The effectiveness of rehabilitation on pain-free farming in agriculture workers with low back pain in India

Abstract

BACKGROUND: Studies have shown that farming is associated with many agricultural workers experiencing low back pain (LBP). The rehabilitation of these workers should facilitate their functioning, activities and level of participation in an adequate way.

OBJECTIVE: The objectives of this study were to identify the health components associated with LBP and to evaluate the effectiveness of the interventions in returning agricultural workers with LBP to their vocation using the International Classification of Function (ICF) -based tools.

METHODS: Thirty-one full time agricultural workers from 3 different Indian states were prospectively assessed using the ICF core set for LBP. ICF core sets permitted analysis of limitations of function from both the participant and rehabilitation team’s perspectives. Each ICF category was rated using an ICF qualifier. The components identified were linked to the ICF categorical profile and assessment sheet. The clinicians identified the global, service program and cycle goals based on ICF. The participants’ functioning was followed over a 4-month period.

RESULTS: After intervention, the participants were able to undergo their routine activities without increases in pain. However, on returning to active farming, participants noted few improvements in the components d410 (changing basic body position), d415 (maintaining body position), d430 (lifting and carrying objects), d465 (moving around using equipment), d850 (remunerative employment) and d859 (work and employment, other specified and unspecified).

CONCLUSION: The results of the study conclude that the current interventions for LBP are not effective in returning agriculture workers with LBP in India to pain-free farming. There is an urgent need to individualize the health needs of agriculture workers.

Keywords

Occupations return to work human engineering international classification of functioning disabilityand health

1 Introduction

India is one of the world’s largest agricultural economies and has the second largest agricultural workforce, with 260 million workers [1]. Agriculture and its allied sectors accounted for 13.7% of the gross domestic product (GDP) in 2013 for India [2]. Agriculture work is a highly physically demanding occupation [3] involving static positioning, forward bending, heavy lifting and carrying, kneeling, and exposure to vibration. Work-related musculoskeletal disorders are one of the greatest occupational health concerns today. Agriculture work is associated with the development of musculoskeletal disorders and studies have revealed a high percentage of the workers (62.8%) reporting back pain, followed by work-related musculoskeletal disorders of the lower limbs (25.6%), and upper limb or neck complaints (23.2%) [4, 5].

Low back problems (LBP) among agriculture workers appear to be associated with the frequency of using postures requiring back flexion, carrying and lifting of heavy loads and exposure to whole body vibration [6, 7]. The 12-month prevalence rates of LBP among farmers in various developed countries are 37% in Ireland [4, 5], 37% in the USA [8] and 47% in Sweden [9]. In developing countries, the prevalence rates are higher: 72% in Nigeria [10], 64% in China[11] and 56% in Thailand [12]. The higher percentage of low back pain may be attributed to human effort that provides more than 70 per cent of the energy required for crop production tasks in developing countries [13].

Very few studies have examined the issues of musculo-skeletal disorders in an Indian population [14 –16]. An epidemiological study of nine villages in Northern India [17] indicated that, in a population of 30,000, only 258 cases of musculoskeletal problems were formally reported in one year. However, medical and MRI examinations revealed high levels of abnormal objective findings. However, LBP is neither a fixed disease nor a diagnostic entity. LBP is a chronic problem with periods of symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences [18]. The symptoms of LBP need to be viewed as a reflection of psychophysical performance, rather than true physiological abilities [19]. Due to the multi factorial nature of LBP, biopsychosocial models are necessary to understand the experiences of people living with LBP.

