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Low Back Pain in Medical Students and Professors During the Pandemic: Retrospective Cohort Study* * Work developed in the Universidade AnhembiMorumbi, Sao Paulo, Brazil.

Abstract

Objective

This study aimed to determine the prevalence of low back pain before and during the pandemic, comparing both periods.

Methods

A questionnaire was administered, containing questions about the presence of low back pain, sociodemographic characteristics and environmental factors that could be related to such pain.

Results

Among the 978 responses obtained, the prevalence of low back pain during the pandemic was 69.94%, which represented a significant increase over values from the pre-pandemic period (57.37%). A high prevalence of low back pain was found between all groups, especially among women. Some factors were associated with the incidence of low back pain, such as having previously diagnosed spinal problems and sedentary lifestyle.

Conclusions

The prevalence of low back pain increased significantly during the pandemic in the studied groups.

Keywords
low back pain; students; pandemics; prevalence; risk factors

Resumo

Objetivo

Este estudo teve como objetivo determinar a prevalência de lombalgia antes e durante a pandemia, comparando os dois períodos.

Métodos

Foi aplicado um questionário contendo questões sobre a presença de lombalgia, características sociodemográficas e hábitos que poderiam estar relacionados à essa dor.

Resultados

Entre as 978 respostas obtidas, a prevalência de lombalgia durante a pandemia foi de 69,94%, o que representou um aumento significativo em relação aos valores do período pré-pandêmico (57,37%). Foi encontrada alta prevalência de lombalgia entre todos os grupos, principalmente entre as mulheres. Alguns fatores foram associados à incidência de lombalgia, como ter problemas de coluna previamente diagnosticados e sedentarismo.

Conclusões

A prevalência de lombalgia aumentou significativamente durante a pandemia nos grupos estudados.

Palavras-chave
dor lombar; estudantes; pandemias; prevalência; fatores de riscos

Introduction

Approximately 80% of the population, at some point in their lives, will suffer a brief and acute episode of low back pain.11 Vlaeyen JWS, Maher CG, Wiech K, et al. Low back pain. Nat Rev Dis Primers 2018;4(01):52,22 Furtado RN, Ribeiro LH, Abdo BdeA, Descio FJ, Martucci CE Jr, Serruya DC. [Nonspecific low back pain in young adults: associated risk factors]. Rev Bras Reumatol 2014;54(05):371–377 Generally, low back pain is divided into two types: specific and nonspecific, where the nonspecific has no apparent cause and accounts for up to 90% of the cases.33 Elias HE, Downing R, Mwangi A. Low back pain among primary school teachers in Rural Kenya: Prevalence and contributing factors. Afr J Prim Health Care Fam Med 2019;11(01):e1–e7 Low back pain, in addition to limiting various daily activities and impairing quality of life, is also one of the main factors responsible for absenteeism from work and decreased productivity in the workplace.44 Krismer M, van Tulder MLow Back Pain Group of the Bone and Joint Health Strategies for Europe Project. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol 2007;21(01): 77–91

A number of risk factors are described in the literature that can play a crucial role in the etiology of low back pain, such as being female, overweight, previous history of spinal problems, family history of spinal problems, prolonged sitting time and sedentary lifestyle,55 Han TS, Schouten JS, Lean ME, Seidell JC. The prevalence of low back pain and associations with body fatness, fat distribution and height. Int J Obes Relat Metab Disord 1997;21(07):600–60788 Ganesan S, Acharya AS, Chauhan R, Acharya S. Prevalence and Risk Factors for Low Back Pain in 1,355 Young Adults: A Cross-Sectional Study. Asian Spine J 2017;11(04):610–617 or even psychological factors, such as anxiety and stress.88 Ganesan S, Acharya AS, Chauhan R, Acharya S. Prevalence and Risk Factors for Low Back Pain in 1,355 Young Adults: A Cross-Sectional Study. Asian Spine J 2017;11(04):610–617,99 Currie SR, Wang J. More data on major depression as an antecedent risk factor for first onset of chronic back pain. Psychol Med 2005;35(09):1275–1282 Due to the highly demanding schedule of medical courses, students and professors are often exposed to several of these risk factors, such as stress and sedentary lifestyle, long hours in hospitals and clinics, which can contribute to a higher prevalence of low back pain when compared to the general population.1010 Vujcic I, Stojilovic N, Dubljanin E, Ladjevic N, Ladjevic I, SipeticGrujicic S. Low Back Pain among Medical Students in Belgrade (Serbia): A Cross-Sectional Study. Pain Res Manag 2018;2018; 8317906 Furthermore, the presence of low back pain can affect the productivity and participation of students during classes, which could influence their future medical career.1010 Vujcic I, Stojilovic N, Dubljanin E, Ladjevic N, Ladjevic I, SipeticGrujicic S. Low Back Pain among Medical Students in Belgrade (Serbia): A Cross-Sectional Study. Pain Res Manag 2018;2018; 8317906

