THESIS BODY

2
1.1 Introduction
According to the anatomical view, the term LBP refers to pain in the lumbosacral
area of the spine from the 1st
lumbar vertebrae to the 1st
sacral vertebrae. The most
frequent site of LBP is around the 4th
and 5th
lumbar segment.[1]
The worldwide
annual incidence of LBP ranges from 1.5% to 36%, and one year prevalence ranges
from 22% to 65%. The annual incidence of occupational LBP is about 5%.[2]
The
recurrent episodes of LBP range from 24% to 33%.[3]
Prevalence of LBP increase
with age, with the greatest frequency for LBP occurring between the ages of 35–55
years.[4],[5]
LBP is a significant problem for both genders and there is no clear
consensus signifying one gender or another having an overall higher risk for LBP.[6]
1.2 Etiological factors and risk factors of LBP
The etiological factors include poor posture, muscle weakness and imbalance;
degenerative changes in the disc and vertebral bodies, trauma, anxiety and
depression.[7]
Risk factors are characteristics, specific to people that have been
correlated to incidents of LBP. These risk factors associated with LBP include age,
gender, anthropometrics, overall health, and socioeconomic status, education levels,
smoking habits and awkward occupational postures, whole body vibration and
prolonged static work postures.[1],[5],[6]
Rates increase with taller and heavier
individuals, possibly due to increases in moment-loads on the spinal column.
Smoking habits have an impact on the musculoskeletal system.[8]
Occupational disorders are important because they affect a large number of workers.
The pain develops when the same muscles are used over and over again for a long
time without taking adequate time to rest. This tendency to LBP further increases if
the force or muscle work exerted is high and the job type requires an awkward
posture. There is no internationally accepted definition for the term occupational
disease or disorders. However, occupational disease or disorders are usually
defined as disease/disorders arising out of or in the course of employment.
Occupational risk factors are elements of a job task those have been correlated to

3
incidence of LBP. Risk factors for LBP include a worker’s inappropriate posture and
heavy weight lifting required to complete required job tasks.[9]
Static work postures
of prolonged sitting can be correlated to incidents of LBP.[10]
In vehicle driving these factors are further compounded by long duration sitting work
postures which may be cramped and cause a significant static loading on the
structures of the spine. Further driving has been noted to contribute to a herniated
disc due to the vibration caused by automobiles.[11]
The lumbar spine has a natural
resonance frequency of 4-5 Hz and when driving, the vibration causes the body to
resonate at that frequency. The 4 Hz vibration frequency has the most important
effect on the back muscle fatigue under simulated driving condition.[12]
1.3 Risk factors of LBP among auto-rickshaw drivers
Various studies have been conducted on vehicle drivers of different types of
vehicles. Driving is a task which involves prolonged sitting, a fixed posture and
vibration, any of which could directly lead to musculoskeletal stress. Studies have
shown that when a vehicle is in motion, the body is subjected to different forces:
accelerations, decelerations, lateral swaying from side to side, and whole-body up
and down vibrations. As study among car driver in Dhaka, Bangladesh [13]
found that
driving for 1-7 hours/day is the main cause of LBP. Traffic congestion is a
phenomenon commonly seen on our roads; this usually leads to the long hours of
driving experienced by the drivers in overpopulated cities.
A review of literature revealed that scarce number of studies had been conducted or
reported on auto-rickshaw drivers. Among light vehicle the auto-rickshaws is a
popular mode of transport in some cities of the world. These vehicles provide an
efficient and economical system of travelling in busy congested road. In India many
cities have this mode of transport. In Kolkata, auto-rickshaws were introduced in
1983-84 and the current fleet of registered vehicles is 10,000.[14]

4
Out of the two previous studies on auto-rickshaw drivers, one was conducted in
Guntur, Andhra Pradesh, India and the other in Galle, Sri Lanka. Shaik et al
(2014)[15]
explored age, work experience (number of years), working hours, seat
vibrations, lower cabin space and shoulder to handle distance for right and left upper
limbs. Their study associated these risk factors with pain in all parts of the body
(neck, shoulder, elbow, wrist, upper and lower back, hip, knee and ankle). Out of all
the risk factors, driver’s seat vibration was the single risk factor which had a positive
association with LBP. The positive association between long term exposure to
whole body vibration and LBP has been reported in studies considering tractor
drivers, truck drivers, bus drivers and drivers of heavy off-road machines (e.g. earth
moving machines, cranes, excavators).[16]
Another study in Galle, Sri Lanka by Kirkorowicz et al. (2013)[17]
was a qualitative
study which investigated risk factors in chronic illnesses in auto-rickshaw drivers.
Musculoskeletal pain in lower back, shoulders and knees were the most common
complaint. The cause for this was attributed to vehicular vibrations and staying in
the same posture for many hours. Although staying in the same posture was
reported as a risk factor, the posture analysis was not conducted. Neither was
posture analysis considered in the study from Guntur.[15]
The study by Shaik et al. (2014)[15]
did not analyze several other risk factors known
to cause LBP such as anthropometric measures (weight, height), education levels
and marital status. These were reported in the study by Kirkorowicz et al. (2013).[17]
Although the latter study concluded that vibration was a causative factor for
musculoskeletal pain, since the research was qualitative, it did not measure the
vibration.
Smoking has been an established cause for LBP. Smoking was assessed as one of
the risk factors in three-wheeler drivers by Kirkorowicz et al (2013).[17]
Smoking was
not considered in the study by Shaik et al (2014).[15]
LBP results in disability and loss of work days, resulting in loss of income. Resultant
disability levels and its effects on the drivers were not assessed in both the studies.

5
The sample size in the study by Shaik R et al (2014)[15]
was 300, although the
authors do not explain the basis of the sample size for a survey design. The study
by Kirkorowicz J et al (2013)[17]
was a qualitative study which conducted interviews
on 33 drivers.
1.4 Justification for the study
Considering the growing popularity of improvised transportation systems such as the
auto-rickshaw, our growing population and traffic congestion, the auto-rickshaw
drivers’ health issues should be investigated. Given the limited amount of previous
research, inadequate assessment of risk factors, small sample size, a survey needs
to be conducted which can explore all relevant risk factors in an adequate sample of
drivers. These results should prove to be useful in government analysis and policy
development concerning auto-rickshaw drivers.
1.5 Purpose of the study
The purpose of this study is to find out the prevalence and risk factors of LBP in
auto-rickshaw drivers in urban Kolkata.

6
CHAPTER 2
REVIEW OF LITERATUTE

7
2.1 Introduction
Although certain risk factors related to LBP are universal, different occupations
generate risk factors that pertain to the occupation specifically. Hence driving too
has its unique set of risk factors. Here, the risk factors vary significantly with the
type of vehicle. This review of literature will explore the risk factors of LBP,
associated with auto-rickshaw drivers.
2.2 LBP definition and causes
One definition of LBP is any pain between the ribs and the top of the leg, from any
cause. LBP may originate from any one or more spinal structures namely facet
joints, intervertebral discs, neural foramen and paraspinal muscles.[6]
Mechanical pain (80-90%) occurs when two or more vertebral bodies are placed in
opposition causing the surrounding ligaments and other soft tissues to be
overstretched. The patient initially feels only discomfort but with the elapse of time,
pain eventually develops (Mckenzie, 1995). Mechanical LBP has been classified in
three relatively simple categories: postural syndrome, dysfunctional syndrome, and
derangement syndrome (Mckenzie, 1995). The other mechanical causes of LBP are
Diffuse Idiopathic Skeletal Hyperostosis, degenerated discs, Scheuermann's
kyphosis, spinal disc herniation("slipped disc"), thoracic or lumbar spinal stenosis,
spondylolisthesis and other congenital abnormalities, fractures, sacroiliac joint
dysfunction, leg length difference, restricted hip motion, misaligned pelvis-pelvic
obliquity, anteversion or retroversion, abnormal foot pronation (Shiel, 2007).
The inflammatory causes of LBP are Seronegative spondylarthritis (e.g – ankylosis
spondylosis) Rheumatoid arthritis, Infection-epidural abscess or osteomyelitis,
Sacroiliitis. The neoplastic causes are bone tumors (primary or metastatic), intradural
spinal tumors. The metabolic causes are osteoporotic fractures, Osteomalacia and

