|Year : 2018 | Volume
| Issue : 2 | Page : 85-92
Demographic characteristics of patients suffering from low back pain attending outpatient department in Burdwan Medical College and Hospital
Biplab Chatterjee1, Ram Prasad Sinha1, Soumyadeep Duttaroy1, Pritam Paul1, Amrita Chaudhuri2, Abhilash Sarkar1
1 Department of Orthopedics, Burdwan Medical College, Bardhaman, West Bengal, India
2 Department of Obstetrics and Gynaecology, Central Hospital, South Eastern Railway, Kolkata, West Bengal, India
|Date of Web Publication||16-Oct-2018|
Department of Orthopedics, Burdwan Medical College, Room No-11, J.R. Hostel, Bardhaman - 713 104, West Bengal
Background: Chronic low back pain is a multidimensional issue which is expensive due to necessary spending towards repeated treatment. LBP is considered to be the most common, and costly disabling musculo-skeletal condition.
Materials and Methods:
Study area: Burdwan Medical College, Department of Orthopedics and Radiodiagnosis.
Study population: The patients attending the OPD of Burdwan Medical College & Hospital with complaint of LBP.
Age group: 20-60 years
Sex: Both sexes.
Duration: More than 3 weeks.
Traumatic back pain
Patient having history of surgical interventions.
Patient having any co-morbid conditions like hypertension, diabetes mellitus, etc.
Patient having other musculo-skeletal pain like cervical spondylosis, etc.
Study period: January 2015 - October 2016
Sample size: One hundred (n=100)
Study design: Hospital based cross sectional socio-demographic study.
Skiagram of LS spine.
MRI of LS spine.
Data analysis: Data analysis was done accordingly.
- There was a female preponderance among the study population (1.3:1=Female:Male).
- LBP was found to be most common in the age group of 31-40 with mean age of population was 41.82.
- Distribution of the study population according to BMI revealed equal distribution.
- LBP was found to be most common in the heavy lifestyle(48%).
- LBP was most common in the lower socio-economic status(61%).
- A total of 41% population suffering from LBP is in mental stress and victim of depression. Majority of the patients with depression were of low socio-economic status.
Conclusion: In conclusion, female population who tend to be over-weight and from a low socio-economic background with a definite psychosocial component is at risk. The study is small and direct association cannot be assessed but the epidemiological parameters clearly indicate preponderance of different factors associated with LBP. From this understanding, diagnosis, treatment and rehabilitation protocol can be planned and prevention can be achieved.
خلفية الدراسة: آلام الظهر المزمنة هي مشكلة متعددة الأبعاد مكلفة بسبب الإنفاق الضروري نحو علاجها المتكرر. يعتبر الم أسفل الظهر LBP هي الحالة الأكثر شيوعاً، والمكلفة، في اعتلالات الهيكل العضلي العظمي.
المواد والطرق: منطقة الدراسة: كلية بردوان الطبية، قسم جراحة العظام والتشخيص الشعاعي. مجتمع الدراسة: المرضى الذين يحضرون للعيادة الخارجية لكلية بردوان الطبية والمستشفى بشكوى من الم أسفل الظهر.
الفئة العمرية: 20-60 سنة؛ الجنس: كلا الجنسين. المدة: أكثر من 3 أسابيع.
آلام الظهر الناتجة من الصدمة. المريض بعد التدخلات الجراحية. المريض الذي يعاني من أي مرض مثل ارتفاع ضغط الدم، داء السكري، وما إلى ذلك؛ المريض الذي يعاني من آلام أخرى في العضلات والهيكل العظمي مثل داء الفقار العنقي، إلخ.
فترة الدراسة: يناير 2015 -أكتوبر 2016
حجم العينة: مائة (ن = 100)
تصميم الدراسة: دراسة استعراضية اجتماعية -ديموغرافية مقطعية.
أدوات الدراسة: جهاز وزن؛ شريط قياس؛ Skiagram للعمود الفقري السفلى. التصوير بالرنين المغناطيسي.
تحليل البيانات: تم تحليل البيانات ولوحظ الاتي:
1. كان هناك إناثا أكثر من الذكور بين عينة الدراسة (1.3: 1 = أنثى: ذكر).
