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A Research Presented to
The Special Studies Committee
of the
College of Public Health
University of the Philippines, Manila
Submitted by Group 8
Gail M. Culla
Felicidad Clare S. Martinez
Jay Patrick R. Santiago
Mia Marie M. Tad-y
Adviser
Benjamin C. Vitasa, MD, MPH, PhD
23 February 2004
Abstract
The general objective of the study is to determine the risk factors associated
with low back pain among Filipino male air-conditioned bus drivers. It specifically
aims to describe the distribution of bus drivers according to age, long driving time,
vibration exposure, long distance driving, duration of employment, driving posture,
seat/workplace design and psychological factors; describe the distribution of bus
drivers with low back pain by age, long driving time, vibration exposure, long
distance driving, driving posture, seat/workplace design, and psychological factors;
and determine the association of different risk factors with low back pain adjusting
for the effects of confounders and other independent variables.
The outcome variable, low back pain was assessed based on questions
asked in the questionnaire, using as inclusion criteria, chronicity of at least 6 months,
recurring at least twice a week and 30 minutes duration per experience of pain.
Using logistic regression, the association of risk factors with low back pain
was determined. The identified risk factors included age, insufficient work space,
abnormal vibration, uncomfortable sitting posture, constrained posture, rough roads,
boredom, depression, frequent movement of back, frequent movement of shoulders,
long distance driving, long driving time, vibration exposure, employee satisfaction
with management and height.
Results showed that constrained posture, long distance driving and employee
satisfaction with management were significantly associated with low back pain.
Drivers with any one of these characteristics have greater odds of having low back
pain of 3, 2.2 and 2, respectively.
2
1.0 Introduction
traveling by land would not be possible without the vehicle and the driver himself.
Drivers are people who consider driving as their profession and source of income. It
is of great importance for them to know that aside from the benefits they can get
from this job, their life can still be at risk. Aside from possible accidents due to work,
their health can also be at risk. Low back pain is a form of occupation-related
disease which may cause increased cases of absenteeism and lesser productivity
for the working population. Drivers, as part of this population, should be aware that
this health issue is not a minor problem and should be taken seriously because it
All over the world, several studies on low back pain have been conducted but
only few have established its association with driving a bus. No known Philippine
study on low back pain among bus drivers exists. Bus driving is only one of many
jobs that persons with a driver’s license can go into. Having little knowledge on the
possible occurrence of low back pain due to driving and its prevention can adversely
affect the health and productivity of bus drivers. For these reasons, a study to
establish the association between long driving time and low back pain is important
and timely. Recommendations on the prevention of low back pain can be formulated
3
2.0 Review of Related Literature
Low back pain (LBP) is chronic pain localized in the lumbo-sacral spine with
acute and sudden onset lasting for about thirty minutes and is intermittent and
recurring for at least twice a week for six months. It is the most common cause of
the most frequent variety of pain which workers have to contend with. However,
physicians diagnose low back pain as acute if it lasts less than a month and is not
caused by serious medical conditions. Most cases clear up in a few days without
Between 60% and 90% of the general population experience back pain at one
time or another during their lifetimes. In a study done in Denmark, it was noted that
40% of the general population had recurrent LBP in 5 years (2). A cross-sectional
study done in Nigeria among office workers revealed that 38% suffer from episodes
of LBP in a 12-month period (3). Another cross-sectional study showed that 60% of
women in a textile factory in Vietnam suffer the same condition (4). Greater in
in an eight-year cohort study (5). Every year, nearly 15% of American adults visit
their doctors because of low back pain episodes (6). These data were gathered
Men and women are equally at risk. Low back pain is second to upper
respiratory infection as the reason for seeing a doctor. In the US, its cost is second
to cancer and heart disease. The Center for Disease Control reported that in 1995,
4
over 20 million visits to physicians and clinics were related to back symptoms. Low
back pain occurred in 25% of the working population and the economic impact in the
United States has been estimated to be over $75 billion per year (6). According to
the National Research Council and the Institute of Medicine of the National
Academies, it affects about 1 million workers and costs the nation between $45
billion and $54 billion in compensation expenditures, lost wages and decreased
The majority of patients with low back pain state that they have increased
pain while sitting or upon arising from sitting. It is believed that almost all LBP is
aggravated and perpetuated by poor sitting posture in both sedentary and manual
workers.
frequent low back pain among urban bus drivers was 57% (2). This figure is not far
from the 56.62% LBP prevalence seen among bus drivers in Lithuania (8).
However, the figure is slightly lower in a study done among Japanese truck drivers.
From 153 respondents, the prevalence of LBP in one month was 50.3% (9).
The important functions that the lower back or lumbar area serves for the
human body include structural support, movement and protection of certain body
tissues. It holds most of the body’s weight and is involved in bending, extending or
rotating at the waist. The lumbar spine and muscles protect the soft tissues of the
5
nervous system and spinal cord as well as adjacent organs of the pelvis and
abdomen (10).
movable support structure and protects the spinal cord from injury. Each vertebra
possesses a spinous process, a bony prominence behind the spinal cord, which
shields the cord's nervous tissue. There is also a strong bony "body" in front of the
spinal cord to provide a platform suitable for weight-bearing. The lumbar vertebrae
stack immediately atop the sacrum bone in between the buttocks. On each side, the
sacrum meets the iliac bone of the pelvis to form the sacroiliac joint of the buttocks
(10).
The discs are pads that serve as "cushions" between each vertebral body
which minimize the impact on the spinal column. Each disc is designed like a jelly
doughnut with a central softer component, the nucleus pulposus, which is capable of
rupturing or herniating through the surrounding outer ring, the annulus fibrosus, and,
Ligaments are strong fibrous soft tissues that firmly attach bone to bone.
