UNIVERSITE SORBONNE-PARIS VI
UFR MEDECINE
Diplôme Inter-Universitaire
Pédagogie Médicale
Aymeric AMELOT
CCA Neurochirurgie, Pitié-Salpétrière
Low back pain in medical students: state of affairs,
education and prevention with video support
Sous la Direction du Pr Olivier Steichen
Années 2017-2018
Low back pain in medical students: state of
affairs, education and prevention with video
support
Aymeric Amelota,d,e
MD-PhD, Rebecca Haddadb,e
MD, Bertrand
Mathona,d,e
MD, Marie-Christine Renaulte MD, Alexandre Duguet
c,e
MD-PhD, Olivier Steichend,e
MD-PhD
a) CHU La Pitié-Salpétrière, Department of Neurosurgery, Paris, France. b) CHU La Pitié-
Salpétrière, Department readaptative medecine, Paris, France. c) CHU La Pitié-Salpétrière,
Department of Pneumology, Paris, France. d) CHU Saint-Antoine, Department of internal
medicine, Paris, France. e) Sorbonne-University, UPMC, University Paris 06, Paris, France.
Corresponding author:
Dr Aymeric Amelot, Department of Neurosurgery
Groupe Hospitalier Universitaire de la Pitié-Salpêtrière, 47-83, Boulevard de l’Hôpital 75013
Paris, France. Email: [email protected]
Running title: Low back pain in Medical students
Word count: 2877
Disclosure: The authors declare that they have no personal conflicts of interest and no
institutional or financial interest in any drugs, materials, or devices described in this
manuscript. The authors have no financial disclosures to report. In addition, all patients gave
their informed consent for any medical and scientific investigations. This paper has not been
published previously, is not under consideration for publication elsewhere and we
acknowledge that, if accepted, this paper will not be published elsewhere in the same form, in
English or in any other language, without the written consent of the publisher.
Abstract
Background: Low back pain (LBP) is one of the most prevalent complaints among students.
The vulnerability of medical students due to stress and numerous hours of studying and
training makes them at risk of LBP
Methods: For our study, we submitted an online self-administered questionnaire to 1800
medical students from 2nd
to 6th
year from December 2017 to February 2018. The
questionnaire was a modified version of the Standardised Nordic Questionnaire. Once the
LBP risk factors were identified, an educative video was concerted by three spine disease
specialists: 1 neurosurgeon, 1 functional rehabilitation reeducator, and 1 physiotherapist.
Results: A total of 1243/1800 (68.9%) students responded to our survey. Mean age was 23.3 ±
2.9 years ranging from 18 to 44 years. 835 (72.1%) students reported suffering from LBP. In
multivariate analysis with logistic regression analysis model, the third year of medical studies
[Odds ratio (OR): 0.558, CI 95 % 0.387-0.805; p=0.002] was identified as an independent
prognostic factor of LBP. Moreover, exercising weekly [OR: 1.835, CI 95 % 0.933-2.5;
p=0.01] and walking at least 30 minutes a day [OR: 1.458, CI 95 % 1.129-1.876; p=0.01]
significantly improve LBP. LBP generate higher monthly consumption of an analgesic [OR:
32.8, CI 95 % 4.271-252.2; p<0.001]. Finally, LBP had a severe repercussion on student work
[OR: 18.89, CI 95 % 10.122-35.253; p<0.0001], on the quality of sleep [OR: 12.162, CI 95 %
6.917-21.386; p<0.0001] and on their personal life [OR: 12.343, CI 95 % 5.681-26.8;
p<0.0001].
Conclusions: Medical students reported high prevalence of LBP with severe consequences.
Our educational perspective is to identify the risk factors of LBP and to fight them with an
educational video. Our research perspective is to evaluate the impact of this video on the
prevalence and consequences of low back pain in the future.