A study carried out in Brazil with 629 medical students revealed that recurrent low back pain was present in 81% of them.1111 Tavares C, Salvi CS, Nisihara R, Skare T. Low back pain in Brazilian medical students: a cross-sectional study in 629 individuals. Clin Rheumatol 2019;38(03):939–942 Another study, carried out with 1,243 medical students from a French college, reported a prevalence of low back pain of 72.1%.1212 Amelot A, Mathon B, Haddad R, Renault MC, Duguet A, Steichen O. Low Back Pain Among Medical Students: A Burden and an Impact to Consider!. Spine 2019;44(19):1390–1395 Despite the limitation that musculoskeletal pain represents for adolescents and young adults, there is a lack of data regarding low back pain in medical students.1313 Aggarwal N, Anand T, Kishore J, Ingle GK. Low back pain and associated risk factors among undergraduate students of a medical college in Delhi. Educ Health (Abingdon) 2013;26(02):103–108

Similarly, few studies have investigated the presence of low back pain in professors,1414 Zamri EN, Hoe VCW, Moy FM. Predictors of low back pain among secondary school teachers in Malaysia: a longitudinal study. Ind Health 2020;58(03):254–264 and this dearth is even greater when it comes to medical school professors, who are also exposed to several risk factors for the presence of low back pain, such as repetitive movements when writing, standing for long periods of time and daily use of the computer.1515 Kraemer K, Moreira MF, Guimarães B. Musculoskeletal pain and ergonomic risks in teachers of a federal institution. Rev Bras Med Trab 2021;18(03):343–351 In a study carried out with teachers at a primary school in Ethiopia, a prevalence of low back pain of 74.8% was found, which was related to some risk factors, such as standing for a long period of time, lack of sleep and sedentary lifestyle.1616 Kebede A, Abebe SM, Woldie H, Yenit MK. Low Back Pain and Associated Factors among Primary School Teachers in Mekele City, North Ethiopia: A Cross-Sectional Study. Occup Ther Int 2019;2019:3862946

During the COVID-19 pandemic, face-to-face classes were canceled, forcing universities to adopt a remote learning model. However, this change favored some aspects related to the prevalence of low back pain, such as sitting for a long period of time, physical inactivity and greater psychological stress, which could increase the prevalence of low back pain in students and professors during this atypical period. The aim of this study was to determine the prevalence of low back pain in medical students and professors at three Brazilian universities during the pandemic and compare this to the pre-pandemic period, in addition to identifying associated risk factors to develop such pain.

Materials and Methods

Ethics Approval

The protocol was approved by the institutioǹs research ethics committee, in October 4, 2020 (CAAE No. 38595320.9.0000.5492).

Questionnaire and Participants

This research has been approved by the IRB (Institutional Review Board) of the authors' affiliated institutions, and consent was obtained from all participants. A retrospective cohort study was carried out through the administration of a questionnaire to medical students and professors from three Brazilian medical schools located in different states of the country. The inclusion criteria were that participants had to be medical students or professors from the three participating universities. Participants were excluded from the study if they disagreed in signing consent form, those who were not medical students or professors from the participating universities, and women in gestational period. The questionnaire was distributed between December 2020 and March 2021 and covered questions about sociodemographic characteristics (such as gender, age and ethnicity), presence of low back pain before and during the pandemic, quantification of the intensity of this low back pain, family history of diseases and spinal surgeries and several behavioral factors that could be associated with the prevalence of low back pain in this population, in addition to the impact on their daily activities and on their emotional state.

Statistical Analysis

In view of the approximate total of 3,000 medical students and 200 professors in these three universities, we adopted a confidence level of 95% and a margin of error of 5%, calculating a sample of 341 students and 132 professors. And since the three universities are located in different states and may present regional discrepancies, with the purpose of analyzing subgroups by educational institution, while maintaining a 95% confidence level and 5% margin of error, the sample by institution had to be at least 278 students and 60 professors.