8
Chondrocalcinosis. Others causes are Psychosomatic (Tension myositis syndrome),
Paget’s disease.
The role of muscle functioning as a cause of LBP has to be underscored here.
Although, the bones of the spine provide the supporting frame for the back,
connected to this frame is an intricate system of muscles and ligaments that
increase the strength and stability of the spine, arms and legs. The abdominal
muscles and back muscles are key components of this muscular network, and
provide the strength to keep the body upright and functional movement for core
muscles involve the major muscles in the abdomen, (internal and external oblique
and the transverse abdominals) as well as the spinal extensors. These muscles
tend to weaken with age, poor posture, occupational demands, lifestyle, obesity,
unless specifically exercised. When these core muscles are in poor condition,
additional stress is applied to the spine as it supports the body. This may result in
back injury or back pain is more likely. Weak abdominal muscles may contribute to
LBP. The abdominals are the front anchor of the spine; if they are weak, then the
other structures supporting the spine, for example the back muscles will have to
work harder causing pain.[18]
2.3 Prevalence and incidence of LBP
It is estimated that 70% to 80% of the world’s population has at least one episode of
LBP in their lifetime with a one-year prevalence rate of 22-65%.[2]
In industrialized
societies, it is a common health condition and a major cause of absenteeism and
disability thereby posing an enormous societal cost. Occupational factors are a
major source of LBP and cause a decrease in the quality of work life as well as
deterioration in physical activity. Studies among different groups of working people
show different percentages prevalence of LPB in their life time.[6]
A study was done among health care givers in a hospital of Malaysia. The response
rate was 61.2%. 570 out of 931 subjects showed a lifetime prevalence of 72.5% and
a 12 month prevalence of 56.9%.[19]
A study among computer office workers in the

9
city of Bangladesh found among any other musculoskeletal problems, LBP the
highest at 61.5%, compared to any other area like neck, shoulder and knee and the
prevalence was 47.5%.[20]
In a survey study among 122 female nurses, the 12
months prevalence of LBP was 84%.[21]
Like many studies among different working population, drivers were also surveyed in
different countries for their prevalence of LBP. In a German study of professional
drivers, the prevalence of LBP was around 60% in operators of earth moving
machines, truck drivers and fork-lift truck driver. In a study of 169 fork-lift truck
drivers from 13 companies in Copenhagen metropolitan area, the point prevalence
and the 12-month prevalence of LBP were 21% and 65%, respectively. In a study in
Finland a very high prevalence of 7-day and 12-month low back troubles (51% and
82%, respectively) was found in machine operators (541 longshoremen and 311
earthmover operators). In a previous study of port machinery operators exposed to
whole body vibration and postural load, the overall 12-month prevalence of LBP was
63%.Bus drivers have been investigated in several epidemiological studies
performed in US and European countries. Review of the available literature showed
that the range of the prevalence of musculoskeletal disorders in the lower back of
bus drivers was very wide between studies, from 40% to 82%.[22]
Studies on small car drivers showed a prevalence of LBP as well. A study in
Malaysia where 97 taxi drivers responded, 59% had had LBP during the last 12
months, 15.5% of them experienced LBP for two to three days every week and
24.7% experienced it every day.[23]
Another survey from Southampton on 209 taxi
drivers and 365 police car drivers showed the 12 months prevalence of LBP was
46% and 45% respectively.[24]
A study from Pondicherry India where government
and private company employed car drivers were surveyed for LBP, the 1 week
prevalence was found 23.9%.[25]
In a study among car drivers in Dhaka,
Bangladesh, 78% of total 246 subjects had LBP for at least 1day during the past 12
months.[26]

10
Only one previous study analyzed the prevalence of LBP in auto-rickshaw drivers. A
study among auto-rickshaw drivers in Guntur, India analyzed the 12 months
prevalence of LBP as 63.66%.[15]
2.4 Risk factors associated with LBP
2.4.1 Age: a risk factor
Ardiana M et al (2012): In a cross sectional survey was conducted on 394 workers
from Kosovo power plant to investigate the prevalence of LBP among the workers.
The principal job tasks were working with their trunk in awkward postures, necessity
to change posture regularly, driving vehicles or machines, lifting weights, pushing
and pulling of loads. The job tasks of office workers often involved long periods of
seated work. After using the outcome measures ODI and Visual Analogue Scale
(VAS), the result shows that the age group of 33 to 55 years was at a high risk of
LBP. When considering age, the severity of LBP was stronger in older employees
than in younger ones.[8]
Nahar N et al (2012): conducted questionnaire based survey of male car drivers in
Dhaka city, Bangladesh. Subject’s age ranged from 25-65 years. The results
indicated that the age group between 25–39 years (n= 124) had less prevalence of
LBP compared to the age group 40 – 65 years (n=122).[13]
Shaik R et al (2014)[15]
explored age as a risk factor in auto-rickshaw drivers. The
authors found no significant association.

11
2.4.2 Gender: a risk factor
Aminuddin A et al. (2014): In their community based case-control study both sexes
between 30 and 60 years of age were selected who had LBP. The results pointed
that the prevalence of LBP among females was 70% which was higher than males,
who were 30%. The authors concluded that females were associated with working
postures of bending and twisting moments of the body and therefore more
susceptible to LBP.[27]
Kuwashima A et al. (1997): On their national survey of LBP from different
manufacturing and non manufacturing work places in Japan. Where 13166 cases of
LBP diagnosed out of which 85.5% were male workers and 14.5% were female
workers. LBP was more higher in middle aged group 30 – 40 of age, where males
are 4 times greater incidence of LBP than that in women [28]
2.4.3 Anthropometrics: risk factor
Bovenzi M et al (2006): Measured the prevalence and risk factors of LBP in Italian
professional drivers. The average height was 177cm and weight was average 82kg.
The average BMI was 26 and disability was associated positively with BMI > 27.[29]
Nasrin S et al. (2012): Measured the anthropometric dimensions of private vehicle
drivers of Gonabad, Iran and correlated with musculoskeletal disorders (MSD). The
drivers described the level of discomfort in different parts of their bodies, based on
the Body Discomfort Chart. This study showed that drivers' MSDs are related to
their height, weight and age. The height, weight and age increases the probability of
MSDs; while the height of drivers appeared to be negatively associated. It seemed
reaching the steering wheel resulted in back and neck pain; therefore, taller
individuals spend lower energy for reaching to steering wheel and therefore had less
MSD.[30]

12
2.4.4 Education level: a risk factor
Dionne C et al. (2001): An association of low education with adverse consequences
of LBP suggested that the course of a LBP episode is less favorable among persons
with low educational attainment. Mechanisms that could explain these associations
include variations in behavioral and environmental risk factors due to educational
status, differences in occupational factors, compromised "health stock" among
people with low education, differences in access to and utilization of health services
and adaptation to stress.[5]
Shamsul B et al. (2007): To determine the risk factors associated with complain of
LBP a cross sectional study was done among 760 commercial vehicles drivers from
11 bus companies in central, northern and eastern regions of Malaysia, Modified
Nordic questionnaire was used to determine the prevalence of LBP, a modified
OWAS was used to assess the awkward posture of the driver torso namely bending
forward movement, leaning, sitting straight and twisting. Logistic regression analysis
for age, income, education level and non occupational activities were factors
analyzed for association with LBP showed no significant results.[31]
2.4.5 Smoking: a risk factor
Racheal M (2014): In this study the author concluded that smoking does progressive
harm to the musculoskeletal system. Smoking has a negative impact on bone
mineral density, reducing calcium absorption and lowering levels of vitamin D,
changing hormone levels and reducing body mass. Smoking is associated with
more bone fractures and slower healing and is associated with up to a 40% increase
in the risk of hip fractures.[12]
Ardiana M et al. (2012): Conducted across sectional survey on 206 workers from
Kosovo power plant to investigate the prevalence of LBP among the workers. They
found that former smokers were more prone to LBP.[7]