The biopsychosocial model forms the basis of the International Classification of Functioning, Disability and Health (ICF) [20]. In the ICF model, functioning and disability are classified in terms of body structure and function as well as in terms of activity and participation of the individual. Function is conceptualized by the World Health Organization(WHO) as the dynamic interaction of a person’s physical activity within his or her environment [21]. Conventional functional assessments (both objective and subjective) provide a limited picture of a person’s overall function, because they only assess functional abilities within the testing environment and over a short period of time. Likewise, subjective measures are limited because they rely on a person’s ability to accurately recall activities they have been able/unable to do over a specific period of time [22]. The ICF attempts to provide a coherent view of health from a biological, individual, and societal perspective. The ICF core sets have been developed to facilitate the use of the ICF in clinical practice and research. The ICF core sets facilitate a systematic and comprehensive description of functioning in high-risk populations by including the typical spectrum of problems in functioning. The ICF core sets and categories help clinicians determine what should be measured, rather than how they should be measured. ICF based documentation allows illustration of the person’s experience of functioning. Functioning and health shall be considered as the starting point for assessing functioning and health of people rather than as an outcome. Objectively measuring these components of the ICF may provide a better measure of a person’s true level of function and offer additional insight into the impact of disability.

Agriculture work has been rated as one of the most dangerous occupations in the United States [23]. Despite the wide spread reporting of musculoskeletal signs and symptoms by agriculture workers, there has been limited application of research related to ergonomics and musculoskeletal disorders [24]. A systematic review by Lilley and coworkers [25] reviewed the effectiveness of interventions on agricultural injury and disease prevention. They reported that many interventions have shown little or no effect on injury or ill-health outcomes on farms. There has been criticism that health care providers do not focus upon musculoskeletal disorders in the agriculture population due to the assumption that musculoskeletal disorders are an unavoidable result of farm labor [26]. The burden of LBP in agriculture workers is of concern not only to those working in the agricultural sector but also to researchers, policy makers, and government. Though the negative impact of LBP on agricultural farmers is well known, effective prevention and attempts to reduce the disproportionate levels of ill-health have remained elusive [27, 28].

Though previous studies have looked in to the prevalence of musculoskeletal disorders in Indian populations [14 –17], there is a lack of understanding of those factors associated with LBP in agriculture workers. Further no Indian study has evaluated if a multi-disciplinary rehabilitation intervention is effective and capable to bring a positive change in the performance of agriculture workers. The objectives of this study were to identify the biological, psychological and social components influencing agriculture work in participants with LBP and to use ICF based tools to evaluate the effectiveness of rehabilitation programs designed to return workers to agricultural work.

2 Methodology

This was a multicenter study with three participating institutes in different states of India conducted from January 2013 to August 2014. All centers of study received research ethics approval for this study, and participants gave informed consent. The first author provided a comprehensive written manual in order to ensure a standardized approach to ICF application and treatment across the study centers. The authors coordinated the ICF administration in the respective study centers. All the authors were trained in ICF application. All the members of the research team attended a session prior to the study, where they discussed the evaluation procedure and overall study. All assessments and treatment procedures were conducted by healthcare professionals (prosthetist/orthotist, psychologist, physiotherapist, social worker, occupational therapist and physician). A prospective design was used to determine the effectiveness of rehabilitation interventions on agriculture workers with LBP during a 6-week program.

All agriculture workers reporting with LBPwere screened in the out-patient department of therespective study centers by a physician to identify potential study participants. The inclusion criteria were (1) full time agriculture workers for minimum 5 years of both genders, (2) work-related back pain provoked with postures, movement and activities, (3) not receiving any other treatment other than stable doses of analgesics or non-steroidal anti-inflammatory drugs and (4) normal neurological examination. Participants with the following criteria were excluded: (1) unable to adhere to interventions and advice for the total duration of the study period, (2) any pathology, trauma or surgery at or around spine, pelvis, hip, knee and ankle, (3) pregnancy, (4) psychiatric disorder (5) systemic diseases, (6) gross structural deformities to lower limb or spine and (7) any contra-indications for physiotherapy and occupational therapy. There were no restrictions in terms of duration of symptoms or manifestations of clinical symptoms.