Descriptive analysis of the results was performed to characterize the research participants. To describe the results, the absolute frequency and percentage for categorical variables were used. In order to compare the proportion of low back pain before and during the pandemic within the different groups, the McNemar test was used. To investigate possible factors associated with low back pain during the pandemic, univariate logistic regression was used, estimating odds ratios (OR) as a measure of effect, with a 95% confidence interval (CI). Subsequently, the variables that showed at least moderate association (P < 0.25) with the variable of interest were selected using the chi-square test. These variables were included in the multivariate model, estimating the adjusted odds ratio, considering possible interactions between them. The quality of the multivariate model was assessed using the Hosmer and Lemeshow test. For all analyses, only P < 0.05 was considered statistically significant.

Results

In total, 978 individuals answered the questionnaire. Among them, 831 were students from the 1st to the 4th year, 60 students from the 5th and 6th year (medical internship) and 87 professors (Table 1).

Table 1
Number of participants from each university, per group

Prevalence of Low Back Pain

When asked about the presence of low back pain before and during the pandemic, the percentages of affirmative answers increased among professors and students from 1st to 4th year, and decreased among students from 5th to 6th year. Among professors, 28.74% who did not have low back pain started to experience it during the pandemic (P < 0.001). Similarly, 20.10% of 1st to 4th year students who did not have low back pain before the pandemic began to complain of low back pain (P < 0.001). During the pandemic, only for the group of 5th and 6th year students there was no increase in the prevalence of low back pain (P = 1.000).

For 1st to 4th year students, the prevalence of low back pain increased from 54.75% before the pandemic to 71.48% during the pandemic (P < 0.001). Among 5th and 6th year students, the prevalence did not change significantly, registering 66.67% before and 65% during the pandemic (P = 1,000). Finally, among professors, the prevalence increased from 31.03% before to 58.62% during the pandemic (P < 0.001) (Table 2).

Table 2
Frequency of low back pain in each group, comparing before and during the pandemic

Associated Risk Factors

Students from 1st to 4th year were significantly more likely to have low back pain when compared to professors (OR: 1.77, 95% CI: 1.12-2.77; P = 0.013). Among survey participants who do not have back pain, 60.2% are female, while among those who do, this percentage rises to 79.97%, with men having significantly lower chances of having low back pain when compared to women (OR: 0.38, 95% CI: 0.28-0.51; P < 0.001). It was also noted that those previously diagnosed with any spinal problems had significantly higher chances of low back pain when compared to those who did not (OR: 3.56, 95% CI: 2.4-5.43; P < 0.001). In addition, individuals with a family history of spinal problems were also significantly more likely to experience low back pain (OR: 1.78, 95% CI: 1.35-2.36; P < 0.001). Respondents from university 2 were less likely to have low back pain when compared to the other institutions (OR: 0.56, 95% CI: 0.4-0.77; P < 0.001).

Regarding posture when sitting, those who always sit correctly, those who sit correctly most of the time, and even those who sit correctly less often, had significantly lower chances of having low back pain when compared to those who never sit correctly (ORs of 0.11; 0.32 and 0.65 and P < 0.001; P < 0.001 and P = 0.012, respectively). Considering the consumption of tobacco, coffee and alcoholic beverages, none of them was statistically significant for the prevalence of low back pain among any of the groups (P = 0.915; P = 0.274 and P = 0.255, respectively).

Sleeping hours also significantly affected the chances of experiencing low back pain. Those who slept 6 to 9 hours a day before the pandemic had a lower chance of low back pain when compared to those who slept less than that (OR: 0.61, 95% CI: 0.45-0.83; P = 0.002). Similarly, individuals who sleep 6 to 9 hours a day during the pandemic also had a lower chance of low back pain (OR: 0.41, 95% CI: 0.26-0.63; P < 0.001). Moreover, individuals who sleep more than 9 hours a day during the pandemic also had lower chances of experiencing low back pain (OR: 0.54, 95% CI: 0.3-0.96; P = 0.038). Also, those who exercise during the pandemic had significantly lower odds of having low back pain when compared to those who do not (OR: 0.57, 95% CI: 0.42-0.76; P < 0.001). For all the other variables, there is insufficient evidence that the odds of individuals with such characteristics were significantly different compared to the characteristics set as a baseline at 5% significance.