Ligaments attach each of the vertebrae and surround each of the discs (10).
The nerves that provide sensation and stimulate the muscles of the low back
as well as the lower extremities (the thighs, legs, feet, and toes) exit the spinal
6
Many muscle groups which are responsible for flexing, extending, and
rotating the waist, as well as moving the lower extremities attach to the lumbar spine
The aorta and blood vessels that transport blood to and from the lower
extremities pass in front of the lumbar spine into the abdomen and pelvis.
Surrounding these blood vessels are lymph glands and involuntary nervous system
tissues which are important in maintaining bladder and bowel control (10).
The uterus and ovaries are important pelvic structures in front of the lumbar
area of women. The prostate gland is a significant pelvic structure in men. The
kidneys are on either side of the back of the lower abdomen in front of the lumbar
spine (10).
The skin over the lumbar area is supplied by nerves that come from the roots
A back strain usually occurs when the muscles surrounding the spine are
forced to stretch too far, lift too much weight or move in such a way that they sustain
very small tears. A microscopic amount of bleeding into the muscle usually results
from the tearing of the muscles and ligaments, followed by swelling and muscle
spasms (10).
The actual damage that is done when someone suffers a strained back can
be quite variable. The muscles that support and move the spinal column may be
injured, the ligaments that connect the vertebral bodies together or form strong
capsules around the facet joints might be partially torn or a mild case of a slipped
7
intervertebral disc may be the source of the pain. In each of these situations, the
human body is usually able to heal itself and will do so without surgery if given the
proper treatment.
There are many sources of low back pain involving the vertebrae,
intervertebral disks, and nerves. Low back pain caused by soft tissue problems is
and its adjacent structures. Quadratus lumborum is the muscle between the bottom
rib and the top of the pelvis. It is a key muscle in coordinating upper and lower body
connective tissue: the thoracolumbar fascia, the gluteal aponeurosis, and other
tough connective tissue cover and surround these muscles. 2) The buttock muscles.
These include the three gluteal muscles—gluteus maximus, medius and minimus—
and the deep lateral rotators of the hip, especially pyriformis. 3) Iliopsoas. This is the
primary hip flexor—its chief assistant being rectus femoris—running down through
the abdominal cavity and the groin to the lesser trochanter. But its origins are the
inner surface of the ilium (iliacus muscle) and the transverse processes of the
lumbar vertebrae, which mean that every lifting of the leg pulls on the pelvis and the
design, long driving time, long distance driving, duration of employment, social and
8
psychological factors and long term whole body and hand-arm vibration exposure
volumes, masses of body segments, center of gravity and inertial properties (12).
and physical characteristics of the body as they occupy space, move and apply
energy to physical objects. Static or structural body dimensions are taken with the
dimensions are taken when the body of the subject is involved in some physical
movement (14).
be included in determining causation of low back pain among bus drivers. Unequal
lengths of both legs might contribute to posture, which if improper might significantly
lead to low back pain. Weight, on the other hand would influence how the spine
would support the body especially the upper back. Anthropometers, tapes and
Another risk factor for LBP is height. It has been suggested that tall people
are at higher risk of having low back pain than short people (15). The average
heights for Filipino adults are as follows: those aged 60 and over, 153 centimeters or
five feet; those aged 40 to 59, 156.2 cm or 5 feet 1 inch; and those aged 20 to 39,
9
heights by sex. Among those aged 20 to 39, the average height for men was 163.3
Prolonged sitting may result in excessive loading and tissue deformation of the
The type of sitting posture also plays a role in reducing excessive stresses on
the spine which may lead to LBP. Flexed postures are advantageous, as flexion
results in increased fluid flow and improved transport of nutrients into the
intervertebral discs (18). This may decrease the likelihood of degenerative changes,
which have been associated with decreased metabolic transport in the disc (19).
A similar study also concluded that flexed postures are favorable when sitting
and when lifting heavy materials (20). In a population study on primitive cultures
who squat while sitting in a flexed position, it was found that there was decreased
On the other hand, a recent study supports the lordotic or extended position
for sitting as beneficial since this posture helps to balance the loads on various
spinal structures and prevents stressing the posterior ligaments (22, 25).
Sitting with the back slouched for as little as 20 minutes can result in
increased laxity of the posterior spinal ligaments. It may take 30 minutes or more for
these ligaments to regain their previous level of stiffness (22). Also, sitting with the
10
spine in extension reduces the intradiscal pressure. Extension helps to cause the
nucleus to move anteriorly, thus helping to prevent and reduce the tendency for
Research has also shown that lumbar disc herniation may result from
Lordotic, extended position should be preferred for sitting over the flattened or
flexed posture. However, given that any sitting posture results in increased spinal
loading, frequent changes in posture from sitting to standing, etc., over the course of
There are several sources of pain in postural problems. The ligaments, facet
capsules, periosteum of the vertebrae, muscles, anterior dura mater, dural sleeves,
epidural areolor adipose tissue and walls of blood vessels are innervated and
of blood vessels, causes distention or compression of the nerve endings that leads
the stress to the pain-sensitive structure relieves the pain stimulus and the person
capabilities of the tissues, breakdown will occur. If this continues without adequate
healing, overuse syndromes with inflammation and pain will affect function without
an apparent injury. Relieving the mechanical stress along with decreasing the
11
Pain can come from muscles, ligaments, nerves, discs, or bones. People who
lead a sedentary lifestyle are especially at risk, because their bodies are not
conditioned. They are prone to strains when they use their backs. Other risk factors
include advancing age, frequent or heavy lifting, obesity, poor posture and repetitive
of low back pain. Driving is different from ordinary sitting in that the body is subject
to different forces such as accelerations and decelerations, lateral swaying from side
to side and whole body up and down vibrations while the vehicle is in motion (27).
design during a trip may result in de-conditioning, which is the weakening of the
muscles supporting the spine and trunk due to inactivity, less exercise, and lack of
balance. These muscles cannot fully withstand pressure or even support the spinal
cord to its normal position. Thus, the entire back becomes sore and tired (28).