Fifty-one agriculture workers (47 males and 4 females) (mean age of 42.4±6.6 years) who met the inclusion criteria and had LBP as their chief complaint were enrolled. Four participants (all males) were eliminated due to noncompliance with the intervention program, 11 participants (m=8, f=3) withdrew from the study for personal reasons and 5 participants (all males) were lost in follow-up. Thirty-one participants (30 males and 1 female) with mean age (43.8±7.4) participated and completed the study (Table 1). Due to the specific population recruited, many had associated disorders affecting the lower extremities and neck. Though the ICF evaluates disability by incorporating social aspects of daily living, contextual factors and environmental impact on function and health status, we restricted the focus of the study on activities pertaining and related to farming. This was justified as the aim of the study was to identify the factors associated with LBP in agriculture workers and evaluate the effectiveness of rehabilitation interventions applied in agriculture workers with LBP. The farmers in this study sample were not actively involved in farming at the time of study; some (n=24) due to the seasonal nature of agriculture and others owing to LBP (n=7). The outcomes were again evaluated at the completion of rehabilitation (6 weeks) and after the participants had entered active farming (4.1+2.2 months).

3 Procedures

Demographic data was collected from all participants and the assessment was made using the ICF comprehensive core set for LBP [29] (Table 2). The comprehensive core set for LBP has 78 second-level categories, 19 from the component body functions, 5 from body structures, 29 from activities and participation, and 25 from environmental factors. ICF requires analysis of limitations of function from both the patient and health professional’s perspectives. As ICF based clinical measures are not available currently to assess all the relevant domains of LBP core set, the authors agreed to use the following selected scales, tests and measures to facilitate uniformity and reliability among assessment and grading: b126 (Temperament and personality functions) – Jung Typology Test [30], b130 (Energy and drive functions) – multi dimensional assessment of fatigue [31], b152 (Emotional functions) – PROMIS (Patient Reported Outcomes Measurement Information System) [32, 33], b180 (Experience of self and time functions) – Self-report questionnaire that include the body shape questionnaire [34], body esteem scale [35] and the body shape satisfaction scale [36], b260 (Proprioceptive functions)- reproduction of angular position for joint position sense, b280 (Sensation of pain) – visual analogue scale [37], b455 (Exercise tolerance functions) – 6 minute walk test [38], b710 (Mobility of joint functions) – goniometer (to measure lumbar spine range of motion) [39, 40], b730 (Muscle power functions) – pressure biofeedback (to measure strength and endurance of trunk muscles) [41], and b770 (Gait pattern functions) – visual gait analysis[42]. Where objective examination was not feasible [domains b134 (Sleep functions), b715 (Stability of joint functions), b720 (Mobility of bone functions), b735 (Muscle tone functions) and b780 (Sensations related to muscles and movement functions); activities and participation components (Table 2)], subjective estimation of the persons’problems in ICF domains was done using a 0–4 likert scale (0-none, 1- mild, 2-moderate, 3- severe, 4 – complete) to quantify the magnitude of participants’ and clinicians’ perception of problems. Activities and participation of the participants was rated from the perspective of capacity and performance. The performance qualifier is described as what an individual does in his or her current environment whereas the capacity qualifier describes an individual’s ability to execute a task in a “standardized environment”. Information regarding environmental factors (facilitators and barriers) was collected from participants through an interview. All the measurements were taken prior to the beginning of the intervention, at 6 weeks and once the participants had re-enteredactive farming.

Limitations of function were analyzed from both the participant and team’s perspectives. The participants’ views of their problem and health functions was extracted via interview and the health professionals’ perspective of the participants’ health was assessed by relevant multi-disciplinary team members. The ICF categorical profile and assessment sheet was framed for each participant at the time of assessment by rating each ICF category using ICF qualifiers. The goals were identified by the treating clinicians within the components of functioning. Global goals target on the achievement of the optimal performance at the societal level and participants expressed their desire to return to pain free farming. Service program goals are the final targets to be achieved by different health professionals through achievement of several cycle (short term) goals. The cycle goals set to achieve the service goals were reducing the participant’s pain, improve range of motion and muscle strength of trunk, improve cardio-respiratory endurance, ability to walk, carry, and move objects and promote a healthylife style.

