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Sachdeva A, Athavale A, Gupta S, Tiwari P K. A study on neck pain and low back pain among the undergraduate students of a medical college in Bhopal, India. JCHR 2022; 11 (2) :70-81
URL: http://jhr.ssu.ac.ir/article-1-762-en.html
1- nternist, Chirayu Medical College and Hospital, Bhopal, India
2- Professor and Head Department of Community Medicine, Chirayu Medical College and Hospital, Bhopal, India
3- Associate Professor Department of Community Medicine, Chirayu Medical College and Hospital, Bhopal, India
4- Statistician cum Assistant professor Department of Community Medicine, Chirayu Medical College and Hospital, Bhopal , India
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Development of at a younger age is a potential risk of developing chronic low back pain in adulthood. The study was planned with the purpose to know the extent of the less studied musculoskeletal disorders as a health problem among Indian medical students. The study was conducted to assess the prevalence of low back and neck pain among medical students, find the associations of low back and neck pain with quality-of-life issues, self-perceived stress and lifestyle.

Methods: A cross-sectional study was conducted at the Bhopal, India from May to July 2019, total 220 medical students were randomly selected. A questionnaire including the pre-validated instruments viz. Oswestry Disability Index, Visual Analog Scale and Perceived Stress Scale-10 were used to collect the data. Frequency (percentage), mean (SD), Chi square test, One way ANOVA, Pearson correlation coefficient were used to statistical inference. Microsoft Excel software 2016 and SPSS version 23 were used for data analysis. Significant level were considered 5 %

Results: The overall prevalence of Low Back and Neck Pain were 49.1% and 56.4% respectively. A significant association of female gender was found with Neck and Low Back Pain.  Low Back and Neck Pain were related to BMI and Stress (p<0.05).
Conclusion: There was a high prevalence of low back pain and neck pain in medical students at Bhopal. Females were affected more than males. Complaint of lower back pain was more than neck pain. Playing outdoor sports and weightlifting was found to be having protective effect on low back pain and neck pain.

Key Word: Lower Back Pain, Medical Students, Neck Pain, Prevalence


Musculoskeletal disorders (MSDs) are one of the major causes of disability worldwide. MSDs include a wide range of inflammatory and degenerative conditions affecting the muscles, tendons, ligaments, joints, etc. (1). MSDs can range from pain in the upper limbs, such as the forearm and wrist, to postural muscles such as the upper and lower back, neck and shoulders as well as lower extremities such as hips, thighs, knees and ankles. Left untreated, MSDs can evolve in to more severe degenerative and inflammatory conditions (2).
According to Global Burden of Disease (2016), low back pain (LBP) and neck pain (NP) are the two largest causes of musculoskeletal disability in general population and LBP is the single largest contributor to years lived with disability (3). It is not only associated with old age but affects people of all ages. About 80% of adults experience low back pain at some point in their lifetimes, and 20-30%people across the world are suffering from LBP at any given time (3, 4). It is often seen in individuals during their peak income-earning years. It represents huge burden on the economic growth of many countries by increasing load to the health care system and contributing to missed workdays (5).
Work related musculoskeletal disorders (WMSDs) are a subset of musculoskeletal disorders that arise from occupational exposures (6). Musculoskeletal conditions significantly limit mobility and dexterity, leading to reduce productivity and social responsibility of individual (5). High task repetition, forceful exertions, repetitive or sustained awkward postures are the common causes of WMSDs (7,8). Various studies on WMSDs have identified many factors like poor work practices, poor overall health habits etc. as related risk factors (7,8,9). In addition, physical inactivity and high BMI have also been identified as the risk factors for musculoskeletal pain in the general adult population (10).
Musculoskeletal pain is one of the most prevalent complaints among medical students. Time-consuming curricula at medical schools, lot of psychological stress, and sedentary lifestyle has led to a high prevalence of LBP and NP among the medical students worldwide. (4,11-14). Their total course of five and a half years requires long hours sitting to cover theory part and even longer hours for hospital wards and clinics. Apart from academics, they have to deal with psychological stress due to ethical and financial pressures which has high prevalence of psychological morbidity, including burn-out and depression (11,14-15).
A study was conducted by Hendi OM et al. (2019) (16) among various health specialty students in Saudi Arabia in which highest prevalence of MSDs was among medical students (48.4%) which was significantly higher than among pharmacy and health science students. There are many studies done on LBP among working groups and general population in India, however there is scarcity of such studies on medical students of India. Moreover, Indian studies regarding NP are negligible.
Aggarwal N et al (2013) found the overall prevalence of LBP among the medical students in Delhi, India to be 47.5%. Prevalence among males and females was 45.3% and 50%, respectively (4).  
Development of musculoskeletal disorders at a younger age is a potential risk of developing chronic low back pain in adulthood (17).  This fact should be taken seriously as it will not only affect the general quality of life but also decrease the productivity of the individual in early stages of his/her career.
With the above background the present study was planned with the purpose to know the extent of the less studied LBP and NP as a health problem among Indian medical students. It aimed to find out the prevalence and severity of LBP and NP among the medical students, its associated risk factors and related disabilities. The other objectives of the study being to determine the association of NP and LBP with quality of life (QOL) issues, self-perceived stress and lifestyle in the study population.