There is growing evidence that the combination of these factors, coupled with the
design of the seat itself, may increase the risk and occurrence of back problems for
some people.
focus of designing technological systems. The aim is to ensure that humans and
technology work in complete harmony, with the equipment and tasks aligned to
human characteristics. The term originated from the Greek words “ergon” which
12
Ergonomics, also called human factors, is based on biological or natural
sciences. Its main components are anatomy, physiology, psychology, medicine, and
engineering.
The contribution of basic anatomy lies in improving the physical fit between
people and the things they use. Anthropometry provides data on the structure of
human body, in various postures. On the other hand, biomechanics considers body
various internal and external forces. It ensures that working postures are beneficial
how the body functions when performing work. It addresses the energy
requirements of the body and sets standards for acceptable physical work rate and
the body functions when subjected to climatological factors. It also includes analysis
of the impact of physical working conditions, such as thermal, noise and vibration,
and lighting, and sets the optimum requirements for these (29).
capabilities. It aids in the cognitive fit between people and the things they use (29).
13
Ergonomic stressors result from poor workplace designs. These stressors
may include the following: repetition, the number of motions or movements that are
performed per cycle or per shift; force, the power of the muscles used to produce
muscles are required to work at a level near or at their maximum capacity. Before
considered (31).
extremities, shoulders and neck, lower back, and lower extremities that are primarily
also known as repetitive stress injury, is a type of stress injury that results from
performed over extended periods of time without allowing for sufficient rest. RMI
includes medical conditions resulting from repeated use of a body part (31).
implications for efficiency, productivity, safety and health in work settings (29). The
different aspects of the workstation are then evaluated to determine if it fits the
Workspace is the area within which a person performs the tasks that add up
to one’s job. Its physical design includes working out how much space is needed
14
and positioning of furniture, tools, equipment and other items needed to perform
tasks, in respect with posture, access, clearance, reach and vision of the user (32).
The evaluation of the seating of Qantas flight deck crew showed that there is
a widespread postural discomfort due to insufficient room space and LBP during
flying among middle- and long-distance Qantas pilots (33). It was also found that an
can cause poor body positions. The physical arrangement of work space elements
such as work surfaces, tools and equipment may not correspond with the reaches
because the seats are too high or low for an employee's body size and shape.
of driver safety and health protection. The relative comfort and functional utility of
the driver’s seat is a consequence of their physical design in relation to the physical
The driver’s seat should be vertically and horizontally adjustable and have
The height of the seat should be such as to avoid excessive pressure on the
thigh. The front edge of the seat should be a bit lower than the distance from the
floor to the thigh, when seated. It was recommended that the front edge be at least
2 inches below the popliteal crease, which is the crease at the back of the hollow
knee (37). The length and width of the seat would partly depend on the type of seat.
In general, the length should be set to be suitable for small persons in order to
15
provide clearance for the calf of the leg and to minimize thigh pressure, and the
The steering wheel should be adjustable along the axis of the steering
column. Possible adjustments in its angle of inclination can provide more comfort.
The pedals should have equal angles and be within easy reach for both short and
The measurements of the workstation and the adjustments that can be made
should fall within a range that is applicable to all drivers. The adjustability and the
ways of adjusting the driver’s seat and steering wheel should be coordinated so
drivers within the design range can find positions for their arms and legs that are
Seats should provide for correct curvature of the lumbo-sacral section of the
spine in order to keep the spinal column in a state of balance. Seats without or with
excessive pressure between the vertebrae. The lordosis type of posture with
of 90 degrees or less between the seat pan and backrest may cause pressure on
the lower lumbar discs and back muscles. The resultant forces contribute to LBP
and degeneration of the lumbar spine (14). Loss of rigidity and sagging of the seat
pan due to wear and tear results in elevation of the knee to a higher level which
causes gravity forces of the upper body to concentrate at the lower lumbar spine.
The seat surface should be more or less plane rather than shaped, although a
rounded front edge is highly desirable. Upholstery should be firm rather than soft.
16
The covering materials should also be porous for ventilation and rough to aid
stability (38).
In order to establish a desirable posture, the angle of the seat and back
should be considered. The seat should be at a moderate angle and the back should
have an angle of from about 95 to 105 degrees or more with the seat. With
balance the trunk is minimized and body weight is transferred to the backrest.
Adequate support for the lumbar area should also be taken into consideration. It is
A probable solution to LBP due to poor posture is the use of a lumbar pad
support. A study in the Philippines showed that use of lumbar pad support
significantly decreased the occurrence of LBP among taxi drivers. Thirty taxi drivers
with LBP due to poor posture were asked to use the pad support. The occurrence of
LBP among them was compared with a similar sample size not using lumbar pad
support (39). Lumbar pad supports can compensate for an ineffective postural seat
Foot posture contributes to development of low back pain in that poor foot
posture can affect the ligaments of the lower limb and put more stress on the back
and knees. Driving involves active use of the feet—the right foot on the accelerator
pedal, the left on the brake and also on the clutch in a stick shift. When the feet are
active, they cannot be used to support and stabilize the lower body unlike ordinary
17
sitting wherein the feet are rested on the floor. Poor quality or worn footwear do not
Long driving time refers to the length of time the driver spends at the wheel
while traveling. Continuous driving for four hours or more can increase the risk of
having low back pain. Driving with limited movements for a prolonged period or
sitting in one position for hours can aggravate back pain and even damage one’s
health because of fatigue and lack of exercise (41). A study found that after
accounting for all the possible psychological causes of back injury, drivers with the
San Francisco Municipal Railway (Muni) still have an elevated risk for injury that can
hours on the job. Drivers who worked full-time had more than twice as many back
Driving distance pertains to the interval, in kilometers, between the origin and
day (27). Long driving distance is applicable to buses, which travel from urban to
has been engaging his services as a driver of a company. This factor usually goes
with age. Young drivers have more acute episodes of back pain while older people
have more cases of chronic pain (43). High-risk occupations such as those with
exposure to whole body vibration caused by long distance driving, place workers at
risk for low back pain. The longer a person is on the job, the higher the risk (41).