13
Kirkorowicz J et al. (2013)[17]
found that 98% auto-rickshaw drivers were smokers in
their survey study whilst Nahar N et al (2012)[13]
calculated the number of smokers
as 80%.
2.4.6 Marital status: a risk factor
Lela M et al. (2012): Conducted a study on 122 female and male nurses from
Kanombe Hospital, Kigali, Rwanda. They found the majority of nurses were married
(74.6%) and reported a high prevalence of LBP (84%). The chi square test revealed
a significant relationship between LBP and marital status.[21]
Borle A et al. (2012): Conducted a cross sectional study among truck drivers of
goods transport companies in Nagpur city, India. A total of 256 truck drivers were
selected randomly and information gathered with a predesigned and pretested
questionnaire. The Ronald –Morris Disability Questionnaire score was used to
assess the physical disability due to LBP. The study analyzed the physique of
drivers and demographics (age, gender and marital status) as risk factors for LBP.
They no significant association between measured demographics and LBP.[32]
2.4.7 Work experience
Rajnarayan R. et al. (2003): A study was carried out among 514 males cotton textile
workers of Sri Bapurao Deshmukh Sut Girni, Wardha. Self reported back pain since
last six months in or near the lumbosacral spine was considered to be LBP. Of the
six study factors, except family history of musculoskeletal disorders, other five
factors viz. age >35 years, obesity, smoking, duration of exposure >10 years and
working position requiring prolonged sitting were found to be significantly associated
with development of LBP.[33]

14
Work experience was explored as a risk factor for LBP in auto-rickshaw drivers of
Guntur, Shaik R et al (2014)[15]
but the results of the logistic regression analysis
were non- significant (p = 0.38).
2.4.8 Working hours
Holmberg S et al. (2005): A cross-sectional study done among 1,221 male farmers
of Swedish population, 40-60 years of age, working on farm spending at least 25
hours per week, showed significant association between LBP. Additionally the
presence of digestive and respiratory disorders doubled the LBP prevalence.[34]
Gangopadhyay S et al. (2012): Conducted a study among 160 male government bus
drivers of Kolkata, India. The drivers worked in shifts-morning, day or night and an
average duration of driving was 8-10 hours per day, 6 days in a week and one day
off. This amounted to 60 hours per week. They found that in the drivers who
worked prolonged hours, the ones who had LBP were significantly more than the
number without LBP.[35]
Odebiyi D et al. (2007): Designed a survey study to determine and compare the
prevalence of LBP in Commercial Motor Drivers (CMD) and Private Automobile
Drivers (PAD). LBP was a major problem among the respondents; but was
experienced more among CMD. The higher prevalence of LBP in CMD was
attributed to the length of time spent sitting when driving.[36]
Shaik R et al (2014)[15]
analyzed associations between hours of driving per week and
LBP in auto-rickshaw drivers. The results were non-significant.

15
2.4.9 Work posture related to risk factor
Charoenchai L et al (2006): Examined the relationship between low back disorder
and bending, twisting and awkward postures and found that flexion or lateral
bending of the spine and bending or rotation of the spine are considered potential
risk factors for LBP. Static work posture included positions where very little
movement occurred, along with cramped or inactive postures that caused static
loading on the muscles. This included prolonged standing or sitting and sedentary
work. During sitting, the continuous activity of some type 1 motor units (back)
muscle may contribute to the development of fatigue.[37]
Gangopadhyay S et al. (2012): In their cross sectional study among 160 male full
time urban bus drivers, information was collected on their regular physical activity
and work related ergonomics and psychological stress factors. Ergonomics factors
associated with LBP included uncomfortable seat, uncomfortable back rest and
uncomfortable steering wheel. Uncomfortable seat and uncomfortable back rest had
significantly higher number of drivers with LBP.[35]
2.4.10 Vibration: a risk factor for drivers
Olanrewaju O et al. (2007): In their cross sectional study to investigate worker
exposure to postural demands, manual material handling and whole body vibration.
80 healthy bus driver were observed during service and vibration was measured.
About 68.8% indicated discomfort from vibration of any kind, 31 indicated
discomforts from vertical vibration, 16 indicated discomforts from aft-vibration, 15
indicated from lateral vibration and 23 discomforts from shocks and jerking
events.[22]

16
Gregory P et al. (2008): Conducted a study to measure the acute effect of seated
whole-body vibration on the postural control of the trunk during unstable seated
balance and their result suggested an impairment in spinal stability and a
mechanism by which vibration may increase low back injury risk.[6]
Shaik R et al (2014) Vibration measured in auto-rickshaws was considered as a
significant risk factor for LBP.[15]
2.4.11 Disability level caused by LBP
Massimo B et al.(2006): Performed an epidemiological study of LBP among 598
professional drivers (drivers of earth moving machines, fork lift truck drivers, truck
drivers, bus drivers). These were exposed to whole body vibrations. The study
results showed that the exposure to vibration caused LBP due to which disability
score >12 was found in Ronald and Morris Disability scale.[38]
Gangopadhyay S et al (2012): In their study to find the disability level of the bus
drivers due to LBP they used the ODI scale and the results showed that sitting
posture among them was the highest (89%) which was restricted due to LBP, lifting
(78%), standing (65%) and travelling (65%) respectively and it was found that
maximum number of subjects suffering from moderate followed by minimal and
severe disability.[35]
2.5. Risk factors of LBP among Auto-rickshaw drivers
Shaik R et al.(2014):conducted a study among 300 auto-rickshaw drivers of Guntur
City and found that the auto-rickshaw drivers experienced musculoskeletal problems
of low back, knee, neck and ankle due to their work experience and working hours
per week. They concluded that driver’s seat vibration was significantly associated
with LBP. Although the authors did not measure posture, they felt that improper

17
seating posture with continuous bending; twisting, leaning and stretches placed a
load on lower back and caused LBP among drivers.[15]
Kirkorowicz J et al.(2013):In their study among three-wheeler drivers found that the
most frequent health complaint was musculoskeletal pain. This was most likely
linked to occupation. The survey indicated that the primary cause of
musculoskeletal pain (which included LBP, shoulder and knees pain) was due to
vibration and staying in the same position for hours. Moreover, the authors did not
measure the duration of being in one posture or the posture type.[17]
2.6. Review of outcome measures
2.6.1. Nordic Musculoskeletal Questionnaire (NMQ)
The standardized NMQ is used to analyze musculoskeletal systems in an ergonomic
or occupational health studies and collects information on the period prevalence of
symptoms and interference with work and leisure arising from symptoms.
Investigations of lower back symptoms and their potential relation to working
activities have commonly employed the NMQ. The questionnaire content is of a
general questionnaire of 40 forced choice items identifying areas of the body
causing musculoskeletal problems. Completion is aided by a body map to indicate 9
symptoms sights, namely neck, shoulders, upper back, elbows, low back,
wrist/hands, hip/thighs, knees and ankle/feet. Respondents are asked if they have
had any musculoskeletal trouble in the last 12 months, and in the last 7 days which
have prevented normal activities. Additional questions relating to the lower back
further ask relevant issues. The reliability of the NMQ, using a test-retest
methodology, found to be the number of different answers ranged from 0-23%. The
authors concluded this was acceptable in a screening tool. Comparing pain in the
last 7 days and clinical examination, the author analyzed sensitivity ranged between
66% to 92% and specificity between 71 to 88%. Validity of NMQ was found to be

18
acceptable for the purpose of workplace ergonomics programmes. Validity tested
against clinical history and the NMQ found a range of 0-20% disagreement.[39]
2.6.2. 101 Numerical Pain Rating Scale (101 NPRS)
Jenson M et al (1986) had done a study to compare six pain measuring scales,
namely, Visual Analogue Scales, the 11 point Box Scale, 6 point Behavioral Rating
Scale, 4 point Verbal Rating scale, 5 pointing Verbal Rating Scale and 101
Numerical Pain Rating Scale in the patients with chronic pain. The scales were
assessed according to five criteria that were a) ease of administration of scoring, b)
relative rates of incorrect responding, c) sensitivity as defined by the number of
available response categories, d) sensitivity as defined by the statistical power and,
e) the magnitude of the relationship between each scale and linear combination of
pain intensity indices. From this study author concluded that 101 Numerical Rating
Scale is the most practical index comparing the other scales because it is easy to
administer and simple to score.[40]
Williamson A et al(2005) reviewed three commonly used pain rating scales, namely
the Visual Analogue scale, Verbal Rating Scale and the 101 Numerical Pain Rating
Scale. They used Pub Med as data base and papers which were methodologically
sound were included for this study. The search terms included pain rating scales,
pain measurement, Visual Analogue Scale, Verbal Rating Scale or the Numerical
Rating Scale. From this study the author concluded that all the three pain rating
scales were valid, reliable and appropriate for use in clinical practice. The Visual
Analogue Scale had more practical difficulties than the Verbal Rating Scale or the
101 Numerical Pain Rating Scale. The author also concluded that for general
purpose the Numerical Rating Scale had good sensitivity and patients who seek a
sensitive pain rating scale would probably choose this scale. Although for simplicity
patients prefer Verbal Rating Scale but it lacks sensitivity.[41]