In the multiple logistic model, only being male (adjusted OR: 0.47, 95% CI: 0.33-0.66; P < 0.001), always sitting correctly (adjusted OR: 0.11, 95% CI: 0.04-0.3; P < 0.001), sitting correctly most of the time (adjusted OR: 0.31, 95% CI: 0.19-0.49; P < 0.001), sitting correctly less often (adjusted OR: 0.59, 95% CI: 0.4-0.86; P = 0.006), being from the university 2 (adjusted OR: 0.54, 95% CI: 0.35-0.83; P = 0.005), studying/working between 1 to 4 hours per day during the pandemic (adjusted OR: 0.49, 95% CI: 0.24-0.97; P = 0.046) and sleeping 6 to 9 hours per day during the pandemic (adjusted OR: 0.4, 95% CI: 0.23-0.66; P < 0.001) stood out as protective factors for low back pain. On the other hand, still in the multiple logistic model, only having previously diagnosed spinal problems (adjusted OR: 3.79, 95% CI: 2.42-6.14; P < 0.001) and a positive family history of spinal problems (adjusted OR: 1.82, 95% CI: 1.32-2.52; P < 0.001) stood out as risk factors. Table 3 summarizes important factors and their association with low back pain.

Table 3
Factors associated with low back pain

Moreover, 41.2% of the participants who had low back pain reported that their pain affects their performance in college related activities. Besides that, 52.3% of the participants who reported having low back pain indicated that it impairs their concentration. Also, 59.6% of them reported that the pain altered their humor significantly, causing anxiety, sadness or anger. Other than that, 37.9% of those who reported low back pain also reported that the pain makes it difficult to remain sited for more than 30 minutes. Thus, it is evident that low back pain in these individuals is certainly able to impair their academic and daily life.

When asked about the intensity of their pain in a scale of 1-10, before the pandemic, the most common reported pain intensities were between 4 and 5. During the pandemic, however, the most common reported pain intensities were between 6 and 7. Although there was only a slight increase in pain intensity, due to a higher exposure to risk factors, the pandemic could have had worsen these individuals low back intensity.

Discussion

The aim of this study was to investigate the presence of low back pain in medical students and professors in three universities located in different regions of Brazil.

There was a significant increase in the prevalence of low back pain in all studied groups, except in 5th and 6th year students. This probably occurred because these students continued their normal schedule, even with the pandemic, because at this stage of the medical course, they basically only go to hospitals. The overall prevalence of low back pain, considering all participants, increased from 53.37% before the pandemic to 69.94% during the pandemic. Considering only 1st to 4th year students, the prevalence of low back pain was 54.75% before and 71.48% during the pandemic. It is evident that, during the pandemic, the academic routine of 5th and 6th year students was altered as much when compared to the routine of 1st to 4th year students and professors, which may explain the unaltered prevalence of low back pain in this group, as there was no increased exposure to risk factors related to low back pain.

Also, the prevalence of low back pain is higher among women than among men, corroborating findings by other authors.1717 Bento TPF, Genebra CVDS, Maciel NM, Cornelio GP, Simeão SFAP, Vitta A. Low back pain and some associated factors: is there any difference between genders? Braz J Phys Ther 2020;24(01):79–871919 Bansal D, Asrar MM, Ghai B, Pushpendra D. Prevalence and Impact of Low Back Pain in a Community-Based Population in Northern India. Pain Physician 2020;23(04):E389–E398 Furthermore, in our study, the existence of a family history of spinal problems was related to the prevalence of low back pain. The same result was obtained by Alshagga et al.2020 Alshagga MA, Nimer AR, Yan LP, Ibrahim IA, Al-Ghamdi SS, Radman Al-Dubai SA. Prevalence and factors associated with neck, shoulder and low back pains among medical students in a Malaysian Medical College. BMC Res Notes 2013;6:244 and Ilic et al.,2121 Ilic I, Milicic V, Grujicic S, Zivanovic Macuzic I, Kocic S, Ilic MD. Prevalence and correlates of low back pain among undergraduate medical students in Serbia, a cross-sectional study. PeerJ 2021;9: e11055 who found a positive relationship between family history of musculoskeletal disorders and the prevalence of low back pain.

