Prevalence and Risk Factors for Low Back Pain in Industrial Workers

Abstract

The aim of the present study was to determine the prevalence of low back pain (LBP) in industrial workers, check for possible LBP related risk factors and investigate the associations between physical activity and severity of low back pain.
We conducted a cross-sectional study among 430 workers of an industrial company over the previous 12 months. The industrial workers were given questionnaires and assigned to two groups: (1) with low back pain, (2) without low back pain. Group 1 was then divided into three subgroups according to the answer to question (a) LBP without irradiation, called mild cases, (b) LBP with irradiation above the knee, called moderate cases, LBP with the irradiation below the knee, called severe cases.
LBP was found in 61.6% of workers. The prevalence of LBP was significantly associated with physical activity (p = 0.03). There was a significant difference between frequent physical activity and severity of LBP (p = 0.01). Work-related physical factors showed strong associations with LBP. The main risk factors for low back pain among production workers were extreme trunk flexion (OR = 3.5, 95% CI 1.7-7.3), as well as lifting of loads (OR = 3.5, 95% CI 1.9-6.2), pushing or pulling heavy loads (OR = 3.5, 95% CI 1.9-6.2) and exposure to whole body vibration (OR = 1.7, 95% CI 1.0 -3.0).
Daily life conditions, job-related factors are associated with the occurrence of low back pain. These results suggest that individuals with LBP should avoid nonspecific physical activities to reduce pain and improve psychological health.

Full text

68
Folia Medica 2011; 53(3): 68-74
Copyright © 2010 Medical University Plovdiv
doi: 10.2478/v10153-011-0060-3
Correspondence and reprint request to: A. Murtezani, Physical Medicine and Rehabilitation Clinic, University
Clinical Center of Kosovo; E-mail: ardianaa@yahoo.com
rr. Spitalit pn. 10000 Prishtina, Republic of Kosovo
Received 25 May 2011; Accepted for publication 7 July 2011
PREVALENCE AND RISK FACTORS FOR LOW BACK PAIN IN INDUSTRIAL
WORKERS
Ardiana Murtezani, Zana Ibraimi
1
, Sabit Sllamniku
2
, Teuta Osmani, Seven Sherifi
1
Physical Medicine and Rehabilitation Clinic, University Clinical Center of Kosovo
1
Department of Phar-
macy, Faculty of Medicine, University of Kosovo,
2
Orthopedic and Traumatic Clinic, University Clinical
Center of Kosovo, Republic of Kosovo
ABSTRACT
O
BJECTIVES: The aim of the present study was to determine the prevalence of low back pain
(LBP) in industrial workers, check for possible LBP related risk factors and investigate the
associations between physical activity and severity of low back pain.
M
ETHODS: We conducted a cross-sectional study among 430 workers of an industrial com-
pany over the previous 12 months. The industrial workers were given questionnaires and
assigned to two groups: (1) with low back pain, (2) without low back pain. Group 1 was
then divided into three subgroups according to the answer to question (a) LBP without
irradiation, called mild cases, (b) LBP with irradiation above the knee, called moderate
cases, LBP with the irradiation below the knee, called severe cases.
R
ESULTS: LBP was found in 61.6% of workers. The prevalence of LBP was signifi cantly
associated with physical activity (p = 0.03). There was a signifi cant difference between
frequent physical activity and severity of LBP (p = 0.01). Work-related physical factors
showed strong associations with LBP. The main risk factors for low back pain among pro-
duction workers were extreme trunk fl exion (OR = 3.5, 95% CI 1.7-7.3), as well as lifting
of loads (OR = 3.5, 95% CI 1.9-6.2), pushing or pulling heavy loads (OR = 3.5, 95% CI 1.9-
6.2) and exposure to whole body vibration (OR = 1.7, 95% CI 1.0 -3.0).
C
ONCLUSION: Daily life conditions, job-related factors are associated with the occurrence
of low back pain. These results suggest that individuals with LBP should avoid nonspecifi c
physical activities to reduce pain and improve psychological health.
Key words: low back pain, work-related, physical risk factors, physical activity
INTRODUCTION
Low back pain (LBP) is one of the most signifi cant
medical and socioeconomic problems in modern
society.
