Prevalence of low back pain in different educational levels: a systematic review

Prevalência de dor lombar em diferentes níveis educacionais: uma revisão sistemática

Alexandre Apolinário de Souza Batista Nicholas Henschke Vinícius Cunha Oliveira About the authors

Abstract

Introduction:

Non-specific low back pain (LBP) can be understood through the interaction of biopsychosocial factors such as education. Unfortunately, it remains unclear whether education can be considered an important risk and prognostic factor for the occurrence of LBP.

Objective:

To investigate the association between education and LBP.

Methods:

The following databases were searched: MEDLINE, EMBASE, Cochrane, AMED and PsyINFO.

Results:

Thirteen studies were included in the review. The Prevalence Critical Appraisal Instrument (PCAI) was used to assess risk of bias. Methodological quality scores ranged from 7 to 10 on a scale of 0-10. There was a 23% (95% CI, 13-37) prevalence of LBP (10,582 out of a total of 99,457 cases) in the general sample at the time of assessment. The meta-analysis of studies on the prevalence of LBP in people with low, medium or high educational level found the following results, respectively: 24% (95% CI, 12-43), 27% (95% CI, 9-56), and 18% (95% CI, 5-50). The meta-regression identified heterogeneity among the studies included in the review. This can be explained by educational differences (p < 0.05).

Conclusion:

Occurrence of LBP varies according to educational level. Individuals with higher educational levels are less often affected by LBP than individuals with medium or low educational levels.

Keywords:
Low Back Pain; Prevalence; Education

Resumo

Introdução:

A dor lombar inespecífica (DL) pode ser compreendida através da interação de fatores biopsicossociais, como por exemplo a educação. Infelizmente, ainda não é sabido se a educação é uma característica social importante como fator de risco e prognóstico para a ocorrência de DL.

Objetivo:

Investigar a associação entre educação e ocorrência de DL.

Métodos:

Buscas em MEDLINE, EMBASE, Cochrane, AMED e PsyINFO.

Resultados:

Incluídos 13 estudos na revisão. Para o risco de viés foi utilizado a Prevalence Critical Appraisal Instrument (PCAI) obtendo na avaliação da qualidade metodológica os escores menor e maior de 7 e 10 em uma escala de 0 a 10. Amostra geral compreendeu prevalência de DL no momento da avaliação de 23% (IC95% 13 até 37), sendo 10582 o número de casos em 99457. Meta-analysis com estudos investigando prevalência de DL no momento da avaliação em pessoas de baixo, médio e alto nível educacional estimou respectivamente os valores 24% (IC95% 12 até 43), 27% (IC95% 9 até 56), e 18% (IC95% 5 até 50). Meta-regressão identificou heterogeneidade entre os estudos incluídos e essa pode ser explicada pelo nível educacional (p < 0,05).

Conclusão:

Ocorrência de DL varia de acordo com o nível educacional, onde indivíduos com nível educacional mais alto possuem menor ocorrência de DL quando comparados com indivíduos com nível educacional baixo ou médio.

Palavras-chave:
Dor Lombar; Prevalência; Educação

Introduction

Spinal problems are one of the most common reasons for clinical visits and the leading cause of disability in the adult population11 Buchbinder R, Batterham R, Elsworth G, Dionne CE, Irvin E, Osborne RH. A validity-driven approach to the understanding of the personal and societal burden of low back pain: development of a conceptual and measurement model. Arthritis Res Ther. 2011;13(5):R152.. Non-specific low back pain (LBP) affects approximately 70-80% of workers in industrialized cities at some point in life, leading to cases of retirement due to functional disability22 Deyo RA, Cherkin D, Conrad D, Volinn E. Cost, controversy, crisis: low back pain and the health of the public. Annu Rev Public Health. 1991;12:141-56.. About 10 million Brazilians have disabilities due low back pain and 70% of the Brazilian population will experience pain episodes at some time in life33 Silva MC, Fassa AG, Valle NCJ. Chronic low back pain in a Southern Brazilian adult population: prevalence and associated factors. Cad Saude Publica. 2004;20(2):377-85.. Moreover, due to the high incidence and prevalence of disability in people of economically active age, LBP is considered a public health problem33 Silva MC, Fassa AG, Valle NCJ. Chronic low back pain in a Southern Brazilian adult population: prevalence and associated factors. Cad Saude Publica. 2004;20(2):377-85..

