Clinically Relevant

Physical Activities and Low Back Pain: A

Community-Based Study
TAMAR JACOB
1,2
, MARIO BARAS
3
, AVIVA ZEEV
2
, and LEON EPSTEIN
3
1
Department of Physiotherapy, College of Judea and Samaria, Ariel, ISRAEL;
2
Zinman College of Physical Education
and Sport Sciences at the Wingate Institute, Netania, ISRAEL; and
3
Department of Social Medicine, Hadassah Medical
Organization and Hebrew University, Hadassah School of Public Health and Community Medicine, Jerusalem, ISRAEL
ABSTRACT
JACOB, T., M. BARAS, A. ZEEV, and L. EPSTEIN. Physical Activities and Low Back Pain: A Community-Based Study. Med. Sci.
Sports Exerc., Vol. 36, No. 1, pp. 915, 2004. Purpose: Very little is known about the relationship between physical activity and low
back pain (LBP) in general populations. This study aimed to evaluate the relationship between different dimensions of physical activity
and LBP among all adults of a defined community. Methods: A cross-sectional survey addressed all adults aged 2270 of a single town.
Inhabitants were asked to complete a self-administered questionnaire regarding physical activities, LBP, and related characteristics. The
Beacke Physical Activity Questionnaire evaluated physical activity, and the Modified Roland and Morris Disability Questionnaire, a
pain severity scale, and the Pain Symptoms Frequency and Bothersomeness Indices evaluated LBP. Results: High occupational activity
demands contributed to increased LBP prevalence, and, conversely, high sporting activity participation contributed to a decline in all
LBP measures. Subjects free of LBP and subjects who participate in sporting activities are more likely not to smoke and not to
participate in high occupational activity demands. Type of sporting activity was not associated with LBP prevalence or severity.
Conclusions: Different dimensions of physical activity yield different relationships to LBP. There are several shared characteristics
of those participating in sport on a regular basis and those free of LBP. Both groups present a healthier lifestyle. Although LBP was
less frequent among those who participate in sporting activities, participating in sporting activities did not contribute independently to
a lower prevalence of LBP. However, once LBP was established, participating in sporting activities contributed indirectly to its severity.
Key Words: PHYSICAL ACTIVITY, HEALTHY LIFESTYLE, PARTICIPATION
L
ow back pain (LBP) is the primary cause of activity
limitation in both men and women (12) and the
second most frequent reason, after upper respiratory
infections, for physician visits (7). Evidence of the contri-
bution of physical activity to the prevention and manage-
ment of LBP is still inconclusive. In a review of both
randomized trial and observational studies (8,14), the au-
thors concluded that there is limited evidence that exercises
to strengthen back and abdominal muscles and to improve
overall fitness can decrease the incidence and duration of
LBP episodes. These conclusions should be viewed cau-
tiously as they are based on studies conducted in the work-
place rather than in clinical settings or among general pop-
ulations. LBP was less frequent among those participating in
sporting activities in a study conducted in a clinical setting
(6) and among industrial workers (23), but this relation was
not established in a community-based study (13) and in
another study of industrial workers (16). Campello et al. (4)
suggested that the relationship between level of activity and
LBP follows a U-shape curve (too little or too much activity
is equally hazardous for the back). There is evidence of
indirect association between LBP and sports physical activ-
ities (1), and of direct association between LBP prevalence
and physical load during work (1,13). In a review of the
literature regarding low-status jobs and their relationship to
health risks (17), the authors claimed that physically mo-
notonous or repetitive work, which is very common in
low-status jobs, are associated with an increase in neck,
shoulder, and low back problems.
Possible explanations for the inconsistent conclusions of
previous studies might be differences between populations,
inappropriate sampling, or the use of inappropriate measures
of physical activity. Most of the above-mentioned studies
addressed LBP patients in clinical settings or in workplace.
Evidence stemming from the general population that repre-
sents workers and nonworkers, participants and nonpartici-
pants in regular sporting activities, participants in various
types of sporting activities, and its relationship with LBP
prevalence and severity is quite rare if it exists at all. In
addition, most available studies did not use a valid measure
Address for correspondence: Tamar Jacob, P.O.B. 185, Even Yehuda,
40500, Israel; E-mail: tamar@ycariel.yosh.ac.il.
Submitted for publication December 2002.
Accepted for publication September 2003.
