Education for Health

: 2013  |  Volume : 26  |  Issue : 2  |  Page : 103--108

Low back pain and associated risk factors among undergraduate students of a medical college in Delhi

Nupur Aggarwal, Tanu Anand, Jugal Kishore, Gopal Krishna Ingle 
 Department of Community Medicine, Maulana Azad Medical College and Associated L.N, G.N.E.C and G.B. Pant Hospitals, New Delhi, India

Correspondence Address:
Tanu Anand
Department of Community Medicine, Maulana Azad Medical College and Associated L.N, G.N.E.C and G.B. Pant Hospitals, New Delhi - 110 002


Context: Low back pain (LBP) is the most common orthopedic problem worldwide and is known to affect both younger and older adults. The stressful and time consuming curriculum of medical students predisposes them to this problem. Few statistics are available on prevalence rates of LBP among medical students in India. This study assesses the prevalence and risk factors of LBP in students of a medical college in Delhi. Methods: A cross-sectional study was carried out in a medical college in Delhi. The study subjects (n = 160; 100% participation) were selected via stratified random sampling from all undergraduate medical students (aged 17-25 years). A validated questionnaire was used to collect the data. Results: The overall prevalence of LBP among the students over the past one year was 47.5% (n = 76) with a prevalence of 32.5% at the time of data collection. Prevalence among males and females was 45.3% and 50%, respectively. Significant associations were found between LBP in the past year and coffee drinking (Regular = 57%, Occasional = 38.9%, Never = 65.2%, χ2 = 7.24, P= 0.02), body posture (Normal = 32.6%, Abnormal = 75%, χ2 = 18.97, P < 0.001), place of study (Study table = 33.8%, Bed = 58.6, Both = 61.5% χ2 = 10.51, P = 0.01), family history of LBP (Present = 75%, Absent = 38.3%, χ2 = 16.17, P < 0.001) and carrying backpacks (Regular = 50%, Occasional = 33%, Never = 0%, χ2 = 16.17, P < 0.001). The mean scores of depression (2.7 vs. 1.6), anxiety (3.5 vs 1.9), and monotonous work (3.9 vs. 1.8) were found to be significantly higher in group with LBP than in the non-LBP group. However, no association with LBP was seen for weight lifting, watching television/working on computers, driving, wearing heels, or body mass index. Discussion: The high prevalence of LBP among medical students and its association with poor study habits, lifestyle habits, and psychological factors highlight a need for life skills training, education, counseling, and restructuring of the medical curriculum.

How to cite this article:
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 2013;26:103-108

How to cite this URL:
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 [serial online] 2013 [cited 2023 Feb 8 ];26:103-108
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Full Text


Low back pain (LBP) is the most common orthopedic problem worldwide. According to some estimates approximately 60-80% of the general population will suffer from LBP at some point in their lifetime and 20-30% are suffering from LBP at any given time. [1] Cross-sectional data demonstrate that initial onset of lower back pain commonly occurs around the age of 30 [2] and peaks in occurrence between the ages of 45 and 60 years. [2],[3] LBP is no longer the disease of the old. Surprisingly, 39.8% of the adolescent population is also found to suffer from LBP. [4] It limits daily activities in 10-40% of adolescents. In the US, LBP has been reported as the major factor responsible for limiting peoples' activities in those aged below 45 years and is a common patient complaint in clinics and frequent reason for hospitalization and surgery. [5] In India, approximately 35% of people suffer from chronic LBP, which significantly hampers their day-to-day routine. [6] LBP also affects people's mood leading to depression, anxiety, irritability, poor social interactions, and lower overall health status. [7] In adolescents, LBP has been found to be associated with growth spurts, hamstring and abdominal muscle flexibility, and smoking. It has also been correlated with discomfort in bed, physical inactivity, poor posture, and heavy back-packs. [8]

Medical schools tend to have demanding curricula, making students prone to a sedentary lifestyle and possibly increasing the risk of LBP. [9],[10] The undergraduate medical curriculum in India spans five and one-half class years, with 3820 hours. It calls for long hours of sitting during study, hence, predisposing to LBP. A recent study by Majra et al. [11] of medical students in southern India reveals an increase in health risk behaviors and a decline in health promoting behaviors among students over the years of their medical schooling. In another study conducted in a medical school in Malaysia, Indian ethnicity came with a greater risk of being obese than other ethnic groups. [12] A study of similar student groups in the same setting found that the mean hours spent by medical students in recumbent or sitting postures was 9.5 (±5.34) hours per day. [10] Lifestyle factors, including smoking behavior, lack of physical exercise, and short sleep hours, are also considered to be risk factors of LBP. [13]

Few statistics are available on the prevalence of LBP in India. Further, there is a paucity of studies of LBP and its associated risk factors among younger age groups, including medical students. Once the true prevalence rate is known, the societal impact of LBP in terms of cost and disability can be better assessed and interventions developed. Therefore this study was undertaken to estimate the prevalence of LBP and identify its various associated risk factors among undergraduate students of a medical college in Delhi.


