Faculty of Medicine, MBBS Programme

Session 2018/2019, Semester 6 (Year 3)

RESEARCH PROPOSAL

TITLE: PREVALENCE OF LOW BACK PAIN AND ITS ASSOCIATED FACTORS

AMONG COMMUNITY MEMBERS IN TAMAN MEDAN

GROUP 3 (ROTATION 4), 2018

Prissha Kaur A/P Beker Singh BMS15091329

Nida Nawaz BMS15091593
Mariyam Lujainy Athif BMS15091658
Muhammad Syakir Bin abdul Razak BMS15091480
Zeinab Ali Chamkha BMS15091665
Nur Aifaa Adnan BMS15091593
Amal Abdulkadir BMS15091333
Abdul Rahman Khan BMS15091329
Safia Abdi Mohamed BMS15091696
Daniel Hazzim Bin Imran BMS15091509
Nur Liyana Maryam Binti Zaini BMS15091451
Shafa Ahmed. BMS15091813

FACULTY SUPERVISOR: Prof. Dr. Than Winn, Dr.Sowmya Ramakrishnappa,Dr. Meer

Ahmed Dr. Than Tun Aung, Dr. Aung Ko Ko Min
Table of Contents

No
i. Acknowledgement
ii. Abstract
1. Introduction
1.1:Background information
1.2:Problem statement
1.3:Research Question
1.4: Objectives
 General objective
 Specific objectives
1.5: Hypothesis
1.6: Conceptual framework
2. Literature review
 (i) Acknowledgement
First and foremost, we would like to thank MAHSA University for providing us a platform to
conduct researches. Furthermore, we would like to express our deepest gratitude to our Dean of
Faculty of Medicine, Dato’ Dr. Ravindran Jegasothy and our Program Coordinator Dr. Sowmya
Ramakrishnappa for giving us the opportunity to conduct a research. Besides that ,we would like
to express our gratitude to our lecturers Prof Dr. Than Winn, Prof Dr. Hematram Yadav, Dato’
Assoc. Prof. Dr. C. Prathapa Senan, Dr. Than Tun Aung, Dr. Kay Khine Nyo, Dr. Aung Koko
Minh and Dr. Meer Ahmad Mydin Meera for their persistent guidance, support and advice
throughout the course of the research. Lastly, the gratitude goes to all of the group members for
their endless commitment and determination in ensuring the success of the research.
 Abstract
Introduction: Low back pain (LBP) is a very common health problem worldwide and a major
cause of disability - affecting performance at work and general well-being. Approximately 9 to
12% of people (632 million) have LBP at any given point in time, and nearly 25% report having
it at some point over any one-month period. About 40% of people have LBP at some point in
their lives, with estimates as high as 80% among people in the developed world. According to
Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and
sixth in terms of overall burden (DALYs). In Malaysia, LBP is a common musculoskeletal
problem among the elderly population. Older population is expected to increase from 4% in 1998
to 9.8% in 2020 and LBP is also expected to increase among this group. At present, there is lack
of study reported with LBP in the country. Reference

Objective:To determine the prevalence of low back pain and its associated factors among adults
in Taman Medan.

Materials and Methods:The nature of our research is using the cross sectional study design as
we will be meeting the participants at a specific point in time. The sampling method to be used is
convenient sampling. The approach of the collection of data is by giving out questionnaire
among the residence of Taman Medan.

Result: Studies have showed that the result is expected to have a high prevalence of lower back
pain in increasing of age. It also correlates with other risk factor such gender, occupation,
smoking, body mass index (BMI) and type of work. It is expected to show an increase in lower
back pain in all this risk factor.

Conclusion: Low Back Pain (LBP) is a relatively common complaint among adults. As age
progresses, global number of individuals with low back pain are also likely to increase
substantially over the coming decades. Various risk factors of LBP including gender, age,
occupation, smoking, body mass index (BMI) and type of work will be present in the study
population. Further studies are required to develop an effective preventive method for this
relatively common problem.

Key words : Prevalence , Risk Factors, Low Back Pain, Malaysia,

Chapter 1
 Introduction

1.1 Background information

Low back pain (LBP) is the pain that is located in the lumbosacral region in the back, below
the 12th rib and above the gluteal folds with or without leg pain that lasted for at least 24 hours
and had a pain score of 3 out of 10 or higher and it is an important public health issue as
reflected by its high prevalence rates in many countries, and the costs associated with its
management. It is estimated that up to 84 percent of adults mention age group of adult have low
back pain at some time in their lives. For many individuals episodes of back pain are self-limited.
Low back pain is a common painful condition that is encountered both in general and specialist
practice. The prevalence of low back pain varied between 10-63% with a median of 37% in
several studies and it did not differ by sex in most of them. Recent studies in Malaysia have
shown similar results: in a semi-rural community survey the incidence of low back pain was
found to be around 12% whereas there was a much higher prevalence (60%) in a population at
risk (commercial vehicle drivers). Put reference

The prevalence of reported LBP varies from country to country. In south East Asia e.g. in
Thailand, high prevalence of LBP is reported. The six month prevalence of LBP was more than
50% in the study population over 50 yearr olds. For instance, LBP is considered a major health
problem in Germany with an annual prevalence rate of more than 70%. 3 In Norway, the lifetime
prevalence was reported to be about 69.9%, while in Sweden the prevalence is about 60.7%. In
2010 lower back symptoms were the principal reason for 1.3 percent of hospital visits in the
United States. Risk factors associated with lower back pain complaints include smoking, obesity,
age, female gender, physically strenuous work and sedentary work.