Our knowledge of risk factors and predisposition to LBP may benefit substantially from bibliographic searches11 Buchbinder R, Batterham R, Elsworth G, Dionne CE, Irvin E, Osborne RH. A validity-driven approach to the understanding of the personal and societal burden of low back pain: development of a conceptual and measurement model. Arthritis Res Ther. 2011;13(5):R152.), (44 Skovron ML, Szpalski M, Nordin M, Melot C, Cukier D. Sociocultural factors and back pain: a population-based study in Belgian adults. Spine (Phila Pa 1976). 1994;19(2):129-37.), (55 Waddell G. The back pain revolution. London: Churchill Livingstone; 2004.. LBP may be understood through the interaction of risk factors and biopsychosocial prognostic factors that are determined by physical (e.g., physical strength), psychological (e.g., kinesiophobia) and social aspects (e.g., social support)44 Skovron ML, Szpalski M, Nordin M, Melot C, Cukier D. Sociocultural factors and back pain: a population-based study in Belgian adults. Spine (Phila Pa 1976). 1994;19(2):129-37.), (55 Waddell G. The back pain revolution. London: Churchill Livingstone; 2004.. In this context, education is the best substitute to measure social status, because it is easy to collect information on it and it is not likely to be affected by chronic diseases66 Heistaro S, Vartiainen E, Heliövaara M, Puska P. Trends of Back pain in eastern Finland, 1972-1992, in relation to socioeconomic status and behavioral risk factors. Am J Epidemiol. 1998;148(7):671-82.. This provides a rapid and useful strategy for a more complex understanding of the set of social factors that predispose the occurrence of LBP66 Heistaro S, Vartiainen E, Heliövaara M, Puska P. Trends of Back pain in eastern Finland, 1972-1992, in relation to socioeconomic status and behavioral risk factors. Am J Epidemiol. 1998;148(7):671-82.), (77 Keefe FJ, Lumley M, Anderson T, Lynch T, Studts JL, Carson KL. Pain and emotion: new research directions. J Clin Psychol. 2001;57(4):587-607.), (88 Callahan LF, Pincus T. Formal education level as a significant marker of clinical status in rheumatoid arthritis. Arthritis Rheum. 1988;31(11):1346-57.), (99 Pincus T. Formal education level - A marker for the importance of behavioral variables in the pathogenesis, morbidity, and mortality of most diseases? J Rheumatol. 1988;15(10):1457-60.), (1010 Pincus T, Callahan LF. Formal education as a marker for increased mortality and morbidity in rheumatoid arthritis. J Chronic Dis. 1985;38(12):973-84.), (1111 Pincus T, Callahan LF. Taking mortality in rheumatoid arthritis seriously--predictive markers, socioeconomic status and comorbidity. J Rheumatol. 1986;13(5):841-5.), (1212 Pincus T, Callahan LF, Burkhauser RV. Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18-64 United States population. J Chronic Dis. 1987;40(9):865-74.), (1313 Syme SL, Berkman LF. Social class, susceptibility and sickness. Am J Epidemiol. 1976;104(1):1-8.. Education is one of the social factors often studied in relation to LBP66 Heistaro S, Vartiainen E, Heliövaara M, Puska P. Trends of Back pain in eastern Finland, 1972-1992, in relation to socioeconomic status and behavioral risk factors. Am J Epidemiol. 1998;148(7):671-82.), (77 Keefe FJ, Lumley M, Anderson T, Lynch T, Studts JL, Carson KL. Pain and emotion: new research directions. J Clin Psychol. 2001;57(4):587-607.), (88 Callahan LF, Pincus T. Formal education level as a significant marker of clinical status in rheumatoid arthritis. Arthritis Rheum. 1988;31(11):1346-57.), (99 Pincus T. Formal education level - A marker for the importance of behavioral variables in the pathogenesis, morbidity, and mortality of most diseases? J Rheumatol. 1988;15(10):1457-60.), (1010 Pincus T, Callahan LF. Formal education as a marker for increased mortality and morbidity in rheumatoid arthritis. J Chronic Dis. 1985;38(12):973-84.), (1111 Pincus T, Callahan LF. Taking mortality in rheumatoid arthritis seriously--predictive markers, socioeconomic status and comorbidity. J Rheumatol. 1986;13(5):841-5.), (1212 Pincus T, Callahan LF, Burkhauser RV. Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18-64 United States population. J Chronic Dis. 1987;40(9):865-74.), (1313 Syme SL, Berkman LF. Social class, susceptibility and sickness. Am J Epidemiol. 1976;104(1):1-8.), (1414 Blyth FM, Macfarlane GJ, Nicholas MK. The contribution of psychosocial factors to the development of chronic pain: the key to better outcomes for patients? Pain. 2007;129(1-2):8-11.), (1515 Dionne CE, Von Korff M, Koepsell TD, Deyo RA, Barlow WE, Checkoway H. Formal education and back pain: a review. J Epidemiol Community Health. 2001;55(7):455-68..