2. وجد أن الم أسفل الظهر الأكثر شيوعًا في الفئة العمرية 31-40 مع متوسط عمر السكان 41.82
3. توزيع سكان الدراسة وفقا لمؤشر كتلة الجسم كشفت توزيعا متساويا.
4. وضح ان الم أسفل الظهر الأكثر شيوعًا في نمط الحياة الثقيلة (48٪).
5. كان الم أسفل الظهر أكثر شيوعًا في الحالة الاجتماعية الاقتصادية المنخفضة(61٪).
6. 41 ٪ من عينة الدراسة الذين يعانون من الم أسفل الظهر لديهم إجهاد ذهني وضحايا الاكتئاب. وغالبية المرضى الذين يعانون من الاكتئاب كان وضعهم الاجتماعي والاقتصادي منخفضا.
الاستنتاج: في الختام، إن الإناث اللواتي يعانين من زيادة الوزن ومن خلفية اجتماعية اقتصادية منخفضة مع عنصر نفسي واجتماعي محدد يتعرضن للإصابة بألم أسفل الظهر. الدراسة صغيرة ولا يمكن تقييم الارتباط المباشر ولكن المعلومات الوبائية التي حصلنا عليها تشير بوضوح إلى عوامل المختلفة المرتبطة بالإصابة بألم أسفل الظهر. من هذا الفهم، يمكن التخطيط لبروتوكول التشخيص والعلاج وإعادة التأهيل ويمكن تحقيق الوقاية.
Keywords: Burdwan outpatient department, demographic study, low back pain
|How to cite this article:|
Chatterjee B, Sinha RP, Duttaroy S, Paul P, Chaudhuri A, Sarkar A. Demographic characteristics of patients suffering from low back pain attending outpatient department in Burdwan Medical College and Hospital. Saudi J Sports Med 2018;18:85-92
|How to cite this URL:|
Chatterjee B, Sinha RP, Duttaroy S, Paul P, Chaudhuri A, Sarkar A. Demographic characteristics of patients suffering from low back pain attending outpatient department in Burdwan Medical College and Hospital. Saudi J Sports Med [serial online] 2018 [cited 2020 Jul 3];18:85-92. Available from: http://www.sjosm.org/text.asp?2018/18/2/85/243352
| Introduction|| |
Low back pain (LBP) is very broad term covering a large number of disorders. It is defined topographically as pain occurring between the 12th rib and gluteal folds. These are not only be characterized by pain but also discomfort and/or stiffness. LBP probably covers several subgroups with different etiologies and prognosis, but since current knowledge does not allow us to determine the exact medical cause of LBP in most patients; “nonspecific” LBP is determined by exclusion. In fact, it has been estimated by some that a somatic cause is found in 10%–20% of cases with LBP, whereas others find that as much as 97% of LBP is called “nonspecific” or “sprain/strain.” Thus, LBP refers to a set of symptoms or a syndrome rather than a diagnosis.
LBP is commonly defined on a temporal basis, pain that lasts <6 weeks is defined as acute. Subacute pain is defined as pain that lasts between 6 weeks and 3 months. Chronic pain is defined as pain that lasts more than 3 months. Older age, female gender, low educational status, sedentary works, smoking, high body mass index (BMI), and trauma and psychological factors are some factors associated with LBP. LBP is mostly seen by the age of 50 years which falls within the working population. Chronic LBP is a major problem to both the individual and society, due to its large direct and indirect treatment cost, as well as associated disability and suffering.
It is well recognized that chronic pain is a multidimensional issue. It is an expensive issue due to necessary spending toward repeated treatment, as well as the need for additional professional and personal support. LBP is considered to be most common, and costly disabling musculoskeletal condition. This high expenditure is largely due to numbers of lost workdays considered an indirect cost as well as direct treatment cost. The high prevalence of back pain is another factor influencing the cost, with an estimated 70%–90% of any adult population experiencing at least one episode over their lifetime. LBP is the most prevalent of all musculoskeletal problems.,, Over the last two decades, the prevalence of back pain and its associated costs have been increasing considerably. Contemporary health care generally considers back pain to be a multidimensional problem with a multicausal etiology., LBP can, therefore, present with a variety of symptoms, physical limitations, psychological features, and consequences, all of which make effective treatment difficult.,,
Aims and objectives
Considering the huge disease burden of LBP in the society, it need not to be overemphasized that any new study on LBP is always relevant. The aim of this study is to find out salient sociodemographic factors influencing the occurrence and clinical course of LBP. This will improve the understanding of the condition and help in better outcome.