Keywords: Low-back pain, Medical students, Risk factors, Exercise, Analgesics, Educative
video
INTRODUCTION
Low back pain (LBP) is a major health and economic problem among populations in
high resource countries. LBP is one of the prevalent complaints among all age groups
[Nordin]. At least 90% of the population has experienced LBP once in their life [Hafeez,
Falavigna]. LBP is commonly recognized as “non-specific” for no organic cause is found
[Urquhart]. The onset of back pain goes from the age of 30 and peaks between 45 and 60
years of age [Anand].
LBP is reported by many students or leisure club members: among music school
students, the reported LBP prevalence rate was 38.2% [Nawrocka], among dental hygiene
students, the LBP prevalence was high (57%) [Hayes]. The reported prevalence of
musculoskeletal disorder (MSP) and LBP among medical students was between 45.7% and
65.1% [Alshagga].
The onset of LBP is believed to be influenced by factors including frequent repetitive
movements of a particular body part [Gallagher] and positions like prolonged standing or
sitting [Shrier, Feldman]. However, the most important factors that favor the occurrence of
LBP and its transition to chronicity are: stressors, fear of pain and lack of physical activity.
French medical students spend more than 7 hours a day sitting down to study. They
are stressed by the rankings of the competitive final exam, which assesses their 6 years before
residency and they have little spare time for physical activity. Therefore, they are at high risk
of developing LBP.
The aim of this work was to evaluate the prevalence of LBP, of its risk factors and of its
consequences in medical students, and to determine the educational axes that we must
support.
In addition, we produced a video about LBP, its treatment and prevention to educate
medical students about LBP and its risk factors. Our research perspective is to evaluate the
impact of this video on the prevalence and consequences of low back pain in the future.
MATERIALS AND METHODS
Pedagogic statement
Local pedagogic committees of the Pitié-Salpétrière hospital, Sorbonne-University and
Interuniversity Graduate of Medical Pedagogic of Paris approved this study. The pedagogic
committee approved the student questionnaire.
Study population
To obtain a bachelor degree of medicine in France, the candidate has to study for at least 6
years. The first year is a preparatory year, at the end of which the candidate has to succeed a
contest in order to be enrolled. The 6th (final) year ends with a national residency contest,
which allows medical students to choose their future specialty and training city. The academic
years 2 and 3 are preclinical years whereas the academic years 4,5 and 6 are clinical years.
For our study, we sent an online self-administered questionnaire to the 1800 medicine
students from the 2nd
to 6th
year in December 2017. The questionnaire was a modified version
of the validated Standardised Nordic Questionnaire that was adapted for use in medical
students [Alshagga, Kuorinka]. The questionnaire sought information on sociodemographic
characteristics and factors such as exercise, analgesic consumption, any history of spine
trauma, specific questions pertaining to LBP pain frequency and issues (Table 1).
Statistical analysis
All statistical analyses were performed using SPSS program for Windows V17.0 (SPSS,
Chicago, IL, U.S.A). Data is presented as the mean or median ± standard deviation. For all
analyses, a p-value of <0.05 was considered statistically significant. Descriptive and
comparative statistics of demographics were analyzed for all students. In the univariate
analysis, categorical variables were assessed using Pearson Chi-square or Fisher exact test.
Variables with a p value<0.05 in the univariate analysis were carried forward into the
multivariate analysis. This specific selection criterion was used to consider as many potential
risk factors as possible without compromising the validity of regression models. Multivariate
logistic regression analysis was used to determine independent risk factors for each
postoperative complication that showed a significant difference between cohorts in the
univariate analysis.
Video production
We used Panasonic NV-GS180 camera to create a 20-min video covering key aspects of LBP
education including: prevalence in medical students, personal life consequences of this
disease, pharmacological and non-pharmacological management of LBP, signs/symptoms of
LBP, preventive measures, reassurance and anxiolytic advice and physical reconditioning
exercises to combat and to prevent LBP.
The video was created and generated with the free iMovie H.264, AVCHD software,
developed by Apple®.
