JORT Journal

Introduction

Low Back Pain (LBP) is a worldwide condition that affects individuals in all age groups [1]. It is commonly recognized as a health, social and economic burdens in western countries. The onset of LBP is believed to be influenced by numerous variables such as age, gender, smoking habit, poor working posture and stress [2-4]. Although the frequency of LBP increases with age [1], the prevalence among adolescents (18 to 24 years) varies between 14% to 40% [5,6]. Previous studies found that students are prone to various musculoskeletal disorders such as LBP since they are exposed to stress and spend hours in prolonged sitting in most of their daily activities [7-9]. Cakmak and colleagues for example, have reported that lifetime prevalence of LBP among Turkish university students is approximately 41% [10]. Students in the health professions face extra physical demands in their clinical experiences, which include manual and repetitive activities that increase the risk for LBP. In addition, they seem to be at a higher risk for back pain during their academic years before commencement of their full-time clinical duties [11,12]. A recent study has found that final year Swiss female students in health professions manifested a higher prevalence of LBP compared to the general and demography-stratified population [13]. Others have found that the onset of LBP among physiotherapists and nurses begins during their academic studies [14-16]. This leads to the realization that LBP preventive strategies should be initiated among undergraduate students due to their considerable influence on the future workforce and economy. Reported overall prevalence of LBP in health science students ranges between 40% to 58%, but there is controversy regarding which program has the highest prevalence of LBP [1,17]. Accordingly, a prospective study in order to reveal whether health science undergraduates are considered risk factors for LBP is required. Therefore, the aims of the current study are (1) to determine the prevale nce and the characteristics of LBP among first-class health science undergraduate students and (2) to establish the common associated factors related to this population.

Methods

Study Design

Quantitative cross-sectional study was conducted at four health science programs (Nursing, Physical Therapy, Medical Laboratory Sciences and Emergency Medical Services), at Zefat Academic College in the north of Israel. A consent form, which included the purpose of the study and the right of the participant to withdraw at any time, was received from each participant. This survey was conducted in adherence to the Helsinki Declaration and approved by the Departmental Research Ethics Committee, Zefat Academic College (no. 19-2022).

Subject Selection And Instrument

All first-year students (n=222) who were enrolled during May 20212022 academic year in the health science programs at Zefat Academic College were eligible to participate. Only first-year students were invited in order to enable follow-up of these undergraduates and their LBP characteristics for the next 2-3 years. There were no exclusion criteria. First-year curriculum for all the health science programs contains a predominance of theoretical courses without clinical experiences. A self-administered written questionnaire considers the most common method to determine the prevalence of LBP [18]. The hardcopy questionnaire was distributed and explained by one of the authors (towards the end of the second semester) at the beginning / or end of the class at which all students are expected to be present. Completing the questionnaire took 10-15 minutes and they were then collected by the research assistants. The study data were collected from the forms that had been completed in full. In order to ensure the anonymity of the participants, we assigned each with a code number for the purpose of statistical analysis. A structured and anonymous questionnaire that was based on the validated Standarised Nordic Questionnaire [19] included the following variables: gender, age, marital status, program, dominant hand, height, weight, pregnancy and ethnicity (e.g., Jewish and Muslims). We also collected information about religion/faith, sedentary behavior, tobacco use and study-related stress [20] that was graded as follows: (a) very high to quite high and (b) none to very little” (Table 1). Data about physical activity were adapted from the American College of Sport Medicine guidelines [21] and then were graded into three levels: low, moderate and high. History of hospitalization as well as medication use, disability and seeking care due to LBP during the previous year were also reported.

Disability was defined according to the four items of Oswestry Disability Index (ODI) following the study of Falavigna and colleagues [22]. Body mass index (BMI) was calculated as weight (kg) divided by height squared in meters. The students were asked if they had ever experienced LBP at some point in their lives (lifetime prevalence), and if they had suffered during the previous month. Pain frequency during the previous year was also recorded and ranged from (1) several times a day to (4) rarely or never (Table 4). LBP was defined as pain in the area from below the ribs to the hips [23]. Pain intensity during the previous month was assessed by the numerical rating scale ranging from zero to ten [23] and the severity of pain was defined as when the intensity scale was above five. The questionnaire was piloted on 10 student, who were selected randomly from the physiotherapy department (second and third years) to ensure its clarity.