Study design & Study participants:

It is a cross sectional study which was performed among the undergraduate medical students (Bachelor of Medicine and Bachelor of Surgery; MBBS) at Chirayu Medical College & Hospital, Bhopal, India .With the intake of 150 students per year; around 600 students of four batch years study in the college at a given time.
Sample size & Selection criteria
The sample size for this study is determined based on an estimated point prevalence rate of 32.5% of LBP found in an Indian study conducted in a medical college in Delhi (4). The required sample size is calculated to be 217 medical students to yield the prevalence estimate with 5% precision and 95% confidence level with a finite population correction. Students from all four academic batch years were selected by simple random sampling with lottery method(18). Each batch year students were enlisted and 55 students from each batch were selected thus a final sample size of 220 students. Students with any chronic illness, known musculoskeletal diseases (MSD) or pregnancy were excluded.

Study period

The data collection was done in the month of May-July 2019.


We identified all possible subset of variable among study population and carry out pilot study and find the implications for variable selection.

Age, gender ,height, weight, BMI, academic year, playing outdoor sports, doing physical exercise, practicing yoga, weightlifting, carrying back packs/college bags, watching television, working on laptop/personal computers (PC), driving, meeting friends/going to parties, wearing heels, smoking, alcohol intake, tea/coffee intake, travelling by public transport, time spent on studying, place of studying, time spent on clinical postings, use of any extra aids for studying, body posture while studying, family history of musculoskeletal disorders.


LBP was defined for students as pain in the lumbar region and NP was defined for students as pain in the neck region.
LBP/NP was considered as "acute" if present for less than 4weeks and "chronic" if present for more than 12 weeks.
BMI was calculated as per the formula-Weight (kg)/ [Height (m)2] (2).
Various variables especially to assess habituations, exercise and daily routine physical activity e.g. smoking, taking exercise, watching television, etc. were categorized into “regular” for daily, “occasional” for1-2 times a week and “never” (4).
Sitting with a straight back and shoulders is considered “Normal” body posture whereas postures like slouching or slumping are considered “Abnormal” (14).

Study tool

The study questionnaire is well validated and standardized tool used in a study done by Du et.al. (2017) (11) at one of the medical schools in the US. The original questionnaire consisted three types of scales viz. Oswestry Disability Index (ODI) (4), Visual Analog Scale (VAS) and Perceived Stress Scale (PSS)-10 .
In the questionnaire there are multiple choice or open response questions regarding the demographic characteristics.
 All the three tools are well validated and reliable as demonstrated by various investigators.  The ODI questionnaire has good test and retest reliability with the Cronbach ά ranging from 0.71-0.87 (19); the VAS pain scale has the correlation coefficient between 0.60 -0.77 (20, 21); and the PSS -10 scale to assess the degree of perceived stress is reliable and valid with coefficient alpha ranging from 0.84 to 0.86 as found in different studies (22).
In addition to this the study questionnaire included the information on gender, height, weight and BMI of the participants and questions to assess habituations, exercise and daily routine physical activity.
Study procedure and ethical considerations
Survey was conducted among the students at suitable time and opportunity. A pilot testing of questionnaire was done for standardization and for further validation with 10 students before the actual survey in which they had no difficulty filling in the questionnaire; later their responses were included in the final data analysis. Each selected student was asked to fill out a structured questionnaire after obtaining an informed consent in English language. All the participants were informed about the purpose of the study. Forms were distributed manually among all the students. Students were given a time period of 20- 30 minutes to fill the form completely. Before filling up the questionnaire students were guided through questionnaire to fill it up. Forms were scrutinized before collection, to look for any left or improperly filled entries. Height and weight of each participant was measured at the same time using validated methods.
Study was conducted after the clearance from Institutional Ethical Committee (IEC) of Chirayu Medical College &Hospital, Bhopal. Confidentiality of the data of participants of the study was maintained.