The video was administered to medical students through the learning platform in October
2018. The video support was carried out by a neurosurgeon (spine specialist), a physician
specializing in physical and rehabilitative spine medicine, and a physiotherapist specializing
in the rehabilitation of LBP and Musculoskeletal disorder. The educational video will be
available on Modular Object Oriented Support Dynamic Learning Environment (Moodle),
which is an online learning platform used in our University.
RESULTS
Students’ characteristics
A total of 1243/1800 (68.9%) students responded to our survey. Mean age was 23.3 ±
2.9 years ranging from 18 to 44 years. There were 427 (34.4%) males and 816 (65.6%)
females. The breakdown of students was: 263 (21.2%) in second, 264 (21.2%) in third, 240
(19.3%) in fourth, 249 (20%) in fifth and 227 (18.3%) in sixth year of medicine. There were
754 (60.6%) students in the clinical years (47.3%).
109 (8.8%) students were considered to be overweight, with a body mass index (BMI) > 25
kg/m². There were 97 participants (7.8%) who declared to have suffered from spine trauma.
Table 1 reports the demographic characteristics of responders.
Activity
In our series, (170; 13.7%) of students never practice sport activities, (653;52.5%)
reported occasional practice and (420; 33.8%) a frequent practice.
The majority of participants (857, 67.3%) did at least one physical activity per week, 406
(32.7%) had a sports license, 433 (34.8%) exercised by jogging, 850 (68.4%) exercised by
walking at least 30 minutes a day.
Low-Back Pain
The prevalence of low-back pain (LBP) was 835 /1243(72.1%). Frequency of LBP
was variable: 523 (42.1%) of students suffered several times a month, 232 (18.7%) several
times a week, and 80 (6.4%) several times a day. LBP had evolved in the majority of cases
(88%) for several months, and even for 425 (34.2%) for more than 2 years.
Stratification of LBP according to level of medical studies showed a light significant
association: 46.4% in 2nd
, 56% in 3rd
, 49.1% in 4st, 48.2 in 5
st, 59.7 in 6
st years of medicine
p=0.046. In the multivariate analysis, the third year of medical studies was independently
associated with LBP [OR: 0.558, CI 95 % 0.387-0.805; p=0.002].
Predictive Factors Associated with LBP
Table 2 presents the factors associated with LBP in univariate analysis. The overall
prevalence of LBP regardless of the time of occurrence was significantly associated with sex
(p=0.010). There was no significant association between LBP and age (p=0.645) or being
overweight (p=0.617). History of spine trauma was not significantly associated with any LBP
at any time (p=0.526). There was a significant association between the prevalence of LBP and
being in the 3rd
year of medicine (p=0.046). Furthermore, regular physical activity (p=0.032),
exercising every week (p=0.007) and walking at least 30 minutes a day (p=0.001) were
significantly associated with a decrease in the occurrence of LBP. In the multivariate analysis,
the independent predictive factors associated with an improvement of LBP were weekly
exercise [OR: 1.835, CI 95 % 0.933-2.5; p=0.01] and walking at least 30 minutes a day [OR:
1.458, CI 95 % 1.129-1.876; p=0.01].
Consumption of analgesic
Monthly consumption of analgesic was significantly associated with LBP: 98/513
(20%) vs 1/631 (0.1%) (p<0.0001). Similarly, the consumption of analgesic several times a
week was significantly associated with LBP: 23/588 (4%) vs (0%) (p<0.0001).
On the other-hand the over-consumption of analgesic (several times a day) was not associated
with LBP (p=0.118). LBP generate higher monthly consumption of an analgesic [OR: 32.8,
CI 95 % 4.271-252.2; p<0.001].
Impact of LBP
In our series, we analyzed the impact of LBP on the quality of life. Students with LBP
are statistically impacted on: work (282/611, 46%; p<0.0001), quality of sleep (227/611,
37.1%; p<0.0001), personal life (202/611, 33%; p<0.0001), and personal social activities
(83/611, 13.5%; p<0.0001). In the multivariate regression analysis model, LBP had a daily
significant repercussion on students personal schoolwork [OR: 18.89, CI 95 % 10.122-
35.253; p<0.0001], the quality of sleep [OR: 12.162, CI 95 % 6.917-21.386; p<0.0001], and
the personal life [OR: 12.343, CI 95 % 5.681-26.8; p<0.0001].