Statistical Analysis

Statistical analysis was carried out via SPSS version 20. The parametric variables (e.g., age, and height) were checked for normal distribution. In order to compare programs of study and gender for categorical and metric variables, we used Chi square test, MannWhitney test or independent T-test analyses, respectively. Logistic regression analysis (method - forward LR) was also used to detect the odds factors for LBP during the previous month (dependent variable - LBP, independent variables - age, gender, BMI, physical activity, sedentary behavior etc.). Significant difference was noted when the P value was ≤ 0.05.

Results

Demographic and Lifestyle Feature of the Students

A total of 197/222 (88.7%) students were evaluated, in which the majority were females (75%) (Table 1). The mean age and BMI values for all the participants were 23 ±3.5 years (19-47) and 23 ±3.8 (15.6-38), respectively. The majority of the students were Muslim (38.6 %) and Jewish (36.5%) versus Christian (13.2%) and Druze (11.7%). However, the distribution of this ethnicity was significantly different among the four courses (P<0.001). We also noted that the mean age of the physicaltherapy students was significantly higher than the students in the other courses of study. Ninety-three percent (n=184) of the students were single and 15% were habitual smokers. It was observed that 43% of the students defined themselves as traditional, 30% as secular, 18% as religious or orthodox and 14% others. This distribution was significantly different among the courses of study (P<0.001) (Table 1). Among all students, a great prevalence (85%) of them experienced study-related stress graded from very high to quite high. Regarding gender, males have greater BMI and reported more smoking than females (P<0.001) (Table 3). In addition, 44.9% of males define themselves as secular versus 25.7% of females (P<0.002). In this study there were no pregnant students.

BMI-body mass index, SD-standard deviation, n-number.

Table 1: General characteristics of sample and comparisons between programs.

OR- odds ratio, CI- confidence interval.

Table 2 : Variables significantly associated with the prevalence of LBP at the last month among all students.

BMI-body mass index, SD-standard deviation.

Table 3: Variables significantly associated with gender.

Physical Activity and Sedentary Behavior

We found that approximately half of the participants (54%) were involved in physical activity (Table 1) and 53% of them exercised a moderate to high level. Males were significantly more active than females (P<0.001) (Table 3). Our results also indicate that 32% of students spend up to 8 hours a day sitting down, 30% of them between 6-8 hours and 38% sit more than 8 hours a day (Table 1). Forty percent of the students were involved in prolonged sitting up to 3 hours a day.

Low Back Pain (LBP)

For all students, the prevalence of LBP at some point in life and during the last month were 74% (146/197) and 61% (121/197), respectively (Figure 1). No significant differences were found in the prevalence of LBP (lifetime and previous month) among the four programs. However, females had a greater prevalence of LBP during the previous month compared to males (P=0.016) (Table 3). We also noticed that 38.8 % of students who suffered from LBP during the previous month (47/121) reported that their LBP pain reached above 5 on the pain intensity scale (Figure 2). The highest prevalence of pain severity was found among nursing students (46%) whereas the lowest one was in the medical laboratory program (24%). However, no significant difference was noted in pain severity between the different courses (P=0.090) (Figure 2). Frequency of LBP among all students during the last year was variable: 17% (n=34) of them suffered several times a day, 24% (n=47) several times a week and 22% (n=43) several times a month (Table 4). The impact of LBP on those undergraduates who experienced pain (several times/day to several times/month) was as follows: 31.4% (n=39/124) sought care from clinicians and used medication, 52.4% (n=65/124) had disability in daily activities and 6.4 % (n=8/124) have been hospitalized (Table 4). No significant differences were found regarding LBP features between the four courses (P>0.05) (Table 4).

Figure 1: Prevalence of low back pain at the last month and lifetime by program.

Figure 2: Prevalence of pain severity by program.

 Table 4 : Characteristics of LBP during the last year classified by program.

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