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Int.J.Curr.Res.Aca.Rev.2017; 5(5): 85-92
85
International Journal of Current Research
and Academic Review
ISSN: 2347-3215 (Online) ҉҉ Volume 5 ҉҉ Number 5 (May-2017)
Journal homepage: http://www.ijcrar.com
doi: https://doi.org/10.20546/ijcrar.2017.505.011
Prevalence and Risk Factors of Low Back Pain among Auto-Rickshaw Drivers in
Urban Kolkata, India
Shabnam Agarwal*, Anwesh Pradhan, Gargi Ray Chaudhuri and Soumitra Das
Nopany Institute of Healthcare Studies, Chief Physiotherapist, Belle Vue Clinic, Kolkata, India
*Corresponding author email
Abstract
Article Info
Auto rickshaw drivers are prone to Low Back Pain (LBP) due to occupational
exposure. But LBP among auto-rickshaw drivers have hardly been studied. The
drivers work long durations in strenuous postures and seat themselves often with one-
two passengers in front. The present study was to determine the prevalence and risk
factors of LBP in auto-rickshaw drivers of Kolkata.500 auto-rickshaw drivers were
randomly surveyed in auto-stands of various parts of Kolkata. A Nordic Pain
questionnaire was used to determine prevalence, the 101 Numerical Pain Rating Scale
measured current pain intensity and the Oswestry Disability Index evaluated disability
due to LBP. Risk factors included age, height, BMI, socio-demographic and
occupational details, shoulder to handle distance, knee to break distance, pain intensity,
vibration and posture during driving. The Ovako Working postural Analysis System
(OWAS) was used to analyze the posture during driving and a Vibrometer was used to
analyze the vibration. Logistic regression analysis was performed to ascertain the
association of risk factors with LBP. A Pearson‟s chi square test was performed to
determine the association between two categorical variables. The 12 months prevalence
of LBP was 79.8% and 7 days point prevalence was 36%. Forward bent and twisted
sitting posture (OWAS action level 2) was significantly associated with LBP.
Accepted: 05 May 2017
Available Online: 10 May 2017
Keywords
Auto-rickshaw,
Drivers, Kolkata,
Low back pain,
Occupational low back pain,
OWAS, Prevalence,
Risk factors,
Posture while driving.
Introduction
The worldwide annual incidence of Low backs pain
(LBP) ranges from 1.5% to 36%, and the one year
prevalence ranges from 22% to 65% (Hoy et al., 2010).
The recurrent episodes of LBP range from 24% to 33%
(Stanton et al., 2008).
LBP amongst drivers is common due to several reasons.
Driving is a task which involves prolonged sitting,
awkward posture, static position and vibration; any of
which could directly lead to musculoskeletal stress. The
results of the prevalence studies of LBP in heavy vehicle
drivers vary between the type of vehicles and from the
countries they are reported from (Olanrewaju et al.,
2007). The point prevalence and 12 months prevalence
in Danish fork-lift truck drivers is 21% and 65%
respectively (Sami et al., 2012) while in a Finnish study
of earth mover operators, it is higher at 51% and 82%
respectively (Olanrewaju et al., 2007). Among the bus
drivers, prevalence of musculoskeletal disorders and low
back troubles varies between 40% to 82%. The 12
months prevalence of LBP in taxi drivers is lower
compared to heavier vehicle drivers and varies between
59% in Malaysia (Sami et al., 2012) to 46% in
Southampton, UK (Gallais et al., 2008). One would
expect the prevalence of LBP to reduce further in lighter
vehicle, as in an autorickshaw. To the contrary, it is
Int.J.Curr.Res.Aca.Rev.2017; 5(5): 85-92
86
observed that the 12 months prevalence of LBP in auto-
rickshaw drivers in Guntur, India, is as high as 63.66%
(Shaik et al., 2014).
The etiological factors of LBP include poor posture,
muscle weakness and imbalance, (Shaik et al., 2014)
degenerative changes in the disc and vertebral bodies,
trauma, anxiety and depression (Stanton et al., 2008).
