Low Back Flexibility and Pain Middle Tennessee State University 51 Impact of Three-week Educational Program on Low Back Flexibility and Pain in College Students Lauren Easley J. Angela Hart Murdock, Ph.D., and Don W. Morgan Ph. D Abstract Purpose: The purpose of this study was to document the effectiveness of a three-week educational program on low back flexibility and pain reduction in college students between the ages of 18 and 30 who are at risk for low back pain. Methods: Fifty college students were assigned to either an experimental group that participated in a three-week educational program or a control group. Subjects were assessed pre- and post-intervention using the following outcome measures: Oswestry© Low Back Pain Disability questionnaire, the Fitnessgram© Back Saver Sit and Reach test, and pre- and post-low back pain survey. Results: The majority of students decreased in low back pain and felt that the educational program was beneficial in preventing and delaying low back pain. A repeated measures ANOVA revealed that there was no significant interaction between groups over time in low back flexibility and pain intensity, p>0.5. Conclusion: An educational program for college students that increases low back flexibility and decreases pain will prevent or delay low back pain among college students. Scientia et Humanitas 52 Spring 2011 INTRODUCTION Low back pain (LBP) is the second most common ailment in the United States affecting sixty to eighty percent of the American population any given year.2 Previous studies have indicated the first episode of LBP occurs between the ages of 25 and 55.4 LBP takes place in the lumbar vertebrae where the vertebrae carry the majority of the body’s weight and endure a high amount of stress.2 Typically, episodes of LBP are acute and non-specific. LBP duration can be categorized as acute (<6 weeks) and chronic (>12 weeks), and it is defined as specific (i.e. fracture, tumor, infection, or bulging disc) or non-specific, which implies there is not a clear, specific cause.5,6 The majority of LBP experiences can be prevented or delayed with improvements in posture, exercise, and other lifestyle habits.7 With these types of improvements in mind, we have striven to create an educational program that will provide students with information to prevent or delay subsequent episodes of LBP. Risk factors for low back pain are aging, lack of physical fitness, weakness of back and abdominal muscles, smoking, obesity, low educational level, high levels of pain and disability, stress, and anxiety.6 Occupational risk factors that account for most low pain experiences are manual handling, bending, twisting, whole body vibration, monotonous tasks, poor work relationships, and heavy lifting.6 Effective, conservative treatments for low back pain intervention are light to moderate activity, non-steroidal anti-inflammatory drugs (NSAIDS), muscle relaxants, analgesics, exercise therapy, behavior therapy, spine manipulation, and multidisciplinary programs.6 In hopes of decreasing risk factors for students and increase the effectiveness of treatment students seek preventive methods that are conservative and effective such as an educational program. As described in Prevention and Treatment of Acute Low Back Pain: Physical Therapy and Other Non-surgical Methods, we found that Middle Tennessee State University students were experiencing LBP as early as 18 years old and preferred conservative treatment. Although there is evidence that low back education and conservative treatment are effective,4 this study seeks to measure the effectiveness of a three-week LBP education program. The program consists of lectures describing posture management, exercises, and activities. Assessment of the program, including students between the ages of 18 and 30 that are at risk for LBP, is through the analysis of pre- and post-program surveys. We will also use a secondary measurement to evaluate the effects of the program on hamstring flexibility with the Fitnessgram© Back Saver Sit and Reach test and level of back pain with the Oswestry© Low Back Pain Disability questionnaire. METHODS Subjects Fifty-two students participated in the study which received approval from Institutional Review Board of Middle Tennessee State University. Volunteers were recruited from Dr. J. Angela Hart-Murdock’s classes. Subjects were separated into a control group and an experimental group. Students were excluded from the study if they were not between the ages of 18 and 30 or had an Oswestry© Disability Index score of >40%. Low Back Flexibility and Pain Middle Tennessee State University 53 Eligibility Screening Oswestry© Low Back Pain Disability Questionnaire For 25 years, the Oswestry© Low Back Pain Disability questionnaire has been considered the “gold standard” for measuring low back pain functionality.8 Students completed the questionnaire assessing their pain intensity in nine modalities: while standing, conducting personal care, performing sexual acts, sleeping, lifting, walking, sitting, traveling, and socializing. Subjects were included in the study if their pain score was ≤ 40%, implying that the students were categorized as having minimal or moderate disability. Under these criteria subjects experience low back pain, but daily living is not affected. Procedures Fitnessgram© Back Saver Sit and Reach The Fitnessgram© Back Saver Sit and Reach has been shown to