Statistical analysis

For categorical variables the frequency and percentages were calculated, while for continuous variables mean and standard deviation  were calculated as a descriptive statistic. Chi-square test (x2) was used as a test of significance to find association between NP/LBP and various study variables. Comparison of differences between means of various variables of four academic years was done by one way ANOVA. Pearson  correlation coefficient was used to find linear relationship between demographics, stress and neck and back pain scales. Microsoft Excel software and Statistical Package for Social Sciences (SPSS) version 23 were used for data analysis. Significant level were considered 5 %


Out of the 220 study subjects, 66 (30%) were males and154 (70%) were females. The mean age was 21.27±1.33 years. The mean height, weight, and body mass index (BMI) of the study group were 163±9cm   59.19±11.32kg   and 22.17±3.86kg/m2  respectively.
A total of 135 students reported either NP/LBP or both (61.4%). The prevalence of NP and LBP were 49.1% (108/220) and 56.4% (124/220) respectively.  A total of 97 medical students reported both NP and LBP (44.1%).
A significant association of female gender was found with NP (p = 0 .006) and LBP (p < 0 .001) by x2test. No significant association of academic batch year, family history of MSD, study place and use of private coaching was found with NP and LBP. [Table.1]
The overall VAS NP score was 1.7 ± 2.1. In students who complained of NP (VAS neck >1), the average VAS score was to 2.6 ± 1. 8 out of 10 (range: 1-7). There were 71 students (32 %) who reported moderate to severe NP (VAS >3). The overall VAS LBP score was 2.2 ± 2.5. In students that complained of LBP (VAS back >1), the average VAS score increased to 3.2 ± 1.6 out of 10 (range: 1-8). There were 83 students (38%) who reported moderate to severe LBP (VAS >3).
Of the 135 medical students who reported NP or LBP, 47 (35%) medical students began experiencing NP or LBP before medical school (average 2.0 ± 0.9 years before medical school) and 88 (65 %) medical students began experiencing NP or LBP during medical school.
Frequency of NP and LBP episodes was "never" for 64 (29%) students, “almost never “for 30 (14%) students, “sometimes” for 98 (45%) students, "often" for 25 (11%) students and "constant" for 3 (1%) students. Majority of the students reported occasional episodes of NP & LBP.
Of the 135 students with some degree of pain, 62 (46 %) students reported self-treatment of NP or LBP.