Risk factors are characteristics, specific to people that
have been correlated to incidents of LBP. The risk
factors associated with LBP include age, gender,
anthropometrics, overall health (Khan et al., 2014), and
socioeconomic status (Stanton et al., 2008), education
levels (Samsul et al., 2007, Dionne et al., 2006),
smoking habits (Racheal, 2014), whole body vibration
(Gregory, 2008; Charoenchai et al., 2006) and awkward
occupational postures, work experience (number of
years), working hours, seat vibrations, lower cabin space
and shoulder to handle distance for right and left upper
limbs (Shaik et al., 2014).
Scarce number of studies have been conducted or
reported on auto-rickshaw drivers. In India many cities
have this mode of transport. In Kolkata, auto-rickshaws
were introduced in 1983-84 and the current fleet of
registered vehicles is 10,000 (The Hindu Magazine,
2014).
Out of the two previous studies on auto-rickshaw drivers,
one was conducted in Guntur, Andhra Pradesh, India
(Shaik et al., 2014)) and the other in Galle, Sri Lanka
(Kirkorowicz et al., 2013). Both studies conclude the
driver‟s seat vibration as a risk factor for LBP. Further,
the study by (Kirkorowicz et al., 2013), attributed
musculoskeletal pain in lower back, shoulders and knees
to staying in the same posture for many hours. Long
duration cramped sitting work postures in autorickshaw
drivers may cause a significant static loading on the
structures of the spine (Odebiyi et al., 2007). In addition
twisting and bending of vertical column (Rajnarayan et
al., 2003), spinal instability (Panjabi, 2003), intra-discal
pressure, hydrostatic properties of the disc (Nachemson,
1975), muscle fatigue due to lack of oxygenation are also
included as an important causes of LBP.
Given the limited amount of previous research,
inadequate assessment of risk factors, small sample size,
it is evident that a survey is required which explores all
relevant risk factors in an adequate sample of auto-
rickshaw drivers. Further, considering the growing
popularity of this transportation system, the increasing
population and traffic congestion in India, the auto-
rickshaw drivers‟ health issues require attention. The
results could prove to be useful in government analysis
and policy development concerning auto-rickshaw
drivers. Hence, the objectives of this study were (1) To
determine the prevalence of LBP in auto-rickshaw
drivers in urban Kolkata (2) To explain the risk factors,
which may contribute to the development of LBP in
auto-rickshaw drivers in urban Kolkata.
Materials and Methods
The study design was a descriptive type survey using
cluster sampling. The survey method was mainly in the
form of questionnaires which were interviewed in
person, individually to each participant. A total of 575
auto-rickshaw drivers were contacted. 65 declined
participation while 10 terminated participation.
Eventually 500 auto-rickshaw drivers from different
routes of urban Kolkata were surveyed for this study
(Figure 1). Approval for the research was obtained from
the Institutional Human Research Ethics Committee
(meeting on 28 03.2015). Informed consent forms
(Bengali, Hindi or English) were signed by all
participants prior to the survey.
Parameters studied for the participants were intra-
individual (socio-demographics), occupational (work
experience as in number of years, working hours per day,
working hours per week, shoulder to handle distance,
knee to brake distance), posture, pain site, pain intensity,
vibration and disability. The plan of the survey is
illustrated in figure 2.
Outcome measures
Every participant was assessed using the following
outcome measures:
Socio-demographics for intra-individual and
occupational data included questions about age (years),
gender (male), BMI, currently smoking (Yes/ No),
education levels, marital status, (work experience in
number of years, working hours per day, working hours
per week, shoulder to handle distance (cm), knee to
brake distance (cm). Data type was nominal or interval.
Nordic Musculoskeletal Questionnaire (NMQ): NMQ
(Kuorinka et al., 1987) was used to ascertain presence,
extent and prevalence of LBP. The subcomponents of the
NMQ can justify the low back pain properly.For
participants who did not understand English or could not
read the questionnaire was used in an interview format.
Int.J.Curr.Res.Aca.Rev.2017; 5(5): 85-92
87
A Bengali version was used in such cases. The
reliability and validity of the Bengali version was not
tested. However, the translation was done by a language
expert and then tested on three pairs of medical
professional by the back and forth method.
Ovako Working postural Analysis System (OWAS): It
is a method of coding the posture of a worker that allows
the harmfulness of the posture to be categorized into four
action categories of increasing urgency and has been
found reliable (Brujin et al., 1998). In this study two
action levels were considered.
OWAS action level 1 - sitting posture of auto-rickshaw
driver. Level 1definition implied the driver‟s back
posture was „straight‟
OWAS action level 2 - sitting posture of auto-rickshaw
driver. Level 2 definition implied theback posture as
„bent and twisted‟.