1.2 Problem Statement

Low back pain is a very frequently occurring phenomenon of health problem worldwide and a
major cause of disability affecting performance at work and general well-being. Low back pain
can be acute, sub-acute, or chronic. Low back pain is associated with multiple risk factors,
including gender, age, lifestyle, physical demands of the workplace and smoking. Back pain is
not a disease but a constellation of symptoms. In most cases, the origins remain unknown.

Low back pain affects people of all ages, from children to the elderly, and becomes a common
reason people seek medical attention. The 2010 Global Burden of Disease Study estimated that
low back pain is among the top 10 diseases and injuries that account for the highest number of
DALYs worldwide. It is difficult to estimate the incidence of low back pain as the incidence of
first-ever episodes of low back pain is already high by early adulthood and symptoms tend to
recur over time. The lifetime prevalence of non-specific (common) low back pain is estimated at
60% to 70% in industrialized countries (one-year prevalence 15% to 45%, adult incidence 5%
per year). The prevalence rate for children and adolescents is lower than that seen in adults but is
rising. Prevalence increases and peaks between the ages of 35 and 55. As the world population
ages, low back pain will increase substantially due to the deterioration of the intervertebral discs
in older people.

Low back pain is the leading cause of activity limitation and work absence throughout much of
the world, imposing a high economic burden on individuals, families, communities, industry, and
governments. Several studies have been performed in Europe to evaluate the social and
economic impact of low back pain. In the United Kingdom, low back pain was identified as the
most common cause of disability in young adults, with more than 100 million workdays lost per
year. In Sweden, a survey suggested that low back pain accounted for a quadrupling of the
number of work days lost from 7 million in 1980 to 28 million by 1987. However, the authors
state that the existence of social compensation systems in Sweden might account for some of this
increase. In the United States, an estimated 149 million work days are lost every year because of
low back pain, with total costs estimated to be US$ 100 to 200 billion a year (of which two-
thirds is due to lost wages and lower productivity). Taman Medan in Petaling Jaya, Kuala
Lumpur was chosen to conduct this study is because there is no any study conducted before in
Taman Medan that determine the prevalence of low back pain and its associated factors.

1.3 Research Questions

1. What is the prevalence of low back pain among adults in Taman Medan?

2. What are the associated factors of low back pain among adults in Taman Medan?

1.4 Objective
1.4.1 General Objective:

To determine the prevalence of low back pain and its associated factors among community
members in Taman Medan.

1.4.2 Specific Objectives:

1. To determine the prevalence of low back pain among community members in Taman Medan.

2. To determine the association between gender and low back pain among community members
in Taman Medan.

3. To determine the association between age group and low back pain among community
members in Taman Medan.

4. To determine the association between body mass index (BMI) and low back pain among
community members in Taman Medan.

5. To determine the association between occupation and low back pain among community
members in Taman Medan.

6. To determine the association between type of work and low back pain among community
members in Taman Medan.

7. To determine the association between smoking and low back pain among community
members in Taman Medan.

1.5 Hypothesis
1. There is low prevalence of low back pain among community members in Taman Medan.

2. There is no association between gender and low back pain among community members in
Taman Medan.

3. There is no association between age group and low back pain among community members in
Taman Medan.

4. There is no association between body mass index (BMI) and low back pain among community
members in Taman Medan.

5. There is no association between occupation and low back pain among community members in
Taman Medan.

6. There is no association between type of work and low back pain among community members
in Taman Medan.

7. There is no association between smoking and low back pain among community members in
Taman Medan.

1.6 Conceptual framework

 AGE GROUP

GENDER

OCCUPATION

LOW BACK PAIN

SMOKING

BODY MASS INDEX (BMI)

TYPE OF WORK
 CHAPTER 2

Literature review

A study (Bio, Sadhra et al. 2007) was conducted to determine the prevalence and
predisposing factors for Low Back Pain (LBP) among male underground gold miners
at the Obuasi gold mine in Ghana.This is a cross sectional study on 280 male
underground gold miners from June to October 2001 with a structured questionnaire
administered through interviews. Results showed that the twelve months prevalence
of low back pain among miners was 67%. The mean age of the workers was 40 years
(+/- 5.6, ranging from 27 to 53 years). Increasing age was significantly associated
with low back pain, (P=0.05) OR 2.07 (95% CI 0.99 to 4.34) after adjustment for
smoking and occupation. Prevalence of LBP was highest among workers performing
engineering (82%) duties. Heavy physical work (77%), was identified as a major
cause of LBP, which could be prevented by the use of lifting aids (16%). In
conclusion, the prevalence of low back pain in this group is comparable with that
obtained from other studies in Africa and Europe. Training and education as a means
of reducing LBP was suggested by just a few of the respondents.