19
2.6.3. Ovako Working postural Analysis System (OWAS)
The reliability of the OWAS was established in a study showing nurses in different
working postures were used to determine the reliability of OWAS observations.
Each slide was looked at for 3 seconds, while a new slide was shown every 30
seconds to resemble the normal practice of observation. Two observers twice
scored a series of slides, some of them being identical at both viewings. To reduce
effects of recall there was a time interval of 4 weeks or more between the two
viewings and the slides were in a different order the second time. Different series
were used to evaluate inter- and intra-observer reliability. The OWAS scores of
corresponding slides were compared. In almost all comparisons percentages of
agreement were over 85% and kappa's over 0.6 were found, which is considered as
good agreement.[42]
2.6.4. Oswestry Disability Index (ODI)
The World Health Organisation developed the following definition pertaining to the
assessment of LBP. Disability refers to the functional consequences of impairment,
such as inability to perform activities of daily living, tasks such as sitting, walking and
lifting as well as pain. Disability may be self reported (pain ratings) or reported by an
observer (Thomas et al.1993).
For treatment of LBP, symptoms and functional status are outcomes of great interest
(Beurskens et al., 1995). The term functional status questionnaire is used to denote
questions that assess a patient’s limitations in performing usual human tasks of
living.
The Oswestry Disability Index (ODI) is an evaluative, self administered questionnaire
for scoring the disability of patients with LBP and indicates the extent to which a
person’s functional level is restricted by back pain.

20
The ODI is based on ten stem questions which are pain intensity, personal care
(washing, dressing), lifting, walking, sitting, standing, sleeping, sex life, social life
and travelling. These were selected from a series of experimental questionnaires
designed to assess limitations in various activities of daily living. The chosen
sections were those found to be most relevant to the problems suffered by people
with LBP. Each stem question included six mutually exclusive items, covering
aspects of daily living, which may be affected by back pain. Each statement
described a greater degree of difficulty in the activity than the preceding statement.
In each section the six statements scored from ‘0’ to ‘5’, the first statement marked
by ‘0’ and the sixth by ‘5’. (Please see appendix – VI a-b)
If all the questions are answered, the scores for each stem question may be added
together (maximum 50), and expressed as a percentage. If any of the questions are
omitted, then the percentage disability score is scaled appropriately out of the
maximum possible score for the question groups that have been answered. If more
than one answer is given in each question group, then the higher score is added to
the total.
Interpretation of Disability scores is as follows:
0 - 20% Minimal Disability
20 - 40% Moderate Disability
40 - 60% Severe Disability
60 - 80% Crippled
80 - 100% These patients are either bed bound or exaggerating their symptoms
(Fairbank et al., 1980).
Validity
A valid questionnaire should correlate in a predictable direction, and in a statistically
significant manner with external measures of disease severity (Deyo 1988).
Fairbank et al., (1980) found in their study, that the questionnaire, when completed

21
at weekly intervals, reflected a gradual improvement in the scores. The score after
three weeks was significantly better than on admission (t test, P < 0.005).
Reliability
Reliability is a generic term used by psychometricians to indicate both reproducibility
(or precision) of scores and internal consistency of a scale (Deyo, 1988 and
Beurskens et al.1995). Fairbank et al., (1980) found a correlation coefficient of 0.99
(P<0.001) when 22 patients with chronic LBP were asked to complete the ODI
questionnaire at the same time and under similar conditions on two consecutive
days. Hudson Cook (1989), in a similarly designed study achieved a correlation
coefficient of 0.88, (P< 0.001).[43]
2.7. Summary of review of literature
The causes of LBP in the general population are well documented. LBP is
associated with certain occupations, driving, being one of them. Of interest were the
drivers of auto-rickshaw; one of the most efficient transport vehicles in modern India.
The review of literature studied previous published research on prevalence and risk
factors of LBP in auto-rickshaw drivers. It also analyzed outcome measures used in
the previous research. Based on the review of literature, a list of risk factors will be
studied in a population of auto-rickshaw drivers of Kolkata.

22
CHAPTER 3
MATERIALS AND METHODOLOGY

23
3.1 Introduction
The study was a survey design and was completed within a period of seven months.
500 auto-rickshaw drivers of Kolkata participated in the study and were assessed for
the prevalence of LBP and its possible risk factors. The following are the details of
the methods used in the study.
3.2 Objectives and hypothesis
3.2.1 Objectives
The objectives of the study were
• To determine the prevalence of LBP in auto-rickshaw drivers in urban
Kolkata.
• To explain the risk factors which may contribute to the development of the
symptoms of LBP in auto-rickshaw drivers in urban Kolkata.
3.2.2 Hypothesis
The study design was a survey, so a hypothesis was not proposed.
3.3 Human Research Ethics Committee
The present study commenced after obtaining approval from the Institutional Human
Research Ethics Committee (meeting on 28 03.2015), which considered the
protection of rights of the participants and their welfare.
3.3.1 Ethics Consideration
All participants of this study were given a consent form (Appendices Ia and Ib)
approved from the university. Full explanation of the importance of research and
follow up was given to the participants in a language understand by them. The

24
research was started only after receiving the consent form from the participants with
their signature. The participants were explained that they are free to withdraw their
participation at any point of time without prejudice.
3.3.2 Confidentiality
Confidentiality of identity and all records were kept for all subjects who took part in
this study.
3.4 Study design
A quantitative research model in the form of a descriptive type survey design. The
survey method was mainly in the form of questionnaires which were administered in
person, individually to each participant.
3.5 Sample size
A total of 575 auto-rickshaw drivers were contacted. 65 declined participation while
10 terminated participation. Eventually 500 auto-rickshaw drivers from different
routes of urban kolkata were surveyed for this study.
3.6 Subjects
3.6.1 Inclusion criteria
• Male auto-rickshaw drivers
• Driving for average 3 hours a day[33]
• Driving autos from more than 2 years[26]
• Age group 20 to 55 years[13]

25
• Basic education to be able to read Bengali/ Hindi/English
3.6.2 Exclusion criteria
• Previous surgery of the spine
• Any other surgery within last 5 years
• Trauma of spine
• LBP before starting the driving job
• Any deformities of the spine or of the upper and lower limbs
• Anxiety and depression
• Any neurological problem.
• Acute inflammatory conditions
All exclusion criteria was verbally enquired but not physically assessed.
3.7 Study tools
The study tools used in this study were
• Printed socio-demographic questionnaire
• Printed NMQ (English/Bengali)
• Printed OWAS chart
• Printed 101 NPRS
• Printed ODI (English/Bengali)
• Digital camera
• Photographs
• Transparent graph paper
• Inch tape
• Weighing machine
• Pen
• Eraser

26
• Paper
• Pencil
• Ruler
• Laptop
• Vibrometer (an android educational application)
• An android device (mobile phone)
• Statistical software

28
3.8 Parameters and Outcome measures
3.8.1 Parameters to be studied
• Intra-individual – age, gender, BMI, currently smoking, education levels, marital
status
• Occupational – work experience (number of years), working hours per day,
working hours per week, shoulder to handle distance, knee to brake distance
• Posture
• Pain site
• Pain intensity
• Vibration
• Disability
3.8.2 Outcome measures
Participants were assessed with the following outcome measures:
3.8.2.1 Socio-demographics for intra-individual and occupational data
(Appendix-II)
The data was nominal or interval type. The participants were asked questions on
socio demographic background (age, height, weight, education level, marital status,
languages known, socio-economic status, smoking habit), work style (number of
years worked, number of driving hours per day, working hours per week, shoulder to
handle distance, knee to brake distance).
The socio demographic questionnaire was handed over to the auto-rickshaw drivers.
Some of the questions were answered by them (age, number of years worked,
number of driving hours per day). Questions which were mainly interval data type
were assessed by the researcher individually. Weight was measured with the
weighing machine which the researcher carried to the auto stand; height was
measured using the inch tape. Shoulder to handle distance was measured using the