101 Numerical Pain Rating Scale (101 NPRS): The 101
NPRS was used for the drivers to record their perceived
level of pain intensity on a numerical scale from 0–100,
(0 = no pain and 100 representing maximum pain). The
scale is practical, easy to administer and sensitive
(Williamson et al., 2005; Jenson et al., 2011).
Vibrometer (android application): An android
Vibrometer (1.4.6) was used for measuring the vibration
of vehicles. Data type was interval. A Vibrometer
application was used when the vehicle was in motion for
a minimum period of 5 minutes and a maximum period
of 20 minutes. The device was kept at the junction of the
driver‟s seat and backrest to measure the vibration when
the auto-rickshaw was full of passengers. The maximum
vibration (in hertz) was noted.
Oswestry Disability Index (ODI): The ODI is an
evaluative, self-administered questionnaire for scoring
the disability of patients with LBP and indicates the
extent to which a person‟s functional level is restricted
by back pain. The reliability and validity of the ODI has
been established (Fairbank et al., 2000). Ten stem
questions which form the ODI are pain intensity,
personal care (washing, dressing), lifting, walking,
sitting, standing, sleeping, sex life, social life and
travelling. ODI questions number 8 and 9 were omitted
as they related to „Sex life and Social life‟. Hence the
total score was out of 40 instead of 50 and the percentage
of disability was calculated accordingly. The ODI was
translated into Bengali using the same method as the
NMQ. Administration method was the same as well.
Statistical analysis
Logistic regression analysis was performed to
ascertain the association of all risk factors with LBP
(dependent variable).The Pearson‟s Chi square test
was conducted to test the association between
categorical variables and LBP prevalence. The
significance level for all analysis was determined at
p<0.05.
Results and Discussion
The first question of the NMQ asks if the participant has
ever had LBP. 411 (82%) out of 500 auto rickshaw
drivers said “yes”. 399 (79.8%) had pain in the last 12
month period. The data representing LBP troubles of last
12 months was considered for statistical analysis in the
study. The 7 days point prevalence is 36%. Results are
approximately similar to that of Shaik et al., (2014),
where the 12 months prevalence of LBP is 63.66%. One
of the reasons for auto-rickshaw drivers to exhibit a high
prevalence could be that they tend to sit in awkward
postures resulting in musculoskeletal disorders while
driving (Nahar et al., 2012; Bovenzi et al., 2006; Borle et
al., 2012). A further add on is that the drivers often share
the driver‟s seat in front with passengers in order to carry
more passengers and earn more. Sustained continuous
sitting in awkward postures may be contributory
(Ganmgopadhyay and Dev., 2012).
In this study the current pain intensity was measured
using the 101 NPRS. The pain intensity reported by the
auto-rickshaw drivers is 41(±18), range 0 - 80.
Disability is measured using the ODI. ODI scores
revealed that out of 399 auto-rickshaw drivers, 104 have
no current LBP whilst 295 drivers have varying
intensities of current LBP (pain intensity 1=165 persons;
2 = 94 persons; 3 = 32 persons; 4 = 4 persons). Out of
295 drivers, 284 (71.17%) are in the minimal disability
level category (0-20%), 90 (23.55%) are in the moderate
disability level category (21-40%) and 25 (6%) were in
severe disability level. Out of all the 8 stem questions of
the ODI which are asked, namely, pain intensity,
personal care (washing, dressing), lifting, walking,
sitting, standing, sleeping, and travelling, it is observed
that the sitting activity and pain has the least number of
drivers at „0‟ level. 74% drivers have some level of pain;
out of which sitting is a problem for 52% drivers,
walking is a problem for 42% drivers, lifting is a
problem with 31% and standing for 30%. The high
Int.J.Curr.Res.Aca.Rev.2017; 5(5): 85-92
88
percentage of disability in sitting may be attributed to
long hours of driving which the drivers do. In the study
among bus drivers of urban Kolkata (26 Gangopadhyay
and Dev, 2012) cramped sitting posture is the main cause
of LBP.
Several risk factors have been associated with LBP in
drivers and are explored and evaluated in this study as
well.
