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: aymmed@hotmail.fr

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acknowledge that, if accepted, this paper will not be published elsewhere in the same form, in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.