18
Epidemiologic studies on low back pain consistently show a strong correlation
with whole body vibration from motor vehicle driving (44). Other sources of vibration
may include rocky and bumpy roads, worn out shock absorbers and bus engines
that are not well-maintained. Vehicle vibration enters the driver's body through the
seat. The structural properties of automobile seats may be a source of LBP for the
driver. Because of the strong coupling between the seat backrest and the vehicle
floor, a differential motion between backrest and seat cushion occurs when driving. It
inevitably induces continuous strains in the lower lumbar spine of the seat occupant
vibration or WBV (vibration transmitted to the entire body through some support
such as a vehicular seat or building floor); and segmental (e.g. hand-arm) vibration
(vibration locally applied to specific body parts such as hands and arms from a
vibrating hand tool). Bus drivers, among others, are exposed to both types of
vibration. The vehicle moving and hand-arm vibration cause whole body vibration by
marked excess of LBP complaints in workers exposed to WBV, with only moderate
excesses in men exposed above the British Standard and male riders of heavy
Whole body vibration exposure is another risk factor for low back pain. In a
19
factors were found to be related significantly to the prevalence of LBP. These were
irregular duty time, short resting time and long driving time in a day (9). Evidence
also shows that while LBP is age-related, it is also occurring earlier than expected
for workers exposed to whole body vibration (48). Whole body vibration is related to
prolonged sitting posture, poor working posture and inadequate working conditions
exposure and low back pain. It was found that the occurrence of low back
symptoms increased with increasing whole body vibration exposure in terms of total
from years of service. Frequent awkward exposures are also related to some types
of low back symptoms. Moreover, risk may be due to both whole body vibration
determined that in many working situations with a daily exposure of eight hours or
collected using vibration pickup devices, which are usually placed on machinery
bearing caps. The caps are an ideal place for pick-ups because of their accessibility
and because they are the points through which vibration transmits the most readily.
For each point, the vibration signal picked up is then recorded in a vibration meter or
vibration analyzer. A vibration meter will allow defect determination, but to analyze
20
Psychological factors play a role in the three phases of LBP—onset of pain,
perception of pain and chronic pain. Recent research shows that in many people,
preexisting depression and the inability to cope may be more likely to predict the
factors play a part in the severity of pain a person experiences. Depressed people
are more likely to experience vague physical symptoms, including LBP. In a study of
truck and bus drivers, almost all the truck drivers liked their work and their bosses
while bus drivers stated much lower job satisfaction. 50% of the truck drivers
reported LBP but only 24% lost time at work. Bus drivers with LBP had a significantly
higher absentee rate in spite of less stress on their backs. A related study found that
pilots who generally reported high job satisfaction reported much fewer back
problems than their flight crews. Another study stated that low rank, low social
support and high stress in soldiers were associated with a higher risk for disabling
back pain. Also, the way a patient perceives and copes with pain at the beginning of
an acute attack may in fact condition the patient to either recover or develop a
chronic condition. Those who over-respond to pain tends to feel out of control and
discouraged, increasing their risk for long-term problems. A study found that among
patients with back problems, the fear of pain was actually more disabling than the
Depression, low activity or high pain behavior, negative beliefs or fear of pain
relationship with LBP. However, it has not been determined which of these factors is
21
Emotional factors which increase experienced pain include anxiety, anger and
depression. Specific psychological factors that can increase pain are degree of focus
on the pain, boredom, beliefs about the meaning of the pain and a sense of poor
Psychological factors are important in people with chronic low back pain.
The research on Muni drivers, led by Niklas Krause, showed that physical and
psychosocial conditions in the workplace play a role in causing back injury. The
research also found that after accounting for physical work load, a stressful job with
high psychological demands, low satisfaction and low supervisor support can cause
There are many other factors not related to driving which should also be
considered in LBP. For ages 20-60, a herniated disc may be the cause of LBP.
Other possible causes are myofascial pain, spondylolysis, fracture, facet syndrome,
LBP can also be caused by referred pain. Referred pain is pain caused by
one part of the body and is also perceived in another distant part of the body not
directly involved with the cause. Most common sources of referred pain to the low
back are the organs in the abdomen, pelvis and retroperitoneal space, such as
stomach, intestines, uterus and ovaries and kidneys. For example, pain of peptic
ulcer, diverticulitis of the colon, pelvic inflammatory disease, acute prostates and
22
trochanteric bursitis (inflammation of the bursa of the hip area) can refer pain to the
Low back pain is a persistent global problem and everyone is susceptible. Its
and has been shown to be possibly be prevented with the right measures. Still, the
In the Philippines, no studies have been done on LBP among bus drivers.
Several studies have been done on LBP, but of different population other than bus
drivers. This study would contribute to the pool of knowledge already available
regarding LBP status in the Philippines and possibly that of Southeast Asia.
General Objective: To identify risk factors associated with low back pain among bus
drivers.