4 Intervention and follow-up

Before the study, it was decided to use a multi-disciplinary approach to rehabilitation. The results of a recent systematic review that assessed the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain showed that these interventions were more effective than usual care and physical treatments in decreasing pain and disability [43]. The treatment’s aim was to deliver multidisciplinary biopsychosocial rehabilitation whilst allowing sufficient flexibility to adapt the intervention to participants’ need.

In each center designated qualified health professionals provided the interventions for the goals and intervention targets identified. Participants received standard ergonomic advice and task-focused out-patient rehabilitation tailored to individual’s physical assessment findings. The amount of rehabilitation, such as psychology, physical and occupational therapy received was registered for each participant. The health professionals chose interventions according to the participant’s needs and abilities. Standardized rehabilitation for all participants comprised of back strengthening exercises, abdominal stabilization exercise, stationary cycling at a self selected pace for 15 minutes and back care advice (ergonomic principles, proper posture, and lifting techniques). The health care professionals also prescribed electrical modalities (interferential therapy, ultrasound, or heat pack), passive segmental mobilization to the lumbar spine and stretching exercises depending upon indication. The participants were seen by a clinical psychologist as the assessment revealed issues with energy, drive and emotions. All participants received the intervention for a period of three sessions per week for 6 weeks. At the end of the program, all participants were taught self stretching, core strengthening exercises and received instructionsregarding maintenance of optimal posture and ergonomic advice. Participants were encouraged to follow these instructions, continue exercises and avoid immobility.

5 Results

Thirty-one participants with LBP from three different centers participated and completed the study. A total of 14 of 19 ICF categories of body functions and a total of 15 of 29 categories of activities and participation could be identified as significant problems present in Indian agricultural workers at the time of reporting. The participants reported reduction of symptoms and noticed an improvement in outcomes after the intervention. This improvement was more noticeable for the categories b280 (Sensation of pain), b735 (muscle tone functions), d415 (maintaining a body position) and d430 (lifting and carrying objects). Nevertheless, the number of participants who experienced a functional improvement following intervention decreased once they re-entered active farming. The number and types of problems did not change at the end of final follow-up compared to baseline (Table 3).

The majority of participants (n=26) carried out agricultural work on a family basis (children, women and the elderly) in this study sample. The participants reported experiencing acute recurrent episodes of severe back pain lasting greater than or equal to 1 week. The severity of back pain among men was higher with lower back being the area most often affected. The majority of participants attributed LBP to work related issues, while few attributed back pain to traumatic events associated with farming. The majority of participants worked on farms for 5 days per week. The participants reported undertaking a wide variety of tasks including crop processing, storage and packaging, pest management, poultry, livestock breeding and associated domestic tasks.

The body functions, structure and functioning reported to affect agriculture work at various points of evaluation are presented in Table 3. The severity of the problems identified was rated by the qualifiers based on case history, patient reported questionnaire, clinical examination and/or technical investigation as described in the procedure section. While none of the ICF categories were rated as complete problems [ICF qualifier 4], severe problems [ICF qualifier 3] were identified for categories ‘b260-proprioceptive functions’, ‘b280- sensation of pain’, ‘b710-mobility of joint functions’, ‘b715- stability of joint functions’, ‘b780- sensations related to muscle and movement’ and ‘s760- structure of trunk’. Moderate problems [ICF qualifier 2] were identified for categories “b134- sleep functions’, ‘b455- Exercise tolerance functions’, ‘b720- mobility of bone functions’ and ‘b740- muscle endurance functions’. In Indian farming environments there was not much difference between capacity and performance elements. Functions were moderately affected (ICF qualifiers 2 and 3) for categories ‘d410- changing basic body position’, ‘d415- maintaining body position’, ‘d420- Transferring oneself’, ‘d430 – lifting and carrying objects’, ‘d450- walking’, ‘d465- moving around using equipment’, ‘d475- driving’, ‘d845- acquiring, keeping and terminating a job’, ‘d850 – remunerative employment’ and ‘d859- work and employment, other specified and unspecified’.