Study Setting and Study Participants

A descriptive cross-sectional study was conducted of undergraduate medical students (Bachelor of Medicine and Bachelor of Surgery; MBBS) of all five and one-half class years studying in a medical college in Delhi. Every year 200 students are admitted to the institution; therefore, there are around 1000 students in the medical college studying at any given time. They typically range in age from 17 to 25 years. The sample size for this study was determined on the basis of an estimated prevalence rate of LBP found in the USA. Taking 39% as the expected prevalence rate of LBP [4] at a 95% confidence level, the required sample size was calculated to be 160 medical students to yield prevalence estimate with 5% precision. The sample was selected from different class years of medical students through stratified random sampling. Students of each class year were listed according to their roll numbers, and 40 students were then selected using systematic random sampling. The first number for each class year was selected using random number table and then every fifth roll number from the first selected roll number was enrolled. Selected students were contacted and informed consent was obtained from each participant before data collection.

Study Tool

A pretested, self-administered, structured questionnaire was used for data collection. It included items to record socio-demographic characteristics and assess the presence of risk factors for LBP among the medical students. The questionnaire contained items to assess for LBP and associated factors with the Acute Low Back Pain Screening questionnaire issued by a New Zealand guidelines group. [14] The questionnaire is a screening tool for identifying risk-factors for long-term disability and work loss in patients with LBP. Additional questions regarding students' involvement in various activities like lifting weights and watching television were included based on a literature review. [9] The questionnaire was reviewed for suitability, relevance and accuracy in the Indian context. It was pretested in the English language with ten dental students and was suitably modified. Internal consistencies of the items on LBP were obtained through a Cronbach's alpha coefficient (0.90).

There were 21 questions to screen for psychosocial and physical factors associated with LBP. For question regarding where pain was present in the body other than back, the number of sites indicated by a student were multiplied by two. One to ten scoring was used for questions reflecting the duration of current back pain, rating of pain intensity in the past year, number of episodes of LBP suffered during the past year, days of work missed due to LBP in the past one year, perceived monotony/heaviness of work, whether one feels tense or anxious, feeling depressed in the past year, perceptions of the likelihood that the current episode of LBP will become persistent and attitudinal questions such as 'physical activity worsens the pain', 'one should stop working if the pain increases in intensity', and 'one should not do work when currently suffering from pain'. The score for questions such as decrease in pain following some coping mechanism, chances of studying/working in next six months, satisfaction with current study schedule, and ability to do activities like light work, walk, ordinary household chores, shopping, and sleeping at night was obtained by subtracting the number ticked in each question from 10. A summed score from all the questions was calculated, with a maximum of 210. The score reflects people's perceived ability to function. A score exceeding 105 indicates that a person is at risk for developing greater disability and therefore needs modifications in his/her current LBP management. [14]

Other questions related to the frequency of different activities in which the respondents are involved in a typical week, such as physical exercise, practicing yoga, weight lifting, carrying backpacks, watching television, working on laptop/personal computers (PC), driving, wearing heels, smoking, alcohol, coffee intake, and travelling by public transport.

A nonstretchable measuring tape was used for measuring the student's height to the nearest centimeter and their weight was measured with a portable scale.

Definition of Variables

LBP was defined for students as pain in the lumbar region. [3] We classified LBP as acute (if present for less than 4 weeks) and chronic (if present for more than 12 weeks). For assessment of activities, 'regular' was defined as activity done 'daily' and as 'occasional' if done '1-2 times' per week.