Specific Objectives:
1. Describe the distribution of bus drivers according to age, long driving time,
2. Describe the distribution of bus drivers with low back pain by age, long driving
23
3. Determine the risk factors of low back pain adjusting for the effects of
confounders.
buses, taxis—are at an increased risk of developing low back pain, with contributing
factors such as long driving time, whole body vibration exposure, long distance
However, there are no known studies conducted in the Philippines to look into the
effects of these factors to the development of low back pain among Filipino bus
drivers.
This study will determine if an association exists between the risk factors and
low back pain among Filipino bus drivers. Driving would expose the drivers to long
and long driving time, causing low back pain. Necessary measures can then be
recommended that will alleviate and/or prevent low back pain, which would benefit
the bus drivers in terms of better health as well as the companies in terms of
increased productivity.
24
25
6.0 Materials and Methods
located along Gil Puyat Avenue and Epifanio delos Santos Avenue at Pasay
order to gather preliminary data on the feasibility of the study and to ask initial
drivers from 8 bus stations. Non-airconditioned bus drivers were not included
about low back pain (LBP) than non-airconditioned bus drivers and therefore,
prevalence of about 50% (9). Initial interviews with the bus drivers and
26
n = 0.5662 x 0.4338 x (1.96) 2
(0.05) 2
n = 377.4
= 378 subjects
bus company in the study. Using the formula Pax = ( n1 / T) x n, the number
where:
company
The following were the computed proportionally allocated sample size per bus
station:
• JAC Liner – 4
• Victory Liner – 75
• Philtranco – 74
27
6.3 Data Collection
stated the objectives of the study and asked for their permission to allow their
company to be included in the study. The group also verified the initial data
The researchers went to the bus stations everyday for three weeks,
drivers. Drivers were approached while they were taking a break or waiting
for their buses to get full. The information and consent form was given for
from drivers when necessary. In addition, the same student quickly edited
measured by two other members (S3 and S4) of the group. The subjects
were also asked to show their usual driving posture by sitting on the bus
driver’s seat. Leg reach to the pedal, arm reach to the steering wheel and
arm length and weight) were measured by another member of the group (S2)
after the subjects have finished answering the questionnaires assisted by S1.
questionnaire.
28
6.4 Data Collection Tools
Measuring Tape
taken using a measuring tape. This data was important to relate body
Protractor
Weighing Scale
This was used to estimate the subject’s weight. This data was
important since it had an effect on the force exerted on the lower back
From the data gathered, a coding manual was prepared. Data was
encoded using Epi-Info Software version 6.0 and Statistical Package for
computer. These data were processed into tables and graphs for better
visual analysis.
29
6.6 Data Analysis
The risk factors included were vibration exposure, rough roads, long
factors. The prevalence of LBP among the subjects was also computed. Chi
square test and logistic regression were used to test for the association of risk
factors and low back pain. Finally, multivariate analysis was performed with
Dependent variable:
1. Low Back Pain – chronic pain localized in the lumbo-sacral spine with
an acute and sudden onset lasting for about thirty minutes and is
Independent variables:
1. Long Distance Driving – driving distances wherein low back pain is felt
2. Long Driving Time – driving for more than four hours everyday
30
3. Duration of employment – this is the span of time (number of months
and years) a person has been engaging his services as a bus driver.
body parts while driving which includes reclining angle, sitting, arm,
experienced
Confounding variables:
relation to easing low back pain and other injuries which include the
31
Other definitions:
and weight
livelihood
An informed consent form was prepared which explained all the information
about the study and was signed by each participant. Any information obtained
from the drivers employed in the different bus companies were kept confidential.
The study is not obliged to provide treatment for identified cases of low back pain
(LBP). Instead, any form of intervention will remain as the bus companies’
This study presupposed that all answers to the questions provided to bus
The strength of this study is related to the fact that no similar studies
locally have been done in the past. The results of the study can serve as basis
for future researches among bus drivers in a larger scale. In addition, aside from
32
presenting low back pain among bus drivers, companies will also benefit in terms
of less worker absence and improved productivity once low back pain complaints
are reduced.
random sampling was not done in the selection of the bus drivers for reasons
that their schedules are not fixed and they usually are on a rotation basis.
Drivers also come at different times and based on the limited time available for
data collection, waiting for the driver based on the selection by random sampling
will not allow fulfillment of the sample size required. The subject’s availability
during the scheduled visits of the researchers and willingness to participate were
instead used as criteria for participation. A great degree of selection bias was not
expected since the bus drivers were informed that no treatment would be
provided if found with low back pain. Thus, drivers with low back pain were not
expected to volunteer which will unduly increase the number of LBP cases. In
addition, personal characteristics and risk factors were elicited which were
controlled for in the data analysis using logistic regression. Vibration exposure
put together several risk factors affecting exposure to vibration such as seat
33
due to limitations of time and data gathered. However, these data will be kept
After data collection, the data were presented based on univariate, bivariate
1% Single
95% Married
0%
Separated
4%
Widowed
81% of the drivers experienced abnormal vibration due to their current job.
34
Figure 3. Constrained posture
32%
Yes
No
68%
Figure 4. Boredom
26%
Yes
No
74%
Table 4. Depression
Depression Frequency Percentage
No 154 40.7
Yes 224 59.3
Nearly 60% of the drivers had experienced depression.
8%
Yes
92% No
A little over 90% of the drivers move their backs frequently while driving.
35
Figure 6. Frequent movement of shoulders
4% Yes
96% No
14%
Yes
No
86%
36
Figure 8. Rest period
Yes
99% 1%
No
13% I Am Happy
50% 10% I Like
I Don't Like
27% I Am not Happy
10% Happy
Enough
Not Enough
54% 16% Not Happy
37
Table 12. Seat design
Type of Seat Design Frequency Percentage
With cushion and with lumbar pad support 292 77.2
With cushion but without lumbar pad support 83 22
Without cushion but with lumbar pad support 0 0
Without cushion and without lumbar pad support 0 0
Others 3 0.8
Almost 80% of the driver seats are cushioned and have lumbar pad supports.