0195-9131/04/3601-0009
MEDICINE & SCIENCE IN SPORTS & EXERCISE

Copyright 2004 by the American College of Sports Medicine

DOI: 10.1249/01.MSS.0000106166.94343.02
9
of physical activity in the context of back pain and therefore
should be interpreted cautiously. In fact, studies in which
physical activities were evaluated globally (17,18) failed to
detect a relationship between physical activity and LBP,
whereas a study (13) that used a measure that differentiated
between different types of physical activities succeeded in
finding such a relationship. An association between leisure
time physical activities and LBP has not been demonstrated
in previous studies to date (13).
The International Paris Task Force on back pain (1)
confirmed that the apparently contradictory results can be
partially explained by lack of uniformity in the measure-
ments of physical activity and by the wide range of popu-
lations studied (e.g., athletes and nonathletes). Recognizing
evidence for different effects of occupational and nonoccu-
pational activities on LBP, the task force recommended the
use of measurements that differentiate between three types
of activity: activities of daily living, occupational activities,
and recreational and sport-related activities, because these
may not be associated with LBP in the same way.
Following the task force recommendations, and because
of the paucity of information regarding physical activity in
a general population and methodological flaws in most
previous studies in this area, we chose to investigate occu-
pational, sporting, and leisure time physical activities
among all adults of a defined community (nonathletes) and
their relation to LBP prevalence and severity. We hypoth-
esized that different types of sporting activities might relate
differently to LBP prevalence and therefore evaluated this
potential relationship as well.
Gathering information about the relationship between the
different dimensions of physical activities and LBP in a
defined community, and not only among those who sought
care or among subjects in working places, as was done in
most previously published work in this area, may strengthen
the validity of the present study results and therefore con-
tribute important knowledge to the existing ambiguous ev-
idence. Thus, the aim of the study was to evaluate the
relationship between LBP prevalence and severity and three
dimensions of physical activity in a defined community.
METHODS
Setting and subjects. A cross-sectional survey, con-
ducted in a single town in Israel consisted of all adult
inhabitants aged 2270 (N 3350). A list of all inhabitants
obtained from the local authorities included information
about age, gender, and addresses. The majority could be
characterized as white-collar workers of the high and middle
socioeconomic classes. Inclusion criteria were living in
town at the time of the survey and being fluent in Hebrew.
Those who could not provide information due to physical or
cognitive medical conditions were excluded. That informa-
tion was based on relatives reports during the survey. The
list of reasons for exclusion is in the Results section. The
Institutional Review Board of the Hadassah Medical Center,
Jerusalem, approved the study.
Data collection. The survey encompassed a 12-month
period, from April 1999 to March 2000. All inhabitants were
randomly assigned in 12 clusters by streets. Subjects of the
first cluster were treated as a pilot study. After the pilot
study, several changes were implemented in the data col-
lection procedure in order to improve response rate. To
avoid response bias, this group was not included in the main
study. All inhabitants who met the inclusion criteria re-
ceived, by messengers, self-administered questionnaires ac-
companied by a cover letter and an informed consent form.
Date for collecting the questionnaires was agreed upon few
days later through a telephone call from the principal in-
vestigator. This procedure enabled her to persuade potential
nonrespondents to respond, to identify nonrespondents, and
to ask them for reasons and LBP prevalence during the
previous month.
The questionnaire consisted of two parts. The first part
included questions about back pain prevalence, physical
activity, smoking, working status, work satisfaction, percep-
tion of general health, and demographic information. Those
who reported LBP during the previous month were asked to
complete the second part of the questionnaire as well, which
included questions about pain characteristics and care seek-
ing. This group was followed up after 1 yr using similar
questionnaires. The results of the longitudinal study are
presented elsewhere (10).
Baseline variables. LBP was considered as a pain
between the 12th rib and the lower glutei folds that lasted at
least 1 d and interfered with regular daily activity. A simple
body chart illustrated the location. Prevalence of LBP was
determined by answers to the questions Did you ever/
during the previous year/during the previous month experi-
ence LBP?. The evaluated characteristics of LBP were
functional disability, pain symptoms frequency and bother-
someness, pain severity, and duration. Functional disability
was evaluated by the Modified Roland and Morris Disabil-
ity Scale (MRMQ) (19,21) and pain symptoms by the Pain
Symptoms Frequency (SFI) and Bothersomeness (SBI) In-
dices (21). A 10-degree pain scale registered pain severity.