Another study was done to health insurance policy holder to determine the
prevalence and associated factor to low back pain. It was conducted by (Matos,
Hennington et al. 2008) in Brazil. The study is aimed to determine the prevalence and
associated factor of low back pain in the previous three month. It is done by giving a
self-applied questionnaire that contains socioeconomic, demographic, occupational,
and lifestyle questions. A total of 775 subject of both sexes, around the age of 20-59
years old was involves. It shows that the prevalence of low back pain in that 775
subject was 52.8% in the previous year (95%CI: 49.3-56.3) and 46% in the previous
three months (95%CI: 42.5-49.5). Poisson regression for lower back pain in the
previous 90 days showed an association with: (1) age 40-49 years; (2) self-reported
strenuous or difficult work; and (3) smoking. Despite the high prevalence of lower
back pain and difficulty in performing work activities, the pain was not disabling.
Although 29.9% of workers reported some difficulty in performing their daily or
work-related activities due to lower back pain, absenteeism was quite low. This shows
that low back pain is associated with physical activity.

Although low back pain (LBP) is an important issue for the health profession,
few studies have examined LBP among occupational therapy students. A study was
done by (Leggat, Smith et al. 2008) at Northern Queensland on occupational therapy
student to determine the prevalence and correlation of low back pain to its risk factor.
The study was performed by giving a self-reported questionnaire to occupational
therapy student in Northern Queensland. The study lasted for 72 months. The results
shows that the prevalence of LBP was 64.6%. Nearly half (46.9%) had experienced
pain for over 2 days, 38.8% suffered LBP that affected their daily lives, and 24.5%
had sought medical treatment. The prevalence of LBP ranged from 45.5 to 77.1% (p =
0.004), while the prevalence of LBP symptoms persisting longer than two days was
34.1 to 62.5% (p = 0.020). Logistic regression analysis indicated that year of study
and weekly computer usage were statistically-significant LBP risk factors. The
occupational therapy profession will need to further investigate the high prevalence of
student LBP identified in this study.

Based on study done by (Bjorck-van Dijken, Fjellman-Wiklund et al. 2008)

regarding the prevalence of low back pain is associated with lifestyle factor and
physical activity. The study also include some other factors such as age, sex, level of
education, demographic characteristics. The purpose of this study is to see whether
there is an association of low back pain with this factors. A population based study
where the sample is randomly pick was conducted in Sweden. A total of 5798
subjects aged 25-79 years were selected randomly. They were given questionnaire of
the World Health Organization MONICA health survey with the aim of investigating
prevalence rates and factors associated with low back pain. It shows that forty-one
percent of the participants reported having low back pain (of these 55% were women
and 45% men). The prevalence rate was highest in the age group 55-64 years. Chronic
low back pain was the most frequent occurring problem. Of those with low back pain,
43% of the women and 37% of the men reported having continuous low back pain for
more than 6 months. Individuals with low back pain often experienced a more
physically heavy workload at work and lower physical activity during leisure time,
and they were also more likely to have been smokers, have had higher body mass
index, lived in smaller communities, and were less educated than people without low
back pain. It was concluded that low back pain seems to be associated with physical
activity at work and in leisure time, certain lifestyle factors and demographic
characteristics.

According to (Plouvier S, Leclerc A, Chastang JF, Bonenfant S, Goldberg M. et

al., 2009), biomechanical strains and psychosocial work factors which was analysed
by the GAZEL cohort study played a role in occupational class disparities in low-back
pain. Associations between low-back pain for >30 days in the preceding 12 months
and social position at baseline (four categories) were described with a Cox model to
determine prevalence ratios for each category. We compared adjusted and unadjusted
ratios to quantify the contribution of occupational exposures. Results from
questionnaires in 1996 (past occupational exposure to manual material handling,
bending/twisting, and driving), 1997 (psychosocial work factors), and 2001 (low-back
pain using a French version of the Nordic questionnaire for the assessment of low-
back pain) showed the prevalence of low-back pain for >30 days was 13.6%. The
prevalence of low-back pain adjusted for age was significantly higher for blue-collar
workers and clerks than for managers. The number of socioeconomic disparities
observed was significantly reduced when biomechanical strains were taken into
account; adjusting for psychosocial factors had little impact. Therefore study has
shown that occupational exposures--especially biomechanical strains--played an
important role in occupational class disparities for persistent or recurrent low-back
pain.

Based on a study conducted by (Hoy, D., et al. (2012) low back pain was shown
to be a major problem throughout the world, with the highest prevalence among
female individuals and those aged 40-80 years. It is to perform a systematic review of
the global prevalence of low back pain, and to examine the influence that case
definition, prevalence period, and other variables have on prevalence .The study
included general population studies published between (Hoy et al., 2012) 1980 and
2009. Total 165 studies from 54 countries were identified. Of these, 64% had been
published since the last comparable review. After adjusting for methodologic
variation, the mean +/- SEM point, prevalence was estimated to be 11.9 +/- 2.0%, and
the 1-month prevalence was estimated to be 23.2 +/- 2.9%. As the population ages,
the global number of individuals with low back pain is likely to increase substantially
over the coming decades.
 Based on a research done by (D. Hoy, C. Bain, G. Williams, L. March, P. Brooks,
F. Blyth, A. Woolf, T. Vos and R. Buchbinder et al 2012) the study shows that low
back pain is one of the most common health problems and creates a substantial
personal, community, and financial burden globally. As part of estimating the global
burden of low back pain, with low back pain defined as “activity-limiting low back
pain ( +/- pain referred into 1 or both lower limbs) that lasts for at least 1 day” (5),
country-specific prevalence data were required. The most recent global review of the
prevalence of low back pain in the adult general population was published in 2000
and showed point prevalence of 12–33% and 1-year prevalence of 22–65%. This
study is a systematic review of the global prevalence of low back pain that
includedgeneral population studies published between 1980 and 2009. A total of 165
studies from 54 countries were identified. Of these, 64% had been published since the
last comparable review. Low back pain was shown to be a major problem throughout
the world, with the highest prevalence among female individuals and those aged 40–
80 years. After adjusting for methodologic variation, the mean ± SEM point
prevalence was estimated to be 11.9 ± 2.0%, and the 1-month prevalence was
estimated to be 23.2 ± 2.9%. In conclusion, as the age of the population increases, the
number of individuals with low back pain increases over the coming decades.