47%
8% Reclined
Straight
Stooped
45%
45% of the drivers have reclined driving posture. 47% have straight posture
while driving. Only about 10% have stooped driving posture.
52%
Healthy Weight (18.5-24.9)
11%
1% Overweight (25-30)
36%
Obese (>30)
A little over 60% of the drivers exceeded the normal BMI. Only 36% met the
normal BMI.
38
Table 14. Age Group
Age group Frequency Percentage
20-24 49 13
25-29 60 15.9
30-34 45 11.9
35-39 70 18.5
40-44 70 18.5
45-49 58 15.3
50-54 20 5.3
≥ 55 6 1.6
A little over 90% of the drivers are aged 20-49. The age group 35-44
comprises almost 40% of the drivers.
3%
300-399 400-499
2%
41%
4%
500-599 600-699
7%
> 700
19%
35%
Yes
No
65%
39
Table 16. Long driving time
Hours Frequency Percentage
<8 15 4
9-10 28 7.4
11-12 124 32.6
13-14 84 22.2
15-16 61 16.1
17-18 39 10.3
≥ 19 27 7.1
A little over 30% of the drivers drive from 11-12 hours per day while 56%
drive at least 13 hours per day.
10% 6% 0 >0-<1
13% 2%
9% 1-1.99 2-3.99
5%
13% 4-5.99 6-7.99
8-9.99 10-11.99
9%
33%
> 12
36% of the drivers have experienced LBP from one to less than six years. A
little over 30% did not experience LBP at all.
40
Figure 16. Rough roads experienced
< 20 20-39
18% 9%
12%
40-59 60-79
34%
> 80
27%
A little over 60% of the drivers experience less than or equal to 39% of rough
roads.
41
Figure 17. Seat reclining degree
7%
98-100 101-103
6%
31% 3% 104-106 107-109
> 110
31%
Table 22. Number of buses driven out of 10 buses with adjustable seats
toward and away from the wheel
Number of buses Frequency Percentage
0-1 32 8.5
2-3 18 4.8
4-5 19 5
6-7 9 2.4
8-9 36 9.5
10 264 69.8
Almost 10% of the drivers have driven buses without adjustable seats.
Table 23. Number of buses driven out of 10 buses with reclinable seats
Number of buses Frequency Percentage
0-1 126 33.3
2-3 17 4.5
4-5 20 5.9
6-7 10 2.6
8-9 31 8.2
10 174 46
A little over 33% of the drivers have driven buses without reclinable seats.
42
9.2 Bivariate Analysis
A. Results
Pearson chi square test was used to determine the association of risk factors
with low back pain. Significant associations were based on a 5% level. A p-value cut
off of ≤ 0.2 was used for all independent variables which will subsequently be
included in the multivariate analysis. A summary of the results of the Pearson chi
43
3. Injury to right shoulder LBP 2.18 0.337 No Significant Association
4. Injury to both arms LBP 2.18 0.337 No Significant Association
5. Seat base length LBP 10.05 0.346 No Significant Association
6. Duration of employment LBP 6.44 0.375 No Significant Association
7. Injury to right foot LBP 1.88 0.391 No Significant Association
8. Accident experienced LBP 0.65 0.419 No Significant Association
9. Salary satisfaction LBP 2.67 0.445 No Significant Association
10. Accident injury LBP 1.47 0.479 No Significant Association
11. Frequent movement of arm LBP 0.42 0.519 No Significant Association
12. Injury to left leg LBP 1.24 0.537 No Significant Association
13. Sprain LBP 1.24 0.537 No Significant Association
14. Civil status LBP 2.06 0.559 No Significant Association
15. Seat adjustability towards LBP 0.34 0.559 No Significant Association
and away from the steering
wheel
16. Job training LBP 0.32 0.570 No Significant Association
17. Length of training for LBP 3.76 0.585 No Significant Association
current job
18. Type of seat LBP 0.22 0.63 No Significant Association
19. Self training LBP 0.89 0.641 No Significant Association
20. Injury to chest LBP 0.68 0.712 No Significant Association
21. Injury to back LBP 0.68 0.712 No Significant Association
22. Injury to right thigh LBP 0.68 0.712 No Significant Association
23. Reclining degree of seat LBP 3.68 0.720 No Significant Association
24. Weight LBP 2.86 0.721 No Significant Association
25. Relationship with co- LBP 1.3 0.729 No Significant Association
workers
26. Training from current job LBP 0.6 0.742 No Significant Association
27. Body mass index LBP 1.08 0.783 No Significant Association
28. Frequent movement of feet LBP 0.07 0.790 No Significant Association
29. Work satisfaction LBP 0.06 0.800 No Significant Association
30. Inclination of seat LBP 0.06 0.804 No Significant Association
31. Training from previous job LBP 0.41 0.815 No Significant Association
32. Driving position LBP 0.37 0.830 No Significant Association
33. Injury to left arm LBP 0.33 0.847 No Significant Association
34. Injury to both shoulders LBP 0.03 0.859 No Significant Association
35. Injury to left thigh LBP 0.03 0.859 No Significant Association
36. Injury to both thighs LBP 0.33 0.859 No Significant Association
37. Injury to right knee LBP 0.03 0.859 No Significant Association
38. Injury to left knee LBP 0.03 0.859 No Significant Association
39. Injury to both knees LBP 0.33 0.859 No Significant Association
40. Injury to right leg LBP 0.03 0.859 No Significant Association
41. Injury to both legs LBP 0.03 0.859 No Significant Association
42. Injury to left foot LBP 0.33 0.859 No Significant Association
43. Injury to both feet LBP 0.03 0.859 No Significant Association
44. Dislocation LBP 0.03 0.859 No Significant Association
45. Muscle strain LBP 0.03 0.859 No Significant Association
46. Fracture LBP 0.29 0.864 No Significant Association
47. Injury to right arm LBP 0.18 0.913 No Significant Association
48. Age LBP 1.97 0.962 No Significant Association
49. Number of buses out of 10 LBP 0.61 0.988 No Significant Association
buses with reclining seats
44
Fifteen independent variables cross-tabulated with LBP were found to have a
p-value of ≤ 0.2 using Chi square test for association. These were, constrained
long distance driving, long driving time, insufficient workspace, employee satisfaction
with management, percent of rough roads, rough road experience and height.