1
The main predictors of back pain include
physical stress (e.g., prolonged lifting, driving,
forceful or repetitive movements involving the
back), psychosocial stress (e.g., highly perceived
workload and time pressure, low control and lack
of social support at work, personal characteristics
such psychological status and tobacco use), and
physical characteristics (e.g., obesity and height).
2
LBP prevalence is related to the type of oc-
cupations such as driving, manual handling and
occupations that involve a lot of improper body
movements.
3
Work-related physical exposures, especially heavy
lifting and manual materials handling, working in
awkward postures, and whole-body vibration, are
well established risk factors for LBP.
3,4
Personal
health factors, such as smoking, overweight, and
lack of physical activity, are often listed among the
most important risk factors for LBP, but the scientifi c
evidence is surprisingly vague and inconsistent.
4
Low back syndrome, although self-limiting in
most cases, leads in a small percentage of patients
to chronic problems that can be very costly to
manage, and those cases that resolve are prone to
recurrence at a rate of up to 90%.
5
Over a third
of the handicap burden may be linked to environ-
mental and psychosocial factors.
6
Primary care treatment of chronic LBP is as-
sociated with modest or no improvement.
7
Exercise
PUBLIC HEALTH CARE

Prevalence and Risk Factors for Low Back Pain in Industrial Workers
69
Folia Medica 2011; 53(3): 68-74
© 2011 Medical University Plovdiv
therapy is a management strategy that is widely used
as a treatment for LBP.
8
The theoretical arguments
against bed rest and for the management of back
pain by activity have been reviewed elsewhere.
9,10
Multiple trials show that advice to stay active and
to continue ordinary activity as normally as pos-
sible is likely to give faster return to work, less
chronic disability, and fewer recurrent problems.
9
The aim of this study was to determine the
prevalence of low back complaints in industrial
workers, to assess occupational risk factors related
to the presence of LBP and investigate the associa-
tions between physical activity and severity of LBP.
MATERIAL AND METHODS
STUDY DESIGN AND DATA COLLECTION
A cross-sectional study design was utilized. Self-
administered questionnaires were distributed among
the recruited industrial workers. They answered to the
questions under the guidance of research assistants.
S
TUDY POPULATION
The job titles were categorized into blue-collar
workers (production workers) and white-collar
workers (offi ce workers and managers). Seven main
occupational groups representing those who perform
similar work under similar working conditions were
identifi ed as follows; drilling, blasting, mucking/
loading, tramming, rock-breaking, supervisory, and
engineering. These occupations are directly related
to the production and are therefore involved in
prolonged standing, twisting and turning, lifting
of heavy loads. In this study, physical load was
assessed by detailed observations at the workplace
among a random sample of workers within each
occupational group. The categories of trunk fl exion
that were observed were defi ned as neutral (< 30°),
mild fl exion (30-60°), extreme fl exion (60-90°), and
very extreme fl exion (> 90°).
We created two groups according to the answer
to question (1) without LBP, (2) with LBP. Group
two was then divided into three subgroups according
to the answer to question (a) LBP without irradia-
tion, called mild cases, (b) LBP with irradiation
above the knee, (c) LBP with irradiation below
the knee, called serious cases.
Physical exercise (walking, bicycling, swimming,
etc, weekly during the preceding year), at least 20
minutes per session, classifi ed as 1 = everyday, 2
= 2-3 times/week, 3 = not at all.
Q
UESTIONNAIRE SURVEY
The participants completed a self-administered
questionnaire at their workplace. The fi rst questions
described the worker and his work station according
to known risk indicators: sex, age, weight, height,
smoking habits, duration of employment, physi-
cal activity profi le, regular physical exercise, and
manual lifting of weights, uncomfortable working
positions, and means to achieve good quality work.
The main items of interest in the questionnaire were
experience of LBP within the past 12 months, the
severity of pain, and whether or not it was work
related. During the past year have you experienced
low back problems (back ache, pain, discomfort)?
If the answer was negative, no further questions
were completed. If the answer was yes, the oc-
cupational physician asked another questions: pain
with or without radiation, pain referred above or
below the knee.