Despite the fact that primary observation and sample characterization are present in several studies, it remains unclear whether education is an important social characteristic to be used as a risk and prognostic factor for the occurrence of LBP. Thus, systematic reviews may make it possible to identify findings that elucidate the impact of formal education as a risk and prognostic factor for LBP. Moreover, we believe that these findings may suggest procedures for individual and collective physical therapy treatment of this morbidity. Given the above, the aim of this study was to undertake a systematic review to investigate the association between educational level and the occurrence of LBP.

Methods

We searched the electronic databases MEDLINE (via OVID), EMBASE, Cochrane, AMED and PsyINFO. The searches were conducted between May 1 and 31, 2015. We used keywords related to “low back pain”, “prevalence” and “education”. There were no restrictions on language or publication date. All the studies included in the review met the following criteria: 1) to investigate the LBP of any duration, in patients of both sexes aged 18 years or over; and 2) to associate formal education with the presence or absence of LBP. Papers on conditions specific for the occurrence of LBP, such as fractures, tumors, infection, inflammation, cauda equina syndrome, radiculopathy and pregnancy (non-specific low back pain), were excluded.

Studies selection process

After removing duplicates and screening titles and abstracts, full-text versions of potential papers were selected. A reviewer (AASB) assessed the full versions of the texts according to the inclusion and exclusion criteria. Adjudication by a second reviewer (NH) resolved any ambiguity regarding study inclusion.

Data extraction

Two reviewers (AASB and NH) extracted data using a standardized form. Disagreements were resolved by consensus. Discrepancies were resolved as needed by a third investigator (VCO) who made the final decision. The data were extracted as follows: 1) study design; 2) population characteristics; 3) measures of formal education; and 5) measures of LBP prevalence by educational level.

Risk of bias

Studies were assessed for methodological quality by one reviewer (AASP) using the Prevalence Critical Appraisal Instrument (PCAI)1616 Munn Z, Moola S, Riitano D, Lisy K. The development of a critical appraisal tool for use in systematic reviews addressing questions of prevalence. Int J Health Policy Manag. 2014;3(3):123-8.. The PCAI assesses studies for methodological quality based on 10 questions with four reply options (“yes”, “no”, “unclear” and “does not apply”). The questions refer to: 1) representativeness of the population; 2) sample selection; 3) sample size; 4) subjects’ details; 5) sample conduction and identification; 6) objective, standard criteria used for the measurement of the condition; 7) reapplicability of the measure; 8) appropriate statistical method; 9) confounding factors, subgroups, etc.; and 10) subpopulations identified using objective criteria. A second reviewer (NH) resolved any uncertainties in relation to the assessment through discussion and by consensus with the first reviewer.

Statistical Analysis

Due to differences in the classification of formal education used in the studies, this variable had to be reclassified to allow for synthesis of data. The reclassification was performed by two reviewers (AASB and VCO), who defined three categories (low, medium and high), based on the Brazilian education classification criteria. The number of years of formal education was classified as follows: 0 - 9 years as low educational level; 10 - 12 years as medium educational level; 13 or more years as high educational level1717 Brasil. Ministério da Educação. [cited 2015 Nov 17]. Available from: <Available from: http://portal.mec.gov.br/index.php >.
http://portal.mec.gov.br/index.php...
. This allowed a cutoff value to be defined for the studies and uncertainties were resolved by consensus between the authors.