According to a study done by (O. Eyichukwu, PC. Ogugua at el 2012) in Enugu,

Nigeria, it states that low back pain (LBP) is one of the most frequently reported
chronic health problems affecting the adult population. A retrospective study was
done by analizing and extracting the data from the records of 3200 patients newly
diagnosed for LBP over five years. The data that were extracted inculdes
demographic indices, duration of symptoms before presentation, predisposing factors,
diagnosis and spinal level of involved vertebrae. Patients with vertebral fractures and
spinal cord injuries in the lumber region were excluded. Three thousand two hundred
patients' records met the inclusion criteria. The mean age was 45 years, peak age
incidence was 31 to 40 years; while the age range is 8 to 82 years. The male to female
ratio is 1: 1.5. There were 20% as acute LBP, 6.9% as subacute whereas 73.1%
presented as chronic LBP. The most commonly affected occupational groups are Petty
traders, 720 (22.5%), and Civil Servants 580 (18.1%). The most common
predisposing factor to LBP were trauma to the low back 420 (13.1%), and lifting of
heavy objects 340 (10.6%). . Sedentary life style appears to play a significant role in
the development of LBP in Enugu and environs while trauma, lifting of heavy objects,
obesity and pregnancy are the other common factors. Mechanical LBP in the form of
spondylosis, chronic disc prolapsed and spondylolisthesis are the common causes.
The most affected spinal motion segments are L4/L5 and L5/S1.

The purpose of the study (Bener, Dafeeah et al. 2014) was to determine the
prevalence of low back pain (LBP) in the primary care setting with emphasis on the
socio-demographic contributing factors and impact of LBP on lifestyle habits. The
study is Cross-sectional study. A representative sample of 2,600 patients were
approached and 1,829 subjects agreed to participate in this study (70.0%). Data on
socio-demographic characteristics, life style habits and type of treatment were
collected through a questionnaire. The prevalence of LBP in the study sample was
56.5% (95% confidence interval, 54.2-58.8). LBP was more prevalent among women
(53.9%) compared to men (46.1%). There was significant difference between male
and female patients of LBP in terms of ethnicity (p<0.001), marital status (p=0.010),
occupation (p<0.001), monthly household income (p=0.004), and cigarette smokers
(p<0.001). The percentages of different aspects of functional disabilities were
statistically significantly higher among females compared to male patients with LBP.
Almost a quarter of female patients with LBP (26%) and 18% male patients with LBP
reported pain in the arms and legs (p=0.002). In addition, gastrointestinal complaints
such as abdominal pain and food intolerance were significantly higher among female
patients with LBP as compared to males (31% vs. 24.6%, p=0.018; and 25% vs. 18%,
p=0.008, respectively). Complaints about headache and fainting were also
significantly higher among female patients as compared to male LBP patients (43%
vs. 36%, p=0.029; and 26% vs. 20%, p=0.016, respectively). The multivariate logistic
regression revealed that being female, prolonged standing, prolonged sitting, heavy
weight lifting, weakness in the legs, regular exercise, and cigarette/sheesh a smoking
had a significant effect on the presence of LBP. Low back pain is highly prevalent
among both genders and in older age. Also, weakness in the legs, smoking, prolonged
standing and sitting had a significant effect on LBP. Furthermore, the current study
findings support the fact that LBP continues to be an important clinical, social and
economic, burden and a public health problem affecting the population of the entire
world.
 (Erbay Dundar et al., 2006) conducted a cross-sectional study to determine
the prevalence of low back pain and to evaluate the effects of household jobs on low
back pain in women living in a rural setting in Manisa. 302 women participated in this
study and cluster sampling was performed. Participation ratio of this study was
89.1%. Univariete and multivariete risk approach in 95% CI and t test were performed
in data analysis. Brief Disability Questionnaire was applied to the study group. Life
time and point prevalence of low back pain were determined 79.2% and 34.9% of the
study group. Low back pain risk in 95 % CI was higher in wrong posture during
ironing, heavy load lifting, overweight/obesity and disability 2.2 (1.1- 4.5), 4.5 (2.1-
9.2), 3.8 (1.7-8.3) and 9.2 (4.3-19.7) times respectively. For preventive health
measures it is necessary to apply ergonomic working conditions and to give
appropriate postural habits to women.