Specific objectives of this study
- To analyze different causes of LBP on the basis of age and sex of the patients
- Impact of occupation on causation of LBP
- Relation of LBP with BMI
- Role of psychosocial factors in the evolution of LBP.
Review of literature
LBP is such a frequent cause of disability in the community that it has become almost a disease. According to different demographic characters, the causes are different. So far the according to literature available, the etiology understood is quite confusing. In 1980, Waddell et al. concluded it to be a “nonorganic physical sign.” However, with time the pathologies are being assessed. Careful history taking and examination will uncover the pathology. It has been found that LBP comes under the following headings-transient backache following muscular activities, sudden acute pain and sciatica, intermittent LBP after exertion, back plus pseudoclaudication, severe and constant back pain localized to a particular area. Whatever the pathology is, in every case, it is the demographic character which is the first and most important criteria which guides the surgeon to reach the right way to diagnosis.
In a study by Hestbaek et al., a total 834 patients were included in the study. Of them, 55% reported LBP in the last 12 months. Participants with LBP had higher BMI. The proportion was higher among females, higher education levels, proportion of workers, and the level of alcohol intake and physical activity were lower. In the multivariate analysis, LBP was independently associated with older age, female gender, and inactive working adults.
In a study by Moore et al., a total of 250 patients were made in patients on parameters of different demographic characters. The conclusion was that the ratio of LBP is higher among females of lower psychosocial status, whereas it is higher in males with heavy workers. Both genders are equally affected with patients of higher BMI more affected.
Bindra et al., found in their study the prevalence of back pain to range from as low as 6.2% to high as 92% depending on the population under study. Age ≥35 years was found to have nine times more risk as compared to <35 years. Koley et al. in their study found a gradual increase of pain score with the increase of age in both the sexes, the increment of pain score was more in females. In a study on long-distance truck drivers of mountainous terrain, 44% of the population which suffered LBP was above 40 years old. LBP was found to be more common among females than males in geriatric patients. A large number of farmers with LBP could not complete their primary education and remained below poverty line. Haldiya et al., found that complaints of back pain were higher in rural area than urban area (7.5%: 5.5%). Sidhu et al. found that 68% of the sufferers with LBP belonged to low socioeconomic status. Sharma et al. reported the maximum frequency (50%) of LBP in people involved in jobs requiring handling of heavy loads, followed by people with sitting jobs (19.09%), withstanding jobs (16.36%), and with prolonged standing (14.54%). Joshi et al., observed that lumbar pain was more common in operators working on presses, those using hand and power tools and those lifting heavy manual loads. Sharma et al., found that 57% of participants with LBP, and Joshi et al. reported fewer musculoskeletal disorders in workers experiencing more job satisfaction. Contract workers had less musculoskeletal pain than regular and temporary workers. Skilled workers also had less morbidity. Pande in his study on psychological disturbance in Indian LBP population found a high prevalence of anxiety (71.7%) and depression (64.8%). There was modest but significant correlation between reported disability and levels of anxiety. Tiwari et al., in their study, found obese patients to be at risk of developing LBP.
Manchikanti et al. found that although it has been alleged that LBP resolves in approximately 80%–90% of patients in about 6 weeks, irrespective of the administration or type of treatment, with only 5% to 10% of patients developing persistent back pain, this concept has been frequently questioned as the condition tends to relapse and most patients experience multiple episodes years after the initial attack.
Wheeler et al., observed 84% of adults experience LBP at some point of their life. Most patients who present with back pain to primary care settings will have nonspecific back pain. Less than one percent will have serious systemic aetiologies (e.g., malignancy or infection). Less than ten percent will have less serious, specific aetiologies (e.g., vertebral compression fracture, radiculopathy or spinal stenosis).
