Occupation-based demographic,clinical,and psychological presentation of spine pain: A retrospective analysis of 71,727 patients from urban India

Abstract

BACKGROUND:

Although many studies have investigated the physical and ergonomic risks of spine pain in specific occupation groups, the literature is lacking on occupation-based clinical and psychological presentation in patients with spine pain.

OBJECTIVE:

To analyze occupation-based variation in demographic, clinical, and psychological presentation in patients with spine pain.

METHODS:

This retrospective study analyzed the clinical data of 71727 patients with spine pain visiting a chain of spine rehabilitation clinics. Demographic and clinical variables such as gender, age, affected site, symptom duration, clinical symptoms and presentation, pain intensity, disability, and STarT Back Screening Tool (SBT) risk were compared between 9 occupational groups.

RESULTS:

The service and sales workers (44%) and students (43.5%) groups had the highest percentage of patients who presented with central spine pain; military personnel had the highest percentage of patients who presented with unilateral radicular pain (51.5%); and the retired or unemployed group had the highest percentage of patients who presented with severe myotomal loss (grade≤3) (6%). Homemakers had significantly higher pain intensity and disability (p < 0.001) and had the highest percentage of patients who presented with severe pain (47%), severe and crippled disability (59.5%), and medium to high risk (59%) with SBT when compared to other occupational groups.

CONCLUSION:

Patients with spine pain showed variation in demographic, clinical, and psychological presentation based on their occupation. The findings of this study can be the basis for identifying risk factors for spine pain and helping plan preventive and treatment measures based on their occupation.

Keywords

Spine epidemiology occupation neck pain low back pain radiculopathy India

1 Introduction

Low back pain (LBP) and neck pain (NP) are major causes of disability globally and are responsible for a significant reduction in work productivity, work absenteeism, unemployment, and an increased socioeconomic burden on society [1 –4]. Occupations and different types of work have been linked to specific lifestyle habits and behaviours, health risk exposures, and the overall health status of individuals. Certain occupations increase vulnerability to physical and mental illness and have been reported to affect recovery outcomes [5 –10]. Karran et al. [9], in a systematic review of 2,161,617 adults from 17 countries with LBP, reported that occupation and job characteristics were important social determinants of health (SDH) and independently affected LBP outcomes.

Occupation-related spine pain studies have primarily analyzed and reported the demographic, lifestyle, occupation-related physical activity, and psychosocial characteristics of their subjects [5–8 , 10–13]. However, very few studies have reported the clinical presentation and symptomology of patients with spine pain in the context of their occupation and occupation-related physical activities. Bontrup et al. [14], in a study on sedentary office workers, reported that static sitting behavior was more associated with chronic LBP than acute pain or disability. Bryndal et al. [15], in a study on nurses and physiotherapists, reported higher pain intensity and disability among nurses owing to high physical stress due to bending, lifting, and twisting activities and higher age. Similarly, occupations involving heavy labor or military personnel are more likely to develop radiculopathy than those with a sedentary lifestyle [16, 17].

Clinical presentation in spine pain may include central spine pain, radicular pain (pain radiating to one or both limbs), or radiculopathy (weakness or numbness in a myotomal or dermatomal distribution) [18]. Clinical presentation of the spine, specifically the presence or absence of radicular pain, pain intensity, and disability, has been associated with a higher disability pension [19], a longer duration of sick leave [20], the risk of recurrence after treatment [21], or the need for subsequent surgery [22]. Similarly, psychological factors can affect recovery and treatment outcomes in patients with spine pain [23]. Hence, baseline clinical and psychological presentation may significantly affect the clinical trajectory of patients who are undergoing treatment for spine pain. The literature is lacking on clinical and psychological presentation in patients with spine pain in specific occupation groups, especially in subjects from developing countries. Hence, the aim of this study was to analyze occupation-based variation in demographic, clinical, and psychological presentation in patients with spine pain from urban India.

2 Methods

2.1 Study design

In this retrospective analysis, we reviewed electronic records of 80683 patients visiting a chain of spine rehabilitation clinics (QI Spine Clinic, India) for assessment and treatment of their spine pain between July 2021 and June 2023. The study protocol was approved by an institutional review board and an ethics committee.

2.2 Participants

The inclusion criterion was all patients who visited a chain of spine rehabilitation clinics for assessment and treatment of their spine pain. The exclusion criteria were patients less than 18 years of age, patients with red flag conditions (fracture, infection, tumor, cord compression, cauda equina syndrome), patients with inflammatory conditions (rheumatoid arthritis, seronegative spondyloarthropathy, fibromyalgia, chronic pain syndrome), patients with previous spine surgery, patients who did online consultations, and patients with incomplete records.

2.3 Clinical assessment

All patients were assessed in-person during the first consultation at the clinic by a physiotherapist specializing in spine rehabilitation using a standard pre-treatment patient assessment protocol. All physiotherapists in our chain of clinics had a bachelor’s degree in physiotherapy, and several of them had a post-graduate or master’s degree in musculoskeletal physiotherapy. All physiotherapists, before the start of their service, underwent a 3-month training in evaluation, diagnosis, and treatment of patients with spine pain by a team of instructors with a minimum experience of 10 years in spine rehabilitation. This was followed by a system of continued training and evaluation programs annually. Demographic data, details of presenting symptoms, history of present complaints, medical history, and surgical history were collected as the initial step. Patients were screened for red flag conditions using specific questions in their history, which included persistent fever, recent significant trauma, pain at night or at rest, progressive motor deficit, saddle anesthesia, unexplained weight loss, and a history of cancer. A thorough physical examination was performed by the consulting physiotherapist to assess spine posture and range of motion, nerve tension, and sensory and motor (dermatomes and myotomes) function. Investigation reports such as blood markers, X-rays or MRIs, and medical and surgical records were reviewed as part of their assessment to confirm red flag conditions, inflammatory conditions, or previous spine surgery.