ELIGIBILITY CRITERIA
Inclusion criteria were age from 18-65 years, willing
and able to give informed consent. Workers with
occupational or non-occupational accidents affect-
ing the lower back were excluded from the study.
E
THICAL CLEARANCE
The study was approved by the Ethic Committee
of the Faculty of Medicine, University of Kosovo.
S
TATISTICAL ANALYSIS
The dependent variable adopted in this study was
the presence or absence of LBP, in order to estimate
the prevalence of LBP in industrial workers. In the
statistical analysis differences between normally
distributed continuous variables were tested with
the Student t-test and differences between categori-
cal variables with the chi-square test (χ
2
). For the
continuous data, Mann-Whitney U test were applied.
Univariate logistic regression models were used
to compute adjusted relative risk (RR) and their
95% confi dence intervals (95% CI) for the various
symptoms and causes of, with LBP as the dependent
variable. Wald statistics were used to estimate the
95% confi dence intervals around the RR. Statistical
analysis was performed with SPSS 13.0 software.
A p value < 0.05 was considered signifi cant.
RESULTS
During the two months of data collection, 489 work-
ers were interviewed and 59 refused to participate.
So 430 questionnaires were completed. The response
rate of the questionnaire was 87.9%.
Table 1 summarizes the personal details of the
workers who participated in the study. Altogether
subjects worked in white collar occupations, and

70
A. Murtezani, et al
Folia Medica 2011; 53(3): 68-74
© 2011 Medical University Plovdiv
in blue collar jobs. Of the 430 workers evalu-
ated, 256 (61.6%) presented with LBP, while 165
(38.4%) did not have LBP. The prevalence of LBP
was signifi cantly associated with physical activity
(p = 0.03).
The associations between the physical activity
and the severity of LBP are shown in Table 2. The
severity of LBP was signifi cantly correlated with
regular physical exercise. There was a signifi cant
association between physical activity and severity of
LBP (p < 0.01). Of the 265 subjects of LBP, 112
(42.3%) had mild pain, 58 (21.9%) had moderate
pain and 95 (35.8%) had severe pain.
The number of workers with LBP among the
white and blue collar workers according to the
work-related physical risk factors are shown in
Table 3.
Table 4 presents the results from multiple logistic
regression analysis as related to risk factors. Trunk
fl exion was a risk factor for occurrence of low
back pain among production workers. Among blue
collar workers with mild and extreme trunk fl exion
the RR for LBP increases 2.6 and 3.5 compared
to neutral trunk fl exion.
As risk factors for occurrence of low back pain
among production workers were lifting of loads.
Lifting < 25 kg, and > 25 kg increases the
RR
for LBP 2.9, and 3.5 time respectively compared
Table 1. Characteristics of the study sample
Group with LBP
n = 265
Group without LBP
n = 165
P (t-test)
Mean ± SD Mean ± SD
Age (yrs) 47.95 ± 9.05 48.03 ± 8.85 0.928
Weight (kg) 78.40 ± 10.61 77.69 ± 9.79 0.487
Height (cm) 174.54 ± 6.70 174.81 ± 5.40 0.622
Time in job (yrs) 21.56 ± 9.80 21.76 ± 9.53 0.835
Educational level n (%) n (%)
Basic 59 (22.3) 28 (17.0)
0.399Technical 178 (67.2) 117 (70.9)
Higher 28 (10.6) 20 (12.1)
Physical activity n (%) n (%)
Every day 26 (9.8) 26 (15.8)
0.033
2-3 days per week 112 (42.3) 79 (47.9)
Never 127 (47.9) 60 (36.4)
Smoking n (%) n (%)
Yes 109 (41.1) 67 (40.6)
0.994
No 156 (58.9) 98 (59.4)
Table 2. Associations between the physical activity and the severity of LBP
LPB
Physical activity
Mild
n = 112
Moderate
n = 58
Severe
n = 95
Total
n = 265
n (%) n (%) n (%) n (%)
Every day 18 (16.1) 5 (8.6) 3 (3.2) 26 (9.8)
2-3 day on week 50 (44.6) 27 (46.6) 35 (36.8) 112 (42.3)