LBP prevalence for each educational level was estimated and meta-analysis was conducted whenever possible. I2 statistics1818 Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated 2001 Mar]. The Cochrane Collaboration; 2011 [cited 2016 Feb 18]. Available from: Available from: https://tinyurl.com/34pjxzu
https://tinyurl.com/34pjxzu...
was used to determine the possibility of performing meta-analysis. Whenever I2 < 50%, meta-analysis was conducted using a fixed-effect model, whereas a random-effects model was used when I2 ≥ 50%. If even after using a random-effects model, I2 ≥ 50%, then the results were described qualitatively. Prevalence was presented as percentage, with 95% confidence interval (95% CI). Meta-regression was carried out to test whether educational level could explain the heterogeneity found in LBP prevalence for all groups of educational levels. All the analyses were conducted using the Comprehensive Meta-analysis software, version 2.2.04 (Biostat, Inc.©, Englewood, New Jersey).

Results

Studies selection process

Figure 1 shows a flowchart of the studies process, as well as the total number of original studies included for review.

Figure 1
Selection of studies for review.

Characteristics of the studies included

Thirteen studies from nine countries associated education with LBP and were included in the review. They all had a low risk of bias (7 or more out of 10). The studies with the smallest and the largest sample size included 341919 Lee PW, Chow SP, Lieh-Mak F, Chan KC, Wong S. Psychosocial factores influencing outcome in patientes with low-back pain. Spine (Phila Pa 1976). 1989;14(8):838-43. and 4,760 participants2020 Hurwitz EL, Morgenstern H. Correlates of Back Problems and Back-Related Disability in the United States. J Clin Epidemiol. 1997;50(6):669-81., respectively. Sixty-two percent of the studies included in the review were cross-sectional (Table 1). We found a predominance of people in the economically active age-group, i.e., aged 25-55 years33 Silva MC, Fassa AG, Valle NCJ. Chronic low back pain in a Southern Brazilian adult population: prevalence and associated factors. Cad Saude Publica. 2004;20(2):377-85.), (1919 Lee PW, Chow SP, Lieh-Mak F, Chan KC, Wong S. Psychosocial factores influencing outcome in patientes with low-back pain. Spine (Phila Pa 1976). 1989;14(8):838-43.), (2020 Hurwitz EL, Morgenstern H. Correlates of Back Problems and Back-Related Disability in the United States. J Clin Epidemiol. 1997;50(6):669-81.), (2121 Nagi SZ, Riley LE, Newby LG. A social epidemiology of back pain in a general population. J Chronic Dis. 1973;26(12):769-79.), (2222 Goubert L, Crombez G, De Bourdeaudhuij I. Low back pain, disability and back pain myths in a community sample: prevalence and interrelationships. Eur J Pain. 2004;8(4):385-94.), (2323 van Oostrom SH, Monique Verschuren WM, de Vet HC, Picavet HS. Ten year course of low back pain in an adult population-based cohort - the Doetinchem cohort study. Eur J Pain. 2011;15(9):993-8.), (2424 Shim JH, Lee KS, Yoon SY, Lee CH, Doh JW, Bae HG. Chronic low back pain in young Korean urban males: the life-time prevalence and its impact on health related quality of life. J Korean Neurosurg Soc. 2014;56(6):482-7.. One study associated LBP with education in non-institutionalized older adults2525 Muramatsu N, Liang J, Sugisawa H. Transitions in chronic low back pain in Japanese older adults: a sociomedical perspective. J Gerontol B Psychol Sci Soc Sci. 1997;52(4):S222-34. and three studies included older adults in their samples2121 Nagi SZ, Riley LE, Newby LG. A social epidemiology of back pain in a general population. J Chronic Dis. 1973;26(12):769-79.), (2626 Latza U, Kohlmann T, Deck R, Raspe H. Influence of occupational factors on the relation between socioeconomic status and self-reported back pain in a population-based sample of German adults with back pain. Spine (Phila Pa 1976). 2000;25(11):1390-7.), (2727 Björck-van Dijken C, Fjellman-Wiklund A, Hildingsson C. Low back pain, lifestyle factors and physical activity a population based study. J Rehabil Med. 2008;40(10):864-9..