29
inch tape and was the distance from the greater tuberosity of the humerus (right) to
the styloid process of the ulna (right); the knee to brake distance was measured from
the lateral side of lower limb (head of fibula) to the brake pedal. BMI was calculated
using the calculation formula: weight (in kilograms) divided by height (in meter2
).
3.8.2.2 Nordic Musculoskeletal Questionnaire (NMQ) (Appendices-IIIa & IIIb)
Nordic musculoskeletal questionnaire (NMQ) was used to ascertain presence, extent
and prevalence of LBP. Data obtained was nominal type (Appendices-IIIa & IIIb).
The NMQ questions are forced choice variants and may be self-administered or
used as in an interview. For participants who did not understand English or could
not read, the questionnaire was used in an interview format and the Bengali version
(Appendix-IIIB) was used to ensure correct answers. NMQ various question
responders are suggestive about the prevalence of LBP.
3.8.3.3 Ovako Working postural Analysis System (OWAS) (Appendix-IV)
OWAS was used by taking their photographs for postural analysis in which they
were asked to sit as when they drive the auto-rickshaw. Photographs were taken
from side and front view to carry out the analysis for postural activities and twisting
posture of the body during driving. After the photographs were taken, the pictures
were put under transparent graph paper and lines were drawn using pencil and ruler
over the upper limbs, spine and lower limbs (joints were circled) for the identification
of the posture and to determine the action category level. Data obtained was ordinal
type. The OWAS is a method of coding the posture of a worker that allows the
harmfulness of the posture to be categorized into four (4) action categories of
increasing urgency. (Appendix-IV)

30
3.8.4.4 101 Numerical Pain Rating Scale (101 NPRS) (Appendix-V)
The 101 NPRS was used for the drivers to record their perceived level of pain
intensity on a numerical scale from 0–100, (0 = no pain and 100 representing
maximum pain). The number stated by the participant represented current pain
intensity and was used to measure current pain intensity.
3.8.5.5 Vibrometer (android application)
An android Vibrometer (1.4.6) was used for measuring the vibration of vehicles. Data
type was interval. A Vibrometer application was used when the vehicle was in
motion for a minimum period of 5 minutes and a maximum period of 20 minutes.
The device was kept at the junction of the driver’s seat and backrest to measure the
vibration when the auto-rickshaw was full of passengers. The maximum vibration (in
hertz) was noted.
3.8.6.6 Oswestry Disability Index (ODI) (Appendices-VIa & VIb)
The ODI questionnaire for scoring disability was distributed in both English
(Appendix-VI a) and Bengali (Appendix-VI b) format among the responders and
asked to answer the 8 different sections of the index. This self administered
questionnaire was used to evaluate the disability of the participants with LBP and
extent to which a person’s functional level was restricted by back pain.
ODI questions number 8 and 9 were omitted as they related to ‘Sex life and Social
life’. It was felt that auto-rickshaw drivers may not feel comfortable answering
questions about their private sex life and may not understand questions about
‘Social life’. Hence the total score was out of 40 instead of 50 and the percentage of
disability was calculated accordingly.

31
Both the NMQ and ODI are available in English. It was anticipated that the auto-
rickshaw population may not have knowledge of the English language. The NMQ
can be verbally used. However, for the convenience of the local population, the
NMQ was translated into Bengali (appendix-IIIb). Similarly, the ODI has been
translated into Bengali (appendix-VIb). It is conceded that the reliability and validity
of the translated versions has not been established. The translation was done so
that when these questionnaires would be administered verbally, there would be
uniformity and standardization in the question construct, content and delivery.

32
3.9 Research plan
575 auto drivers were elected as per inclusion and exclusion criteria
An informed consent was obtained from the subjects
Survey was conducted using all outcome measures
Data was collected
Collected data was analyzed for 399 auto-rickshaw drivers
65 denied participation and
10 dropped out. 500 auto-
rickshaw drivers selected
The 12 months prevalence was n
= 399 (79.8%)

33
3.10 Summary of methods
The study was conducted along different routes of auto-rickshaw transport in urban
Kolkata. After thorough explanation and being vigilant about the inclusion and
exclusion criteria, 500 participants were included in the study and were surveyed.
Data was collected by using all outcome measures to analyze prevalence and risk
factors for LBP.

34
CHAPTER 4
STATISTICAL ANALYSIS

35
Data was derived from the following questionnaires; the NMQ, the 101 NPRS, the
ODI as well as the socio-demographic and occupational questionnaire formulated by
the researcher to analyze the risk factors.
The data obtained was analyzed using descriptive statistics of mean, standard
deviations, minimum and maximum values of continuous data and frequency and
percentage values of nominal and ordinal data.
Logistic regression analysis was performed to ascertain the association of risk
factors (age, BMI, shoulder to handle distance, knee to break distance, vibration,
posture, and intensity of LBP) with LBP (dependent variable, nominal type).
A Pearson’s chi square test was also performed to determine the association
between two categorical variables.
The significance level for all analysis was determined at p<0.05. The Statistical
Package for the Social Sciences SPSS trail version 19 was used to data analysis.

37
5.1 Introduction
A total of 575 auto-rickshaw drivers were contacted. 65 declined participation while
10 terminated participation due to various reasons.
The NMQ was used to determine the period prevalence (12months) and the point
prevalence (7days) of LBP in a cohort of auto-rickshaw drivers surveyed for a period
of 6 months. The NMQ was chosen because it is standardized, widely accepted,
easy to administer and cost efficient. The first question of the NMQ asks if the
participant has ever had LBP. 411 (82%) out of 500 auto rickshaw drivers said
“yes”. The fourth question of the NMQ asks about LBP in the last 12 months. 399
(79.8%) mentioned that they had pain in the last 12 months. The data representing
LBP troubles of last 12 months was considered for statistical analysis in the study.
Question number 8 of the NMQ asks about presence of pain in the last 7 days. 144
auto-rickshaw drivers said ‘yes’. The 7 days point prevalence was 36%.
5.2 Socio-demographics of auto-rickshaw drivers chosen
for the study
The total numbers of responders who had LBP were 399 (79.8%) auto-rickshaw
drivers out of 500 who had been selected after being scrutinized for the inclusion
and exclusion criteria for this survey. The mean (±SD) age of the respondents was
40 (±6) years and the range was between 27 to 56 years. All participants were
males. Their mean (±SD) height was 164 (±5) centimeters, range 147-186
centimeters, weight 68 (±6) kilograms, range 52-90 kilograms and BMI was 25 (±
2.5), range from 20-35.
37.3% responders received education till the secondary level (i.e. till class x);
however an equal number were uneducated (31.4%). 24.9 % of auto-rickshaw
drivers received education only till the primary level, 5.2% till higher secondary level
and only a small number (1.2%) reached graduation qualification. (Figure – 5.1 A)

38
Figure – 5.1A: Education level distribution of auto-rickshaw drivers of urban
Kolkata (n=399)
Majority of the responders were married while a considerable number were single.
(Figure – 5.1B)
Figure – 5.1B: Distribution of married/single/others status of auto-rickshaw
drivers of Kolkata (n=399)

39
Most of the drivers were smokers (Figure – 5.1C) and the majority exhibited right
sided hand dominance. (Figure – 5.1D)
Figure – 5.1C: Smoking habit of urban Kolkata auto-rickshaw drivers (n=399)
Figure – 5.1D: Hand dominance a survey of auto-rickshaw drivers of urban
Kolkata (n=399)

40
5.3 Occupation (Work-style) details of auto-rickshaw
drivers of urban Kolkata
The work style details of auto-rickshaw drivers was documented they were a risk
factor for developing LBP (Table 5.1)
Table – 5.1: Occupational (Work-style) details of auto-rickshaw drivers in
Kolkata (n=399)
Work style details Mean (±SD) Range
Driving experience (in years) 14±5.6 3-35
Driving hours per day 11±1.6 7-16
Driving hours per week 69±12 40-112
Shoulder to handle distance (in cm) 50±3.5 38-63
Knee to brake distance (in cm) 46±3 37-57
Vibration measurement (in Hertz) 8.1±61 6-10