Regarding tobacco use, several studies indicate that smoking could be a risk factor for low back pain.2222 Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between smoking and low back pain: a meta-analysis. Am J Med 2010;123(01):87.e7–87.e352424 Citko A, Górski S, Marcinowicz L, Górska A. Sedentary Lifestyle and Nonspecific Low Back Pain in Medical Personnel in NorthEast Poland. BioMed Res Int 2018;2018:1965807 However, in our study, it was not possible to determine this association, as in another study carried out in Brazil with 629 students of medicine during a non-pandemic period.1111 Tavares C, Salvi CS, Nisihara R, Skare T. Low back pain in Brazilian medical students: a cross-sectional study in 629 individuals. Clin Rheumatol 2019;38(03):939–942 Furthermore, engagement in physical exercise proved to be protective against the onset of low back pain, corroborating the study by Sihawong et al.2525 Sihawong R, Janwantanakul P, Jiamjarasrangsi W. A prospective, cluster-randomized controlled trial of exercise program to prevent low back pain in office workers. Eur Spine J 2014;23(04): 786–793

Having good quality sleep, in our study, was also a protective factor against the onset of low back pain, in line with another study that found a trend of worse low back pain in individuals with poor quality sleep.2626 Gerhart JI, Burns JW, Post KM, et al. Relationships between sleep quality and pain-related factors for people with chronic low back pain: tests of reciprocal and time of day effects. Ann Behav Med 2017;51(03):365–375 On the other hand, although sitting correctly was found to be a protective factor against low back pain, De Carvalho et al.,2727 De Carvalho D, Greene R, Swab M, Godwin M. Does objectively measured prolonged standing for desk work result in lower ratings of perceived low back pain than sitting? A systematic review and meta-analysis. Work 2020;67(02):431–440 in their meta-analysis, did not find a significant relationship between sitting positions and the presence of low back pain compared to standing positions, concluding that more studies are needed to better elucidate this issue. It is worth mentioning that sitting correctly was evaluated according to the perception of each respondent and needs to be viewed with caution.

Respondents from institution number 2 were less likely to have low back pain when compared to the other institutions. Comparing the exposure to risk factors among individuals from the three participating universities, individuals from institution number 2 reported greater engagement in exercise during the pandemic (77.96% reported practicing, compared to 65.88% and 48.17% in the other two institutions) and better sleep quality (92.54% reported sleeping more than 6 hours per night, compared to 75.5% in institution number 1, for example). This may reflect lower exposure to risk factors related to low back pain.

Considering the high rate of individuals who reported impairment in their college activities due to the presence of low back pain (28.83%), it is evident that this condition could impact the academic performance of these professors and students.

The main limitations of this study are inherent to the retrospective cohort model. In addition, data related to professors should be analyzed with caution, as the number of participants in this group was below the expected number, except for professors from university 1. However, there is a very high prevalence of low back pain in medical students and professors, indicating the need to implement preventive strategies to minimize the problem.

Conclusion

The prevalence of low back pain is high among medical students and professors, further increasing during the pandemic period, except among 5th and 6th year students. Family and personal history of spinal problems, female gender and poor posture when sitting were found to be risk factors, while physical exercise and good quality sleep were protective factors against the onset of low back pain. Furthermore, considering the paucity of data on the real impacts of this high prevalence of low back pain in these groups, more specific studies on the subject are still needed.

  • Financial Support
    No source of funding that could influence results was received.
  • *
    Work developed in the Universidade AnhembiMorumbi, Sao Paulo, Brazil.