The participants identified ‘e110- drugs (over-the-counter)’, ‘e310-immediate family’, ‘e155- health professionals’ and traditional oils (traditional medicine that carry cultural and religious beliefs) as facilitators to functioning. The components ‘e225- climate’, and ‘e255- vibration’, were marked as complete barriers. The components of ‘e135-products and technology for employment’ and ‘e450- individual attitudes of health professionals’ were considered both as facilitators and barriers to participants’ functioning. Components ‘e550-legal services, systems and policies’, ‘e570- social security services, systems and policies’, ‘e575- general social support services, systems and policies’, ‘e580- health services, systems and policies’, ‘e585- education and training services, systems and policies’ and ‘e590 – labor and employment services, systems and policies’ were graded not specified as participants in this study sample had no experience with these types of support and relationships.

All participants received the same amount of contact and treatment time from treating clinicians, as well as standard and function-focused outpatient rehabilitation. The baseline, post-intervention and follow-up scores of ICF domains are presented in Table 4. The Wilcoxon signed-rank test was used to compare the effects of rehabilitation at 6 weeks and 4 months compared to baseline (Table 4).

The overall results of the study showed that the multidisciplinary rehabilitation was effective in reducing pain (b-280) and improving the spinal range of motion (b-710), strength (b-730) and endurance (b-740) of back muscles (p < 0.01) at 6 weeks. All participants noted an improvement in their activities and social participation. Participants reported an improvement in gait (d-450) as they felt more ‘agile’ and ‘walked faster’. The participants were satisfied with the outcome of the treatment. However once the participants had re-entered active agriculture work the effect of interventions were not sustained. The domains ‘d410-changing body position’, ‘d415-maintaining a body position’, ‘d430-lifting and carrying objects’, ‘d465- moving around using equipment’, ‘d850-remunerative employment’ and ‘d859- Work and employment, other specified and unspecified’ showed very minor changes after intervention (p > 0.05).

6 Discussion

This is the first study to identify factors associated with LBP in agriculture workers and evaluate the effectiveness of healthcare interventions on return to work in a predominantly agricultural community in India using ICF based tools. The results of the study showed that multiple factors contributed to LBP in these populations. The participants in the study carried out their agriculture work in rural environments where working and living conditions are interwoven. Agricultural workers are subjected to the health risks inherent to a rural environment and at the same time to those deriving from the specific work processes involved (e.g. d570 – looking after one’s health). Though the majority of participants reported chronic LBP, they never reported avoiding the tasks associated with agriculture due to the seasonal nature of farming that demands an urgency to complete the work within the stipulated period. Further assessment of ‘b126- Temperament and personality functions’ by the Jung typology test revealed that majority of participants as introverts. This might point out why these participants did not report their symptoms until they reached a level that interfered with their ability to perform their jobs.

More than 60% of the study participants identified issues in ‘d240 – Handling stress and other psychological demands’, ‘b130- Energy and drive functions’ and ‘b152- Emotional functions’. Apart from the ill-effects of chronic pain on mental flexibility and cognition [44, 45], participants identified machinery and tool breakdown, farm-related accident, natural calamities and lack of long term employment (d-845) (d-850) affecting their emotional state. Further time pressures due to increased seasonal workload forced the participants to work for long hours for most days of the week leading to fatigue, both physically and mentally.