2.4 Study variables

Demographic and clinical covariates such as gender, age, occupation, affected site (neck and/or upper back and lower back and/or mid back), symptom duration (acute or chronic), clinical symptoms and presentation, presence or absence of myotomal loss, and spine surgery previously prescribed by their orthopaedic or spine surgeons. For this study, patients were categorized into 10-year age groups as follows: 18–25 years, 26–35 years, 36–45 years, 46–55 years, 56–65 years, and >65 years [24]. The revised International Standard Classification of Occupations (ISCO-08) categorizes occupations into 10 major groups and includes skilled agricultural, forestry, and fishery workers [25]. However, our study involved a population from urban India, where a significant number of patients with spine pain were homemakers, retired individuals, students, and from other sedentary occupations such as professionals and executives working in offices. Furthermore, a smaller number of patients in our study population were involved in elementary and blue-collar occupations such as farmers, craft and related trade workers, and plant and machinery operators, which are more commonly practiced in semi-urban and rural areas. Hence, based on previous studies [3, 25], and our patient population demography, we used a modified version of the ISCO-08, and patients in the current study were categorized into the following 9 occupational subgroups: group 1 –serving military personnel; group 2 –business owners and company management such as chief executive officers, government legislators, and senior officials; group 3 –executives and managers; group 4 –homemakers; group 5 –elementary and blue-collar workers such as farmers, craft and related trade workers, plant and machinery operators, and municipal workers; group 6 –professionals such as lawyers, doctors, dentists, and architects; group 7 –retired or unemployed; group 8 –service and sales workers; and group 9 –students.

Symptom duration was defined as acute (<3 months) or chronic (≥3 months) [26], and presenting symptoms were categorized into central back and/or midback pain, unilateral or bilateral above knee radicular pain, unilateral or bilateral below knee radicular pain, central neck and/or upper back pain, unilateral or bilateral above elbow radicular pain, unilateral or bilateral below elbow radicular pain, and widespread spine pain. Widespread spine pain denotes pain at multiple sites along the spine, such as the low back, midback, upper back, and neck, during presentation. Myotome involvement in all patients was categorized based on a previously published grading method [27] as no myotomal loss, myotomal loss grade > 3, and myotomal loss grade≤3. Based on symptoms and myotomal involvement, all patients were categorized into the following clinical presentation subgroups: central spine pain, unilateral radicular pain, bilateral radicular pain, radiculopathy with myotomal loss grade > 3, and radiculopathy with myotomal loss grade≤3. Pain intensity was measured in all patients during the consultation using the numerical pain rating scale (NPRS), ranging from no pain (0) to the worst pain imaginable (10), with patients having mild (NPRS≤3), moderate (NPRS 4–7), and severe (NPRS > 7) pain [28]. Disability was measured in all patients at the end of consultation using the Oswestry disability index (ODI) or neck disability index (NDI) [29, 30]. Patients were administered the Keele STarT Back Screening Tool (SBT), which consisted of a 9-item tool with a psychological subscale that estimated the risk of unfavorable prognosis and chronic disability and categorized the patients into low, medium, or high risk of unfavorable prognosis [31].

2.5 Statistical analysis

Continuous variables were presented as mean±standard deviation (95% confidence interval), and categorical variables were presented as numbers (percentage). Categorical variables such as gender and age distribution, pain duration (acute/subacute and chronic), clinical symptoms categories, myotomal loss, clinical presentation categories, prescribed surgery, SBT categories, NPRS score categories (≤3, 4–7, and >7), and disability categories (mild, moderate, severe, and crippled) were compared between the 9 occupational groups using the Fisher x² test. Continuous variables such as mean age, NPRS score, and ODI/NDI score were compared between the 9 occupational groups using the analysis of variance (ANOVA) with a Tukey HSD (“Honestly Significant Difference”) post-hoc test. A P value of <0.05 was considered statistically significant. Statistical analysis was performed using the GraphPad QuickCalcs online statistical analysis tool (GraphPad Software, San Diego, CA).

3 Results

3.1 Study population characteristics

Based on the inclusion and exclusion criteria, 1443 patients who were <18 years of age, 188 patients with red flag conditions, 863 patients with inflammatory conditions, 1357 patients with post-surgical spine, 1547 patients who underwent a teleconsultation, and 3558 patients with incomplete records were excluded. Hence, data from 71727 patients was analyzed for this study. The mean age was 44.5±14 years, with the majority of the patients in the 36–45 years (28%) and 26–35 years (26%) age groups, and 66% of the study population was male (Table 1) (Fig. 1). A majority of patients belonged to occupational groups 3 (35.5%) and 4 (19.5%). Spine surgery had been prescribed to 12.5% of patients at the time of presentation.

Fig. 1

Age group distribution of patients in different occupational groups. Group 1 –serving military personnel; Group 2 –business owners, company management, government legislators/senior officials; Group 3 –executives and managers; Group 4 –homemakers; Group 5 –elementary and blue-collar workers; Group 6 –professionals; Group 7 –retired or unemployed; Group 8 –service and sales workers; Group 9 –students.

Table 1

Baseline demographic variables in the study population

Variables	Values
Number of Patients (n)	71727
Gender
Males	47161 (66%)
Females	24566 (34%)
Age (years)	44.5±14 (44.3–44.6)
Age group distribution (years)
18–25	3507 (5%)
26–35	18734 (26%)
36–45	20332 (28%)
46–55	12805 (18%)
56–65	8925 (12.5%)
>65	7521 (10.5%)
Occupation category
Group 1 (serving military personnel)	404 (0.5%)
Group 2 (business owners, company management, government legislators/senior officials)	7758 (11%)
Group 3 (executives and managers)	25523 (35.5%)
Group 4 (homemakers)	14022 (19.5%)
Group 5 (elementary and blue-collar workers)	4293 (6%)
Group 6 (professionals)	9095 (12.5%)
Group 7 (retired or unemployed)	7520 (10.5%)
Group 8 (service and sales workers)	1339 (2%)
Group 9 (students)	1773 (2.5%)
Spine surgery prescribed
Yes	8903 (12.5%)
No	62824 (87.5%)

All values presented as mean±standard deviation (95% confidence interval) or number (percentage).