References

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    Vlaeyen JWS, Maher CG, Wiech K, et al. Low back pain. Nat Rev Dis Primers 2018;4(01):52
  • 2
    Furtado RN, Ribeiro LH, Abdo BdeA, Descio FJ, Martucci CE Jr, Serruya DC. [Nonspecific low back pain in young adults: associated risk factors]. Rev Bras Reumatol 2014;54(05):371–377
  • 3
    Elias HE, Downing R, Mwangi A. Low back pain among primary school teachers in Rural Kenya: Prevalence and contributing factors. Afr J Prim Health Care Fam Med 2019;11(01):e1–e7
  • 4
    Krismer M, van Tulder MLow Back Pain Group of the Bone and Joint Health Strategies for Europe Project. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol 2007;21(01): 77–91
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    Han TS, Schouten JS, Lean ME, Seidell JC. The prevalence of low back pain and associations with body fatness, fat distribution and height. Int J Obes Relat Metab Disord 1997;21(07):600–607
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    Park SM, Kim HJ, Jeong H, et al. Longer sitting time and low physical activity are closely associated with chronic low back pain in population over 50 years of age: a cross-sectional study using the sixth Korea National Health and Nutrition Examination Survey. Spine J 2018;18(11):2051–2058
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    Ganesan S, Acharya AS, Chauhan R, Acharya S. Prevalence and Risk Factors for Low Back Pain in 1,355 Young Adults: A Cross-Sectional Study. Asian Spine J 2017;11(04):610–617
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    Currie SR, Wang J. More data on major depression as an antecedent risk factor for first onset of chronic back pain. Psychol Med 2005;35(09):1275–1282
  • 10
    Vujcic I, Stojilovic N, Dubljanin E, Ladjevic N, Ladjevic I, SipeticGrujicic S. Low Back Pain among Medical Students in Belgrade (Serbia): A Cross-Sectional Study. Pain Res Manag 2018;2018; 8317906
  • 11
    Tavares C, Salvi CS, Nisihara R, Skare T. Low back pain in Brazilian medical students: a cross-sectional study in 629 individuals. Clin Rheumatol 2019;38(03):939–942
  • 12
    Amelot A, Mathon B, Haddad R, Renault MC, Duguet A, Steichen O. Low Back Pain Among Medical Students: A Burden and an Impact to Consider!. Spine 2019;44(19):1390–1395
  • 13
    Aggarwal N, Anand T, Kishore J, Ingle GK. Low back pain and associated risk factors among undergraduate students of a medical college in Delhi. Educ Health (Abingdon) 2013;26(02):103–108
  • 14
    Zamri EN, Hoe VCW, Moy FM. Predictors of low back pain among secondary school teachers in Malaysia: a longitudinal study. Ind Health 2020;58(03):254–264
  • 15
    Kraemer K, Moreira MF, Guimarães B. Musculoskeletal pain and ergonomic risks in teachers of a federal institution. Rev Bras Med Trab 2021;18(03):343–351
  • 16
    Kebede A, Abebe SM, Woldie H, Yenit MK. Low Back Pain and Associated Factors among Primary School Teachers in Mekele City, North Ethiopia: A Cross-Sectional Study. Occup Ther Int 2019;2019:3862946
  • 17
    Bento TPF, Genebra CVDS, Maciel NM, Cornelio GP, Simeão SFAP, Vitta A. Low back pain and some associated factors: is there any difference between genders? Braz J Phys Ther 2020;24(01):79–87
  • 18
    Bento TPF, Cornelio GP, Perrucini PO, Simeão SFAP, de Conti MHS, de Vitta A. Low back pain in adolescents and association with sociodemographic factors, electronic devices, physical activity and mental health. J Pediatr (Rio J) 2020;96(06):717–724
  • 19
    Bansal D, Asrar MM, Ghai B, Pushpendra D. Prevalence and Impact of Low Back Pain in a Community-Based Population in Northern India. Pain Physician 2020;23(04):E389–E398
  • 20
    Alshagga MA, Nimer AR, Yan LP, Ibrahim IA, Al-Ghamdi SS, Radman Al-Dubai SA. Prevalence and factors associated with neck, shoulder and low back pains among medical students in a Malaysian Medical College. BMC Res Notes 2013;6:244
  • 21
    Ilic I, Milicic V, Grujicic S, Zivanovic Macuzic I, Kocic S, Ilic MD. Prevalence and correlates of low back pain among undergraduate medical students in Serbia, a cross-sectional study. PeerJ 2021;9: e11055
  • 22
    Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between smoking and low back pain: a meta-analysis. Am J Med 2010;123(01):87.e7–87.e35
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    Shiri R, Falah-Hassani K, Heliövaara M, et al. Risk Factors for Low Back Pain: A Population-Based Longitudinal Study. Arthritis Care Res (Hoboken) 2019;71(02):290–299
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    Citko A, Górski S, Marcinowicz L, Górska A. Sedentary Lifestyle and Nonspecific Low Back Pain in Medical Personnel in NorthEast Poland. BioMed Res Int 2018;2018:1965807
  • 25
    Sihawong R, Janwantanakul P, Jiamjarasrangsi W. A prospective, cluster-randomized controlled trial of exercise program to prevent low back pain in office workers. Eur Spine J 2014;23(04): 786–793
  • 26
    Gerhart JI, Burns JW, Post KM, et al. Relationships between sleep quality and pain-related factors for people with chronic low back pain: tests of reciprocal and time of day effects. Ann Behav Med 2017;51(03):365–375
  • 27
    De Carvalho D, Greene R, Swab M, Godwin M. Does objectively measured prolonged standing for desk work result in lower ratings of perceived low back pain than sitting? A systematic review and meta-analysis. Work 2020;67(02):431–440

Publication Dates

  • Publication in this collection
    23 Oct 2023
  • Date of issue
    Jul-Aug 2023

History

  • Received
    25 June 2022
  • Accepted
    08 Nov 2022
Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br