Duration of LBP was registered by the question: For how
long did your previous episode of pain lasted? (optional
answers: 1 month; 1 month). Subjects were also asked
about their perception of general health. A single-item self-
rating instrument evaluated it with responses reported along
a 100-point continuum scale (11,20).
Physical activities were evaluated by the Beacke Physical
Activity Questionnaire (BPAQ) (3). This instrument pro-
vides three indices of habitual physical activity during the
previous year: Occupation (OAI), Sport (SAI), and Leisure
(LAI) Activity Indices. The reliability (5) and validity (24)
(evaluated in a population presenting coronary risk factors)
of this measure were acceptable (intraclass correlation
0.85). Canon et al. (5) reported an indirect association be-
tween physical activity at work and direct association be-
tween physical activity at leisure and education, as was
suggested before (24). Consequently, they recommended
analyzing data regarding the three indices separately. The
OAI is composed of sum scores of eight items regarding
10 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org
frequency of specific activities during work (e.g., walking,
sitting, and lifting heavy things). The SAI is composed of
the multiplication of three scores: level of intensity (depends
on type of sport activity), time (number of activity hours per
week), and proportion (number of activity months during
the year). The intensity is determined by expected level of
energy expenditure during a specific activity. Thus, activi-
ties with high-energy demands (e.g., soccer, bicycle riding,
and jogging) received a high score, activities with moderate
energy demands (e.g., swimming and walking) a moderate
score, and activities with low energy demands (e.g., calis-
thenics and yoga) a low score. The LAI is composed of the
sum scores of five items regarding frequency of activities
during leisure time (e.g., cycling, going shopping or to
friends on foot, and watching TV).
Other life style markers were smoking, defined by a
yes/no answer to the question Do you smoke on a regular
basis?, work status (employed/unemployed), and work sat-
isfaction, evaluated by a four-category Likert-type scale (not
satisfied, moderately satisfied, satisfied, or very satisfied).
Demographic variables included in the study were age,
gender, and education (defined by years of formal educa-
tion). All measurement tools were translated into Hebrew,
and their reliability was reevaluated by the authors in a
preliminary study and found to be acceptable (9) (intraclass
correlation 0.89).
TABLE 1. Subjects characteristics.
Characteristic Respondents (Total 2000) Nonrespondents (Total 866) Significance
Age N, mean SD 1838 44.6 10.4 908 42.8 11.6 **
Gender (female) N, % 1080 54 390 45 **
Years of formal education N, mean SD 1899 14.1 3.3
Smoke N, % 467 24.6
Work status (employed) N, % 1565 84.7
Work satisfaction
Total N, % 1820 100.0
Not satisfied 145 8.0
Moderately satisfied 266 14.6
Satisfied 864 47.5
Very satisfied 545 29.9
Beacke Physical Activity Questionnaire (BPAQ)
Sport activity index N, mean SD 975 8.7 6.8
Occupational Activity Index N, mean SD 1885 2.7 0.6
Leisure Activity Index N, mean SD 1852 2.8 0.6
Participate in regular sporting activities N, % 964 49.2
General health N, mean SD 1800 79.6 17.1
LBP prevalence
Prevalence (past month) N, % 615 30.7 195 22.6 *
Prevalence (past year) N, % 931 47.5
LBP characteristics
Pain severity (range 110) N, mean SD 487 5.4 2.1
Pain duration:
1 month N, % 379 76.3
1 month N, % 118 23.7
Modified Roland and Morris Disability Questionaire N, mean SD 511 7.8 5.3
Symptoms frequency index N, mean SD 507 8.7 4.0
Symptoms bothersomeness index N, mean SD 503 8.9 4.7
# Numbers do not sum into total in each category due to missing data.
* Statistical significant at the level of P 0.05.
** Statistically significant at the level of P 0.0001.
TABLE 2. Occupational Activity Index for selected characteristics of study sample
means and 95% confidence intervals.
Selected
Characteristics N Mean
Mean
Difference
95% CI of the
Difference
Gender
Male 874 2.6 0.07 0.12 to 0.01*
Female 1049 2.7
Work status
Employed 1588 2.6 0.32 0.41 to 0.24**
Unemployed 226 3.0
Smoking
Smoke 461 2.8 0.13 0.07 to 0.19**
Do not smoke 1406 2.6
LBP during past month
Yes 596 2.8 0.24 0.18 to 0.30**
No 1327 2.6
LBP during past year
Yes 841 2.8 0.14 0.08 to 0.19**
No 1082 2.6
Means and 95% confidence intervals (95% CI) were estimated by t-tests.