A previous study (Sun, He et al. 2007) was conducted to explore the prevalence
of occupational low back pain (OLBP) and assess work-related risk factors in ICU
nurses. Forty hundred seventy-seven ICU nurses of study group and nurses working
in other wards (control group) of the same comprehensive hospital were investigated
using OLBP Investigation Questionnaire for nurses. Working postures and related
work activities were evaluated by using the Win OWAS software and the compressive
force (Fc) of the disc between L5 and S1 was calculated by using the Bless Pro
software and sampling was taken by digital camera in ICU ward of one hospital.
Results showed that the prevalence of OLBP (87%), frequency of OLBP (48%=1 per
month) and OLBP related work-absence (7%) of the ICU nurses were significantly
higher than the control group (64%, 32% and 2%, respectively). The frequency of
harmful postures occurred during working tasks of observing drainage, lifting and
transferring patients in bed, injection, suctioning and adjusting drip were 99%, 90%,
75%, 75% and 6%, respectively. The ratios of Fc of adjusting drip rate (taken as 100),
suctioning, injection, observing drainage and lifting and transferring patients in bed
were 100:155:199:301:418. In conclusion, prevalence of OLBP in ICU nurses is high.
High frequency of bending and twisting, transferring patients in bed are the main
causes of OLBP in ICU nurses.

Another research (Zhang, Wang et al. 2007) was conducted to study the low back
pain(LBP) and its cause on female workers in flat-grained veneer wood industry.
Bending posture was analyzed by observation and the prevalence of low back pain
was investigated by physical examination and questionnaire among 299 female
workers. Results showed that the prevalence of fatigue compliant in selecting,
remending and sticking workers was 68.8%, 66.7% and 59.0%, respectively, which
mainly involved in the part of low back. The prevalence of low back pain in selection
(53.8%) and remending (58.7%) workers was higher than that in sticking workers
(30.1%), which was in accordance with the tenderness between L4/L5 or L5/L6 and
on the psoas major. Posture analysis indicated that the biggest bending range of
selecting and remending workers (80 degrees ) was larger than that of sticking
workers (60 degrees ), as well as the daily bending times[(4396+/-817), (1696+/-286),
(1094+/-476)] and the time they kept bending[(6.5+/-0.6), (6.2+/-1.3), 4.5+/-0.9) h].
In conclusion, bending posture is common among female workers especially those
who work in selecting and remending and might be the major causes for the high
prevalence of LBP in flat-grained veneer wood industry.

Another study was done by (Landry et al., 2008) in Kuwait to investigate the
prevalence and factors associated with low back pain (LBP). It was a cross sectional
study. A self-administered survey was conducted with health professionals in an
urban orthopedic hospital. The response rate to the survey was 60% (n = 344).
Lifetime prevalence of LBP in the sample was 70.9%, and point prevalence of LBP
was 21.5%. Factors associated with acute LBP included direct patient contact (P =
0.015), performing patient lifts (P = 0.016), low job satisfaction (P = 0.039), and poor
self-reported health status (P = 0.019). The prevalence ratio (PR) of reporting acute
LBP was also found to increase as a function of the number of daily lifts performed
(PR: 1.4; 95% CI: 1.27 to 1.70). Other factors generally associated with LBP, such as
age, sex, professional experience, smoking and exercise, were not found to be
significantly associated with LBP in this study. The results suggest that direct patient
contact that includes lifting patients may be an important risk factor.

Based on (Ochsmann E, Rüger H, Kraus T, Drexler H, Letzel S, Münster E. et al.,

2009), due to more complaints of low back pain by women than man has given rise to
a questioning on whether low back pain is gender specific risk factor. Based on the
bivariate (chi) and multivariate test, results have shown that women (28.5%)
complained about acute low back pain significantly more often than men did (18%;
p<0.001). The multivariate analysis found gender-specific risk estimates for the
following factors: age, degenerative diseases of the joints, osteoporosis, depression,
smoking, employment, municipality size, and impairment of daily work because of
physical impairment. The present examination is an attempt to deduce factors to be
taken into account for gender-specific care of patients with acute low back pain.
Preventive measures and therapy approaches could be influenced by these findings.
To adequately address the problem, future analyses should specifically include
psychosocial factors.

Based on the study done by (Alkherayf F, Agbi C. et al., 2009), chronic low back
pain (LBP) is one of the main causes of disability in the community. Although there
have been studies suggesting an association between smoking and LBP, these studies
were limited by the small numbers of patients, and they did not control for
confounders. The objective of this study was to determine whether cigarette smoking
is associated with an increased risk of chronic LBP among adults. Results of the
multivariate analysis showed prevalence of chronic LBP was 23.3% in daily smokers
and only 15.7% in non-smokers. Age and sex were found to be effect modifiers (P <
0.0001), and the relationship between smoking and chronic LBP risk was dependent
on sex and age. The association between daily smoking and the risk of chronic LBP
was stronger among younger individuals. Occasional smoking slightly increased the
odds of having chronic LBP. Thus, daily smoking increases the risk of LBP among
young adults, and this effect seems to be dose-dependent. Back pain treatment
programs may benefit from integrating smoking habit modification. Further research
is required to develop effective prevention strategies.

