal symptoms among dentists in
Saudi Arabia is high.
142
Musculoskeletal Disorders among Dentists in Saudi Arabia
2
Pain and headache were the most commonly
reported symptoms.
3
Younger dentists had more symptoms than the
older dentists. The female dentists had a significantly higher frequency of pain, headache
and weakness than their male counterparts.
4
Modification of the workplace does not have an
effect on the prevalence of symptoms.
14
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