A focused history and physical examination are sufficient to evaluate most patients with back pain of <4-week duration. The history and physical examination should identify features that suggest that imaging and/or other evaluations are indicated. The majority of patients with LBP of <4 weeks duration do not require imaging. Among patients seen in primary care, <1% will require immediate advanced (e.g., magnetic resonance imaging [MRI] or computed tomography scan) imaging. Any patient with symptoms of the spinal cord or cauda equina compression or severe neurologic deficits should have immediate MRI for further evaluation. Patients who have not improved after 4 to 6 weeks of conservative therapy and who did not receive imaging on the initial evaluation are re-evaluated. Patients with persistent symptoms due to a lumbosacral radiculopathy or spinal stenosis who are candidates for and are interested in invasive therapies (e.g., epidural injection or surgery) should have an MRI and other blood investigations for further evaluation. In other patients where there are no concerns for a particular etiology, we generally treat with conservative therapy for another 8 weeks. For patients without concerns for a particular etiology who have not improved after 12 weeks total, image with a plain film and consider referrals for further evaluation and treatment.
| Materials and Methods|| |
This study was conducted at the Department of Orthopedics and Radiodiagnosis, Burdwan Medical College.
The patients' attending the OPD of Burdwan Medical College and Hospital with the complaint of LBP.
- Age group: 20–60 years
- Sex: Both sexes
- LBP more than 3-week duration.
- Traumatic back pain
- Patient underwent surgical interventions
- Patient having any comorbid conditions such as hypertension, diabetes mellitus, any malignancy, inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, etc.)
- Patient having other musculoskeletal pain such as cervical spondylosis, frozen shoulder, and degenerative arthritis of hip and knee.
January 2015 to October 2016.
One hundred patients (n = 100).
Any patients fulfilling the inclusion criteria of this study will be included in this study.
This was an hospital-based, cross-sectional, sociodemographic study.
Parameters to be studied
- Parameters of specific objective No.-1
- Age-wise incidence of various etiologies of LBP
- Sex-related variations of incidence and etiologies of LBP.
Parameters of specific objective No. 2
Patients are divided into three categories depending on their occupation
- Heavy workers, e.g., factory workers, farmers, agricultural laborer, etc.
- Moderate workers, e.g., serviceman, businessman, etc.
- Sedentary workers, e.g., household jobs, unemployed, etc.
Parameters of specific objectives No. 3
Patients are divided into four categories as per their BMI
- Underweight (<18.5)
- Normal (18.5–24.99)
- Overweight (>25), preobese, obese Class-1, obese Class-2, and obese Class-3.
Parameters of specific objectives No. 4
Patients are classified into four categories as per their socioeconomic status
- Upper class
- Middle class
- Lower class.
- Preformed questionnaires for scoring psychological status [Figure 1]
- Weighing machine
- Measuring tape
- Skiagram of lumbosacral spine
- MRI of lumbosacral spine.
All patients of LBP fulfilling the criteria of this study were interviewed thoroughly about the history of the disease to fill-up preformed questionnaire. Then, the patients were examined properly starting from general survey and systemic examination. Then, examination of the local site, routine blood investigations, and skiagram of lumbosacral area (orthogonal view) was obtained. From these above informations, patients were given advice of MRI where necessary.
All this data were compiled and analyzed to get unbiased result.
Plan for data analysis
Data analysis was done accordingly.
| Discussion|| |
To gain insight into disease development, it is necessary to understand the natural course of the disease. In a disorder with a highly variable course, such as LBP, this is difficult, and requires long-term follow-up as well as careful considerations of outcome measures. Available data on the natural history of LBP were found to be incomplete and confusing by VonKorff M and unfortunately since. It still needs to be established what the chances are, that the pain will run a transient, recurrent or chronic course. Furthermore, most studies have centered on adults, but LBP seems to originate earlier in life. It is important to learn more about this condition in the young in order to implement primary preventive measures at an early age. During the past decades, numerous factors, such as physical characteristics, psychological characteristics, lifestyle factors, employment, social factors and genetic component, have been considered risk factors for developing LBP. Despite considerable research efforts, no clear picture has emerged. Even though different factors are found to be dominant risk factors in different studies,, they may all at the same time be complicating factors or confounders of varying importance. Some factors might enhance each other while some might suppress the effect of others. Furthermore, the same factor may have various influences on different body types, personalities, genetic make-up or subgroups of LBP. To make prevention efficient, risk factors must be known, but risk groups must also be identified to target the prevention at the most needing group. To date, only few attempts have been made to describe the group which is most susceptible to LBP and which will respond with morbidity to external stressors. Epidemiological studies have mainly focused on adult populations and several attempts have been made to predict recovery versus non-recovery of LBP.[16-26] Since, these studies obviously focus on people who already are affected by LBP, this limits the scope to secondary prevention. Ideally, epidemiological studies of the development of LBP should be performed on large, young populations in order to assess the impact of a general inherent frailty on the development of LBP. Obviously, the older a population is, the more difficult it will be to detect the impact of possible inherent risk factors of LBP, as other causative or aggravating factors gradually will confuse the picture. The results obtained are as follows:
There is a slight female (56%) preponderance [Table 1] as also corroborated by studies of Hoy et al., Bindra et al., and Haldiya et al.