41
5.4 Response to NMQ by auto-rickshaw drivers
Table – 5.2: Response to the NMQ by auto-rickshaw drivers of urban Kolkata
(n=399)
NMQ Questions NMQ
answer options
Frequency Percentage
1. Have you ever had low back trouble (ache,
pain or discomfort)?
2. Had you ever been hospitalized
because of low back trouble?
3. Have you ever had to change jobs
or duties because of low back trouble?
4. What is the total length of time that
you have had low back trouble during the last
12 months?
5. Has low back trouble caused you
to reduce you activity during last
12 months?
a. Work activity (at home or away from
home)
b. Leisure activity?
No
Yes
No
Yes
No
Yes
0
1-7 days
8-30 days
More than 30 days by not
every day
Every day
No
Yes
No
Yes
89
411
410
1
405
6
12
204
111
78
6
317
82
329
70
18.8
82.2
99.75
0.25
98.55
1.45
2.91
49.63
27.4
18.97
1.45
79.44
20.56
82.45
17.55
6. What is the total length of time that low back
trouble has prevented you from doing your
normal work (at home or away from home)
during the last 12 months?
0 days
1-7 days
8-30 days
More than 30 days
210
165
24
0
53.63
41.36
6.01
0
7. Have you been seen by a doctor,
physiotherapist, chiropractor or other such
person because of low back trouble during the
last 12 months?
No
Yes
300
99
75.19
24.81
8. Have you had low back trouble at any time
during the last 7 days?
No
Yes
255
144
64
36

42
5.5 Measure of current pain intensity
The current pain intensity was measured using the 101 NPRS. The pain intensity
reported by the auto-rickshaw drivers was 41(±18), range 0 – 80.
5.6 Measure of disability due to LBP
Out of 399 auto-rickshaw drivers, 104 had no current pain whilst 295 drivers
responded in the ODI saying they had varying intensities of current pain. (Table –
5.3)
TABLE – 5.3: The ODI scores of all participants (n = 399) represented by
frequency and percentage of participants
Scores
0 1 2 3 4
1. Pain intensity 104 (27) 165 (41) 94 (23) 32 (8.0) 4 (1.0)
2. Personal care 344 (86) 50 (12) 5 (1.2)
3. Lifting 244 (61) 100 (25) 10 (2.5) 10 (2.5) 2 (0.5)
4. Walking 230 (58) 146 (36) 23 (6.0)
5. Sitting 191 (49) 141 (35) 64 (16) 3 (0.7)
6. Standing 280 (71) 105 (26) 14 (3.5)
7. Sleeping 339 (85) 56 (14) 4 (1.0)
8. Travelling 383 (96) 16 (4)

43
The ODI scores and percentage disability of auto-rickshaw drivers, frequency
of auto-rickshaw drivers ODI scores and percentage distribution out of total
(n=399)
TABLE – 5.4
ODI total score Disability% Frequency Percentage
0 0 69 17.2
1 3 2 0.5
2 5 68 17.0
3 8 12 2.9
4 10 57 14.1
6 15 44 10.9
8 20 32 8.9
11 27 44 11.0
13 33 30 7.4
15 38 16 3.9
17 43 17 4.2
20 50 8 2.0
Total 399 100.0
Logistic regression analysis was performed to ascertain the association of risk
factors (age, BMI, shoulder to handle distance, knee to break distance, vibration,
posture, and intensity of LBP) with LBP (dependent variable, nominal (type). The
analysis showed that there was no contribution from any independent variable. The
logistic regression model was statistically insignificant.

44
The Pearson’s Chi square test was conducted to test the association between
categorical variables and LBP prevalence.
Table – 5.5: Result of the Pearson’s Chi square test to test the association
between posture OWAS and LBP
Risk factor LBP Total Pearson’s
chi square
Phi
No (%) Yes (%)
Posture
(OWAS)
Level 1
Level 2
58 (42.9)
49(18.56)
77(57.03)
215(81.43)
135
264
0.487 0.264
The Pearson’s Chi square test as well as the Phi test for association between two
nominal variables were significant p <0.05. Level 1 implied that the driver’s back
posture was ‘straight’ whilst level 2 implied back posture as ‘bent and twisted’.
(Appendix – IV).
The results imply that these was a significant difference in the prevalence of LBP
between auto-rickshaw drivers who sat ‘straight’ compared to those who sat ‘bent
forward and twisted’ while driving. 81% auto-rickshaw drivers at action level 2
reported ‘yes’ to LBP.

45
Figure – 5.2A: OWAS action level 1 – sitting posture of auto-rickshaw driver of
urban Kolkata
Figure – 5.2B: OWAS action level 2 – sitting posture of auto-rickshaw driver of
urban Kolkata

46
5.7 Summary of results
The results of the survey showed that the only significant risk factor of LBP among
the auto-rickshaw drivers in urban Kolkata was their driving posture. Prevalence of
LPB is high but the disability caused by LBP was minimal to moderate.

48
6.1 Introduction
The study was an attempt to find the prevalence and risk factors of LBP among the
auto-rickshaw drivers in urban Kolkata. This chapter includes a detailed discussion
on the prevalence and risk factors determining the results of the study.
6.2 Prevalence of LBP in auto rickshaw drivers
The results of this study were analyzed in terms of prevalence of the LBP in auto-
rickshaw drivers by using the NMQ questionnaire for LBP.
The prevalence of LBP among the general population as well as different types of
vehicle drivers has been reported before. Prevalence of LBP worldwide among
general population has a wide variation and ranges from 20% to 65%.[2]
The results
of prevalence studies of LBP in heavy vehicle drivers vary between the type of
vehicle and from the country they are reported from. The point prevalence and 12
months prevalence in Danish fork-lift truck drivers was 21% and 65% respectively[23]
whilst in a Finnish study of earth mover operators it was higher at 51% and 82%
respectively.[22]
Among the bus drivers, prevalence of musculoskeletal disorders
and low back troubles varied between 40% to 82%. The 12 months prevalence of
LBP in taxi drivers was lower compared to heavier vehicle drivers and varied
between 59% (in Malaysia)[23]
to 46% in Southampton, UK [24]
One would expect the
prevalence of LBP to reduce further in lighter vehicles but the contrary was observed
in the only one previous study available which analyzed the prevalence of LBP in
auto-rickshaw drivers in Guntur, India and showed a 12 months prevalence of LBP
as 63.66%.[15]
The results of this study showed a fairly high prevalence too: the 7
days point prevalence of LBP among auto-rickshaw drivers was 36% whilst the 12
months prevalence was 81%. One of the reasons for auto-rickshaw drivers to
exhibit a high prevalence could be that they tend to sit in awkward postures while
driving [35]
. A further add on is that the drivers often share the driver’s seat in front

49
with passengers in order to carry more passengers and earn more. Sustained
continuous sitting in awkward postures may be a contributory
6.3 Risk factors associated with LBP
6.3.1 Age as a risk factor of LBP
The mean age of auto-rickshaw drivers in this study was 40 years, ranging from 27
to 56 years. This age group was similar to that noted in previous studies on car
drivers (mean age = 43 years) and auto-rickshaw drivers (mean age 46 years).[17]
Older age has been associated as a risk factor for LBP in car drivers. [13]
Whilst
previous studies on auto-rickshaw drivers explored age as a risk factor, they did not
find any significant association. [15]
The results of this study did not find any
significant association between age and LBP either although when the participants
were divided into age groups, drivers who had current pain and disability were more
in the age group 34-56 years. Middle aged drivers reporting more pain and
disability, compared to a younger group has been reported previously.[13]
6.3.2 Gender as a risk factor for LBP
All previous studies involving any kind of vehicle drivers have assessed only male
drivers. [15][17][35]
All auto-rickshaw drivers are male and hence one of the inclusion
criteria of this study was ‘only male auto-rickshaw drivers’. Hence the role of
gender as a risk factor was not explored.