A majority of the patients presented with chronic symptoms (87%), had LBP and/or midback pain (77.5%), had central spine pain (33.5%) and unilateral below knee lumbar radicular pain (28%) symptoms, and presented as unilateral radicular pain (41.5%) and central spine pain (36.5%) (Table 2). Myotomal loss of grade >3 was present in 10% of patients, and myotomal loss of grade ≤3 was present in 2.5% of patients. A majority of patients had a baseline NPRS score between 4–7 (57.5%), and 33% of patients had an NPRS score >7 (Table 2). Similarly, a majority of patients had moderate (44.5%) or severe disability (29%) (Table 2). The SBT has been used by our patients since January 2022, and this data was available in 33099 patients. Based on SBT, 19% of patients were at high risk and 27% were at medium risk for chronic disability (Table 2).

Table 2

Baseline clinical variables in the study population

Variables	Values
Number of Patients (n)	71727
Case Type
Low Back/Midback pain	55590 (77.5%)
Neck/Upper back pain	16137 (22.5%)
Symptom duration
Acute	9460 (13%)
Chronic or Acute on Chronic	62267 (87%)
Clinical symptoms category
Central Back Pain/Midback pain	18151 (25.5%)
Asymmetrical Radiation above knee	8270 (11.5%)
Symmetrical Radiation above knee	1874 (2.5%)
Asymmetrical Radiation below knee	20185 (28%)
Symmetrical Radiation below knee	5073 (7%)
Central Neck Pain/Upper back pain	5795 (8%)
Asymmetrical Radiation above elbow	2864 (4%)
Symmetrical Radiation above elbow	1035 (1.5%)
Asymmetrical Radiation below elbow	4503 (6.5%)
Symmetrical Radiation below elbow	1165 (1.5%)
Widespread spine pain	2812 (4%)
Clinical presentation category
Central spine pain	26086 (36.5%)
Unilateral radicular pain	29776 (41.5%)
Bilateral radicular pain	6944 (9.5%)
Radiculopathy with myotomal loss grade >3	7049 (10%)
Radiculopathy with myotomal loss grade ≤3	1872 (2.5%)
Myotomal loss
Yes (Grade ≤3)	1873 (2.5%)
Yes (Grade >3)	7050 (10%)
No	62804 (87.5%)
NPRS score	6.3±2 (6.2–6.3)
Pain intensity category
NPRS ≤3	6856 (9.5%)
NPRS 4–7	41284 (57.5%)
NPRS >7	23587 (33%)
ODI/NDI score	40.2±17.6 (40.0–40.3)
Disability category
Minimal	10551 (14.5%)
Moderate	31753 (44.5%)
Severe	20928 (29%)
Crippled	8495 (12%)
SBT category
Low Risk	17864 (54%)
Medium Risk	9013 (27%)
High Risk	6222 (19%)

All values presented as mean±standard deviation (95% confidence interval) or number (percentage). NPRS –numerical pain rating scale; ODI –Oswestry disability index; NDI –Neck disability index; SBT –STarT Back Screening Tool.

3.2 Comparison of occupational groups

The mean age was significantly lower in group 9 (students) and higher in group 7 (retired, unemployed) when compared to other occupational groups (p < 0.001). Occupation groups 1 (95%) and 2 (91.5%) had the highest percentage of male subjects, and the mean age at presentation was highest in group 7 and group 4 subjects (Table 3). Group 9 patients (students) had the highest percentage of subjects (67.5%) in the 18–25-year age group, and group 7 (retired and unemployed) patients had the highest percentage of subjects (60.5%) in the >65-year age group (Table 3, Fig. 1). Group 7 had the highest percentage of patients (22.5%) who were prescribed spine surgery by their orthopaedic or spine surgeons. Although LBP with or without midback pain affected all occupational groups more than NP with or without upper back pain, the highest percentage of LBP cases was seen in group 7 patients (85%), and the highest percentage of NP cases was seen in group 6 patients (25.5%). Similarly, although chronic presentation was more common in all occupational groups, the highest percentage of acute cases was in occupational groups 3, 2, 6, and 9. Group 4 had the highest percentage of patients (37.5%) who presented with unilateral below knee radicular pain, and group 7 had the highest percentage of patients (14%) with bilateral below knee radicular pain (Table 3). Similarly, Group 4 and group 8 had the highest percentage of patients (7.5%) with unilateral below elbow radicular pain, and group 4 had the highest percentage of patients (2.5%) with bilateral below elbow radicular pain (Table 3). Group 7 had the highest percentage of patients (19%) with widespread spine pain. The highest percentage of patients who presented with central spine pain was in groups 8 (44%) and 9 (43.5%); unilateral radicular pain was in group 1 (51.5%); bilateral radicular pain was in group 4 (12.5%); radiculopathy with myotomal loss grade >3 was in groups 4 (16.5%) and 7 (15.5%); and radiculopathy with myotomal loss grade ≤3 was in group 7 (6%). (Table 3, Fig. 2). Subgroup comparison found no significant difference (p = 0) between the 9 occupational groups for all demographic and clinical variables.