Survey Procedure

Questionnaires were distributed to the selected students after obtaining written informed consent. The subjects were given between 15 and 30 minutes to complete the questionnaires. The questionnaires were scrutinized at the time of collection and if any information was missing, students were asked again for that information to be completed. All subjects were told that they could seek professional help for any back pain if they required, available through the Department of Orthopaedics, Lok Nayak Hospital, New Delhi. An Information Education Communication (IEC) in the form of a booklet was also designed and distributed after data collection to educate the students on the problem of LBP. The anthropometric measurements were taken by the investigator at the time questionnaires were collected using validated methods. [15]


Data were entered in Microsoft Excel and transferred into SPSS version 17 for analysis. Findings were presented as group proportions, and difference in proportions for a given factor was assessed by the Chi-square test. A P value cut off for statistical significance was set at 0.05. Difference between the means of the two groups was compared by t-test (for normally distributed variables) or Mann-Whitney test (for nonnormally distributed variables). Factors which were significantly associated (P < 0.05) with LBP in univariate analysis were further analyzed in Multiple Logistic regression analysis. Odds Ratios (ORs) were calculated indicating the relative odds of occurrence of LBP due to the presence of a particular factor.

Ethical Issues

All students who participated in the study were informed about the purpose of the study and full free and voluntary consent was taken before their inclusion. Each medical student who participated in the study was free to withdraw from the study at any point in time and was ensured confidentiality of the responses. The study was approved by the institutional ethics committee of the medical college.


Out of the 160 study subjects, 86 (53.8%) were males and 74 (46.2%) were females. The mean age was 20.6 ± 2.6 years. The mean height, weight, and body mass index (BMI) of the study group were 167 ± 12.58 cm (140-269 cm), 62.15 ± 10.03 kg (40-90 kg), and 22.09 ± 2.71 (13.30-30.11), respectively. There were 77 (48.1%) study subjects whose father worked in a professional occupation and 90 (56.25%) whose mothers were housewives. A strong majority of the subjects were local residents of Delhi (n = 130; 81.2%) [Table 1].{Table 1}

The overall prevalence of LBP among subjects over the past one year was 47.5% (n = 76) with 32.5% (n = 52/160) suffering from LBP at the time of survey. The past year prevalence ratio of LBP among males (45.3%) and females (50%) was found to be close to one (χ2 = 0.34, P = 0.55) indicating that the gender groups did not differ [Table 1].

LBP occurrence in the past year was reported highest in students in the final class year (n = 23; 57.5%) and lowest in the students of the first class year (n = 13; 32.5%) but overall the prevalence differences were not statistically significant (χ2 = 5.61, P = 0.13). No significant association was found between LBP in the past year and father's occupation (χ2 = 1.05, P = 0.78) or mother's occupation (χ2 = 5.06, P = 0.167) [Table 1].

The level of students' many daily activities (regular, occasional, never) including outdoor sports, physical activity, yoga, watching television, working on the computer, driving, travelling by public transport, carrying backpacks, meeting friends, drinking coffee and alcohol, smoking, wearing heels for girls was assessed for association with LBP [Table 2]. The behaviors found to be significantly associated with LBP were coffee drinking (χ2 = 7.24, P = 0.03), body posture (χ2 = 18.97, P < 0.001), and study place (χ2 = 10.51, P = 0.01). Family history of LBP (χ2 = 16.17, P < 0.001) was also found to be significantly associated in the group with LBP. Carrying backpacks (χ2 = 5.29, P = 0.07) was close to being significantly related to having LBP.{Table 2}

Perceived monotonous work, anxiety, satisfaction, and depression scores were each calculated on a scale of 1 to 10 for the group with LBP and those without LBP. Perceived monotony of work, anxiety, and depression was rated significantly higher by the group of students with LBP whereas satisfaction score was higher in the group without LBP. Overall mean scores calculated based on summing all these items assessing LBP physical and psychosocial risk factors was found to be significantly higher in the group with LBP (P < 0.01) [Table 3].{Table 3}

To understand the coassociation of various risk factors in the current occurrence of LBP among medical students, logistic regression analysis was done. The outcome variable was LBP as currently present or absent. Independent variables with P < 0.05 in univariate analysis were entered into the model. Through multiple logistic regression analysis it was found that not studying at a table, abnormal body posture, carrying backpacks regularly or occasionally, family history of LBP, and finding one's work monotonous were independently correlated with LBP [Table 4].{Table 4}