Based on the study by (Yalcinkaya, E. Y., K. Ones, et al., 2010), it had been
conducted to determine the frequency and features of low back pain (LBP) among
stroke caregivers. Participants included 64 caregivers of stroke survivors in our
inpatient clinic. Age, gender, body weight, FIMTM, and Brunnstrom Scale of patients
and low back pain history, Short Form-36 (SF-36), Beck Depression Measure (BDM),
and Oswestry Disability Scale (ODS) of caregivers were reported. Descriptive
statistics, Spearman correlation, and Mann-Whitney U test were used. The results
show fifty-three (82.8 %) of caregivers had LBP. Stroke survivors of caregivers with
LBP (group 1) had significantly lower FIMTM scores when compared with stroke
survivors of caregivers without LBP (group 2) (P < .05). All SF-36 subscores and
total score of group 1 except mental health were significantly lower than SF-36 scores
of group 2. The lifetime, 12-month period, and point prevalence of LBP were 44.1%,
34.0%, and 19.7%, respectively, in our country. Caregivers had a higher frequency of
LBP in this study. However it was a study with a small number of participants. There
are many studies about stroke caregivers' depression and life quality.

According to a research done by (Heuscher, Z., D. P. Gilkey, et al., 2010), back

pain has consistently ranked among the top general health complaints among college
students, but few studies have examined risk factors for back pain in this age group.
This cross-sectional survey evaluated the association between the self-reported annual
low back pain with the estimated usual backpack weight among college students. The
annual prevalence of low back pain was 29.2% (n = 136). A 25% increase in the odds
of annual low back pain for each 4-kg increase in the estimated usual backpack
weight was observed after adjusting for sex, smoking, reporting frequently feeling
overwhelmed, and body mass index (adjusted odds ratio per 4-kg increase, 1.25; 95%
confidence interval, 1.17-1.32). There was no evidence of an increased association of
annual low back pain with carrying a backpack weight greater than 10% of the
students body weight compared with those carrying less (adjusted odds ratio, 1.02;
95% confidence interval, 0.63-1.65). Thus, the results of this study suggest that
increasing reported backpack weight is associated with increased prevalence of annual
low back pain. However, these results do not provide evidence to support the
recommendation that the backpack weight necessarily be less than 10% of body
weight.

This study by (Lunde, L. K., et al. 2015) examined the course of low back pain
and the association between low back pain and leisure time physical activity in a
cohort of young adults in their transition from school to working life. Both low back
pain and leisure time physical activity was monitored over a 6.5 year period in 420
subjects starting out as students within hairdressing, electrical installation and
media/design. The association between physical activity and low back pain was
investigated through the follow-up period by using linear mixed models analysis. Low
back pain was significantly influenced by time and overall there was a decreasing
trend of low back pain prevalence throughout the follow-up. Analysis showed a weak
trend of decreasing low back pain with moderate/high physical activity levels, but this
association was not significant. Low back pain decreased during follow-up with
baseline as reference. Findings in our study did show non-significant trends of
reduced low back pain with increased leisure time physical activity. Still, we could
not support the theory of moderate/high levels of physical activity acting protective
against low back pain in young adults entering working life. Our results, in
combination with previous relevant research, cannot support a clear relationship
between physical activity and low back pain for young adults. Thus,
recommendations regarding effect of physical activity on reducing low back pain for
this group are not clear.

A study done by (Alsiddiky, Algarni et al. 2015) aimed to quantify the prevalence
of LBP among clinicians, and to identify its associated factors. A cross sectional study
was carried out in King Khalid University Hospital (KKUH) among 460 clinicians
from different specialties. A validated questionnaire of 21 items was used to collect
data. Chi-square test and odds ratios were used to observe and measure the association
between categorical variables. Binary logistic regression by Wald method was used to
identify independent factors associated with LBP (yes/no). The result show that the
prevalence of LBP was found to be 59.4% (244) with 38% of them reported as severe.
The distribution of prevalence among consultants, registrars and residents was 110
(45.1%), 91 (37.3%) and 43 (17.6%) respectively. Out of 114 (46.7%) surgeons who
suffer from LBP we found, orthopaedic surgeons had 10.2% prevalence of LBP. Male
clinician (odds ratio: 1.7; 95% Confidence Interval (CI): 1.1- 2.8), consultant (4.1;
95% CI: 2.1-8.3), registrar (2.2; 95% CI: 1.2-4.2), more than 10 hours/week near
bedside (1.8; 95% CI: 1.1-3.0), bending backwards at work (8.3; 95% CI: 5.1-13.4)
and pulling objects during work (3.1; 95% CI: 1.7-5.6) were found to be independent
statistically significant associated factors of LBP. The high prevalence of LBP among
clinicians and its associated factors indicates that clinicians should maintain good
posture and avoid sudden movements during working hours in hospital to reduce this
occupational health problem.

According to (Khruakhorn, S., P. Sritipsukho, et al., 2010), low back pain (LBP)
is one of the most common musculoskeletal disorders in the population especially in
working population. Many intrinsic and extrinsic factors have been evaluated for
associated factor for LBP Epidemiological researches have been provided information
on the prevalence and risk factors of LBP in the workers. Little information has
related individual and work-related factors to the prevalence of LBP among the
university staff in Thailand. The result of multivariate analysis showed that habitual
physical activity level were found to be independent factors associated with the LBP
(p-value = 0.048 by LRT) after adjusted for gender nutritional level and work activity
in a day. The physical activity as athletic level appeared to be the protective effect
when compared to sedentary level (adjusted OR 0.43, 95% CI: 0.20-0.94). Based on
the results of the study, the physical activity as athletic level appears to be associated
with the 6-month prevalence of LBP. Consequently, it is important that prevention
programs take into account this risk factor in order to reduce the frequency of low
back injuries in university staff and improve their work efficiency.

A study was done 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. 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).
(Murtezani, Ibraimi et al. 2011).