The mean age of the respondents is 40 years, range
between 27 to 56 years. This age group is similar to that
noted in previous studies on car drivers (mean age = 43
years) and auto-rickshaw drivers (mean age 46 years)
(Kirkorowicz et al., 2013). Older age has been associated
as a risk factor for LBP in car drivers (Nahar et al.,
2012).Whilst previous studies on auto-rickshaw drivers
explored age as a risk factor, they did not find any
significant association (Shaikh et al., 2014). The results
of this study did not find any significant association
between age and LBP either, although drivers who have
current pain and disability are more in the age group 34-
56years.
The mean height of the surveyed driver is 164
centimeters, weight 68 kilograms, and BMI is
25.Anthropometrics have not been studied in previous
surveys on auto-rickshaw drivers (Shaik et al., 2014;
Kirkorowicz et al., 2013). A previous study on bus
drivers of Kolkata, (Gangopadhyay and Dev, 2012)
revealed that the average height of bus drivers was 162
cm, weight 53 kg and BMI 20. The results of this survey
measured the average height of auto-rickshaw drivers as
similar; 164 cm. However, they weighed much more
than their bus counterparts; mean weight is 68 kg and the
BMI is consequently higher as well (mean =25, range =
20 – 35). Since, both kinds of drivers come from the
same population, it is not clear why the auto-rickshaw
drivers weighed more with a BMI category as „over-
weight‟.
37.3% responders received education till the secondary
level (i.e. till class x); however nearly an equal number
are uneducated (31.4%). Only a small number (1.2%)
reached graduation qualification. The one previous
study (Kirkorowicz et al., 2013) conducted in Galle
which recorded the education levels of their participants
has a similar distribution. However, comparisons are
difficult as their sample size is extremely small. Looking
at a study on bus drivers of Malaysia, a similar education
qualification population distribution is seen for primary
(31.2%), secondary (36.4%) and graduate levels (2.5%)
(Shamsul et al., 2007). A review study by Dionne et al.,
(2001) associated low education qualifications with
adverse consequences of LBP. Various factors are
considered to contribute to this. However, similar to the
results of this study, a previous study (Shamsul et al.,
2007) on commercial drivers demonstrated no significant
association between LBP and educational levels.
The percentage of drivers who are married are 62%
which is less than reported in previous survey studies
where the average percentage of married drivers are 72%
(Bovenzi et al., 2006) and 90% (Kirkorowicz et al.,
2013). A study on truck drivers in Nagpur (Borle et al.,
2012) shows no significant association between marital
status and LBP, which was observed in this study as
well.
Smoking is a common habit among drivers. In this study
81% drivers are smokers similar to studies in Sri Lanka
which reports 98% auto-rickshaw drivers as smokers
(Kirkorowicz et al., 2013) and in Bangladesh where 80%
professional car drivers were smokers. Although it is an
established fact that smoking is a risk factor for
musculoskeletal problems since it has a negative impact
on bone mineral density and causes lowering of vitamin
D levels, changing hormones levels, slowing healing
process and increases fracture chances by 40% (Racheal,
2014), the results of this study as well as that of Nahar et
al., (2012) show no significant association with LBP in
drivers.
Hours of driving and its correlation with LBP has been
primarily explored in bus drivers (Gangopadhyay et al.,
2012) and found significant (Odebiyi et al., 2007),this
study (Table 1) as well as a previous study on auto-
rickshaw drivers found no association(Shaikh et al.,
2014).
The auto-rickshaw drivers in this study have an average
driving experience of 14 (±56) years, similar to a
previous study reported as 16 years (Nasrin et al., 2012)
but more than that reported by Kirkorowicz et al., (2013)
9 years. This study does not find any significant
association between number of years of experience and
LBP. The results are similar to the study from Guntur
(Shaik et al., 2014).
Heavy vehicle drivers are more prone to whole body
vibrations which cause LBP. Vibration measured from
driver‟s seat shows increase risk of low back injury.
Studies say vibration of vehicle in a hertz of 4Hz and
above stimulated back muscle fatigue and cause back
pain. A previous study found vibration as a risk factor
Int.J.Curr.Res.Aca.Rev.2017; 5(5): 85-92
89
for LBP in auto-rickshaw drivers. However, the results
of such an association are not significant in this study. A
possible reason may be the android Vibrometer which is
an amateur device and whose reliability and validity has
not been tested.