accurately measure hamstring flexibility but cannot be used to measure low back flexibility. The objective of the test is to measure the ability of subjects to reach a specified distance on the right and left sides of the body. The student’s highest measured distance was recorded to the nearest fourth an inch. Six students (three men and three women) chosen randomly from each group completed the sit and reach test. Low Back Pain Surveys Prior to the lectures, both the control and experimental group completed the LBP survey (Figure 1) providing information on age, experiences of LBP, posture while sitting, sleeping, standing, and lifting, and exercise history. After the experimental group completed the educational program, both groups completed another survey (Figure 2) to conclude if LBP experiences changed after completing the educational program. Low Back Prevention Worksheet After completing the educational program, the experimental group was provided a LBP prevention worksheet (Figure 3) that served as an overview of the lectures. The worksheet included proper posture and body mechanics, stretching and strengthening exercises, and moderate to low risk physical activities. The worksheet was given to all students for those who may have missed a lecture or did not comprehend the material during the lectures. INTERVENTION Fifty-two students were separated into the control and experimental group. The control group consisted of 23 students, and the experimental group consisted of 29 students. The control and experimental groups completed the LBP survey and Fitnessgram© Back Saver Sit and Reach test. The experimental group completed a three-week LBP educational program. Subjects in the control group were informed about the study, but were not given instructions on how to prevent or delay LBP. Both groups were reassessed and retested with Scientia et Humanitas 54 Spring 2011 the low back pain LBP questionnaire and the back saver sit and reach at the conclusion of the study. The experimental group received a 10 -20 minute lecture once a week for three weeks. The objective of the lectures was to provide students with the knowledge to prevent or delay LBP. The lectures included information regarding LBP prevalence, forms of conservative treatment for LBP, proper posture management while sitting, driving, lifting, and sleeping, strengthening and stretching exercises that targeted low back muscles, abdominal muscles, back extensors, hip extensors, and leg muscles, and physical activities. The lectures also included videos that demonstrated the how to sit while driving and how to properly pick up an object and included pictures on proper postures and exercises. After completing the LBP educational program, students were given a LBP prevention worksheet to help retain the information from the lectures. Data Analysis Descriptive statistics were calculated on all students to determine personal characteristics (Tables 1 and 2). Chi-square tests were performed to determine whether relationships existed on the basis of experiencing LBP while sitting, sleeping, standing, and lifting with the number of hours of sitting during the day, knowledge about proper postures for sitting, sleeping standing, and lifting, and improvement of postures for sitting, sleeping, standing, and lifting after completing the three-week educational program using a level of significance accepted at α=.05 (Table 3). The Fitnessgram© Back Saver Sit and Reach flexibility scores and Oswestry© Low Back Pain Disability questionnaire pain scores from the control and experimental groups were compared with an Analysis of Variance (ANOVA) with two repeated measures using a level of significance accepted as α=.05. RESULTS Descriptive Analysis Fifty-two college students participated in this study. Ten of the 52 students did not complete the post-LBP survey. The majority of the students were male that completed the study, and forty-one of the forty-two students that completed the study experienced low back pain (Table 2). After the three-week educational program, 63.34% of the students indicated LBP decreased compared to 42.11% decreased in LBP in the control group (Table 2). Using chi-square analysis, we could not reject the null hypothesis of independence of the following factors: experience of LBP when sitting and knowledge of proper sitting posture, experience of LBP when standing and knowledge of proper standing posture, experience of LBP when lifting and knowledge of proper lifting posture, experience of LBP when sitting and improvement of sitting posture, experience of LBP when sleeping and improvement of sleeping posture, experience of LBP when standing and improvement of standing posture, and experience of LBP when lifting and improvement of lifting posture (Table 3). However, we conclude experience of LBP is not independent of the number of Low Back Flexibility and Pain Middle Tennessee State University 55 hours a person is seated per day and experience of LBP when sleeping is not independent of knowledge of the proper standing posture (Table 3). Fitnessgram© Back Saver Sit and Reach A repeated measures ANOVA was conducted to determine differences between the experimental and control groups in flexibility scores. As shown in Figure 4, there was no statistically significant interaction (p>0.5) between group and time relative to flexibility score. There was no significant effects for group