The study population was divided in five subgroups according to their chronological age, starting from 20 years. It is observed that the most affected individual age group belongs to 31–40 years, relatively younger age group (i.e., 20–30 years) is affected in a significant magnitude. Patients above the age of 40 years were also significant [Table 2]. This corroborates with various studies of Hoy et al., Bindra et al., and Haldiya et al. The rise in number of affected young individuals is significant. This finding is in contrast to other studies.
Body mass index
Patients were divided into three groups according to BMI. 46% patients are overweight, whereas 47% are normal [Table 3].
In the assessment of lifestyle, it is found that those who are heavy workers, are more at risk (48%) [Table 4]. This corroborates with the studies of Hoy et al., Walker BF, Bindra et al., Haldiya et al., Sidhu et al., and Sharma et al.
People belonging to low socioeconomic strata (61%) are the majority who are affected [Table 5]. This corroborates with the studies of Bindra et al., Haldiya et al., Sidhu et al., and Sharma et al.
|Table 5: Distribution of study population according to socioeconomic status|
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In this study, 59% population is normal, and only three percent is suffering from major depression. A sum total of 41% population suffering from LBP is in mental stress and victim of depression [Table 6]. Majority of the patients with depression were of low socioeconomic status [Table 7]. This is also corroborated in the study of Pande.
|Table 6: Distribution of study population according to psychological status|
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|Table 7: Distribution of study population with depression and socioeconomic status|
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Socioeconomic status was assessed with the Modified BG Prasad scale(2014) [Table 8]. So to summarise, the female population who tend to be over-weight and from a low socio-economic background with a definite psychosocial component is at risk
|Table 8: Modified BG Prasad scale for socioeconomic status assessment (2014)|
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Strength and limitation of the study
- The study is mainly based on the epidemiological characters of LBP. From the study, we can have an insight by which we can prevent the disease and can have a better understanding to drive the population to practice a healthy lifestyle that is essential
- Moreover, studies like this is not common in this part of our country
- The study is totally hospital-based, observational study. Hence, people from all classes with different lifestyles were evaluated
- On the contrary, there are limitations also
- As there is no control group, it could not be standardized
- It is an observational study, so direct recommendation is not acceptable
- The number of study population is small in terms of a demographic study
- Other comorbid conditions which are associated with LBP, particularly in geriatric age group were not evaluated.
| Conclusion|| |
LBP has emerged as a significant cause of morbidity in developing countries at large. The patients are mostly females, sustaining different pathology following different physiological change and faulty job posture.
Moreover, in many parts of the developing world, including ours, even today back pain is neglected and poorly managed. Research is sparse, and data is missing. The demographic and epidemiological pattern of LBP is different in our country from developed countries and should be considered while formulating policies for LBP in future. Large-scale multicentric trials or population-based survey is needed for the assessment of magnitude and impact of the disease. Disease evaluation protocol, recordkeeping, and hospital care should be improved. Regional and national centers for comprehensive treatment and multidisciplinary rehabilitation should be established.
In conclusion, LBP is a common pathological condition with a tendency to affect young population relatively more. Although proportion of heavy workers suffering from LBP are more, moderate workers are also being affected in a comprehensive way. BMI is a significant parameter associated with the condition. Patients having high BMI are more prone. Patients with low socioeconomic status and having subclinical depression are closely related to the condition. The study is small and direct association cannot be assessed, but the epidemiological parameters clearly indicate preponderance of different factors associated with LBP. From this understanding, diagnosis, treatment, and rehabilitation protocol can be planned, and prevention can be achieved.
We would like to thank Prof. (Dr.) Chinmay De, professor and head of the Department of Orthopaedics. His valuable advice and supervision were instrumental for the completion of this project.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Johnson OE, Adegoke BO, Ogunlade SO. Comparison of four physiotherapy regimens in the treatment of long-term mechanical low back pain. J Jpn Phys Ther Assoc 2010;13:9-16.