* Statistically significant at the level of P 0.01.
** Statistically significant at the level of P 0.0001.
TABLE 3. Sport Activity Index for selected characteristics of study sample means
and 95% confidence intervals.
Selected
Characteristics N Mean
Mean
Difference
95% CI of the
Difference
Gender
Male 435 9.5 1.4 0.5 to 2.2*
Female 540 8.1
Work status
Employed 773 8.9 0.8 0.4 to 2.1
NS
Unemployed 129 8.0
Smoking
Smoke 178 8.1 0.7 1.8 to 0.3
NS
Do not smoke 760 8.9
LBP during past month
Yes 279 7.9 1.1 2.0 to 0.2*
No 685 9.0
LBP during past year
Yes 400 8.4 0.4 1.3 to 0.4
NS
No 564 8.9
Means and 95% Confidence Intervals (95% CI) were estimated by t-tests.
* Statistically significant at the level of P 0.01.
** Statistically significant at the level of P 0.0001.
NS
Not significant.
PHYSICAL ACTIVITIES AND LOW BACK PAIN Medicine & Science in Sports & Exercise

11
Analytical methods. Independent sample t-tests were
used to compare means of continuous variables (e.g., pain
and disability scales, general health, age, and physical ac-
tivity indices) and chi-square to compare between categor-
ical variables (e.g., pain duration gender, and smoking))
among participants and nonparticipants in regular physical
activities and between those participating in different types
of sporting activities. Continuous variables were evaluated
for normality by exploring their skewness and kurtosis be-
fore the analysis. Logistic regression was used to evaluate
potential contributors to dichotomous dependent variables
(e.g., LBP and sporting activities participation) and linear
regression for continuous dependent variables (e.g., SAI,
pain severity, and disability score). The relationship be-
tween physical activities and LBP measures was evaluated
among those reporting LBP, in both directions, first with
physical activities as the dependent variable and then with
LBP prevalence and severity. All P values less than 0.05
were regarded as statistically significant. Data analysis was
performed using the SPSS statistical package version 10.
RESULTS
Participants. Of 3350 inhabitants, 355 who were con-
sidered as the pilot study were not included, 129 were
excluded, and 866 did not respond. CS survey data were not
available from 129 inhabitants. The main reasons were
insufficient knowledge of Hebrew (N 59), mental or
cognitive impairment (27), severe chronic illness (11), could
not be contacted (e.g., mourning or living in nursing home)
(20), death (5), and paraplegia (7). Finally, 2000 subjects
completed the questionnaires. Data regarding nonrespon-
dents were available from clusters 5 to 12, of whom only
42.5% provided information. The main reasons for nonre-
sponse were lack of interest (234), lack of time (124), and
protecting privacy (65). Respondents were more often fe-
males, slightly older, and reported higher frequency of LBP
(28.5% vs 22.6%) than nonrespondents (Table 1).
Most participants did not smoke, were employed, and
were satisfied with work. Nearly half participated in regular
sporting activities, about one third experienced LBP during
the previous month, and nearly half during the previous
TABLE 4. Leisure activity index for selected characteristics of study sample
Means and 95% confidence intervals.
Selected
Characteristics N Mean
Mean
Difference
95% CI of the
Difference
Gender
Male 874 2.9 0.18 0.12 to 0.23**
Female 1013 2.7
Work status
Employed 1515 2.85 0.03 0.12 to 0.04
NS
Unemployed 264 2.89
Smoking
Smoke 437 2.7
Do not smoke 1414 2.8 0.08 0.15 to 0.02*
LBP during past month
Yes 577 2.8 0.03 0.9 to 0.02
NS
No 1310 2.6
LBP during past year
Yes 828 2.84 0.02 0.08 to 0.03
NS
No 1059 2.86
Means and 95% confidence intervals (95% CI) were estimated by t-tests.
* Statistically significant at the level of P 0.01.
** Statistically significant at the level of P 0.0001.
NS
Not significant.
TABLE 5. Subjects characteristics stratified by participating in regular sporting activities.
