Low back pain

Low back pain (LBP) is defined as any back pain between the ribs and the top of the leg1. Back pain is a major problem throughout the world and is most prevalent among females and persons ages 40–80 years 2. As part of estimating the global burden of LBP, it is defined as “activity?limiting LBP with or without pain referred into 1 or both lower limbs, that lasts for at least 1 day” 3. World-wide estimates of lifetime prevalence of LBP varied from 50 to 84 percent according to many factors including age, body mass index and other comorbidities 4. In the USA, back pain is considered the most common cause of activity limitation in people younger than 45 years, the second most frequent reason for visits to the physician, the fifth-ranking cause of admission to hospital, and the third most common cause of surgical procedures5.
Several studies reported different prevalence rates depending on the duration in which people report LBP. For example, point prevalence (number of people with the disease in a time interval) was found to be ranged from 12% to 33% 6. Whereas one-year prevalence (number of people diagnosed in the one year) varied from 22% to 65%, and life-time prevalence (number of people who were diagnosed with the disease and experiences it until the rest of their life or until the moment) varied from 11% to 84% 6. Many studies were conducted to determine the risk factors of LBP. An epidemiological study found that many environmental and personal factors influence the onset and course of LBP including age, sex, history of low back pain, low educational status, stress, anxiety, depression, job dissatisfaction, low levels of social support in the workplace and whole-body vibration3. In addition, level of physical activity was found to be correlated with LBP, and increasing physical activity level has become an important part of recommendations in the management of LBP7. Furthermore, LBP was found to be more common among individuals with physically demanding jobs with low physical activity level 8. Other physical factors contribute to occurrence of LBP proposed as heavy physical work, lifting, bending, twisting and static postures 9.
(McKenzie et. al. 2003) stated that low back pain (postural syndrome) could result from prolonged overstretching of the innervated soft tissues when poor sitting or standing postures were maintained for long periods10. The conclusion of McKenzie leads us to think about the importance of exploring if LBP is prevalence in people who are required to move in a physically demanding way. Furthermore, if we have anticipated that LBP is prevalent in specific populations, prevention of the compliant will be easier by targeting these specific populations. Prevention of LBP could help in decreasing time and economical demands that is needed in treatment. Thus, it is of importance to investigate the prevalence of LBP in different populations, in order to anticipated the condition and to take the required treatment earlier stages.
Physiotherapy students are prone to low back pain (LBP) due to the physical demands needed and wrong biomechanical movements including: flexion posture while studying, lifting patients and working in incorrect positions 11. It was found that 27% of physiotherapy students experienced LBP after handling patients in clinical rotations 12.

Several studies were conducted to investigate the prevalence and risk factors of LBP in physiotherapy students. For instance, Cromie et al (2000) reported that one in six physiotherapist changed settings or resigned because of work-related musculoskeletal injuries (WMSD), with the highest annual prevalence of WMSDs was in the low back (45%)13. Burger E. et. Al (2013) reported that the students’ exposure to cumulative practical hours, is the major determinant of LBP, with the lifetime prevalence of LBP of first-to-fourth year physiotherapy students found to be 36% 11. Compared with other medical students, physiotherapy students were found to have higher prevalence of LBP, with a prevalence of 83.3%14. This prevalence was correlated with duration of exposure to the program, and female gender14.

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Considering that occupational LBP is related to exposure to workplace hazards such as frequent lifting of heavy objects, frequent stretching, reaching, pulling, and pushing9, physical therapy program’s curriculum in Jordan University of Science and Technology, contains an intensive clinical training courses in the 4th educational year, including manual handling activities, making the students more prone to have LBP. This condition causes abnormal control and motor recruitment deficits15. But till now no study have examined the prevalence of LBP in physical therapy students in JUST. Thus, we aim in this study to investigate the prevalence of LBP in JUST physical therapy students in the 4th educational year, and to investigate the risk factors that might be associated with it in order to prevent such problem. This could help in prevention of the condition before developing it, or managing it in earlier stages to prevent further complications and to improve future quality of life in this population.

B-II: SIGNIFICANCE OF WORK

Physiotherapists may be at high risk of developing LBP as a result of musculoskeletal demands. Thus, it is of importance to investigate the prevalence of LBP at the undergraduate level in order, before starting their future career. To date there is no study has been examined the prevalence of LBP in physical therapy students in JUST. If found to be highly prevalent, results of this study will shed the lights on the importance of LBP prevention in physical therapy students, through prober body mechanics education (i.e; proper ergonomics while sitting to study, lifting, handling patients, etc.) to reduce exposure to known practical training risk factors. In addition, this can help in improving future quality of life and in reducing the time and economical demands required after suffering from LBP.

C

APPROACH AND METHODOLOGY

C-I: METHODOLOGY

Study design:

This cross-sectional study will be conducted from October to December 2018 at the department of physical therapy at Jordan University of Science and Technology (JUST), Irbid, Jordan, to study low back pain prevalence in physical therapy students in Jordan University of Science and Technology, and try to investigate the correlations with several confounding factors.