Variables with a p-value of ≤ 0.2 were included for purposes of logistic regression
analysis. The following are the cross tabulations of the independent variables with
LBP.
45
Table 28. Relationship of Constrained Posture and LBP
Constrained Posture Low Back Pain
No Yes
Frequency Percentage Frequency Percentage
No 69 56.6.0 53 43.4
Yes 75 29.3 181 70.7
Chi square = 24.89
P value = 0.00000061
There is a significant relationship between constrained posture and LBP.
46
Table 32. Relationship of Depression and LBP
Depression Low Back Pain
No Yes
Frequency Percentage Frequency Percentage
No 70 45.5 84 54.5
Yes 74 33.0 150 67.0
Chi square = 5.45
P value = 0.01953236
There is a significant relationship between depression and LBP.
47
Table 36. Relationship of Long Distance Driving and LBP
Distance (in kilometers) driven Low Back Pain
No Yes
Frequency Percentage Frequency Percentage
100-199 9 64.3 5 35.7
200-299 15 53.6 13 46.4
300-399 25 35.7 45 64.3
400-499 52 33.1 105 66.9
500-599 40 44.9 49 55.1
600-699 3 27.3 8 72.7
≥700 0 0 9 100
Chi square = 16.59
P value = 0.01093037
There is a significant relationship between long distance driving and LBP.
48
164 3 20 12 80
165 7 30.4 16 69.6
166 7 46.7 8 53.3
167 13 46.4 15 53.6
168 8 23.5 26 76.5
169 5 29.4 12 70.6
170 14 53.8 12 46.2
171 11 52.4 10 47.6
172 5 41.7 7 58.3
173 10 43.5 13 56.5
174 1 9.1 10 90.9
> 175 23 47.9 25 52.1
Chi square = 21.80
P value = 0.14962400
There is no significant relationship between height and LBP.
B. Discussion
roads, vibration exposure and rough road complaints were found not to be
significantly associated with LBP in the bivariate analysis. However, the p values of
these variables were within 0.06 – 0.20. Review of related literature showed strong
correlation of these variables with low back pain. Thus, they were included in the
multivariate analysis.
Results show that insufficient room space is associated with low back pain.
This is consistent with a study evaluating the seating of Qantas flight deck
crew which showed that postural discomfort due to insufficient room space and low
back pain during flying among middle- and long-distance Qantas pilots were
widespread (33).
position can cause poor body position. The physical arrangement of workspace
elements such as work surfaces, tools and equipment may not correspond with the
49
reaches and clearances of seated employees. The workstation may also be
unsuitable because the seats are too high or low for an employee's body size and
shape. These changes may ultimately lead to low back pain (34).
Although reports of low back pain were found to be age-related, there was
evidence that low back pain occurs earlier than expected for workers exposed to
whole body vibration (WBV). WBV is also related to poor working posture,
prolonged sitting posture and inadequate working conditions and contribute to the
of low back pain complaints in workers exposed to WBV, with only moderate
excesses in men exposed above the British Standard and male riders of heavy
back pain.
The type of sitting posture also plays a role in reducing excessive stresses on
the spine, which may lead to LBP (18). Sitting with the back slouched for as little as
20 minutes can result in increased laxity of the posterior spinal ligaments (22).
50
4. Constrained Posture
constrained posture.
Posture is the relative arrangement of body parts for a specific activity (1).
Thus, it is important to know and maintain proper posture to avoid stresses which
may cause pain and discomfort. Poor working posture or constrained posture
result, there is de-conditioning of the muscles and the entire back becomes sore and
5. Rough Roads
Rough roads, i.e. rough roads driven and rough road complaints, were found
This is not consistent with the fact that rough roads may result in whole-body
vibration, which occurs while riding vehicles over rough terrain. A related study also
observed a strong correlation between whole body vibration and motor vehicle
driving (44). This may be due to the fact that the bus drivers gave only an estimate
6. Boredom
Results show that a significant relationship exists between boredom and low
back pain.
Psychological factors are even more important in people with low back pain.
Dissatisfaction with a work situation, a supervisor, or a dead end job and boredom
contribute greatly to the onset and persistence of low back pain (56). Other factors
51
which increase the risk of low back pain together with boredom include degree of
focus on the pain, beliefs about the meaning of the pain and a sense of poor control
over the pain (55). In this study, about 66% of the bus drivers who experience
7. Depression
the inability to cope may be more likely to predict the onset of pain than physical
abnormalities. People who are depressed are more likely to have vague physical
symptoms, including low back pain. Depression, low activity or high pain behavior,
negative beliefs or fear of pain are the three psychological-behavioral factors that
However, it has not been determined which of these factors are greatly involved in
About 64% of the subjects with low back pain move their backs frequently.