Table 3
Comparison of demographic and clinical variables in occupation groups

Variables Occupation groups

Group 1 (serving military personnel) Group 2 (Business owners, company management, government legislators/senior officials) Group 3 (executives and managers) Group 4 (homemakers) Group 5 (elementary and blue-collar workers) Group 6 (professionals) Group 7 (retired or unemployed) Group 8 (service and sales workers) Group 9 (students)

Number of patients 404 (0.5%) 7758 (11%) 25523 (35.5%) 14022 (19.5%) 4293 (6%) 9095 (12.5%) 7520 (10.5%) 1339 (2%) 1773 (2.5%)

Gender distribution

Males 384 (95%) 7095 (91.5%) 20907 (82%) 0 (0%) 3513 (82%) 6965 (76.5%) 5856 (78%) 1193 (89%) 1247 (70.5%)

Females 20 (5%) 663 (8.5%) 4616 (18%) 14022 (100%) 780 (18%) 2130 (23.5%) 1664 (22%) 146 (11%) 526 (29.5%)

Mean Age (years) 38±7.5 (37–38.5) 44±11.5 (43.5–44.5) 39.5±9.5 (39–39.5) 49.5±13 (49–49.5) 40.5±11.5 (40–40.8) 40±10.5 (39.7–40.2) 67 ± 10 (66.7–67.2) 39±9.5 (38.5–39.5) 25±6.5 (24.6–25.3)

Age group distribution (years)

18–25 18 (4.5%) 234 (3%) 1037 (4%) 304 (2%) 231 (5.5%) 387 (4%) 57 (0.5%) 55 (4%) 1194 (67.5%)

26–35 151 (37.5%) 1801 (23%) 8985 (35.5%) 2126 (15%) 1420 (33%) 3220 (35.5%) 82 (1%) 467 (35%) 482 (27%)

36–45 153 (38%) 2558 (33%) 9101 (35.5%) 3357 (24%) 1354 (31.5%) 3102 (34%) 128 (1.5%) 526 (39%) 97 (5.5%)

46–55 82 (20%) 1751 (22.5%) 4546 (18%) 3444 (24.5%) 800 (18.5%) 1544 (17%) 387 (5.5%) 207 (15.5%) 0 (0%)

56–65 0 (0%) 1001 (13%) 1589 (6%) 3006 (21.5%) 335 (8%) 593 (6.5%) 2326 (31%) 70 (5.5%) 0 (0%)

> 65 0 (0%) 413 (5.5%) 265 (1%) 1785 (13%) 153 (3.5%) 249 (3%) 4540 (60.5%) 14 (1%) 0 (0%)

Spine surgery prescribed

Yes 69 (17%) 814 (10.5%) 2037 (8%) 2591 (18.5%) 668 (15.5%) 755 (8.5%) 1678 (22.5%) 124 (9%) 168 (9.5%)

No 335 (83%) 6944 (89.5%) 23486 (92%) 13657 (81.5%) 3625 (84.5%) 8340 (91.5%) 5842 (77.5%) 1325 (91%) 1605 (90.5%)

Case Type

Low Back/Midback pain 336 (83%) 6069 (78.5%) 19189 (75%) 11079 (79%) 3411 (79.5%) 6768 (74.5%) 6389 (85%) 1003 (75%) 1345 (76%)

Neck/Upper back pain 68 (17%) 1689 (21.5%) 6334 (25%) 2943 (21%) 882 (20.5%) 2327 (25.5%) 1131 (15%) 336 (25%) 428 (24%)

Symptom duration

Acute 42 (10.5%) 1153 (15%) 3946 (15.5%) 1446 (10.5%) 490 (11.5%) 1367 (15%) 576 (7.5%) 172 (13%) 268 (15%)

Chronic or Acute on Chronic 362 (89.5%) 6605 (85%) 21577 (84.5%) 12576 (89.5%) 3803 (88.5%) 7728 (85%) 6944 (92.5%) 1167 (87%) 1505 (85%)

Clinical presentation category

Center Back Pain/Midback pain 102 (25%) 2128 (27.5%) 7525 (29.5%) 2307 (16.5%) 1224 (28.5%) 2712 (30%) 1182 (15.5%) 449 (33.5%) 522 (29.5%)

Asymmetrical Radiation above knee 50 (12.5%) 1068 (13.5%) 3262 (13%) 1301 (9.5%) 385 (9%) 1202 (13.5%) 664 (9%) 137 (10.5%) 201 (11.5%)

Symmetrical Radiation above knee 10 (2.5%) 237 (3%) 668 (2.5%) 394 (3%) 86 (2%) 196 (2%) 204 (2.5%) 33 (2.5%) 46 (2.5%)

Asymmetrical Radiation below knee 146 (36%) 2072 (26.5%) 6318 (24.5%) 5284 (37.5%) 1293 (30%) 2211 (24.5%) 2076 (27.5%) 311 (23%) 474 (26.5%)

Symmetrical Radiation below knee 23 (5.5%) 458 (6%) 1114 (4.5%) 1591 (11%) 373 (8.5%) 348 (4%) 1040 (14%) 56 (4%) 70 (4%)

Center Neck Pain/Upper back pain 30 (7.5%) 636 (8%) 2518 (10%) 762 (5.5%) 322 (7.5%) 873 (9.5%) 328 (4.5%) 118 (9%) 208 (11.5%)

Asymmetrical Radiation above elbow 8 (2%) 328 (4.5%) 1167 (4.5%) 515 (3.5%) 134 (3%) 418 (4.5%) 162 (2%) 53 (4%) 79 (4.5%)

Symmetrical Radiation above elbow 1 (0.5%) 129 (1.5%) 398 (1.5%) 201 (1.5%) 46 (1%) 148 (1.5%) 65 (1%) 20 (1.5%) 27 (1.5%)

Asymmetrical Radiation below elbow 19 (5%) 422 (5.5%) 1667 (6.5%) 1060 (7.5%) 245 (6%) 657 (7%) 256 (3.5%) 102 (7.5%) 75 (4.5%)

Symmetrical Radiation below elbow 7 (1.5%) 108 (1.5%) 358 (1.5%) 325 (2.5%) 89 (2%) 117 (1%) 111 (1.5%) 26 (2%) 24 (1.5%)

Widespread spine pain 8 (2%) 172 (2.5%) 528 (2%) 282 (2%) 96 (2.5%) 213 (2.5%) 1433 (19%) 34 (2.5%) 47 (2.5%)

Clinical presentation category

Central spine pain 136 (33.5%) 2878 (37%) 10363 (40.5%) 3205 (23%) 1610 (37.5%) 3729 (41%) 2809 (37.5%) 588 (44%) 765 (43.5%)

Unilateral radicular pain 208 (51.5%) 3334 (43%) 10902 (43%) 6264 (44.5%) 1629 (38%) 3969 (43.5%) 2243 (30%) 516 (38.5%) 712 (40%)