Recruitment:
The population is physiotherapy students who are in the 4th academic year at Jordan University of Science and Technology (n=60). Eligible students (according the inclusion and exclusion criteria below) will be invited to participate in the study.

Inclusion criteria:

Physiotherapy students in the 4th academic year at Jordan University of Science and Technology who are involved in clinical trainings.

Exclusion criteria:

• Participants who used back, leg or neck braces.
• Participants who suffer from known diseases such as cancer, tuberculosis, lung diseases, AIDS,.
• Participants with other neurological, musculoskeletal, metabolic or cardiopulmonary diseases.
• Participants who are pregnant.
• Participants who had undergone skeletal, muscular or ligamentous surgery in the previous six months.
• Participants presenting with: scoliosis or any structural deformity.
Outcome measures:
Data collection and sampling technique

This study will be approved by the institutional ethical board of Jordan University of Science and Technology (IRB). Participation will be voluntary and data collected will be anonymous. The researcher will attend nominated clinical placements at which all students could be expected to present. The study’s objectives and information about the instruments will be explained to the participants, and an informed consent will be obtained from each participant. Students participate by filling self-administered written questionnaires. Students will be asked to complete the questionnaires after leaving the clinics. After collecting the data, each paper will be given a serial number and no personal identifiers will be used.

Outcome measures:
Collecting confounding factors:

Confounding factors that will be collected include:
• Demographic: age, sex, weight, height to calculate BMI.
• Personal: Marital status, if single ask about parents’ marital status.
• Academic: The cumulative grade point average (current GPA), load for this semester (number of hours), number of attending days per week, start time for lectures (morning or evening), if the courses are taken for the first time or if they are repeating courses, type of the courses that is registered this year (clinical trainings or theoretical courses).
• Occupational and socioeconomic: part time working if yes ask about total hours of work per week, hours spent on non-academic activities per week.
• Health behaviors: current medications, smoking, alcohol consumption, caffeine consumption (including coffee, tea and energy drinks), regular exercise.
• Environmental: residence, transportation (by bus or car).
Depression assessment:

The Beck Depression Inventory which is a valid questionnaire will be used to evaluate the presence and severity of depressive symptoms among the students. This instrument consists of 21 questions, each question scores 0–3 with a total scoring from 0 to 63. It considers depression if the total score is >1416.

Low back pain prevalence:
Students will be asked about:
• Lifetime prevalence: if they have ever suffered LBP at some point of their lives.
• 1-year prevalence: if they suffered LBP in the last year. If they presented LBP in the last year they will be asked about duration of the pain, and to classify it as acute, if less than 3 weeks; sub-acute, from 3 weeks to 3 months; and chronic, if >3 months17.
• Point prevalence : if they were suffering LBP at the moment they were fulfilling the questionnaire14.
level of physical activity assessment:

The International Physical Activity Questionnaire (IPAQ) will be used to classify the level of physical activity. This instrument was developed by the World Health Organization and it is frequently used worldwide. It evaluates physical activity in many aspects of the daily routine rather than only in one isolated aspect (i.e. leisure time). The IPAq evaluates four dimensions of the daily activity: professional, domestic, during transportation and leisure. Therefore, we were able to classify the physical activity as low, moderate or high. IPAQ questionnaire is validi to assess levels and patterns of PA in healthy adults. 18.
Pain intensity assessment:
The numerical rating scale, ranging from zero (no pain) to ten (worst pain) 17, will be used to evaluate the intensity of the pain.
Disability due to low back pain assessment:
Oswestry Disability Index (ODI) use to measure a patient’s permanent functional disability. Ita a valid and reliable questionnaire to assess pain-related disability in persons with LBP. The test is considered the ‘gold standard’ of low back functional outcome tools. It targets acute, sub-acute, and chronic back pain groups; various conservative, surgical, and behavioral intervention groups19-21.

Table1: summery of outcome measures used in the study
Domain Trait Outcome measure
Personal Demographic and lifestyle variables Gender, age, height, weight, tobacco use, resident, academic performance(GPA), start time for lectures (morning or evening), part time working.
Affective Depression • Beck Depression Inventory
Functional status Physical activity levels • International Physical Activity Questionnaire (IPAQ)

Disability due to low back pain • Oswestry Disability Index (ODI)
Low back pain prevalence
• lifetime prevalence: if they have ever suffered LBP at some point of their lives.
• 1-year prevalence: if they suffered LBP in the last year. If they presented LBP in the last year they will be asked about duration of the pain, and to classify it as acute, if less than 3 weeks; sub-acute, from 3 weeks to 3 months; and chronic, if ;3 months.
• point prevalence : if they were suffering LBP at the moment they were fulfilling the questionnaire .

Pain intensity
• The numerical rating scale

Statistical analysis:
Proper statistical analysis will be done based on the collecting data.