Table 1
Characteristics of the studies included (n = 13)

Two papers had been published in the USA2020 Hurwitz EL, Morgenstern H. Correlates of Back Problems and Back-Related Disability in the United States. J Clin Epidemiol. 1997;50(6):669-81.), (2121 Nagi SZ, Riley LE, Newby LG. A social epidemiology of back pain in a general population. J Chronic Dis. 1973;26(12):769-79., two in Germany2626 Latza U, Kohlmann T, Deck R, Raspe H. Influence of occupational factors on the relation between socioeconomic status and self-reported back pain in a population-based sample of German adults with back pain. Spine (Phila Pa 1976). 2000;25(11):1390-7.), (2727 Björck-van Dijken C, Fjellman-Wiklund A, Hildingsson C. Low back pain, lifestyle factors and physical activity a population based study. J Rehabil Med. 2008;40(10):864-9., two in the Netherlands2323 van Oostrom SH, Monique Verschuren WM, de Vet HC, Picavet HS. Ten year course of low back pain in an adult population-based cohort - the Doetinchem cohort study. Eur J Pain. 2011;15(9):993-8.), (2828 Miedema HS, Chorus AM, Wevers CW, van der Linden S. Chronicity of back problems during working life. Spine (Phila Pa 1976). 1998;23(18):2021-8; discussion 2028-9. and two in Belgium2929 Goubert L, Crombez G, De Bourdeaudhuij I. Low back pain, disability and back pain myths in a community sample: prevalence and interrelationships. Eur J Pain. 2004;8(4):385-94.), (3030 Clays E, De Bacquer D, Leynen F, Kornitzer M, Kittel F, De Backer G. The impact of psychosocial factors on low back pain longitudinal results from the Belstress study. Spine (Phila Pa 1976). 2007;32(2):262-8.. The review also included studies published in Japan, Hong Kong, Brazil, Sweden and South Korea.

Methodological quality of the studies included for review

The reviewers used the PCAI to assess the methodological quality of the studies included in the review. The highest and the lowest scores obtained were 7 and 10, respectively. Three studies were scored as 7, three were scored as 8, three were scored as 9 and four were scored as 10. A detailed view of the scores on the PCAI, the study authors and the year of publication are shown in Table 2.

Table 2
Methodological quality of the studies included (n = 13)

Association between educational level and prevalence of low back pain at the time of assessment

Meta-analysis using a random-effects model and including all educational levels found a weighted prevalence of LBP at the time of assessment of 23% (95% CI, 13-37), from 10,582 cases out of a total of 99,457 (Figure 2). A random-effects model was used due to heterogeneity above 50%. Whereas 99% heterogeneity was observed when using the fixed-effect model, 0% heterogeneity was found when using the random-effects model.

Figure 2
Meta-analysis of prevalence of low back pain at the time of assessment in all education groups.

The meta-analysis of studies on the prevalence of LBP at the time of assessment in people with low educational level found a weighted prevalence of 24% (95% CI, 12-43). Out of a total sample of 14,038, there were 2,044 participants with low educational level. Meta-analysis found a weighted prevalence of 27% (95% CI, 9-56) of participants with medium educational level, i.e., 3,100 out of a total sample of 16,199 participants. Meta-analysis also found a weighted prevalence of 18% (95% CI, 5-50) of participants with high educational level, i.e., 3,100 out of a total sample of 16199 participants (Figure 3).

Figure 3
Meta-analysis of prevalence of LBP at the time of assessment, according to educational level attained.