The exact cause of low back pain may be hard to find. Pain can come from muscles,
ligaments, nerves, discs, or bones. People who are inactive are especially at risk of
LBP, are not conditioned, and prone to strains when they move their back frequently.
Repetitive motion injury (RMI), also known as repetitive stress injuries, is a type of
stress injury that results from repetitive motions such as frequent bending or
52
sustained awkward positioning performed over extended periods of time without
may result in injury or illness of its soft tissues, thus contributing to the development
Results show that long driving time was significantly associated with low back
pain.
This finding is consistent with a study which showed that driving for eight
hours or more may not protect drivers from harmful vibration exposure leading to low
back pain (51). A related publication also showed that drivers have an elevated risk
for injury that can be attributed solely to their physical working conditions, particularly
Results show that long distance driving is significantly associated with low
back pain.
A little over 40% of the subjects drove at a range of 400 to 499 km every day.
Findings from a related study showed that people who drove long distances were at
significantly increased risk of having neck and low back pain. A recent Swedish
53
study found significantly increased risks of low back pain among those who drove
long distances and spent a long time each day in their car (41).
back pain.
(48, 49, 50, 51). There was sufficient evidence that vibration exposure to drivers
could be a health hazard particularly with regard to back problems. The relatively
high vibration exposure levels combined with long exposure duration and prolonged
sitting are likely to contribute to low back pain. From a study on the association of
whole body vibration and low back pain, it was found that the average WBV level
comfort limits of the Australian Standard and most exposures were within the
Caution zone for health according to the current International Standard on whole
body vibration (49). A possible explanation to the negative finding in our study is
policies, attitudes, and actions determine the satisfaction level of employees, which
54
in turn, affects health-related conditions. Social and psychological factors play a role
in how severely someone experiences pain and even vague symptoms. People who
are depressed are more likely to have vague physical symptoms, including low back
pain (53). A related article stated that after accounting for physical work load, a
stressful job with high physiological demands, low satisfaction, and low supervisor
support can cause spinal injury, particularly low back pain (42).
bias may have occurred. Drivers may not have answered honestly for fear of
14. Height
This finding is contrary to previous studies which showed that height is a risk
factor to low back pain. Tall people are at a higher risk of having low back pain than
short people (15). A possible explanation to this finding is that the average Filipino
The Statistical Package for the Social Sciences (SPSS) version 10 was used
to perform logistic regression. The relationship of risk factors with low back pain was
determined while controlling for the effects of confounders and other independent
variables. The risk factors included age, rough roads experienced, percent of rough
55
movement of shoulders, long distance driving, long driving time, height, employee
satisfaction with management and insufficient work space. The confidence level
Using the backward Wald method, the independent variables were analyzed.
The study claims that the independent variables from the bivariate analysis would
increase the probability that a driver will develop low back pain. A step-by-step
and 42-B).
A. Results
the probability of LBP occurrence among bus drivers. These are constrained
B. Discussion
1. Constrained Posture
greater risk of having low back pain compared to those who do not.
56
De-conditioning, which is the weakening of the muscles supporting the
spine and trunk, occurs due to poor working posture or constrained posture. The
former can cause the entire back to become sore and tired, leading to low back
pain.
Drivers who drove for at least 300 km per day have 2.1 times higher risk of
developing low back pain than those who drive for less than 300 km in a day.
According to a study, increased risk of having neck and low back pain was
times more at risk of having low back pain than those who are satisfied.
Vague symptoms, including low back pain, are more likely to occur among
depressed individuals. A related article stated that after accounting for physical
workload, a stressful job with high physiological demands, low satisfaction, and
low supervisor support can cause spinal injury, which may lead to low back pain.
57
10.0 Conclusion
Drivers with constrained posture while driving have 3 times greater odds of
This finding suggests that maintaining proper posture will reduce the risk of
Drivers who drive for at least 300 km per day have 2.2 times higher risk of
This finding suggests that management should look into the possibility of
modifying work shifts of bus drivers based on a 300 km-maximum distance per
day. Hence, this should not generally affect income of drivers on one hand and
back pain.
Drivers who show dissatisfaction to management are 2.1 at risk of having low
back pain.
relationship in improving the drivers’ well being. Thus, better work performance,
58
11.0 Recommendations
1. Health education should be conducted in order to inform the drivers about the
The causes of low back pain will be discussed. Posters, fliers and multi-
media showing the latest concepts and preventive measures on low back pain
should be provided. Measures to alleviate and prevent LBP can then be made.
Low back pain which lasts for less than 6 months is acute. However, it is
considered chronic if it occurs for more than 6 months. Early detection of low
back pain in its acute stage is crucial in the prevention of its progression to
chronicity. Therapy for identified low back pain cases is helpful in improving
worker performance.
may employ a part-time health professional which will provide service to the
3. The company should provide health fitness training for their employees.
and avoiding it in the first place. The bus company is recommended to have a
59
stretching and strength training. Aerobic exercise has been reported to improve
advanced curl ups, side bridge and bird dog exercise are recommended by Joy
Previous studies have found that bus engines and seats kept in good
condition reduce whole body vibration exposure due to rough roads and poorly
assure sufficient workspace and comfortable sitting posture of the bus driver.
supervisor and boredom can greatly contribute to the onset and persistence of
6. Drivers with special needs, e.g. older employees, those with serious health
complaints and those recovering from an illness should be given some degree of
should not affect the performance of the whole workforce. Recent research
shows that in many people, pre-existing depression and inability to cope may be
60
more likely to predict the onset of pain than physical abnormalities. As a result,
there is a significantly higher absentee rate in spite of less stress in their backs.
8. Bus companies should consider developing a working schedule that would allow
driving shifts every 300 km. This would minimize the risk of having low back
least 30 minutes.
61
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13.0 Acknowledgements
67