The ICF categories ‘b260-proprioceptive functions’, ‘b280- sensation of pain’, ‘b710-mobility of joint functions’,‘b715- stability of joint functions’, ‘b780- sensations related to muscle and movement’, ‘b455- Exercise tolerance functions’, ‘b720- mobility of bone functions’, b740- muscle endurance functions’, ‘d410- changing basic body position’, ‘d415- maintaining body position’, ‘d420- Transferring oneself’,’d430 – lifting and carrying objects’, ‘d450- walking’, ‘d465- moving around using equipment’, ‘d475- driving’ were found to influence LBP in the study participants. Agricultural activities comprise of static positioning, forward bending, heavy lifting and carrying, kneeling, and vibration. The majority of participants were involved in small-scale farming that necessitated stooping and static postures. Static forward-bent postures are often associated with working at or near ground level in agriculture. Weeding, harvesting, and cleaning crops are all commonly performed in either stooped or squatting postures. Participants’ work frequently involved postures, requiring severe flexion, lateral twisting, bending, and kneeling, along with heavy lifting and repetitive and forceful exertions with heavy overhead lifts, and awkward work positions. Even animal-assisted tasks such as sowing, and fertilizer application using bullocks involved prolonged trunk flexion. In plowing fields, a stooped posture has to be maintained while simultaneously exerting substantial force to maintain the depth of the furrow [46]. Biomechanical research has shown that high spinal compression forces occur in stooped postures, and sustained or repeated flexion of the spine can disturb the neuromuscular stability of the lower back and increase the risk of fatigue. Energy expenditures of common agricultural tasks using hand tools range from 13 to 40 kilojoules per minute that exceeds the NIOSH (National Institute for Occupational Safety and Health) [47] recommendations for exertions of more than one hour per day [1].

The participants identified ‘e110- drugs (over-the-counter)’, ‘e310-immediate family’, ‘e155- health professionals’ and traditional oils (traditional medicine that carry cultural and religious beliefs) as facilitators to functioning. The components ‘e225- climate’, and ‘e255- vibration’, were marked as complete barriers. The components of ‘e135-products and technology for employment’ and ‘e450- individual attitudes of health professionals’ were considered both as facilitators and barriers to participants’ functioning. Participants reported using hand hoes and various hand tools that assist in their work. Though these tools facilitated their work tasks, those who use semi-mechanized fodder cutting machines complained of sustained stooping or squatting during feeding the machine due to the design of the equipment. Those who used tractors for ploughing and transportation of goods complained of excessive amount of whole-body vibration. Participants complained that agriculture equipment was not designed to their physical strength, working and cultural habits. Further the participants expressed their inability to enforce mechanical changes or adaptations to machines and vehicles as design change is very expensive.

Components ‘e550-Legal services, systems and policies’, ‘e570- Social security services, systems and policies’, ‘e575- General social support services, systems and policies’, ‘e580- Health services, systems and policies’, ‘e585- Education and training services, systems and policies’ and ‘e590 – Labor and employment services, systems and policies’ were graded not specified as participants in this study sample had no experiences with these types of support and relationships. Most of the specific regulations related to agriculture in India concern safety of machinery and equipment and chemicals used in agriculture. Further, the safety and health legislation does not apply to the agricultural sector. Accordingly, in India, national trade union organizations have denounced the fact that rural workers outside of plantations are not protected by the law on industrial relations. Though policies, such as Rashtriya Swasthya Bima Yojana (all India) and Biju Krushak Kalyan Yojana (Odisha state), exist for the poor and farmers respectively, they do not extend their benefits to work related musculoskeletal disorders. Agricultural workers are excluded from any employment injury benefit or insurance scheme. Self-employed farmers are not covered by any recording and notification system, and do not have access to social security benefits except on a voluntary basis on the grounds of their own contributions. There is no administrative machinery for collecting injury records for farmers and the incentives to report injuries are also insufficient. The participants of this study were not associated with any farmer organizations and the existing farmer organizations do not always have the opportunity to participate actively in policy-making, nor do they have any influence on the decisions taken on their behalf.