Association between educational level and prevalence of low back pain at other time points

Studies that did not investigate LBP at the time of assessmen 2323 van Oostrom SH, Monique Verschuren WM, de Vet HC, Picavet HS. Ten year course of low back pain in an adult population-based cohort - the Doetinchem cohort study. Eur J Pain. 2011;15(9):993-8.), (2626 Latza U, Kohlmann T, Deck R, Raspe H. Influence of occupational factors on the relation between socioeconomic status and self-reported back pain in a population-based sample of German adults with back pain. Spine (Phila Pa 1976). 2000;25(11):1390-7.), (2828 Miedema HS, Chorus AM, Wevers CW, van der Linden S. Chronicity of back problems during working life. Spine (Phila Pa 1976). 1998;23(18):2021-8; discussion 2028-9.), (2929 Goubert L, Crombez G, De Bourdeaudhuij I. Low back pain, disability and back pain myths in a community sample: prevalence and interrelationships. Eur J Pain. 2004;8(4):385-94.), (3030 Clays E, De Bacquer D, Leynen F, Kornitzer M, Kittel F, De Backer G. The impact of psychosocial factors on low back pain longitudinal results from the Belstress study. Spine (Phila Pa 1976). 2007;32(2):262-8.), (3131 Schneider S, Mohnen SM, Schiltenwolf M, Rau C. Comorbidity of low back pain: representative outcomes of a national health study in the Federal Republic of Germany. Eur J Pain. 2007;11(4):387-97. were not included in the meta-analysis. Qualitative analysis was conducted to investigate the prevalence of LBP at each time point studied and for each educational level. Two studies investigated the prevalence of LBP in the last twelve months2828 Miedema HS, Chorus AM, Wevers CW, van der Linden S. Chronicity of back problems during working life. Spine (Phila Pa 1976). 1998;23(18):2021-8; discussion 2028-9.), (3131 Schneider S, Mohnen SM, Schiltenwolf M, Rau C. Comorbidity of low back pain: representative outcomes of a national health study in the Federal Republic of Germany. Eur J Pain. 2007;11(4):387-97. in low, medium and high educational levels. The prevalence of low, medium and high educational levels, respectively, was: 30.8%, 28.7% and 17.1%2828 Miedema HS, Chorus AM, Wevers CW, van der Linden S. Chronicity of back problems during working life. Spine (Phila Pa 1976). 1998;23(18):2021-8; discussion 2028-9.; and 38.9%, 36.0%, 28%3131 Schneider S, Mohnen SM, Schiltenwolf M, Rau C. Comorbidity of low back pain: representative outcomes of a national health study in the Federal Republic of Germany. Eur J Pain. 2007;11(4):387-97.. One study investigated the prevalence of LBP in the last six months2929 Goubert L, Crombez G, De Bourdeaudhuij I. Low back pain, disability and back pain myths in a community sample: prevalence and interrelationships. Eur J Pain. 2004;8(4):385-94. in high and low educational levels. The prevalence of low and high educational levels, respectively, were 44.3% and 41.7%. One study investigated the prevalence of LBP in the last ten years in low, medium and high educational levels2323 van Oostrom SH, Monique Verschuren WM, de Vet HC, Picavet HS. Ten year course of low back pain in an adult population-based cohort - the Doetinchem cohort study. Eur J Pain. 2011;15(9):993-8.. The prevalence of low, medium and high educational levels, respectively, was 7.2%, 3.9% and 4.2%.

Meta-regression to investigate whether educational level impacts prevalence of low back pain

The use of meta-regression to investigate whether educational level could explain heterogeneity in LBP prevalence was only possible for studies that reported prevalence at the time of assessment. This is because only a small number of studies reported prevalence of LBP at other time points. The educational level attained explained the 99% heterogeneity found in the meta-analysis on LBP prevalence at the time of assessment in all educational levels grouped together (p < 0.05).

Discussion

This systematic review aimed to investigate the association between educational level and the occurrence of LBP. Our findings suggest that, in a heterogenous sample for prevalence of LBP in all educational levels grouped together, people who attained higher educational levels show lower prevalence rates than people with low or medium educational levels.

These findings corroborate those of a systematic review by Dionne1515 Dionne CE, Von Korff M, Koepsell TD, Deyo RA, Barlow WE, Checkoway H. Formal education and back pain: a review. J Epidemiol Community Health. 2001;55(7):455-68., demonstrating that individuals with less years of education are more susceptible to LBP and disability. They are also in line with the results found by Meucci3232 Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Rev Saude Publica. 2015;49:1., who found that, just like smoking and low economic status, low educational level is associated with an increased prevalence of LBP. In addition, when compared with previous reviews, the current review included newer studies and its meta-analysis on the prevalence of LBP in different educational levels was larger and more accurate. Moreover, meta-regression indicated that educational level is an important risk factor for the occurrence of LBP (p < 0.05).