50
6.3.3 Anthropometrics risk factors
These measures have not been studied in previous surveys on auto-rickshaw
drivers.[15][17]
A previous study on bus drivers of Kolkata, Gangopadhyay S (2012)
revealed that the average height of bus drivers was 162 cm, weight 53 kg and BMI
(20). The results of this survey measured the average height of auto-rickshaw
drivers as similar; 164 cm. However, they weighed much more than their bus
counterparts, mean weight was equal to 68 kg and the BMI was consequently higher
as well , 25, range 20 – 35. Since, both drivers came from the same population, it is
not clear why the auto-rickshaw drivers weighed more with a BMI category as ‘over-
weight’.
Previous studies [30]
from other countries show a positive association between LBP
in drivers and high BMI levels. Although the BMI levels measured in this study is
comparable to those studies and is in the category ‘over weight’, no significant
association was seen.
6.3.4 Education level as a risk factor for LBP
In this study, the auto-rickshaw drivers who had LBP in the last 12 months had
varied educational qualifications. 31.4% had no education, 24.9% had primary level
education, 37.3% had achieved secondary level of education, 5.2% higher
secondary level and only a handful were graduates (1.2%). A study in Galle
Kirkorowicz J (2013)[17]
is the only auto-rickshaw drivers study to have recorded the
education levels of their participants. Although they had a similar distribution,
comparisons are difficult as their sample size was extremely small. However, a
similar educational qualification population distribution was seen in bus drivers of
Malaysia for primary (31.2%), secondary (36.4%) and graduate levels 2.5%)
Shamsul B (2007).[31]

51
A review study by Dionne C (2001) [5]
associated low education qualifications with
adverse consequences of LBP. Various factors were considered to contribute to
this. However, similar to the results of this study, a previous study Shamsul B
(2007),[31]
which explored the association between LBP and educational levels
showed no significant results
6.3.5 Smoking as a risk factor
Smoking is common among drivers. In this study 81% drivers were smokers similar
to studies in Sri Lanka which reported 98% auto-rickshaw drivers as smokers
Kirkorowicz J (2013)[17]
and in Bangladesh[13]
where 80% professional car drivers of
were smokers.
Although it is an established fact that smoking is a risk factor for musculoskeletal
problems since it has a negative impact on bone mineral density and causes
lowering of vitamin D levels, changing hormones levels, slowing healing process and
increases fracture chances by 40% Racheal M (2014)[12]
, the results of this study as
well as that of Nahar N (2012)[13]
showed no significant association with LBP in
drivers.
6.3.6 Marital status as a risk factor
The percentage of drivers who were married were 62% which is less than reported
in previous survey studies where the average percentage of married drivers were
72% Bovenzi M (2006)[29]
and 90% Kirkorowicz J (2013).[17]
No significant association was seen between marital status and LBP in auto-
rickshaw drivers in this study similar to a study on truck drivers in Nagpur, Borle A
(2012).[32]

52
6.3.7 Work experience as a risk factor
The auto-rickshaw drivers in this study had an average driving experience of 14.56
years, the results of which are similar to Bovenzi M (2006),[29]
(16 years) but more
than that reported by Kirkorowicz J (2013)[17]
(9 years).
This study did not find any significant association between number of years of
experience and LBP. The results are similar to the study from Guntur [15]
which
explored this association but found no significant results.
6.3.8 Hours of driving
The surveyed auto-rickshaw drivers of this study drove an average 11 hours per day
and 69 hours per week. Another study on bus drivers in Kolkata had similar data.
The drivers drove 60 hours per week Gangopadhyay S (2012).[35]
Although most studies conducted on bus drivers Gangopadhyay S (2012)[35]
or other
vehicles Odebiyi D (2007)[36]
found a significant positive association between hours
of working and risk of LBP, this study as well as a previous study on auto-rickshaw
drivers Shaikh R (2014)[15]
found no such association.
6.3.9 Vibration as a risk factor
Heavy vehicle drivers are more prone to whole body vibrations which cause LBP.
Vibration measured from driver’s seat shows increase risk of low back injury.
Studies say vibration of vehicle in a hertz of 4Hz and above stimulated back muscle
fatigue and cause back pain. A previous study found vibration as a risk factor for
LBP in auto-rickshaw drivers. However, the results of such an association was not

53
significant in this study. A possible reason may be the android Vibrometer which is
an amateur device whose reliability and validity has not been tested.
6.3.10 Working posture related to risk factor
In this study, the OWAS was used to measure the working posture. The result
implied that drivers who were in OWAS action category 2, a posture described in the
scale as (the drivers have their back posture as bent and twisted, upper limbs (arms)
below shoulder level, lower limbs (legs) are hanging free and use of force needed
10kg or less) were at a higher risk of having LBP than drivers who were categorized
as OWAS action category 1 (drivers having their back posture straight, upper limbs
(arms) below shoulder level, lower limbs lower limbs (legs) are hanging free and use
of force needed is 10kg or less).
Category 1 means ‘posture is acceptable’ and action category 2 means ‘Some
strain- action or investigation is required’. In category action 1, those having LPB
were 77 (57.3%) drivers and those in category action 2 were 215 (81.43%) drivers.
Previous literature indicates that working posture in which the individual is mostly
bending or rotating, is in flexion or lateral bending, is twisting and or is in an
awkward posture, doing the same activity continuously causes muscle fatigue
Charoenchai L (2006)[37]
Sedentary work like driving causes LBP, where driver’s hip
at an angle of 900
or less produces continuous pressure over lumbar discs which
may lead to degeneration of the lumbar spine. Posture has not been evaluated in
previous studies of auto-rickshaw drivers. A study on bus drivers of Kolkata
Gangopadhyay S (2012)[35]
evaluated torso posture in as much details as the
current study and similar to the results of the study concluded that poor posture
while driving was a significant risk factor in LBP.

54
6.3.11 Other risk factors among auto-rickshaw drivers
Other risk factors which were explored in previous surveys Kirkorowicz J (2013),[17]
Shaikh R (2014)[15]
on auto-rickshaw drivers explored risk factors such as shoulder
to handle distance and lower cabin space. No significant associations were found.
In this study too, these risk factors were analyzed as well but no significant
associations were seen.
6.3.12 Disability due to LBP
In this study the disability was measured by using the ODI. The results implied that
284 (71.17%) were in the minimal disability level category (0-20%) and 90 (23.55%)
were in the moderate disability level category (21-40%) and 25 (6%) were in severe
disability level as interpreted by the ODI scale. So, it may be said that disability
levels were not very high in the population of auto-rickshaw drivers surveyed in this
study. Out of all the 8 stem questions of the ODI which were asked, namely, pain
intensity, personal care (washing, dressing), lifting, walking, sitting, standing,
sleeping, and travelling, it was observed that the sitting activity and pain had the
least number of drivers at ‘0’ level. 74% drivers had some level of pain and sitting
was a problem for 52% drivers, walking was a problem for 42% drivers and lifting
was a problem with 31%, and standing (30%) respectively. The high percentage of
disability for sitting may be attributed to long hours of driving which the drivers do. In
the study among bus drivers of urban Kolkata by Gangopadhyay S (2012)[35]
sitting
posture was mainly restricted among them due to LBP.

56
The 12 months prevalence of LBP was 79.8% and 7 days point prevalence was 36%
in this survey of auto-rickshaw drivers of urban Kolkata.
The risk factor for LBP in a survey of auto-rickshaw drivers was the forward bent and
twisted sitting posture which is frequently adopted by auto-rickshaw drivers while
driving.

57
CHAPTER 8
LIMITATION OF THE STUDY

58
The short time-span available during the course of the Masters programme
prevented acquisition of a larger survey population.
Bias in the results cannot be entirely ruled out as the researcher was not blinded.

59
CHAPTER 9
FUTURE RECOMENDATION

60
• More auto routes may be surveyed.
• The same type of auto models should be selected.
• Measurements for the upper limbs (shoulder to handle distance) should be
taken for the both sides.
• Vibration measurement tool should be tested for accuracy and reliability.
1.