Bilateral radicular pain 36 (9%) 773 (10%) 2179 (8.5%) 1768 (12.5%) 432 (10%) 679 (7.5%) 825 (11%) 112 (8.5%) 141 (8%)

Radiculopathy with myotomal loss grade >3 18 (4.5%) 586 (7.5%) 1699 (6.5%) 2287 (16.5%) 473 (11%) 593 (6.5%) 1166 (15.5%) 104 (7.5%) 124 (7%)

Radiculopathy with myotomal loss grade ≤3 6 (1.5%) 187 (2.5%) 380 (1.5%) 498 (3.5%) 149 (3.5%) 125 (1.5%) 478 (6%) 19 (1.5%) 31 (1.5%)

Myotomal loss

Yes (Grade ≤3) 6 (1.5%) 187 (2.5%) 380 (1.5%) 498 (3.5%) 149 (3.5%) 125 (1.5%) 478 (6.5%) 19 (1.5%) 31 (2%)

Yes (Grade >3) 18 (4.5%) 586 (7.5%) 1699 (6.5%) 2287 (16.5%) 473 (11%) 593 (6.5%) 1166 (15.5%) 104 (7.5%) 124 (7%)

No 380 (94%) 6985 (90%) 23444 (92%) 11237 (80%) 3671 (85.5%) 8377 (92%) 5876 (78%) 1216 (91%) 1618 (91%)

Pain intensity category

NPRS ≤3 44 (11%) 934 (12%) 2786 (11%) 651 (4.5%) 401 (9.5%) 944 (10.5%) 765 (10%) 143 (10.5%) 186 (10.5%)

NPRS 4–7 260 (64.5%) 4719 (61%) 15604 (61%) 6800 (48.5%) 2329 (54%) 5807 (64%) 3906 (52%) 835 (62.5%) 1033 (58%)

NPRS >7 100 (24.5%) 2105 (27%) 7133 (28%) 6571 (47%) 1563 (36.5%) 2344 (25.5%) 2849 (38%) 361 (27%) 554 (31.5%)

NPRS score 6±2 (5.8–6.2) 6±2.1 (5.9–6) 6.1±2 (6–6.1) 7 ± 1.9 (6.9–7) 6.5±2.1 (6.4–6.5) 6.1±2 (6–6.1) 6.4±2.2 (6.3–6.4) 6.1±2 (5.9–6.2) 6.2±2.1 (6.1–6.2)

Disability category

Minimal 64 (16%) 1465 (19%) 4413 (17%) 1020 (7%) 597 (14%) 1645 (18%) 821 (11%) 213 (16%) 313 (17.5%)

Moderate 191 (47%) 3629 (46.5%) 12856 (50.5%) 4669 (33.5%) 1922 (44.5%) 4482 (49%) 2474 (33%) 724 (54%) 807 (45.5%)

Severe 113 (28%) 1982 (25.5%) 6482 (25.5%) 5400 (38.5%) 1207 (28.5%) 2301 (25.5%) 2651 (35%) 310 (23%) 482 (27.5%)

Crippled 36 (9%) 682 (9%) 1772 (7%) 2933 (21%) 567 (13%) 667 (7.5%) 1574 (21%) 92 (7%) 171 (9.5%)

ODI/NDI score 37.8±16.1 (36.2–39.3) 37.3±16.9 (36.9–37.6) 36.8±15.9 (36.6–36.9) 47.4 ± 18.1 (47.1–47.7) 40.8±18.1 (40.2–41.3) 36.8±15.9 (36.4–37.1) 46±19.2 (45.5–46.4) 36.9±15.9 (36–37.7) 38.3±17.4 (37.4–39.1)

SBT category

Low Risk 103 (60%) 2155 (59%) 7248 (58%) 2648 (41%) 1164 (52%) 2584 (61.5%) 1152 (46.5%) 355 (55%) 455 (57%)

Medium Risk 41 (24%) 912 (25%) 3204 (25.5%) 2094 (32.5%) 590 (26%) 1045 (25%) 760 (31%) 179 (27.5%) 189 (23.5%)

High Risk 27 (16%) 579 (16%) 2027 (16.5%) 1711 (26.5%) 495 (22%) 564 (13.5%) 555 (22.5%) 111 (17.5%) 152 (19%)