Our results suggest an important clinical implication. If educational level influences the occurrence of LBP, educational level may be an important psychosocial factor to be used in preventive and treatment approaches for LBP. Low and medium educational levels may be seen as risk and/or prognostic factors. Individual and group educational approaches should stress the importance of spine care and other factors that may influence the occurrence of LBP.

A cohort study by Mustard3333 Mustard CA, Kalcevich C, Frank JW, Boyle M. Childhood and early adult predictors of risk of incident back pain: Ontario Child Health Study 2001 follow-up. Am J Epidemiol. 2005;162(8):779-86. found low educational level to be a risk factor for LBP (Odds Ratio: 1.8; 95% CI, 1.2-2.7) and parental educational level to be a risk factor for LBP in children (Odds Ratio: 2.0; 95% CI, 1.3 - 3.1). Thus, in addition to the individual consequences of LBP, parental educational level also seems to affect the occurrence LBP in children and adolescents.

It is possible that people’s adherence to risky behaviors is greater in people with lower educational levels. One possible cause for the higher prevalence of LBP among people with medium and low educational levels could be that these people are exposed to different workloads and work activities than people with high educational levels3434 Griffith LE, Shannon HS, Wells RP, Walter SD, Cole DC, Côté P, et al. Individual participant data meta-analysis of mechanical workplace risk factors and low back pain. Am J Public Health. 2012;102(2):309-18.), (3535 Kujala UM, Taimela S, Viljanen T, Jutila H, Viitasalo JT, Videman T, et al. Physical loading and performance as predictors of back pain in healthy adults. A 5-year prospective study. Eur J Appl Physiol Occup Physiol. 1996;73(5):452-8.), (3636 Latza U, Karmaus W, Stürmer T, Steiner M, Neth A, Rehder U. Cohort study of occupational risk factors of low back pain in construction workers. Occup Environ Med. 2000;57(1):28-34.), (3737 Bakker EW, Koning HJ, Verhagen AP, Koes BW. Interobserver reliability of the 24-hour schedule in patients with low back pain: a questionnaire measuring the daily use and loading of the spine. J Manipulative Physiol Ther. 2003;26(4):226-32.), (3838 Parato SMS, Fernandes RCP. Heavy physical work and low back pain: the reality in urban cleaning. Rev Bras Epidemiol. 2014;17(1):17-30..