The level of students’ daily activities (regular, occasional, never) including outdoor sports, physical exercise, yoga, weightlifting, carrying backpacks, watching television, working on the computer, driving, meeting friends, wearing heels, smoking, alcohol, drinking tea/coffee and travelling by public transport was assessed for association with NP & LBP [Table 2a & 2b]. Variables like history of trauma, time spent on clinical postings and body posture, were also assessed for association with NP &LBP. [Table 2b]
Majority of the students with NP and LBP were not involved in lifting weight and the difference in categories was found to be significant- NP (p=0.001) & LBP (p=<0.001).
Complaint of LBP was more among the students who were never or occasionally involved in playing outdoor sports than those who were regularly involved, and the difference was statistically significant (p=0.011).
Majority of the students with NP and LBP were occasionally involved in activities like meeting friends/going to parties and the difference in categories was found to be significant-NP (p=0.006) & LBP (p=0.024). History of trauma was found significant associated with LBP (p=0.026) but not with NP (p=0.081) Other activities like doing physical exercise, practicing yoga, carrying backpacks, watching television, working on computers, driving, wearing heels, smoking, alcohol intake, tea/coffee intake, travelling by public transport, time spent on clinical postings and body posture were not found to be significantly associated with NP and LBP.
Table 3. The Quality-of-life issues related with neck and lower back pain severity by ODI scale among medical students
Overall, the average ODI score was 7.2 ± 7.6. Among students who reported NP or LBP by VAS scores, the average ODI score was 10.3± 7.9 (range: 0-37).The most commonly reported QOL issue associated with NP was headache (n=112), followed by pain during reading (n=109) and difficulty in concentration (n=101).The most commonly reported QOL issue associated with LBP was pain exacerbated during sitting (n=90), followed by pain exacerbated during standing (n=86). [Table.3]
A significant negative correlation was found between BMI and VAS neck (p=0.047) &VAS back (p=0.003). The average PSS score was 22.0 ± 5.3 (range: 11-34), with a significant positive correlation between a PSS score and VAS neck (p=0.011) and VAS back (p=0.001). No significant correlation was found between age and VAS neck and VAS back. [Table.4]
In terms of demographics, there was a significant difference between batch 2015 and 2018, in BMI from 23.34 ± 4.67 to 21.16 ± 3.31 (p = 0.023). There was no significant difference in PSS score across the batches (p = 0.23). There was no significant difference in VAS neck (p = 0.26), VAS back (p = 0.54) or ODI (p = 0.70) across the batches.


This self-administered questionnaire based cross-sectional study carried out in a medical college of Bhopal revealed a high prevalence (61.4%) of NP/LBP or both among the medical   students. This finding is very close to the 65.1% rate of musculoskeletal pain at least one site reported by Al Shagga et. al. among Malaysian medical students (23).
The present study showed the higher prevalence of LBP among the medical students as compared to other  regional studies both from Delhi reported by Aggarwal N et al (2013)(4) & Ganeshan et al (2017) (24 ) viz. 56.4% vs 45.3% & 42.4% respectively. On the contrary, a lower prevalence of NP was found in our study as compared to the study done among medical students in central India reported by Behra P (2020) (25) viz. 49.1% vs 58.3%. Such differences in prevalence of LBP/NP among the regional studies can partly be explained on the basis of actual rise in LBP/NP among the study population through years and partly with the differences in study patterns prevalent in the institutions among medical students i.e., academic load, long standing hours or long studying hours, etc.    
In the present study, the prevalence of NP  and LBP and their ODI scores were comparatively higher than that found in a study conducted Du et al in an American medical school (11). This difference may be due to variations in the socio-cultural and lifestyle factors, study pattern, BMI, physical activity in Indian students as compared to American medical students.
Prevalence of LBP was found more than NP in the present study which is similar to the findings of previous studies by Smith DR et al. (2015) (26) among Chinese medical students and Al Shagga MA et al. (2013) (23) among Malaysian medical students. There are no other studies from India addressing NP and LBP in a single study.
Hoy D et al (2010) (27) in their systematic review found mean and median prevalence of low back pain to be higher in women as compared with men.  In the present study a significant association of NP and LBP was found with female gender, whereas, no such significant association was found in the study conducted by Aggarwal N et al (4) in Delhi though the prevalence of LBP was more in females as compared to males. This difference in findings to certain extent may be attributed to the higher proportion of females in present study as as compared to the study by Aggarwal N et al (4) i.e., 70% vs 46.2% respectively.  Similarly, Haroon H et al (28) reported the combined prevalence of LBP , NP and shoulder pain among females to be more than males among the medical students of a medical college in Karachi but the difference was not statistically significant.  According to a community-based study conducted during 2015-16 in northern India by Bansal D (2020) (29) the point prevalence of LBP was found to be 32% with significantly higher prevalence in females as compared to males. Differences in findings from all the above studies showing preponderance of LBP/NP with female gender can partly be explained with differences in physical activity related to socio-cultural aspects by gender and the status of female in the society in addition to the differences in age group of the study subjects in these studies.
In our study activities like involvement in - playing outdoor sports, weightlifting, meeting friends/going to parties; and presence of history of trauma, were found to be significant protective effect with LBP. This finding itself points towards a link between the sedentary lifestyle with that of NP or LBP in the present study. Behra P et al (2020) (25) also have reported protective effect of taking light exercise against NP among medical students.
According to Nilsen TI et al. (10) physical inactivity and high BMI are associated with an increased risk of chronic pain in the low back and neck/shoulders in the general adult population. A study conducted among university students by Meman SH et al (2017) (30) in southern India has reported a significant association between overweight and obese individuals with LBP. In the present study a negative but weak correlation of NP and LBP was found with BMI. This may be explained by the fact that the mean BMI in our study population was 22.17 kg/m2 and more than 90% of the students were in the normal range of BMI. Moreover, for the correct measurement of association between LBP and BMI a larger sample size may be required.
 In this study a positive correlation of NP and LBP was found with perceived stress whereas no such correlation was found in American study conducted by Du et.al. (2017) (11). In a  study conducted in 2008 by Kennedy C et al. among college students in a major university in Colorado (31) showed association of stressful psychosocial variables of feeling very sad, being exhausted, and whelmed with LBP.
In present study, no significant differences were found in PSS score, VAS neck, VAS back and ODI among various academic batch years which is a finding similar with previous study conducted among American medical students (11). No other studies from India are available establishing any relationship between perceived stress and LBP/NP among student population.
This study is done with appropriate sampling procedure and used well validated and standardized questionnaire.  This is the one of the few studies from India including both LBP and NP among medical students within a single study, probably the only study. No other study from the region has measured perceived stress by a scale in the given study population. There is a significant association between the scales assessing severity of LBP/NP and the perceived stress scale confirming to the valid conduction of the study. 
The present study has few limitations also. First, this study was conducted in a medical college of Bhopal, so its results cannot be generalized for the medical students at all other colleges. Second, as it was a cross sectional study using self-administered questionnaire including various pain scales, there is a risk of response and recall bias in the study due to the subjective variation in the responses by the study participants. 