or time with respect to flexibility score (Figure 4). Oswestry© Low Back Pain Disability Questionnaire A repeated measures ANOVA was conducted to determine differences between the groups in low back pain scores. As shown in Figure 5, there was no statistically significant interaction (p>0.5) between group and time relative to pain score. There was no significant effects for group or time with respect to pain score (Figure 5). DISCUSSION The three-week educational program used in this study appears to be effective in decreasing number of experiences of LBP among college students between the ages of 18 and 30. The educational program’s purpose was to inform students of LBP prevalence, forms of conservative treatment for LBP, proper posture management while sitting, driving, lifting, and sleeping, strengthening and stretching exercises that targeted low back muscles, abdominal muscles, back extensors, hip extensors, and leg muscles, and physical activities. The students attended one 10-20 minute lecture every week for three weeks. Prior to the intervention, the majority of the students experienced LBP in the control and experimental groups (Table 1). After completing the three-week educational program, a majority of the experimental group decreased in LBP and felt that the three- week educational program was beneficial in preventing LBP (Table 2). The majority of the control group did not decrease in LBP (Table 2). Although when using chi-square analysis we could not reject the null hypothesis for a majority of the relationships, we could conclude that experience of LBP is not independent of the number of hours a person is seated per day, and experience of LBP when sleeping is not independent of knowledge of the proper standing posture (Table 3). Although the repeated measures ANOVA performed on the Fitnessgram© Back Saver Sit and Reach flexibility scores and Oswestry© Low Back Pain Disability questionnaire pain scores showed no statistically significant change within or between groups, there was a trend for improvement in flexibility and LBP between pre- and post-testing for the control group. The experimental group did not improve flexibility scores or LBP scores. This trend implied that the three-week educational program did not increase low back flexibility nor decrease level of pain for college students. Although speculative, the lack of Scientia et Humanitas 56 Spring 2011 effectiveness may be due to the short duration of the study and to the small sample size used for statistical analysis (ANOVA). CONCLUSION Interventions that help delay and prevent LBP among college students are essential, and educational programs may be an effective option. Future studies should increase the sample size of the experimental and control groups, increase the length of the education program, and require active participation during the education program by having students perform exercises and practice proper postures. Although students reported when they experienced LBP by completing the pre-program LBP survey, students should record their experiences of LBP in a journal during future educational programs. A three-week educational program did not appear to have an impact on low back flexibility and pain intensity, however the majority of students from the experimental group believed the program was beneficial in preventing low back pain. An education program for college students that increases low back flexibility and decreases pain could prevent or delay low back pain among college students. ACKNOWLEDGEMENTS This study was supported by the STEP MT grant. I would like to thank Dr. J.Angela Hart-Murdock, Dr. Don Morgan, and Elizabeth Holbrook for helping me conduct the study. I would also like to acknowledge the students of Dr. J. Angela Hart-Murdock’s classes for being involved in the study. Low Back Flexibility and Pain Middle Tennessee State University 57 REFERENCES 1 Hertling, D., Kessler, R. (2006). In Lippincott, Williams, and Wilkins, Management of common musculoskeletal disorders: physical therapy principles and methods .4th ed. Philadelphia, PA. 2006:843-890. 2 Nieman, David C. The Exercise-Health Connection. Champaign, IL: Human Kinetics; 1997. 3 Trevathan, W., Smith E., McKenna, J. (Eds.). Evolutionary medicine. New York: Oxford University Press; 1999. 4Braggins, Sheila. Treatment and prevention of low back pain. Back Care: A Clinical Approach. London: Harcourt Publishers Limited;2000:137-138. 5 Lippincott, Williams, and Wilkins. Exercise and activity for individuals with nonspecific back pain. In Wolters Kluwer, ACSM’s Resources for Clinical Exercise Physiology: Musculoskeletal, Neuromuscular, Neoplastic, Immunologic, and Hematologic Conditions.2nd ed. Baltimore, MD: American College of Sports Medicine; 2009:148-161. 6 Koes BW, van Tulder MW, and Thomas S. Diagnosis and treatment of low back pain. bmj.com;2006;332: 1430-1434. 7 The Fit Back: Prevention and Recovery. Time Life Education;1988;1:7-69. 8 Fairbank JCT, Couper J, Davies JB. The oswestry low back pain questionnaire. Physiotherapy;1980;66:271-273. Scientia et Humanitas 58 Spring 2011 APPENDIX Figure 1. Low Back Pain Pre-Survey Low Back Education Survey 1 The purpose of this study is to survey students between the ages of eighteen and sixty years old to determine the education levels of students about low back prevention methods. For additional information about giving consent or your rights as a participant in this study. Directions Please answer all questions. Please ask me any questions if you have any problems. 