Never 44 (39.3) 26 (44.8) 57 (60.0) 127 (47.9)
P < 0.01

Prevalence and Risk Factors for Low Back Pain in Industrial Workers
71
Folia Medica 2011; 53(3): 68-74
© 2011 Medical University Plovdiv
Table 3. Number of workers with LBP among the white and blue collar workers according to the work-related
physical risk factors
Risk factor Category
White collar workers (n = 54) Blue collar workers (n = 376)
LBP LBP
Yes No Total Yes No Total
Trunk fl exion
Neutral 14 9 23 15 24 39
Mild 17 14 31 109 68 177
Extreme 0 0 0 105 48 153
Very extreme 0 0 0 5 2 7
Lifting of loads
No lifting 25 20 45 52 67 119
Lifting < 25 kg 6 3 9 112 49 161
Lifting > 25 kg 0 0 0 70 26 96
Pushing or pulling
heavy loads
No 29 22 51 91 71 162
< 1 time/hour 1 1 2 107 51 158
> 1 time/hour 1 0 1 36 20 56
Exposure to whole body
vibration
No 24 19 43 178 120 298
Yes 7 4 11 56 22 78
Static work postures
No 12 8 20 167 92 259
Yes 19 15 3 4 67 50 117
Ability to change
posture regularly
No 11 10 21 28 25 53
Yes 20 13 33 206 117 323
to no lifting conditions.
With the same signifi cance as risk factors for
occurrence of low back pain among production
workers were pushing or pulling heavy loads.
Pushing or pulling heavy loads < 1 time/hour and
> 1 time/hour increases the odds for LBP 2.9, and
3.5 time respectively compared to no pushing or
pulling conditions.
Exposure to whole body vibration was the
signifi cant risk factor for occurrence of low back
pain among production workers (RR = 1.7, 95%
CI [1.0;3.0], p = 0.05).
LBP in the white collar workers did not cor-
relate signifi cantly with trunk fl exion, lifting of
loads, pushing or pulling heavy loads, exposure
to whole body vibration, and ability to change
posture regularly.
Mild trunk fl exion, lifting of loads < 25 kg,
pushing or pulling heavy loads, exposure to whole
body vibration, and ability to change posture regu-
larly did not increase signifi cantly the RR for LBP
in white-collar workers.
DISCUSSION
We studied the prevalence of LBP among industrial
workers in order to describe the occurrence of
LBP. The hypothesis that was considered in this
study was that LBP would be highly prevalent in
industrial workers since they spend much of their
time in the seated position frequently twisting and
bending their torsos, are exposed to whole body
vibration, awkward postures and load lifting. The
low back pain prevalence was 61.6% among indus-
trial workers, which is consistent with most of the
epidemiological studies investigating the 12- month
LBP prevalence in workers.
3,10-13
According to the literature, manual handling of
materials, heavy physical work, frequent bending
and twisting, lifting and forceful movements are
relevant risk factors for onset of LBP.
14,15
Sitting
has been associated with risk of developing LBP.
16
No association was found between weight and
height and the prevalence rate of LBP. This is in
agreement with the fi ndings of other researchers.
12
There was signifi cant association between physi-
cal activities with severity of low back pain in our
study population. Less activity employees had more
severe LBP than the others.
This fi nding is consistent with the results in
another study
13
where regarding exercising habits
only a small proportion (12.1%) of their sample
participated in regular exercise which suggests
that industrial workers are mostly non-exercising
individuals.
A review of patients with LBP considered smok-
ing and low levels of fi tness as risk factors of
the occurrence of LBP but found no associations

72
A. Murtezani, et al
Folia Medica 2011; 53(3): 68-74
© 2011 Medical University Plovdiv
between leisure time physical activity and LBP.
17
Some earlier studies have shown a small-to-moderate
association between higher body weight or lack of
physical exercise and LBP.