Characteristic Participate in Sporting Activities Do not Participate in Sporting Activities Significance
Total no. N, % 964 48.2 N, % 1036 51.8
Age N, mean SD 908 44.9 10.3 N, mean SD 996 44.2 10.4 NS
Gender (male) N, % 432 44.8 N, % 930 47.6 NS
Years of formal education N, mean SD 936 14.7 3.1 N, mean SD 474 13.6 3.2 ***
Smoke N, % 178 19.0 N, % 963 30.1 ***
Work status (employed) N, % 773 49.4 N, % 289 50.6 NS
Work satisfaction 792
Total N, % 900 100.0 N, % 920 100.0 *
Not satisfied 55 6.1 90 9.8
Moderately satisfied 132 14.7 134 14.6
Satisfied 428 47.6 436 47.4
Very satisfied 285 31.7 260 28.3
Beacke Physical Activity Indices (BPAQ)
Occupational Activity Index N, mean SD 929 2.6 0.58 N, mean SD 956 2.7 0.62 ***
Leisure Activity Index N, mean SD 944 3.1 0.61 N, mean SD 908 2.6 0.57 ***
General health N, mean SD 893 82.1 15.3 N, mean SD 907 77.1 18.5 ***
LBP prevalence (past month) Yes, N, % 279 28.9 Yes, N, % 336 33.7 **
No 685 71.1 No 660 66.3
LBP prevalence (past year) Yes, N, 436 45.2 Yes, N, % 495 49.7 *
No 528 54.8 No 501 50.3
LBP characteristics
Pain severity (range 110) N, mean SD 224 5.0 2.1 N, mean SD 263 5.7 2.0 **
Pain duration:
1 month N, % 171 74.7 N, % 208 77.6 NS
1 month N, % 58 25.3 N, % 60 22.4
Modified Roland and Morris Disability
Questionnaire
N, mean SD 231 6.8 4.9 N, mean SD 280 8.7 5.5 ***
Pain symptoms frequency index N, mean SD 230 8.1 4.1 N, mean SD 277 9.2 3.8 **
Pain symptoms bothersomeness index N, mean SD 229 8.5 5.0 N, mean SD 274 9.3 4.4 *
#
Numbers do not sum into total in each category due to missing data.
* Statistical significant at the level of P 0.05.
*** Statistically significant at the level of P 0.0001.
** Statistically significant at the level of P 0.01; NS, Not significant.
12 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org
year. A total of 555 subjects who reported LBP during the
previous month completed the second part of the question-
naire. More than three quarters of the LBP group had short
duration pain (less than 1 month) over the previous month.
Mean scores of all LBP measures indicated low or mild LBP
in most cases (Table 1). Age and educational distribution of
the population revealed a slightly higher rate of young and
educated people than for of the general Jewish population of
Israel (2) (for example, the proportion of those with over 16
yr of schooling among age group 2544 is 18% in the
general population and 35% in the study population).
Females, unemployed, smokers, and those experiencing
LBP during the previous month and year presented higher
OAI (Table 2). Males and those who did not experience
LBP during the previous month presented higher SAI. The
SAI was not related to work status, smoking, and LBP
during the previous year (Table 3). Males and those who did
not smoke presented higher LAI. This was not related to
work status or to LBP prevalence (Table 4).
Nearly 50% participated in regular sporting activities.
This group was more educated, smoked less, was more
satisfied with work, participated less in occupational activ-
ities and more in leisure activities, and presented better
perception of general health and lower prevalence of LBP
during the previous month and year compared with those
who did not participate in regular sporting activities. In
addition, those participating in sporting activities, among
the LBP group, presented lower scores for all LBP measures
(pain severity scale, MRMQ, SFI, and SBI) compared with
those who did not. No age, gender, and work status differ-
ences were detected between the groups (results of univar-
iate analysis; Table 5).
Regression analysis revealed similar results to those of
univariate analysis. High OAI, low LAI, low perception of
general health, female gender, low education, and smoking
increased the risk of not participating in sporting activities.
Age, work status, and work satisfaction did not contribute to
sporting activities participation (Table 6). In addition, in-
creased LBP measures (MRMQ and SFI) among those re-
ported LBP contributed to nonparticipation in regular sport-
ing activities (Table 7).
The majority of those who were engaged in regular
sporting activities participated in moderate (56.4%), fol-
lowed by high (27.7%), and by low (15.9%) energy
expenditure activities. Men, younger people, and those
with higher perception of general health were more likely
to participate in high energy activities than women, older
people, and those with low perception of general health,
respectively. No differences were detected between those
who experienced LBP during the previous month and
year, and those who did not with regard to the type of
sporting activity (Table 8).