62
2. Kreavitz A, Andrews L. Fitness and LBP. Medicine Science and Sports in
Exercise. 2011;22:265-274.
3. Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of LBP. Best
Practice and Research Clinical Rheumatology. 2010; 24: 769-781.
4. Stanton TR, Henchke N, Maher CG. After an episode of acute LBP, recurrence
is unpredictable and not as common as previously thought. Spine. 2008 Dec
15;33(26):2923-8.
5. Deyo R, Tsui W. Descriptive epidemiology of LBP and its related medical care in
the United States. Spine; 1987:(12) 264-268.
6. Dionne CE, Dunn K.M, Croft PR. Does back pain prevalence really increase with
increasing age? A systemic review. Age and ageing; 2006:35(3):229-34.
7. Gregory PS. Effects of Seated Whole-Body Vibration on Spinal Stability Control.
Virginia Polytechnic Institute and State University. (2008).
8. Linton, SJ. A review of psychological risk factors in back and neck pain. Spine,
2000; 25: 1148-56.
9. Ardiana M, Zana I, Ela P, Merita B, Teuta O. LBP among Kosovo power plant
workers: a survey. IJPH 2012; 9: 4.
10.Rajnarayan RT, Mrinalini CP, Sanjay PZ. LBP among Textile Workers. Indian
Journal of Occupational and Environmental Medicine, 2003; 7:1.
11. Kelsey JL, Hardy RJ. Driving of motor vehicles as a risk factor for acute
herniated lumbar intervertebral disc. Am J Epidemiol. 1975; 102(1):63-73.

63
12. Li ZY, Jiao K, Chen M, Wang CT, Yang YS. Spectral analysis of
electromyography of low back muscle fatigue induced by simulated driving, 2003;
21(5): 365-367.
13. Racheal M. The role of smoking in the progressive decline of the body’s major
systems. Public Health England. 2104: 597
14. Nahar NB, Ahsam GU, Nazmul AK. Prevalence of LBP and associated risk
factor among any professional car drivers in Dhaka city Bangladesh. SEAL of
Public Health, 2012; 2(1):60-63.
15. The Hindu magazine. Booklet informing auto rickshaw drivers of laws, rights
launched in kolkata. 2014; August 9.
16. Shaik R, Christie KG, Chintada GS, Sandeep R. The Prevalence of
Musculoskeletal disorders and their association with Risk Factors in Auto
Rickshaw Drivers-A survey in Guntur City. Int J Physiotherapy 2014; 1(1): 2-9.
17. Jadhav AV. Prevalence of backache among bus drivers and associated
modifiable risk factors in Latur, Maharashtra. Trivandrum, Achutha Menon
Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical
Sciences and Technology, 2012 Working Paper no. 14.
18. Kirkorowicz J, Sapukotana P, De Silva P.V, Noda M, Oliveira de PV, Ostbye T.
Work-Related Stress and Substance Use as Risk Factors for Chronic Disease
Among Three-Wheel Drivers in Galle, Sri Lanka: A Qualitative Study.
International Journal of Occupational Safety and Health, 2013; 3(2): 21-24.
19. Mohammad ATE. Prevalence of LBP among the bank workers at some
selected banks in Savar. BHPI, 2012.

64
20. Wong TS, Teo N, Kyew MO. Prevalence and Risk factors associated with LBP
among Healthcare providers in a district hospital. Malaysian Orthopaedic
Journal; 2011:4(2).
21. Chowdhury F. Self-reported musculoskeletal symptoms its physical and
psychological risk factors of arm, neck and shoulder among computer office
worker. BHPI:2014.
22. Lela M., Frantz JM. The Relationship Between LBP and Physical Activity
among Nurses in Kanombe Military Hospital. AJPARS, 2012; 4(1&2): 63-64.
23. Olanrewaju O, Steven JS, Marianne M, Malcolm P. City bus driving and LBP-
A study of the exposures to posture demands, manual materials handling and
whole-body vibration. Applied Ergonomics. 2007; 38:29-38
24. Sami ARD, Ahmed MQ, Noor HI, Krishna GR. Prevalence and determinants of
LBP among taxi drivers in Malaysia. A cross sectional study. Journal of
Advance Medical Research. 2012; 2(4): 129-143.
25. Gallais L. LBP and risk factors for LBP in car drivers. University of
Southamptom. Institute of Sound and Vibration Research.2008:phD
thesis.206-317.
26. Jaiswal. A. LBP and Work – related Risk Factors among Drivers of
Pondicherry. International Journal of Scientific Footprints. 2013;1(2): 7-16.
27. Begum N., Ahsam GU, Nazmul AK. Prevalence of LBP and associated risk
factor among any professional car drivers in Dhaka city Bangladesh. SEAL of
Public Health, 2012; 2(1):60-63.

65
28. Aminuddin AK, Mohammad MU, Ahsanul HC, Ranjan KG. Association of LBP
with Common Risk Factors: A Community Based Study. IJPMR 2014; 25 (2):
50-5.
29. Kuwashima A,Yoshiharu A, Nakamura K, Taniguchi S, Watanabe M. National
Survey on accidental LBP in Work place. Industrial Health. 1997;(35): 187-193
30. Bovenzi M, , Corrado N, Flavia Giuliano A, Francesca R, Sandra B, Lucia B,
GianLuca F, Silvana G, Pinto L , Livia R, Nicola S. An epidemiological study of
LBP in professional drivers. Journal of Sound and Vibration 2006; 298: 514–539
31. Nasrin S, Ehsanollah H, Seyed A.S. The relationships between
musculoskeletal disorders and anthropometric indices in public vehicle drivers.
International Journal of Collaborative Research on Internal Medicine & Public
Health. 2012; 4:(6).
32. Shamsul BT, Kazuhito Y, Juliana J,Nasaruddin A.A, Nizam J, Rusli N, Ayub LN,
Yunus A, Mazlan A. The Association between Risk Factors and LBP among
Commercial Vehicle Drivers in Peninsular Malaysia: A Preliminary Result.
Industrial Health 2007; 45: 268–278.
33. Borle A, Agawane S, Gunjal S, Tayde P. Study of Occupational Factors
Associated with LBP in Truck Drivers of Nagpur City, India. Int J Med Health
Sci. 2012; 1:3
34. Rajnarayan RT, Mrinalini CP, Sanjay PZ. LBP among Textile Workers. Indian
Journal of Occupational and Environmental Medicine, 2003; 7:1.
35. Holmberg S, Thelin A, Stiernstrom EL, Svardsudd K: LBP comorbidity among
male farmers and rural referents: a population-based study. Ann Agric Environ
Med 2005; 12: 261–268.

66
36. Gangopadhyay S, Dev S. Effect of LBP on social and professional life drivers
of Kolkata. IOS press and the authors. 2012; 41: 2426-33.
37. Odebiyi D, Ogwezi D, Adegoke B. The Prevalence of LBP in Commercial
Motor Drivers and Private Automobile Drivers. Nigerian Journal of Medical
Rehabilitation (NJMR). 2007; 12(1&2): 20.
38. Charoenchai L, Chaikoolvatana A, Chaiyakul P, 2006, The relationship
between health behaviour and pain scale in patients with LBP in Thailand,
Department of Pharmacological science, Ubon Ratchathani University, Ubon
Ratchathani, Thailand, 37(5): 1040.
39. Massimo B, Francesca R, Corrado N, Flavia D’A, Giuliano A, Sandra B, Lucia
B, GianLuca F, Silvana G, Pinto L , Livia R, Nicola S. An epidemiological study
of LBP in professional drivers. Journal of Sound and Vibration 2006; 298: 514–
539.
40. Kuorinka I, Jonsson B, Kilbom A. Standardized Nordic questionnaires for the
analysis of musculoskeletal symptoms. Appl Ergon 1987; 18:233-237.
41. Jenson MH, Peter MF, Dagny FH, Augusto C, Geoffery WH, Jon HL, Robin F,
Nina A, Stein K. Studies comparing Numerical Rating Scale, Visual Rating
Scale, Visual Analogue Scale for assessment of pain intensity in adults. A
systemic Literature Review. Journal of Pain and System. 2011; 41(6):1073-
1093.
42. Williamson A, Hoggart B. Pain: a review of three commonly used pain rating
scales. J Clin Nurs. 2005;14:798–804.
43. Bruijn I, Engels JA, Gulden JW. A simple method to evaluate the reliability of
OWAS observations. Appl Ergon. 1998; 29(4):281-3.

67
44. Fairbank, Jeremy CT., Paul B. The Oswestry Disability Index. Spine 2000;
25(22): 2940-2953.

THESIS BODY

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to THESIS BODY

Similar to THESIS BODY (20)

THESIS BODY