Linton3939 Linton SJ. A review of psychological risk factors in back and neck pain. Spine (Phila Pa 1976). 2000;25(9):1148-56. analyzed psychological factors for the occurrence of LBP and reported that a confounding variable was the sample’s educational level. Thus, education might not only be associated with the occurrence of LBP. If left unchecked, it could also produce information bias. Consequently, even in studies whose primary aim is not to investigate the prevalence of LBP, checking the education variable could possibly explain the results obtained. Thus, we found that educational level attained or number of years of education is a variable that is frequently used to characterize study samples, although this was not a primary aim in our searches. Studies with other aims have also described associations with education4040 Lings S, Leboeuf YC. Whole-body vibration and low back pain: a systematic, critical review of the epidemiological literature 1992-1999. Int Arch Occup Environ Health. 2000;73(5):290-7.), (4141 Armenian HK, Halabi SS, Khlat M. Epidemiology of primary health problems in Beirut. J Epidemiol Community Health. 1989;43(4):315-8.), (4242 Croft PR, Rigby AS. Socioeconomic influences on back problems in the community in Britain. J Epidemiol Community Health. 1994;48(2):166-70.), (4343 Leigh JP, Sheetz RM. Prevalence of back pain among fulltime United States workers. Br J Ind Med. 1989;46(9):651-7.), (4444 Mäkelä M, Heliövaara M, Sievers K, Knekt P, Maatela J, Aromaa A. Musculoskeletal disorders as determinants of disability in Finns aged 30 years or more. J Clin Epidemiol. 1993;46(6):549-59.), (4545 Stronks K, van de Mheen H, van den Bos J, Mackenbach JP. The interrelationship between income, health and employment status. Int J Epidemiol. 1997;26(3):592-600.), (4646 Tate DG. Workers' disability and return to work. Am J Phys Med Rehabil. 1992;71(2):92-6.), (4747 Volinn E, Van Koevering D, Loeser JD. Back sprain in industry. The role of socioeconomic factors in chronicity. Spine (Phila Pa 1976). 1991;16(5):542-8.), (4848 Lancourt J, Kettelhut M. Predicting return to work for lower back pain patients receiving worker's compensation. Spine (Phila Pa 1976). 1992;17(6):629-40.. Studies assessing the prevalence of LBP reported associations with educational level, even though this was not their primary search goal4949 Almeida ICGB, Sá KN, Silva M, Baptista A, Matos MA, Lessa I. Chronic low back pain prevalence in the population of the city of Salvador. Rev Bras Ortop. 2008;43(3):96-102.), (5050 Blay SL, Andreoli SB, Dewey ME, Gastal FL. Co-occurrence of chronic physical pain and psychiatric morbidity in a community sample of older people. Int J Geriatr Psychiatry. 2007;22(9):902-8.), (5151 Dellaroza MSG, Pimenta CAM, Duarte YA, Lebrão ML. Chronic pain among elderly residents in São Paulo, Brazil: prevalence, characteristics, and association with functional capacity and mobility (SABE Study). Cad Saude Publica. 2013;29(2):325-34.), (5252 Dotta TAG, Bonadio MB, Furlaneto ME, Silva JS, Leme LEG. Prevalence of acute diseases in the elderly assisted in emergency department of orthopedics. Acta Ortop Bras. 2014;22(2):99-101.), (5353 Lima MG, Barros MB, César CL, Goldbaum M, Carandina L, Ciconelli RM. Impact of chronic disease on quality of life among the elderly in the state of São Paulo, Brazil: a population-based study. Rev Panam Salud Publica. 2009;25(4):314-21.), (5454 Mascarenhas CHM, Silva Neto DG, Sampaio LS, Reis LA, Oliveira TS, Torres GV, et al. Prevalência e padrão de distribuição de patologias ortopédicas e neurológicas em idosos no hospital geral Prado Valadares. Rev Baiana Saude Publica. 2008;32(1):43-50.), (5555 Meneses SG. Correlação das alterações osteomioarticulares e dor em idosos de Morrinhos (CE). RBCEH. 2013;10(2):139-49.), (5656 Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil. BMC Musculoskelet Disord. 2013;14:155.), (5757 Pereira LV, Vasconcelos PP, Souza LAF, Pereira GA, Nakatani AYK, Bachion MM. Prevalência, intensidade de dor crônica e autopercepção de saúde entre idosos: estudo de base populacional. Rev Lat Am Enfermagem. 2014;22(4):662-9.), (5858 Silva EF, Paniz VM, Laste G, Torres IL.. The prevalence of morbidity and symptoms among the elderly: a comparative study between rural and urban areas. Cien Saude Colet. 2013;18(4):1029-40.. Further studies having as their primary aim the investigation of the association of educational level attained or number of years of education with other variables are therefore needed to increase the number of studies eligible for meta-analysis that correlate education with the occurrence of LBP.

The small number of studies found for this review and the matching of these studies using the Brazilian education model may be one limitation of this review. We found 13 studies conducted in nine countries with different cultural, socioeconomic backgrounds. Because the formal education categories used in the studies included in this review were not consistent with each other, we had to recode the educational level variables based on Brazilian education classification criteria. This allowed the summary of the data. We suggest that future studies use years of formal education to facilitate the understanding of the role played by education in the occurrence of LBP. Possible limitations of this study include the lack of recording of the protocol used in the studies and the non-use of the GRADE approach5959 GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2014;328:1490. to assess evidence quality, as suggested by PRISMA6060 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. Ann Intern Med. 2009;151(4):264-9, W64.. There were no limitations regarding the methodological quality of the studies included for review, as all the studies included had a score of 7 or more out of a maximum of 10 points on the scale.

Conclusion

Occurrence of LBP varies according to educational level. Individuals with higher educational levels are less often affected by LBP than individuals with medium or low educational levels.

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Publication Dates

  • Publication in this collection
    2017

History

  • Received
    05 May 2016
  • Accepted
    10 Apr 2017
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