Variables	Occupation groups
Number of patients	404 (0.5%)	7758 (11%)	25523 (35.5%)	14022 (19.5%)	4293 (6%)	9095 (12.5%)	7520 (10.5%)	1339 (2%)	1773 (2.5%)
Gender distribution
Males	384 (95%)	7095 (91.5%)	20907 (82%)	0 (0%)	3513 (82%)	6965 (76.5%)	5856 (78%)	1193 (89%)	1247 (70.5%)
Females	20 (5%)	663 (8.5%)	4616 (18%)	14022 (100%)	780 (18%)	2130 (23.5%)	1664 (22%)	146 (11%)	526 (29.5%)
Mean Age (years)	38±7.5 (37–38.5)	44±11.5 (43.5–44.5)	39.5±9.5 (39–39.5)	49.5±13 (49–49.5)	40.5±11.5 (40–40.8)	40±10.5 (39.7–40.2)	67 ± 10 (66.7–67.2)	39±9.5 (38.5–39.5)	25±6.5 (24.6–25.3)
Age group distribution (years)
18–25	18 (4.5%)	234 (3%)	1037 (4%)	304 (2%)	231 (5.5%)	387 (4%)	57 (0.5%)	55 (4%)	1194 (67.5%)
26–35	151 (37.5%)	1801 (23%)	8985 (35.5%)	2126 (15%)	1420 (33%)	3220 (35.5%)	82 (1%)	467 (35%)	482 (27%)
36–45	153 (38%)	2558 (33%)	9101 (35.5%)	3357 (24%)	1354 (31.5%)	3102 (34%)	128 (1.5%)	526 (39%)	97 (5.5%)
46–55	82 (20%)	1751 (22.5%)	4546 (18%)	3444 (24.5%)	800 (18.5%)	1544 (17%)	387 (5.5%)	207 (15.5%)	0 (0%)
56–65	0 (0%)	1001 (13%)	1589 (6%)	3006 (21.5%)	335 (8%)	593 (6.5%)	2326 (31%)	70 (5.5%)	0 (0%)
> 65	0 (0%)	413 (5.5%)	265 (1%)	1785 (13%)	153 (3.5%)	249 (3%)	4540 (60.5%)	14 (1%)	0 (0%)
Spine surgery prescribed
Yes	69 (17%)	814 (10.5%)	2037 (8%)	2591 (18.5%)	668 (15.5%)	755 (8.5%)	1678 (22.5%)	124 (9%)	168 (9.5%)
No	335 (83%)	6944 (89.5%)	23486 (92%)	13657 (81.5%)	3625 (84.5%)	8340 (91.5%)	5842 (77.5%)	1325 (91%)	1605 (90.5%)
Case Type
Low Back/Midback pain	336 (83%)	6069 (78.5%)	19189 (75%)	11079 (79%)	3411 (79.5%)	6768 (74.5%)	6389 (85%)	1003 (75%)	1345 (76%)
Neck/Upper back pain	68 (17%)	1689 (21.5%)	6334 (25%)	2943 (21%)	882 (20.5%)	2327 (25.5%)	1131 (15%)	336 (25%)	428 (24%)
Symptom duration
Acute	42 (10.5%)	1153 (15%)	3946 (15.5%)	1446 (10.5%)	490 (11.5%)	1367 (15%)	576 (7.5%)	172 (13%)	268 (15%)
Chronic or Acute on Chronic	362 (89.5%)	6605 (85%)	21577 (84.5%)	12576 (89.5%)	3803 (88.5%)	7728 (85%)	6944 (92.5%)	1167 (87%)	1505 (85%)
Clinical presentation category
Center Back Pain/Midback pain	102 (25%)	2128 (27.5%)	7525 (29.5%)	2307 (16.5%)	1224 (28.5%)	2712 (30%)	1182 (15.5%)	449 (33.5%)	522 (29.5%)
Asymmetrical Radiation above knee	50 (12.5%)	1068 (13.5%)	3262 (13%)	1301 (9.5%)	385 (9%)	1202 (13.5%)	664 (9%)	137 (10.5%)	201 (11.5%)
Symmetrical Radiation above knee	10 (2.5%)	237 (3%)	668 (2.5%)	394 (3%)	86 (2%)	196 (2%)	204 (2.5%)	33 (2.5%)	46 (2.5%)
Asymmetrical Radiation below knee	146 (36%)	2072 (26.5%)	6318 (24.5%)	5284 (37.5%)	1293 (30%)	2211 (24.5%)	2076 (27.5%)	311 (23%)	474 (26.5%)
Symmetrical Radiation below knee	23 (5.5%)	458 (6%)	1114 (4.5%)	1591 (11%)	373 (8.5%)	348 (4%)	1040 (14%)	56 (4%)	70 (4%)
Center Neck Pain/Upper back pain	30 (7.5%)	636 (8%)	2518 (10%)	762 (5.5%)	322 (7.5%)	873 (9.5%)	328 (4.5%)	118 (9%)	208 (11.5%)
Asymmetrical Radiation above elbow	8 (2%)	328 (4.5%)	1167 (4.5%)	515 (3.5%)	134 (3%)	418 (4.5%)	162 (2%)	53 (4%)	79 (4.5%)
Symmetrical Radiation above elbow	1 (0.5%)	129 (1.5%)	398 (1.5%)	201 (1.5%)	46 (1%)	148 (1.5%)	65 (1%)	20 (1.5%)	27 (1.5%)
Asymmetrical Radiation below elbow	19 (5%)	422 (5.5%)	1667 (6.5%)	1060 (7.5%)	245 (6%)	657 (7%)	256 (3.5%)	102 (7.5%)	75 (4.5%)
Symmetrical Radiation below elbow	7 (1.5%)	108 (1.5%)	358 (1.5%)	325 (2.5%)	89 (2%)	117 (1%)	111 (1.5%)	26 (2%)	24 (1.5%)
Widespread spine pain	8 (2%)	172 (2.5%)	528 (2%)	282 (2%)	96 (2.5%)	213 (2.5%)	1433 (19%)	34 (2.5%)	47 (2.5%)
Clinical presentation category
Central spine pain	136 (33.5%)	2878 (37%)	10363 (40.5%)	3205 (23%)	1610 (37.5%)	3729 (41%)	2809 (37.5%)	588 (44%)	765 (43.5%)
Unilateral radicular pain	208 (51.5%)	3334 (43%)	10902 (43%)	6264 (44.5%)	1629 (38%)	3969 (43.5%)	2243 (30%)	516 (38.5%)	712 (40%)
Bilateral radicular pain	36 (9%)	773 (10%)	2179 (8.5%)	1768 (12.5%)	432 (10%)	679 (7.5%)	825 (11%)	112 (8.5%)	141 (8%)
Radiculopathy with myotomal loss grade >3	18 (4.5%)	586 (7.5%)	1699 (6.5%)	2287 (16.5%)	473 (11%)	593 (6.5%)	1166 (15.5%)	104 (7.5%)	124 (7%)
Radiculopathy with myotomal loss grade ≤3	6 (1.5%)	187 (2.5%)	380 (1.5%)	498 (3.5%)	149 (3.5%)	125 (1.5%)	478 (6%)	19 (1.5%)	31 (1.5%)
Myotomal loss
Yes (Grade ≤3)	6 (1.5%)	187 (2.5%)	380 (1.5%)	498 (3.5%)	149 (3.5%)	125 (1.5%)	478 (6.5%)	19 (1.5%)	31 (2%)
Yes (Grade >3)	18 (4.5%)	586 (7.5%)	1699 (6.5%)	2287 (16.5%)	473 (11%)	593 (6.5%)	1166 (15.5%)	104 (7.5%)	124 (7%)
No	380 (94%)	6985 (90%)	23444 (92%)	11237 (80%)	3671 (85.5%)	8377 (92%)	5876 (78%)	1216 (91%)	1618 (91%)
Pain intensity category
NPRS ≤3	44 (11%)	934 (12%)	2786 (11%)	651 (4.5%)	401 (9.5%)	944 (10.5%)	765 (10%)	143 (10.5%)	186 (10.5%)
NPRS 4–7	260 (64.5%)	4719 (61%)	15604 (61%)	6800 (48.5%)	2329 (54%)	5807 (64%)	3906 (52%)	835 (62.5%)	1033 (58%)
NPRS >7	100 (24.5%)	2105 (27%)	7133 (28%)	6571 (47%)	1563 (36.5%)	2344 (25.5%)	2849 (38%)	361 (27%)	554 (31.5%)
NPRS score	6±2 (5.8–6.2)	6±2.1 (5.9–6)	6.1±2 (6–6.1)	7 ± 1.9 (6.9–7)	6.5±2.1 (6.4–6.5)	6.1±2 (6–6.1)	6.4±2.2 (6.3–6.4)	6.1±2 (5.9–6.2)	6.2±2.1 (6.1–6.2)
Disability category
Minimal	64 (16%)	1465 (19%)	4413 (17%)	1020 (7%)	597 (14%)	1645 (18%)	821 (11%)	213 (16%)	313 (17.5%)
Moderate	191 (47%)	3629 (46.5%)	12856 (50.5%)	4669 (33.5%)	1922 (44.5%)	4482 (49%)	2474 (33%)	724 (54%)	807 (45.5%)
Severe	113 (28%)	1982 (25.5%)	6482 (25.5%)	5400 (38.5%)	1207 (28.5%)	2301 (25.5%)	2651 (35%)	310 (23%)	482 (27.5%)
Crippled	36 (9%)	682 (9%)	1772 (7%)	2933 (21%)	567 (13%)	667 (7.5%)	1574 (21%)	92 (7%)	171 (9.5%)
ODI/NDI score	37.8±16.1 (36.2–39.3)	37.3±16.9 (36.9–37.6)	36.8±15.9 (36.6–36.9)	47.4 ± 18.1 (47.1–47.7)	40.8±18.1 (40.2–41.3)	36.8±15.9 (36.4–37.1)	46±19.2 (45.5–46.4)	36.9±15.9 (36–37.7)	38.3±17.4 (37.4–39.1)
SBT category
Low Risk	103 (60%)	2155 (59%)	7248 (58%)	2648 (41%)	1164 (52%)	2584 (61.5%)	1152 (46.5%)	355 (55%)	455 (57%)
Medium Risk	41 (24%)	912 (25%)	3204 (25.5%)	2094 (32.5%)	590 (26%)	1045 (25%)	760 (31%)	179 (27.5%)	189 (23.5%)
High Risk	27 (16%)	579 (16%)	2027 (16.5%)	1711 (26.5%)	495 (22%)	564 (13.5%)	555 (22.5%)	111 (17.5%)	152 (19%)