As LBP is common among health-worker, a study in Iran was done to investigate

the prevalence and risk factors of LBP in surgeons and to analyze how individual and
occupational characteristics contribute to the risk of LBP. In which a cross sectional
study was conducted on 250 randomly selected surgeons including 112 general
surgeons, from 21 hospitals at northern Iran. A structured questionnaire including
demographic, lifestyle, occupational characteristics as well as prevalence and risk
factors of LBP was used. Visual analogue scale and Oswestry low back disability
questionnaires were also used to assess the pain intensity and functional disability,
respectively. Result shows that point, last month, last six months, last year and
lifetime prevalence of LBP was 39.9%, 50.2%, 62.3%, 71.7% and 84.8%,
respectively. The highest point prevalence was related to the gynecologists with
44.9%, and the lowest for general surgeons (31.7%). Age, body mass index, smoking,
general health, having an assistant, job satisfaction, using preventive strategies and
years of practice were found to be correlated with the prevalence of LBP (P < .05 in
all instances except for age and job satisfaction). Prolonged standing, repeated
movements and awkward postures were the most prevalent aggravating factors
(85.2%, 50.2% and 48.4%, respectively). Rest was found to be the most relieving
factor (89.5%). This demonstrates that the prevalence of LBP amongst surgeons
appears to be high and highlights a major health concern. (Mohseni-Bandpei, Ahmad-
Shirvani et al. 2011).

A cross-sectional study was done in Hong Kong by (Yeung and Yuan 2011) to
explore the work-related and individual factors that contributed to the occurrence of
low back pain and affected activities of 36 personal care workers at an old age home.
The study was divided into four parts: (1) a questionnaire documenting workload
exposure factors; (2) a musculoskeletal symptoms survey documenting the prevalence
of low back pain in this group of workers; (3) a worksite evaluation focusing on
personal care workers' work postures and the work environment; and (4) an
evaluation of physical fitness and lifting capacities of personal care workers.
Univariate followed by multiple logistic regression analyses were used to identify the
risk factors associated with low back pain that affected work activities. The results
revealed that low back pain was associated with the perceived physical demands of
cleaning tasks (odds ratio [OR] = 7.28, 95% confidence interval [CI] = 1.35-39.35, p
< .05), perceived demands of awkward sustained back (OR = 4.46, CI = 0.86-22.97, p
= .074) and neck (OR = 0.18, CI = 0.04-0.81, p < .05) postures, and thermal stress at
work (OR = 49.80, CI = 0.70-3541.79, p = .072). The results of the current study
indicated that the work environment contributed to low back pain at work. Workers
perceived that exertion in workplaces has a role in assessing workplace risk. To avoid
progression of low back pain in the workplace, work adjustment or modification
should be considered when workers report high levels of perceived exertion at work.

Cross sectional study by (Tamrin et al., 2007) to determine

the risk factors associated with complain of low back pain. The participants of this
study were 760 commercial vehicle drivers from 11 bus companies of different
regions in Malaysia. Modified Nordic questionnaire was used for determining the
prevalence of low back pain. Besides, Maestro human vibration meter, Modified
Owas , Profile of Mood States (POMS) were used to measure the personal R.M.S
values of lateral, anterior-posterior and vertical axes; assessing the awkward posture
of the driver torso and to evaluate the mood states of bus drivers with complain
of low back pain. A high prevalence of low back pain (60.4%) among
Malaysian commercial vehicle drivers was found. Logistic regression analysis
controlling for age, income, education level and non-occupational activities revealed
that the following factors were related to low back pain: Tension-anxiety [1.080, 95%
CI 1.041-1.121], depression dejection [1.047, 95% CI 1.023-1.072], anger-hostility
[1.053, 95% CI 1.027-1.081], fatigue [1.132, 95% CI 1.089-1.177] and confusion
[1.114, 95% CI 1.061-1.169] of POMS, length of employment [1.001, 95% CI 1.0-
1.003], steering wheel adjustment [1.521, 95% CI 1.101-2.101], perception of
exposing to vibration [1.943, 95% CI 1.389-2.719]. In conclusion, combinations of
risks lead to high increase of low back pain complain among Malaysian bus driver.

A study conducted by (N.A.M Nordin, D.K.A Singh & L. Kanglun. et al. 2014) to
determine the incidence of LBP and identify the associated risk factors among health
science undergraduates. Identification of associated risk factors is important to enable
successful implementation of low back pain prevention strategies. To date, there is
limited research data on back pain among young adults in Malaysia despite an
increasing incidence of this disabling condition worldwide. A cross-sectional survey
was conducted to determine the incidence of low back pain (LBP) and associated
factors among health science undergraduates. A self-administered questionnaire was
distributed to full time students of a main public university. One hundred and forty
undergraduates; mean age 21.4±1.3 years, 70% female, 60% in year 3 of study,
participated in the survey. The results showed that 31% spent between 6 and 8 h and
another 31% spent more than 9 h sitting in a day. Twelve percent of the
undergraduates rated their fitness level as 'poor'. The incidence of LBP was 40.3%
among the undergraduates. LBP incidence was associated with age (X2=12.1,
p=0.007), years of study (X 2=8.7, p=0.03), self-rated physical fitness (X2=7.0,
p=0.02) and hours spent sitting (X2 =8.7, p=0.03). Gender, body mass index and
hours spent in sports and physical activity were not associated with LBP. The findings
from this study demonstrate that physical fitness and sitting duration is associated
with low back pain among health science undergraduates. Health science
undergraduates should improve their physical fitness, practice frequent breaks and
stretching during sitting. This will help to minimize LBP related to decreased fitness
levels and prolonged sitting.