1. Age 2.Sex  Male  Female 3. Race American Indian or Alaskan Native White Hispanic/ Latino Asian, Pacific Islander, or Hawaiian native African American or Black Other 4. Have you ever experienced back pain? Yes No 5. How often do you experience low back pain?  Daily  Weekly  Monthly 6. Do you experience low back pain when sitting? Yes No 7. How long do you sit during the day? (i.e. during class, while driving, etc.) 1-2 hours 3-4 hours 5-6 hours 7 or more hours 8. Circle the correct sitting posture and box the sitting posture that you find yourself in the most. 9. Do you experience low back pain when sleeping? Yes No Low Back Flexibility and Pain Middle Tennessee State University 59 10. Circle the correct sleeping posture and box the sleeping position that you find yourself in the most. 11. Do you experience low back pain while standing? Yes No 12. Circle the correct standing posture and box the standing position that you find yourself in the most. 13. Do you experience low back pain while lifting? Yes No Scientia et Humanitas 60 Spring 2011 14. Circle all of the correct lifting postures. 15. You experience low back pain more when  Sitting Sleeping Standing Lifting 16. How often do you exercise within a week?  0-1 days 2-3 days 4-5 days 6-7 days 17. Does your exercise program include exercises that strengthen or stretch your abdominal exercises? Yes No 18. Do you feel behavioral changes will prevent or delay low back pain? Yes No Low Back Flexibility and Pain Middle Tennessee State University 61 Figure 2. Low Back Pain Post-Survey Low Back Pain Education Survey 2 The purpose of this study is to survey students between the ages of eighteen and sixty years old to determine if the low back pain education lecture delayed or prevented experiences of low back pain for students. For additional information about giving consent or your rights as a participant in this study. Directions Please answer all questions. Please ask me any questions if you have any problems. 1. Age 2.Sex  Male  Female 3. Race American Indian or Alaskan Native White Hispanic/ Latino Asian, Pacific Islander, or Hawaiian native African American or Black Other 4. Did you improve your posture when sitting? Yes No 5. Did you improve your posture when sleeping? Yes No 6. Did you improve your posture when standing? Yes No 7. Did you improve your posture when lifting? Yes No 8. Have your experiences of low back pain lessened? Yes No 9. Do you feel improving posture lessened your experiences of low back pain? Yes No 10. Have you increased how many times you exercise within a week? Yes No 11. Do you include exercises that strengthen or stretch your abdominals? Yes No 12. Do you feel that the lecture was beneficial to you in preventing low back pain? Yes No Scientia et Humanitas 62 Spring 2011 Figure 3. Prevention of Low Back Pain Worksheet Low Back Flexibility and Pain Middle Tennessee State University 63 Table 1. Pre-Program Personal Characteristics for Participants Pre-Personal Characteristics Control (n) Experimental (n) Control (%) Experimental (%) Sex Male 11 10 52.17 65.52 Female 12 19 47.83 34.48 Race White/Caucasian 18 18 78.26 55.17 Black/African-American 4 7 17.39 31.03 Hispanic/Latino 0 3 0 10.35 Asian/Pacific Islander/ Hawai- ian native 0 1 0 3.45 Other 1 0 4.34 0 Experience LBP Yes 22 27 95.65 93.10 No 1 2 4.35 6.90 Frequency of LBP Daily 4 5 19.05 18.51 Weekly 1 8 4.76 29.63 Monthly 16 14 76.19 51.85 Frequency of Exercise 0-1 day 4 9 18.18 31.03 2-3 days 11 12 50.00 41.38 4-5 days 4 7 18.18 24.14 6-7 days 3 1 13.64 3.45 Scientia et Humanitas 64 Spring 2011 Table 2. Post-Program Personal Characteristics for Participants Post-Personal Characteristics Control (n) Experimental (n) Control (%) Experimental (%) Sex Male 9 7 47.37 30.43 Female 10 16 52.63 69.57 Race White/Caucasian 14 17 73.69 73.91 Black/African- American 4 4 21.05 17.39 Hispanic/Latino 0 1 0.00 4.35 Asian/Pacific Islander/ Hawai- ian native 0 1 0.00 4.35 Other 1 0 5.26 0.00 Experience LBP Yes 19 22 100.00 95.65 No 0 1 0.00 4.35 LBP Decreased Yes 8 14 42.11 63.64 No 11 8 57.89 36.36 Exercise Increased Yes 7 11 36.84 50.00 No 12 11 63.16 50.00 Lecture Beneficial Yes N/A 21 N/A 95.45 No N/A 1 N/A 4.55 Low Back Flexibility and Pain Middle Tennessee State University 65 Table 3. Results of Chi-Square Testing for Independence in Experimental Group Factors Chi-Squared Value (χ2) Degrees of Freedom (df ) Cut Off Value (α=.05) Experience of LBP and Amount of Sitting per Day 6.365 2 5.911 Experience of LBP Sitting and Sitting Posture 0.089 1 3.841 Experience of LBP Sleeping and Sleeping Posture 6.390 1 3.841 Experience of LBP Standing and Standing Posture 0.244 1 3.841 Experience of LBP Lifting and Lifting Posture 0.024 1 3.841 Experience LBP Sitting and Improved Sitting Posture 1.317 1 3.841 Experience LBP Sleeping and Improved Sleeping Posture 1.498 1 3.841 Experience LBP Standing and Improved Standing Posture 0.176 1 3.841 Experience LBP Lifting and Improved Lifting Posture 1.011 1 3.841 Scientia et Humanitas 66 Spring 2011 Figure 4. Fitnessgram Back Saver Sit and Reach Flexibility Scores *Significant interaction of flexibility intervention by time, p>0.5 Figure 5. Oswestry Low Back Pain Disability questionnaire Pain Scores *Significant interaction of flexibility intervention by time, p>0.5