All values presented as mean±standard deviation (95% confidence interval) or number (percentage). Highest values for each variable among occupational subgroups are denoted in bold. NPRS –numerical pain rating scale; ODI –Oswestry disability index; NDI –Neck disability index; SBT –STarT Back Screening Tool.

Fig. 2

Clinical presentation in different occupational groups. Group 1 –serving military personnel; Group 2 –business owners, company management, government legislators/senior officials; Group 3 –executives and managers; Group 4 –homemakers; Group 5 –elementary and blue-collar workers; Group 6 –professionals; Group 7 –retired or unemployed; Group 8 –service and sales workers; Group 9 –students.

The mean NPRS score was significantly higher (p < 0.001) in group 4 when compared to other occupational groups. The mean ODI/NDI score was significantly higher (p < 0.001) in groups 4 and 7 when compared to other occupational groups (Table 3). Group 2 patients had the highest percentage of subjects (12%) with mild pain (NPRS≤3), group 1 patients had the highest percentage of subjects (64.5%) with moderate pain (NPRS 4–7), and group 4 patients had the highest percentage of subjects (47%) with severe pain (NPRS > 7) (Table 3, Fig. 3). Similarly, Group 2 patients had the highest percentage of subjects (19%) with mild disability, group 8 patients had the highest percentage of subjects (54%) with moderate disability, group 4 patients had the highest percentage of subjects (38.5%) with severe disability, and group 4 and 7 patients had the highest percentage of subjects (21%) with crippled disability (Table 3, Fig. 4). Based on SBT categories, group 6 patients had the highest percentage of subjects (61.5%) with low risk, group 4 patients had the highest percentage of subjects (32.5%) with medium risk, and group 4 patients had the highest percentage of subjects (26.5%) with high risk (Table 3). A subgroup comparison based on NPRS, disability, and SBT found no significant difference (p = 0) between the 9 occupational groups.

Fig. 3

Pain intensity in different occupational groups. Group 1 –serving military personnel; Group 2 –business owners, company management, government legislators/senior officials; Group 3 –executives and managers; Group 4 –homemakers; Group 5 –elementary and blue-collar workers; Group 6 –professionals; Group 7 –retired or unemployed; Group 8 –service and sales workers; Group 9 –students. NPRS –numerical pain rating scale.

Fig. 4

Disability in different occupational groups. Group 1 –serving military personnel; Group 2 –business owners, company management, government legislators/senior officials; Group 3 –executives and managers; Group 4 –homemakers; Group 5 –elementary and blue-collar workers; Group 6 –professionals; Group 7 –retired or unemployed; Group 8 –service and sales workers; Group 9 –students.