DISCUSSION
69% students responded to our survey. We identified that the third year of medical
studies was associated with LBP. In contrast, exercising weekly and walking at least 30
minutes a day significantly improve LBP.
LBP generate higher monthly consumption of an analgesic and had severe
repercussion on; student work, quality of sleep and personal life.
LBP and medical students
Previously most of the work has mainly focused on musculoskeletal pain (MSP) in
students, and rarely has it specifically dealt with LBP. Alshagga et al. have studied the
prevalence of MSP among Malaysian medical students. The authors found that 45.7% and
65.1% of all students had at least one site of MSP in the past week and in the past year,
respectively. Among Chinese medical students, MSP was reported most commonly,
especially LBP with a prevalence rate of 46.9% in the past week and 67.6% in the past year
[Binsaeed]. Algarni et al. recently reported that the prevalence of MSP in Saudi medical
students was also high and comparable to the reported rates from the Malaysian and Chinese
studies. They found that 85.3% of all the students had MSP in at least one body site at any
time, 54.4% in the past week, and 81.9%, in the past year [Algardi].
To the best of our knowledge, there are only few reports in the literature that
specifically address the occurrence of LBP in medical students. Yucel et al. reported that
medical students had the highest prevalence of LBP compared to dentistry, pharmacology and
health sciences students [Yucel]. The overall lifetime prevalence of LBP among
undergraduates was determined to be high, from 40.1 to 57.9% according different studies
[Hafeez, Nordin, AlShayhan]. In our series, LBP prevalence (72.1%) was more consistent
with these previous studies. In our study, a significantly higher prevalence of LBP was found
among medical students in their 3rd
year, that is to say in our faculty in the first clinical years.
Previous studies were consistent with these reported findings [Alshagga]. We think that
maybe during this first year of "clinical study" 3eme année définit comme pre-clinical ci
dessus.. students have little? difficulties organizing their schedule between hospital
internships (morning) and educational lessons (afternoon). So they have more difficulty
finding time for physical activities, and are possibly more stressed.
BMI, sex/ gender or young age was not significantly associated with LBP, which is
consistent with previous studies [Stienen, McLean, Nordin, Yucel], in contrary to MSP
[Butterworth, Waersted]. We have not been able to investigate tabacco and coffee
consumption in students having LBP, but in previous studies, no significant correlation was
found between coffee consumption and LBP [Mas Partland, Alshayhan]. Hafeez and Yucel
found an association between LBP and a history of back trauma, or trauma with important
velocity but it was not significant [2, 15]. In our study, a previous history of back trauma was
not associated with the incidence of LBP (p=0.526).
170 students (13.7%) are physically inactive, and an association was found between
physical activity and LBP (80%). In our study, it was pointed out that by simply walking 30
minutes each day, or weekly practicing a sports activity significantly limited LBP (p=0.01)
[Akodu]. Ultimately these recommendations are exactly the same in order to avoid becoming
overweight. A study involving undergraduates from a sport and physical education institute
reported that some sports are significantly associated with LBP [Triki], but we did not detail
in our questionnaire the nature of the sport practiced.
We have been amazed to note that LBP had a very significant repercussion on the
daily personal school work of students (OR 18.89), the quality of sleep (OR: 12.162) and
personal life (OR:12.343).
The students of the faculties spend the majority of their extra-hospital time preparing for the
“residency contest” which closes the 6 years of medical studies. This exam determines the
choice of their future and definitive medical specialty. The observed impact of LBP on
student’s quality of life and therefore student’s work performance is therefore very
significant.
We were very surprised to see that so many students were answering this
questionnaire. The very important number of participants (1243) in the present study was
homogenous according to the different medical year levels. This series represents the largest
sample size to date, and demonstrated a solid base, which limits the bias.