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Chapter 3

Methodology

3.1 Study design and study setting

The study design that was used to conduct this research is cross sectional study. This
method of study measures the relationship between disease and other variables of
interest which exist in defined population at a single point in time or over a short
period of time. There are two types of cross sectional study, descriptive and
comparative. Descriptive cross sectional study is used to assess the burden of a
particular disease in a defined population whereas in analytical it is used to investigate
the association between a risk factor and health outcome.
 VARIABLES TEST
STATISTIC
DEPENDENT TYPE OF INDEPENDENT TYPE OF
DATA DATA
Low Back Pain Categorical Gender Categorical Chi square
Low Back Pain Categorical Age group Categorical Chi square
Low Back Pain Categorical Ethnicity Categorical Chi square
Low Back Pain Categorical Marital status Categorical Chi square
Low Back Pain Categorical Body Mass Index Categorical Chi square
(BMI)
Low Back Pain Categorical Occupation Categorical Chi square
Low Back Pain Categorical Type of Work categorical Chi square
Low Back Pain Categorical Level of Categorical Chi square
education
Low Back Pain Categorical Smoking Categorical Chi square
Low Back Pain Categorical Chronic illness Categorical Chi square

3.2 Variables and hypothesis testing

3.3 Sampling method

The general sample size for this research is 275. Convenience sampling method was
applied in this study to obtain data from people who are conveniently available to
participate in study during the given short period of time. In convenience sampling no
inclusion criteria identified prior to the selection of subjects thus any subject can take
part in the participation of this study. The advantage of this sampling method is
simplicity of sampling and the ease of research and is also helpful for pilot studies and
for hypothesis generation with facilitation of data collection in short duration of time
and is also the cheapest. It’s disadvantages are however this method is highly
vulnerable to selection bias and influences beyond the control of the researcher and
have a high level of sampling error.

3.4 Sample size calculation

Sample size estimations are measures of how many participants are needed in a study.
Nearly all studies entail studying a sample of participants with a particular
characteristic rather than the whole population.
General Objective : To determine the prevalence of low back pain among adults in
Taman Medan

Z 2 pq
n=
d2

Z = 1.96 for 95% CI

p = 0.23 (Yamada K et al.,2015)
q = (1-p) = 0.77
d = precision 5% point, 0.05

2
n = 1.96 * 0.23 * 0.77 = 275
2
0.05

275 adults will be conveniently selected to obtain the prevalence of low back pain
among adults in Taman Medan with 95% CI and precision of 5%.
 Chapter 4

Data Collection

4.1 Introduction
A sample of 300 people from Taman Medan community will participate voluntarily in
this cross-sectional study to determine the prevalence of low back pain in that area of
community. Prior to the study, participant was informed of the study protocol and had
given consent to proceed. Data collection is done by giving a set of questionnaire in
paper for the participant to answer. Participant are required to complete all the
question where necessary. Any identification information will not be asked for
anonymity to allow them to answer the question honestly without being recognized.
They only need to state their gender, age and ethnicity.
Participant were instructed on how to fill out the questionnaire completely and
honestly. The questionnaire consist of 17 questions that inquire about the patients past
or recent low back pain and any surgical or medical treatment that has been done at
the lower back area. The question were categorized into part A which is regarding the
socio-demographic factor (9 question) such as gender, age, height, weight, ethnicity,
marital status, occupation, work description and education. For part B it is regarding
social and medical history (3 questions) such as smoking, chronic illnesses (Diabetes
Mellitus, Hypertension, Heart Disease, Bronchial Asthma) and history of any injury in
the lower back for the past 1 year. In this section the question is a “Yes or No” answer
only. For part C is regarding low back pain (5 questions) such as recent low back pain
in last 6 month, pain interference and any treatment receive. In this section it is also a
“Yes or No” answer plus a pain scale to determine the severity of the pain.
The questionnaire will be collected and the data will be entered into the SPSS
for analysis. We will check for any correlation of low back pain to it potential factors
and a conclusion would be made.

4.2 Data Entry

Information on the questionnaire was entered into the Statistical Package of Social
Science (SPSS) version 19.0 in computer. Accuracy and efficiency of research is
improved by using SPSS for data entry. In SPSS, the information is categorized into
tables before data analysis.

4.3 Data Cleaning

Data cleaning will be done to check for any incorrect or error of data such as illegal
data entry, missing data and out-of-range data from data set. By using SPSS all the
variable will be checked consistently and the correct data will be entered.
a. Checking for illegal data entry – In frequency tabulation, each category in the
variable will be assigned a number. For example: Male = 1, Female = 2. Any
numbers other than the assigned numbers are the illegal data entry
b. Checking for missing data – SPSS helps to identify the amount of missing
data. The “Statistics” box tells the number of missing value for each variable.
c. Checking for ou-of-range data – checking for errors in categorical variables.
This can be detected by checking against the minimum and maximum value
column in frequency table. Once the error was identified, correct data will be
entered.

4.4 Data management

4.5 Data analysis