The results indicated that there was a reduction in frequency counts, especially in activities and participation at 6 weeks implying that the multidisciplinary biopsychosocial rehabilitation approach was effective in reducing pain and improving other outcomes. However, the results were not sustained once the participants returned to active agricultural work. The increase in participants’ muscle strength, mobility and stability was not maintained when the demands of agricultural work were reintroduced. This may be attributed to the highly physically demanding needs of agriculture [5]. Agriculture workers adopt a variety of different awkward postures for an extended period of time while performing various tasks. Agriculture workers prefer stooping to other positions as it demands less energy expenditure. Stooping also provides increased mobility compared to kneeling or squatting [1]. The results are consistent with other studies that conclude multidisciplinary rehabilitation is no more effective than usual care on its effect on return to work [48, 49].

The results show that health professionals were unable to design operations that ensure proper selection and use of tools, job methods, and materials that impose no undue stress and strain on the agricultural worker. Current ergonomic research and its application are mainly focused on the industrial sector and the authors found that the advice offered to participants was taken from industry based ergonomics. Though appropriate in theory, it did not answer the demands of the farmers and some strategies [asking farmers to lift by bending at knees and lifting with legs (Indian farmers are habituated to lifting weight on their back), wearing boots with high quality insoles] were not accepted by the agriculture workers. There is an urgent need to develop individualized interventions based on the needs of agriculture in India and other developing countries and not to be based on successful demonstrations in other industries or those from other industrializedcountries.

Unfortunately, limited research has been conducted in agriculture and none at the small-scale farmer’s level with respect to ergonomics and musculoskeletal disorders in an Indian scenario. Dr. Kumar and the Indian Agricultural Research Institute team [1] have been successful in optimizing tools to reduce the risk of stooped posture work. It needs combined efforts of health care and ergonomics team for controlling the problem of stooped postures in agricultural work. Further, there is limited information on the extent to which ergonomics may alleviate the constraints on manual operations for crop cultivation in India.

Training needs are mandatory for health-care professionals involved in the rehabilitation of LBP in agriculture workers. Agriculture workers are analogous to an athlete experiencing phases of pre-season, in-season, and off-season physical demands. The same practice may be employed for agriculture workers to prepare for season-specific demands and be most physically capable during peak production periods. Interventions for agriculture workers should address exercise interventions, behavior modification strategies and by implementing proactive ergonomic principles to prevent injury and help workers remain healthy, satisfied, and productive.

The potential limitations of this study include involving those participants who work on small farms, where it is difficult to distinguish between work-related back pain and domestic activities and only one female participant. The participants of the study were predominantly involved in selected crop cultivation (Table 1), which may have unique farming characteristics. The contribution of other musculoskeletal disorders and occupational injuries to agriculture was not considered. The use ofdifferent objective and subjective measures to estimate participants’ problems and conversion of their outcomes in to ICF qualifiers might have lead to false interpretation of results as the inter-rater reliability of qualifiers is only moderate [50, 51]. ICF based clinical measures are much needed to facilitate uniformity and reliability among rehabilitationprofessionals

7 Conclusion

The results of the study has provided a platform from which future works can move towards developing effective interventions, engineering/design changes, ergonomic guidelines, organizational and legislative/enforcement solutions, policy and practice aimed at reducing LBP in this sector. The results conclude that the current interventions for LBP are not effective in returning the agriculture worker with LBP to pain-free farming. The study also suggests a need for training for health care providers, especially in the areas of ergonomic modifications and designing adaptive equipment. This needs to be individualized considering the crop cultivated and the stage of agriculture. Government initiatives are very much needed especially in the areas of social policies, procurement of adequate safety equipment and vehicles with inbuilt safety features. Agriculture workers must also realize that safety and ergonomics are as important as productivity issues.

Conflict of interest

The authors have no conflict of interest to report.

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