Universities should take preventive educative measures in order to provide their
students with a healthy environment for a successful academic life. So it would be healthy to
reserve a few hours exclusively for sports activities. One of the weaknesses of this study
remains the absence of measures of stress and anxiety in the questionnaire. Indeed, the stress
participates in a consequent pathway alongside the psychogenic component of LBP
[Oliveira].
In addition, developing and implementing corrective measures to prevent depressive
symptoms and to improve the quality of life of medical students are warranted.
That's why in our educational video we make sure to adopt a reassuring position of destress to
break the anxiety loop that maintains LBP.
Educational Video support
The first aim of this video was to educate students on good-practices (ergonomics,
sleeping, activities, risk factors, reeducation) to reduce and eliminate LBP. The second
purpose of this video was to avoid consequences of pain like fear avoidance, catastrophism,
and to reduce the risk of chronicity by addressing student’s beliefs and related behaviors, and
to increase student empowerment [Ihlebaek, Burton, Symonds].
It promotes direct learning, with examples, that everyone can look at based on how often they
learn. Various videos, produced by the public authorities, intended for the entire population or
even a smaller sample have already been developed.
For exemple, a low-quality trial of 100 patients who were potential surgical candidates
compared the efficacy of an interactive videodisc with a biomedical booklet to the booklet
alone for informing patients about back surgery. The patient’s knowledge improved after
exposure to either intervention, but the videodisc with the booklet was significantly more
efficient than the booklet alone. The videodisc-booklet group showed significantly greater
gains in knowledge among subjects with the worst baseline knowledge scores. Those who
viewed the videodisc expressed a somewhat lower preference, but not significant, for surgery
than those who received the booklet alone [Phelan].
The majority of LBP education-videos are based on the traditional biomedical model and
focus on issues such as the knowledge of spinal anatomy, biomechanics, pathology,
avoidance of activities that generate pain and advice on “good posture,” ergonomic advice,
and back-specific exercises. Most are based on theoretical considerations rather than evidence
and fail to be in line with the modern guidelines for the clinical management of LBP. These
educative-videos can have roles that are still very discussed. Indeed, Schenk et al., designed a
video-education trial including 205 healthy employees, to determine whether a back school
video is as effective as a live back school presentation to learn lifting techniques. In
comparison to the control group, back school videos did not significantly improve knowledge
of lifting techniques and lifting tasks, whereas live presentation was an effective and useful
program [Schenk].
More recently, a multidisciplinary team produced an educational booklet (“The Back Book”)
based on the biopsychosocial model that emphasizes the role of psychological and social
factors in the development and maintenance of complaints [Burton]. The message was
focused on patients’ beliefs and attitudes; it stressed the advantages of remaining active and
avoiding bed rest, combined with reassurance that there is likely to be nothing seriously
wrong. Traditional information on anatomy, ergonomics, and back-specific exercises was
markedly reduced.
Thus in our educational video, it was important to i) describe the results of the questionnaire,
ii) warn about the prevalence of LBP in medical students, iii) explain the anatomo-physio-
pathology of LBP, iv) reassure students about the benign and reversibility of LBP in the vast
majority of cases, v) educate students on their work position, sleep, and vi) teach them daily
exercises to treat and prevent LBP.
To measure the educational effects of our video, we shall carry out the same remote self-
questionnaire called "closing", in several months, and determine the beneficial and
educational effects of this support by measuring the improvement of LBP on our students.
CONCLUSIONS
LBP among medical students is frequent, with serious consequences on their personal life and
work. Properly exercising every week can improve LBP and reduce the consumption of
analgesics. Medical school authorities should be aware of this health issue and formulate
corrective measures. We suppose that a brief educational video can improve medical students’
knowledge, attitudes and beliefs towards LBP.
NOTES
Une première vidéo pédagogique a été réalisée, d’une durée de 20,2 minutes.
Malheureusement suite à des problèmes de qualité de son et de taille (2,09 Go), cette vidéo est
entrain d’être retravaillée au niveau du son et de la compression par Mr Jean-Jacques Repain,
assistant des métiers de l’image et du son au sein du Service Pédagogique Numérique à la
Faculté Médecine-Sorbonne Université.