Other risk factors explored in previous surveys (Shaik et
al., 2014; Kirkorowicz et al., 2013) are shoulder to
handle distance and lower cabin space. In this study too,
these risk factors are analyzed but no significant
associations are seen similar to the results of the previous
studies.
The logistic regression analysis showed that none of the
independent variables were risk factors for LBP. The
Pearson‟s Chi square test as well as the Phi test for
association between two nominal variables (LBP and
posture) were significant (p <0.05) between LBP and
posture (Table 2). 81% auto-rickshaw drivers at action
level 2 reported „yes‟ to LBP. The results implied that
these were a significant difference in the prevalence of
LBP between auto-rickshaw drivers who sat „straight‟
(OWAS action category 1) compared to those who sat
„bent forward and twisted‟ while driving (OWAS action
category 2). This indicates that drivers who are in a
posture described in the scale as (the drivers have their
back posture as bent and twisted, upper limbs (arms)
below shoulder level, lower limbs (legs) are hanging free
and use of force needed 10kg or less) are at a higher risk
of having LBP than drivers who are categorized as
(drivers having their back posture straight, upper limbs
(arms) below shoulder level, lower limbs lower limbs
(legs) are hanging free and use of force needed is 10kg or
less). Category action 1 means „posture is acceptable‟
and category action 2 means „Some strain- action or
investigation is required‟. In category action 1, those
having LPB are 77 (57.3%) drivers and those in category
action 2 are 215 (81.43%) drivers.
Previous literature indicates that working posture in
which the individual is mostly bending or rotating, is in
flexion or lateral bending, is twisting and or is in an
awkward posture, doing the same activity continuously,
eventually is a cause for muscle fatigue (Charoenchai et
al., 2006; Nasrin et al., 2012). Sedentary work like
driving causes LBP, where driver‟s hips at an angle of
900 or less, produces continuous pressure over lumbar
discs which may lead to degeneration of the lumbar
spine. A study on bus drivers of Kolkata
(Gangopadhyay and Dev, 2012) evaluated torso posture
in as much details as the current study and similar to the
results of the study concluded that poor posture while
driving is a significant risk factor in LBP.
Table.1 Occupational (Work-style) details of auto-rickshaw drivers in Kolkata (n=399)
Work style details Mean (±SD) Range
Driving experience (in years) 14±5.6 3-35
Driving hours per day 11±1.6 7-16
Driving hours per week 69±12 40-112
Shoulder to handle distance (in cm) 50±3.5 38-63
Knee to brake distance (in cm) 46±3 37-57
Vibration measurement (in Hertz) 8.1±61 6-10
Table.2 Result of the Pearson‟s Chi square test to test the association between posture (OWAS) and LBP
Risk factor
LBP
Total
Pearson‟s chi
square
Phi
No (%)
Yes (%)
Posture
(OWAS)
Level 1
Level 2
58 (42.9)
49(18.56)
77(57.03)
215(81.43)
135
264
0.487
0.264
Int.J.Curr.Res.Aca.Rev.2017; 5(5): 85-92
90
Figure.1 OWAS action level 1 - sitting posture of auto-rickshaw driver of urban Kolkata: OWAS action level 2 -
sitting posture of auto-rickshaw driver of urban Kolkata
Action level 1 Action level 2
Figure.2 Research plan
Int.J.Curr.Res.Aca.Rev.2017; 5(5): 85-92
91
Conclusion
The prevalence of LBP in auto-rickshaw drivers of
urban Kolkata is higher than the LBP prevalence in
other vehicle drivers. The risk factor for LBP in auto-
rickshaw drivers is the forward bent and twisted sitting
posture which is frequently adopted by auto-rickshaw
drivers while driving.
Recommendations for future research
More auto routes may be surveyed.
The same type of auto models should be
selected.
Measurements for the upper limbs (shoulder
to handle distance) should have be taken for
the both sides.
Vibration measurement tool should be tested
for accuracy and reliability.
The survey population could have been more
in number.
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How to cite this article:
ShabnamAgarwal, Anwesh Pradhan, GargiRayChaudhuri, SoumitraDas. 2017. Prevalence and Risk Factors of Low
Back Pain among Auto-Rickshaw Drivers in Urban Kolkata. Int.J.Curr.Res.Aca.Rev. 5(5), 85-92. doi:
https://doi.org/10.20546/ijcrar.2017.505.011