This descriptive, cross-sectional, self-administered questionnaire-based study in an Indian medical college revealed a LBP prevalence of 48% in medical students over the past year. This finding is very close to the 43% rate reported for medical students of the University of Colorado in the U.S. in 2008 [16] and a 53% rate reported for medical students at Paracelsus Medical University in Austria. [9] These high figures point toward medical students' sedentary lifestyles and stressful routines predisposing them to this painful morbidity. [9] Their hectic study curriculum and busy schedules make their lives sedentary devoid of any physical activities like jogging, exercises, yoga, sports, outdoor games, etc., A study done with students of this same Delhi college in 2010 revealed that only one-third of the medical students were doing the generally recommended amount of physical activity. [10] Their long college work hours meant that students study late into night and often with poor posture, leading to complaints of LBP. [9]

A general trend of increasing LBP with each class year was noted with a slight dip in the third year. The reason for this could be increasing levels of work, stress, anxiety, dissatisfaction, and book bag load with each year. Further, with each progressing year in the MBBS curriculum, clinical postings increase requiring longer periods of standing. Students stand with heavy bags on their backs, promoting bad body posture and strained backs.

Students who found their work monotonous were at more likely to report LBP. Recent literature supports the biological plausibility of this relationship. There is little information on the specific pathophysiologic connections between emotional states and perception of pain in the lower back. [17] According to the recent U.S. National Institute for Occupational Safety and Health review of work-related musculoskeletal problems, including LBP, there is accumulating scientific evidence of connections between the brain and the locomotor system. In particular, it is suspected that perception of lack of well-being operating through the hypothalamic-pituitary-adrenal axis and the sympatho-adrenal medullary axis alters muscle tone and function, predisposing to injury. [17],[18] Monotony is a part and parcel of the lives of medical students and other adolescents too whose curriculum and lifestyle completely lacks recreational activities. These students lack time to spend on hobbies, predisposing them to mental stress, and depression, [19] which in turn, are important components for development of pain. Therefore, medical schools should take steps to incorporate mind-refreshing activities within the curriculum to promote health among students and doctors.

Although no significant association was found between LBP and mother's occupation, students who have working mothers showed a greater prevalence of LBP than students whose mothers are housewives. This group difference cannot be explained in this study, but we wonder if the quality of time spent under constant supervision is important.

More students who carried backpacks regularly or occasionally reported LBP. We find that with each study year, the load of bags increases with increasing weight of medical books, which might explain the increase in LBP. This finding is supported by a study done by Heuscher et al. [20] on 465 health education students. One solution is to provide lockers in college or hostel accommodations for students. Students should also be taught the correct way of handling bags on their back to minimize harm.

Abnormal body posture and studying in bed were found to be significantly more common among students suffering from LBP. Accurate guidance to students should be provided for correct standing, sitting, lying, and bending postures. The family history of LBP was found to be significant in those suffering from LBP, consistent with research done elsewhere. [21],[22]

Limitations of the Study

The study is not without limitations. The biggest limitation is that this study has been undertaken in a single medical college of Delhi and its findings may not fully reflect the situation for medical students elsewhere in India or internationally. The sample group selected also may not fully reflect the population of students at our school. Further, the subjects' assessment of LBP (both current and past episodes) may be subject to recall bias and subject bias. This would have been addressed if daily logs recording each episode of LBP were maintained by the students. Further, the level of daily activities and psychological state of mind was evaluated for relation with LBP based on subjective questions with 0 to 10 score/regular/occasional/never categories, which were answered according to what the subject felt, which might actually differ from the actual severity of the problem. Finally, psychological stress due to work monotony has not been evaluated over a period of time, which might have adverse affect on the prevalence of LBP. Better results could have been obtained if monotony before LBP onset was compared with index of monotony after LBP onset in a cohort or intervention study.


The study concluded that prevalence of LBP in a medical college in Delhi is 48% (annual prevalence) and 33% (point prevalence), which is quite high. Limitations notwithstanding, the study has provided useful insight into the problem of LBP among medical students. This research should be expanded to other Indian medical schools to get a broader assessment of the problem of LBP among Indian medical students.

This study also highlights the need for a back school or a college health program [23] for medical students, that provides education and guidance to all. Students should be taught methods promoting a pain free life, including correct body postures, the benefits of exercise, and exercises to relax the back and release tension. More focus should be given to second and fourth year professional students, perhaps through opportunities for recreation and restructuring of medical curriculum to redistribute the subjects in different professional years to lessen the stress of the medical curriculum.


This project was done as a part of short-term studentship received by the first author from the Indian Council of Medical Research. Their support is greatly acknowledged by the authors.


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