La vidéo a été visualisée par le Pr Olivier Steichen, des corrections y ont été apportées
et elle sera mise en ligne sur le Moodle dès que les retouches conséquentes numériques auront
pu être réalisées.
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LEGENDS
Table 1: Low-back pain (LBP) questionnaire for medicine Students
Male/Female:
Date of birth:
Medical year level:
History of spine trauma: (yes/no)
Overweight (BMI> 25kg/m2): (yes/no)
Exercice
Never (yes/no)
Sometimes (1/week) (yes/no)
Often (>2/week) (yes/no)
Exercice type
Licensed sport (yes/no)
Indoor sport (yes/no)
Jogging (yes/no)
Daily walk > 30 minutes (yes/no)
Low-back pain (yes/no)
Low-back pain > 2 years (yes/no)
Frequency of low-back pain
Several times/ month (yes/no)
Several times/ week (yes/no)
Several time/ day (yes/no)
Analgesic consumption
Several times/ month (yes/no)
Several times/ week (yes/no)
Several time/ day (yes/no)
Low-back pain issue
Student work (yes/no)
Daily life (yes/no)
Social activities (yes/no)
Quality of sleep (yes/no)
Table 2: Characteristics and multivariate logistic regression analysis of prevalence for
Univariate analysis Multivariate analysis
N (%) p value Odd
Ratio 95% CI p value
Gender : N (%) Male : 427 (34.4) 188 (44.0) 0.010 1.143 [0.835-1.564] 0.405 Female : 816 (65.6) 423 (51.8) Age>23 years : 680 (55.6) 264 (41.0) 0.645 Medical school level : N (%) DFGSM2 (2nd) : 263 (21.2) 112 (42.5) DFGSM3 (3rd) : 264 (21.2) 148 (56.0) 0.046 0.558 [0.387-805] 0.002
DFASM1 (4th) : 240 (19.3) 118 (49.1)
DFASM2 (5th) : 249 (20.0) 120 (48.1) DFASM3 (6th) : 227 (18.3) 113 (49.7) Spine trauma history: 97 (7.8) 51 (52.5) 0.526 Overweight: 109 (8.8) 51 (46.7) 0.617 Exercice
Sometimes : 653 (52.5) 341 (52.2) 0.126
Often/regular : 420 (33.8) 190 (45.2) 0.032 1.027 [0.778-1.356] 0.849
Never: 170 (13.7) 80 (47.05) 0.089 Exercice type Weekly : 857 (68.9) 458 (72.4) 0.007 1.835 [0.933-2.5] 0.01 Licensed sport : 406 (32.7) 219 (34.6) 0.131 Indoor sport : 308 (24. 8) 155 (24.5) 0.844
Jogging : 433 (34.8) 237 (37.5) 0.057
Walk > 30 min/day : 850 (68.4) 405 (64.0) 0.001 1.458 [1.129-1.876] 0.01
Low-back pain 835 (72.1) Low-back pain > 2 years 425 (34.2) Frequency of low-back pain Several times/ month 523 (42.1) Several times/ weeks 232 (18.7) Several times/ day 80 (6.4) Analgesic consumption Several times/ month : 99 (8.0) 98 (20.1) <0.0001 32.8 [4.271-252.2] < 0.001 Several times/ week : 23 (1.9) 23 (4.0) <0.0001 123 [0.000-2123] 0.998 Several times/ day : 3 (0.2) 1 (0.1) -
LBP impact Personal school work 282 (46.3) <0.0001 18.89 [10.12-35.25] < 0.0001 Personal life 202 (33.4) <0.0001 12.343 [5.681-26.82] < 0.0001 Personal social activities 83 (13.5) <0.0001 2.394 [0.560-10.171] 0.239 Quality of sleep 227 (37.1) < 0.0001 12.162 [6.917-21.386] < 0.0001
lumbar-back pain (LBP) for medical students. Statistically significant differences are in bold.