Nachemson A. Chronic pain – The end of the welfare state? Qual Life Res 1994;3 Suppl 1:S11-7.
Cedraschi C, Robert J, Goerg D, Perrin E, Fischer W, Vischer TL, et al.
Is chronic non-specific low back pain chronic? Definitions of a problem and problems of a definition. Br J Gen Pract 1999;49:358-62.
Krismer M, van Tulder M, Low 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;21:77-91.
Lehmann TR, Spratt KF, Lehmann KK. Predicting long-term disability in low back injured workers presenting to a spine consultant. Spine (Phila Pa 1976) 1993;18:1103-12.
Deyo RA. Practice variations, treatment fads, rising disability. Do we need a new clinical research paradigm? Spine (Phila Pa 1976) 1993;18:2153-62.
Dankaerts W, O'Sullivan P. The validity of O'sullivan's classification system (CS) for a sub-group of NS-CLBP with motor control impairment (MCI): Overview of a series of studies and review of the literature. Man Ther 2011;16:9-14.
Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24:769-81.
Walker BF. The prevalence of low back pain: A systematic review of the literature from 1966 to 1998. J Spinal Disord 2000;13:205-17.
Gregg CD, Hoffman CW, Hall H, McIntosh G, Robertson PA. Outcomes of an interdisciplinary rehabilitation programme for the management of chronic low back pain. J Prim Health Care 2011;3:222-7.
Waddell G. The Back Pain Revolution. 2nd
ed. Elsevier Canada: Churchill Livingstone; 2004.
Gurcay E, Bal A, Eksioglu E, Hasturk AE, Gurcay AG, Cakci A, et al.
Acute low back pain: Clinical course and prognostic factors. Disabil Rehabil 2009;31:840-5.
Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine (Phila Pa 1976) 1980;5:117-25.
Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: What is the long-term course? A review of studies of general patient populations. Eur Spine J 2003;12:149-65.
Moore A, Mannion J, Moran RW. The efficacy of surface electromyographic biofeedback assisted stretching for the treatment of chronic low back pain: A case-series. J Bodyw Mov Ther 2015;19:8-16.
Bindra S, Sinha AK, Benjamin AI. Epidemiology of low back pain in Indian population: A review. Int J Basic Appl Med Sci 2015;5:166-79.
Koley S, Singh G, Sandhu R. Severity of disability in elderly patients with low back pain in Amritsar, Punjab. Anthropologist 2008;10:265-8.
Goon M, Ghoshal S, Chandrasekaran B, Sharma BC. Prevalence of low back pain in long distance truck drivers of mountainous terrain. Adv Occup Soc Organ Ergon. CRC Press, Taylor & Francis Group(NW) 2011;55:516-22.
Haldiya KR, Mathur ML, Mathur NC, Mathur A. Epidemiology of Musculoskeletal Conditions in India. Dr. S.N. Medical College, Jodhpur: Annual Report; 2009-2010.
Sidhu A, Sidhu G, Jindal RC, Banga A, Nishat S. Sociodemographic profile of low back pain- Saharanpur spine. Pb J Orthop 2012;8:1.
Sharma SC, Singh R, Sharma AK, Mittal R. Incidence of low back pain in workage adults in rural North India. Indian J Med Sci 2003;57:145-7.
] [Full text]
Joshi TK, Menon KK, Kishore J. Musculoskeletal disorders in industrial workers of Delhi. Int J Occup Environ Health 2001;7:217-21.
Pande KC. Psychological disturbance in Indian low back pain population. Indian J Orthop 2004;38:175-7. [Full text]
Tiwari RR, Pathak MC, Zodpey SP. Low back pain among textile workers. Indian J Occup Environ Med 2003;7:27-9. [Full text]
Manchikanti L, Singh V, Falco FJ, Benyamin RM, Hirsch JA. Epidemiology of low back pain in adults. Neuromodulation 2014;17 Suppl 2:3-10.
Wheeler SG, Wipf JE, Staiger TO, Deyo RA, Atlas SJ, Eamranond P. Approach to the Diagnosis and Evaluation of Low Back Pain in Adults. Waltham: UpToDate; 2010. p. 1-29.
Von Korff M. Studying the natural history of back pain. Spine (Phila Pa 1976) 1994;19:2041S-6S.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]