4
Multiple logistic regression models have re-
vealed that signifi cant determinants for predicting
LBP occurrence are extreme trunk fl exion, heavy
lifting, and exposure to whole body vibration. The
occupational physical risk factors for LBP (i.e.,
awkward postures, heavy lifting, and whole body
vibration) were, as expected, signifi cant predictors,
but not uniformly across all workers. Among 430
workers included in the logistic model, LBP oc-
curred signifi cantly more often among blue collar
workers reporting manual material handling of
weights and uncomfortable working positions. Blue
collar workers comprise a unique occupational
group characterized by heavy physical labor with
high level of force being exerted.
As reported in other studies
11,18
, this study also
found LBP to be associated with increasing work-
place activities heavy lifting, whole body vibration
and extreme trunk fl exion. Risk factors of LBP
are known to include workplace activities such as
heavy load lifting, repetitive tasks and awkward
working postures, while demographic character-
istics and psychosocial factors are also known to
be important predictive variables.
12
Heavy lifting
and whole-body vibration had a relatively strong
association with LBP among the blue collar work-
ers. Extreme fl exion of the trunk had a modest
association with LBP among blue collar workers.
Table 4. Univariate logistic regression analysis for occurrence of LBP among the white and blue collar workers
according to the work-related physical risk factors
Rc - reference category
Risk factor Reference category
White collar workers (n = 54) Blue collar workers (n = 376)
RR 95% CI P RR 95% CI P
Trunk fl exion
Constant
0.9
0.3 - 2.3 0.8
0.6
0.3 - 1.2 0.2
Neutral
Rc
Trunk fl exion 30-60°
(mild)
1.8
0.6 - 5.9 0.3
2.6
1.3 - 5.2 0.01
Trunk fl exion 60-90°
(extreme)
-
--
3.5
1.7 - 7.3 < 0.001
Trunk fl exion > 90°
(very extreme)
-
--
4.0
0.7 - 23.0 0.1
Lifting of loads
Constant
1.3
0.7 - 2.3 0.5
0.8
0.5 - 1.1 0.2
No lifting
Rc
Lifting < 25 kg
1.6
0.4 - 7.2 0.5
2.9
1.8 - 4.8 < 0.001
Lifting > 25 kg
-
--
3.5
1.9 - 6.2 < 0.001
Pushing or pulling
heavy loads
Constant
1.32
0.76 -2.29 0.33
1.3
0.9 - 1.8 0.1
No
Rc
<1 time/hour
0.76
0.04 to 12.8 0.85
1.6
1.0 – 2.6 0.03
>1 time/hour
-
--
1.4
0.8 – 2.6 0.3
Exposure to whole
body vibration
Constant
1.3
0.7 - 2.3 0.4
1.5
1.2 - 1.9 < 0.001
No
Rc
Yes
1.4
0.4 - 5.4 0.6
1.7
1.0 - 3.0 0.05
Static work
postures
Constant
1.5
0.6 - 3.7 0.4
1.8
1.4 - 2.3 < 0.001
No
Rc
Yes
0.8
0.3 to 2.6 0.8
0.7
0.5 - 1.2 0.2
Ability to change
posture regularly
Constant
1.1
0.5 to 2.6 0.8
1.1
0.7 - 1.9 0.7
No
Rc
Yes
1.4
0.5 to 4.2 0.6
1.6
0.9 - 2.8 0.1

Prevalence and Risk Factors for Low Back Pain in Industrial Workers
73
Folia Medica 2011; 53(3): 68-74
© 2011 Medical University Plovdiv
Considering the European defi nition of manual
handling of materials, this relation is exactly what
should be expected: manual handling of materials
is defi ned as any transporting or supporting of a
load, by one or more workers, including lifting,
lowering, pushing, pulling, carrying, or moving of
a load, which by reasons of unfavorable ergonomic
conditions, involves a risk particularly of back
injury to workers.
14
The fi ndings from the present study are in the
agreement with the results of two recent reviews
of the literature on physical risk factors for LBP,
which also showed that the evidence is strongest
for trunk fl exion and rotation, manual material
handling as risk factors for low back pain.
19,20
This indicates that the lower back pain problem
in the power plant company was serious and needed
resolving. Back symptoms were found to be the
most prevalent among blue collar workers. This
could be attributable to awkward working postures,
manual material handling, which were common at
almost all workstations and job activities observed.