There was a total of 135 students reported either NP/LBP or both (61.4%). The prevalence of NP and LBP were 49.1% (108/220) and 56.4% (124/220) respectively  among medical students at Chirayu Medical College & Hospital, Bhopal. Females were affected more than males.
With a high prevalence of NP & LBP among students, this study underscores a need for orthopedic screening for NP and LBP among medical students at the time of entry into the medical college with appropriate remedial measures. Additionally, as the association with sedentary lifestyle aspects with NP and LBP was evident from the study, daily exercise promotion is underscored. Students should be taught correct postures [14] to maintain the balance of the body and the benefit of various posture exercises that strengthen the muscles of the back, relieve tension and help to decrease the pain.
Complaint of lower back pain was more than neck pain. Headaches and pain exacerbated while sitting were the most frequently associated quality of life issues with NP and LBP respectively.  These can limit the working ability and may affect the academic performance of the students.
In terms of demographics, there was a significant difference between batch 2015 and 2018, in BMI from 23.34 ± 4.67 to 21.16 ± 3.31 (p = 0.023).
Further studies may be initiated to look into the intricate relationship between habitual physical activities, BMI, socio-cultural aspects & nutrition with musculoskeletal disorders.


Supported by Indian Council of Medical Research, New Delhi under STS-2019 Project.

Conflict of Interest

We certify that we have participated sufficiently in the research content, conception and design of this work or the analysis and interpretation of the data (when applicable), as well as the writing of the manuscript, to take public responsibility for it and have agreed to have our name listed as a contributor. No author has any conflicts of interest related to this research article.

Authors Contributions’

Aditi Sachdeva: has carry out responsibility of Selection of Topic, Planning of Study, Data Collection and Compilation, Manuscript Preparation.
Arvind Athavale: Arvind Athavale Selected the Topic, Planning of Study, Manuscript Preparation and Manuscript Reviewed.
Sachin Gupta: Reviewed Manuscript and submitted the manuscript. He has also done statistical analysis review.
Pradeep Kumar Tiwari: Done Data cleaning and analysis.

Review: Research | Subject: Public Health
Received: 2021/05/13 | Accepted: 2022/06/20 | Published: 2022/07/5

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