4 Discussion

This study found that a majority of the patients were in the 36–45 years (28%) and 26–35 years (26%) age groups and presented with chronic symptoms (87%). A majority of the patients had LBP and/or midback pain (77.5%) and presented as unilateral radicular pain (41.5%) or central spine pain (36.5%), with 12.5% having radiculopathy with myotomal loss. Although there was no significant difference between the occupational groups when subgroups based on demographic, clinical, and psychological variables were compared, the retired or unemployed group had the highest percentage of patients who had LBP (85%), and the professionals’ group had the highest percentage of patients who had NP (25.5%). The homemakers’ group had the highest percentage of patients who presented with severe pain (47%), severe and crippled disability (59.5%), and medium to high risk (59%) with SBT.

Previous studies that have analyzed the global burden of LBP and NP have reported higher prevalence rates among females across all age groups, with peak LBP prevalence rates at 85 years of age and peak NP incidence rates between 45–49 years of age [1, 2]. This is contrary to the findings of our study, where a majority of patients suffering from spine pain (either LBP or NP) were males, with the majority of the patients (54%) in the 26–45-year age group. This could be explained by the difference in the design of our study and source of data, which was a retrospective analysis of data collected from subjects seeking treatment for spine pain at a rehabilitation clinic versus data collected from various sources globally across various heterogenous population groups in the above studies. Previous occupation- and workplace-related studies have reported the age prevalence of spine pain similar to our study [32, 33]. The overall prevalence of LBP and NP has been reported to be higher in women than in men in most studies in the literature. However, the male gender has been associated with being at higher risk for LBP when compared to the female gender [34]. The higher number of males being affected in our study population when compared to females could be due to the lower percentage of women employees in most occupational groups in a developing country like India, where only 15.4% of urban women were associated with economic activities or the workforce [35], and the probability that female subjects with spine pain prioritized family and household duties, used different pain coping strategies, and avoided or delayed treatment [36].

Serving armed forces personnel had the highest percentage of patients with unilateral radicular pain presentation (51.5%), homemakers had the highest percentage of patients with bilateral radicular pain presentation (12.5%) and radiculopathy with myotomal loss grade >3 (16.5%), and the retired and unemployed group had the highest percentage of patients with radiculopathy with myotomal loss grade ≤3 (6%). Kuijer et al. [17], in a systematic review and meta-analysis, reported moderate-to-high-quality evidence to suggest that lumbar radiculopathy was associated with work-related exposure to bending of the trunk or lifting and carrying involved in physically demanding work. Furthermore, female gender and increasing age have been reported to be risk factors for developing lumbar radicular pain or radiculopathy [16, 37]. This is consistent with the findings of our study, where radicular pain and radiculopathy were seen in greater numbers during presentation among serving military personnel, homemakers, and older retired patients. In the current study, homemakers (group 4) had the largest percentage of patients who presented with severe pain and severe or crippled disability and had the largest percentage of patients who were medium or high risk for SBT. Although not considered a profession or occupation, homemakers, especially in developing countries, are involved in household activities and tasks that involve working long hours in awkward postures and frequently performing activities involving prolonged standing and sitting and repetitive bending, lifting, and arm movement activities [38, 39]. Women are at greater risk for nutritional deficiencies, the metabolic effects of perimenopause, and psychosocial factors, which may increase their risk of severe disability due to spine pain [40, 41]. Furthermore, patients with psychological factors such as catastrophizing symptoms and maladaptive behaviors are more likely to have severe pain and functional limitations [23].

Verwoerd et al. [42], in a systematic review, reported that high baseline radicular pain intensity was strongly associated with subsequent surgery in patients with lumbar radicular pain. Chen et al. [43], in a 5-year prospective study of patients with LBP, reported that pain intensity and negative beliefs about their LBP were negative predictors of poor outcomes at 6 months and 5 years. Similarly, psychological factors such as kinesiophobia, depression, self-efficacy, and catastrophizing have been reported to be predictors of disability outcomes, irrespective of the type of conservative intervention [44]. The initial risk measured with the SBT has been reported to be a prognostic indicator for 6-month disability and may provide important clinical decision-making information for treatment monitoring [45]. The findings of our study indicate that certain occupational groups have a distinct pattern of clinical presentation, especially service and sales workers, armed forces personnel, and homemakers, which can help predict treatment outcomes and recovery trajectories in these groups. The findings of this study can be the basis for identifying potential demographic predictors of spine injury categories or spine pain risk profiles and designing prevention and treatment plans based on their occupation. This will help initiate early intervention to treat symptoms and associated physical and psychological comorbidities and set correct expectations in patients regarding their expected recovery and return to work and activities of daily life with treatment based on their specific occupation.

To the best of our knowledge, this is the first and largest study to report the demographic, clinical, and psychological presentation of spine pain based on occupation groups. However, our study has a few limitations. First, participants in the current study were recruited from among patients who visited spine rehabilitation clinics in urban centers, due to which subjects from industries and occupations prevalent in semi-urban and rural areas could not be investigated. Second, causal inferences between occupational risk factors and spine pain were not an objective of this study and could not be reported. Lastly, details of co-morbidities such as hypertension, diabetes, and heart disease, which can independently affect the clinical presentation of spine pain [46], were not available in most of our patients and could not be included as part of the analysis.

5 Conclusion

Based on the results of our study, patients with spine pain showed variation in demographic, clinical, and psychological presentation based on their occupation. Service and sales workers (44%), and students (43.5%) groups had the highest percentage of patients who presented with central spine pain; military personnel had the highest percentage of patients who presented with unilateral radicular pain (51.5%); and the retired or unemployed group had the highest percentage of patients who presented with severe myotomal loss (grade ≤3) (6.5%). Homemakers had a significantly higher mean NPRS and ODI/NDI score on presentation and had the highest percentage of patients who presented with severe pain (47%), with severe and crippled disability (59.5%), and with medium to high risk (59%) with SBT when compared to other occupational groups.

Ethics statement

The study was approved by the Institutional Ethics Committee of Madha Medical College and Research Institute (MMCRI/IEC/2022/006) and has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki.

Informed consent

Informed consent was obtained from all subjects for participation in this study and their anonymized data was used for the research.

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

Acknowledgments

The authors wish to thank Dr. Raj Kanna for his review of the study design.

Funding

No benefits or funds were received in support of this study by any of the authors.

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