This implies that interventional programs are neces-
sary to prevent or reduce physical exposure to the
lower back risk factors in these regions.
A particular strength of this study was that all
subjects worked in the same company and were
comparable for several factors such as cultural and
socioeconomic factors. Limitations of this study
are that psychological factors were not addressed
and thus their potential infl uence on occurrence
of LBP could not be established. Future research
might include the infl uence of psychological factors
on the occurrence of LBP.
CONCLUSIONS
LBP is highly prevalent in this company. Flexion
of the trunk and lifting at work are moderate risk
factors for LBP. An ergonomics interventions pro-
gram in the workplace should focus on eliminating
awkward postures, manual handling of heavy loads
and designing sitting-standing workstations on the
production line.
ACKNOWLEDGEMENT
We would like to thank Col. Joel Abramovitz, MD
(US Army MC, Neurosurgeon) for his valuable
suggestions and technical assistance.
Author Contributions:
Sllamniku was overseeing this research project, had
full access of the data in this study, meanwhile, he
takes responsibility for the integrity of the data.
Study Design: Murtezani, Osmani, Sllamniku
Instruction on the use of instruments for the outcome
measures used in this study: Murtezani, Osmani
Analysis and interpretation of data: Ibraimi, Sherifi
Manuscript preparation: Murtezani, Osmani, Sl-
lamniku
Statistical Analysis: Murtezani, Ibraimi, Sherifi
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БОЛИ В ЛЮМБАЛЬНОЙ ОБЛАСТИ – РАС -
ПРОСТРАНЕНИЕ И ФАКТОРЫ РИСКА ДЛЯ
РАБОТАЮЩИХ В ОБЛАСТИ ПРОМЫШ-
ЛЕННОСТИ
A. Murtezani, Z. Ibraimi, S. Sllamniku, T. Osmani, S. She-
rifi
РЕЗЮМЕ
ЦЕЛЬ: Настоящая работа ставит себе целью
определить распространение болей в люмбальной
области и факторы риска для работающих в
промышленных предприятиях, а также и исследо-
вать связи между физической активностью и
интенситетом болей.
МЕТОДЫ: Проведено срезовое обследование 430
рабочих промышленного предприятия (период
обследования - последние 12 мес.). Рабочие получили
вопросники, после чего разделены на две группы:
группа 1 – жалующиеся на боль в нижней части
поясницы и группа 2 – без болей в области пояс-
ницы. Группа 1 в зависимости от их ответа на
вопрос о характере болей разделена еще на три
подгруппы:
Подгруппа А – жалующиеся на люмбальные боли
без иррадиации (легкие случаи);
Подгруппа В – жалующиеся на люмбальные
боли, распространяющиеся выше колена (умеренные
случаи);
Подгруппа С - жалующиеся на люмбальные боли,
иррадиирующие ниже колена (тяжелые случаи).
РЕЗУЛЬТАТЫ: Боли в люмбальной области уста-
новлены в 61.6% случаев. Распространение бо-
лей коррелирует сигнификантно с физической
активностью рабочих (р = 0.03). Установлена
также статистически сигнификантная разница
между частотой физической активности и силой
болей (р = 0.01). Сильная корреляция наблюдает-
ся и между физическими факторами, связанными
с работой и болями в люмбальной области. Ос-
новными факторами риска болей в люмбальной
области у работающих в области промышленности
являются: максимальная флексия торса (OR = 3.5,
95% CI 1.7-7.3); поднятие тяжелых грузов (OR
= 3.5, 95% CI 1.9-6.2); толкание или дергание
тяжелых грузов (OR = 3.5, 95% CI 1.9-6.2);
подставление всего тела сильным вибрациям (OR
= 1.7, 95% CI 1.0 -3.0).
ЗАКЛЮЧЕНИЕ: Появление болей в люмбальной об-
ласти связано с проведением рутинной деятель-
ностью и с деятельностью при рабочих условиях.
Результаты исследования показывают, что лица с
болями в нижней части спины следует избегать
неспецифических физических деятельностей с целью
уменьшения силы боли и улучшения своего психи-
ческого здоровья.