The only contributors to LBP prevalence (dependent vari-
able) during the previous month and year were high OAI,
and low perception of general health. Increased age contrib-
uted also to LBP during the previous month. Participating in
any sporting activity, type of sporting activity, LAI, work
status, work satisfaction, level of education, and smoking
did not contribute to LBP prevalence (Table 9). However,
low SAI, low education, and low perception of general
health contributed to higher score in most LBP measures.
This was demonstrated with regard to pain severity scale,
MRMQ, SFI, and SBI (Table 10).
DISCUSSION
This community-based study describes three dimensions
of habitual physical activities and their relation to LBP
prevalence and severity among adults, age 2270, and
among LBP subjects in a defined community. Whether
participating in physical activities leads to less frequent LBP
or to decreased severity rather than the opposite is beyond
the scope of a cross-sectional survey. Therefore, data were
analyzed in two directions, first with participating in phys-
ical activities as the dependent variable and then with LBP
prevalence and severity as dependent variables. The rela-
tionship between physical activities and LBP was evaluated
in three steps. The first step addressed the three dimensions
of physical activity, the second addressed participation ver-
sus nonparticipation in sporting activities, and the third
addressed type of sporting activities.
The three dimensions of physical activities yield dif-
ferent relationships to LBP prevalence and to partici-
TABLE 6. Selected characteristics associated with nonparticipation in regular
sporting activities among adult population in a single town in Israel.
Characteristics
Do not Participate in
Regular Sporting
Activities (Any Sport)
OR 95% CI
Occupation activity index 1.5 1.21.9
Leisure activity index 0.2 0.10.25
Perception of general health
(increase in 10 on 100 scale)
0.88 0.820.95
Gender (female) 1.4 1.11.8
Education (increase in 3 schooling yr) 0.76 0.680.85
Smoking 1.4 0.90.5
Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated by logistic
regression analysis.
The variables removed from the model were: LBP during the past month, age,
work status, and work satisfaction.
TABLE 7. Low back pain measures and perception of general health associated with
participating in regular sporting activities among adult population in a single town
in Israel.
Contributors
Nonparticipating in Regular
Sporting Activities
OR 95% CI
Perception of general health
(range: 0100)
0.88 0.790.99**
(Increase in 10 on 100 scale)
Roland and Morris Disability Scale
(range: 023)
1.1 1.01.3*
(Increase in 3 on the scale)
Symptoms Frequency Index
(range: 020)
1.4 1.01.8*
(Increase in 3 on the scale)
Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated by logistic
regression analysis.
* Statistical significant at the level of P 0.05.
** Statistically significant at the level of p 0.01.
The variables removed from the model were: 10-degree pain severity scale,
Symptoms Bothersomeness Index.
PHYSICAL ACTIVITIES AND LOW BACK PAIN Medicine & Science in Sports & Exercise

13
pants sociodemographics as has been demonstrated be-
fore (1,13,17). Low OAI, high SAI, and to some extent
high LAI were associated with low prevalence of LBP
and with several markers of healthy lifestyle (e.g., non-
smoking and participation in sporting activities) (results
of univariate analysis). The inverse relationship between
OAI and LBP and between SAI and LBP was also con-
firmed by multivariate analysis. High OAI contributed to
increased frequency of LBP and high SAI contributed to
decline in all LBP measures. These results are in congru-
ence with previous reports about low-status jobs, which
stressed the relationship between high physical load dur-
ing work and LBP (13,16,17) and with evidence regard-
ing the contribution of sporting activities to less frequent
LBP (6,22).
The relatively high proportion of participation in reg-
ular sporting activities (50%) can be attributed to the
sociodemographic characteristics of this population
(characterized as white-collar workers, and middle and
high sociodemographic class) and to differences from the
general population in Israel (slightly younger and more
educated) (2). The results indicated some common char-
acteristics of those who were free of LBP and those who
participated in regular sporting activities. Both groups
were presented healthier lifestyle (e.g., smoked less and
had lower OAI) and reported higher perception of general
health as compared with those who experienced LBP or
did not participate in regular sporting activities. How-
ever, regression analysis revealed that although increased
LBP measures contributed to decline in sporting activities
participation, participating in regular sporting activities
did not contribute to low LBP prevalence or to decreased
severity (dependent variables were exchanged). The sig-
nificance of decreased prevalence of LBP among those
who participated in sporting activities can be debated. It
seems that participating in regular sporting activities is an
indicator of a healthy lifestyle, indicating less smoking,
participating frequently and intensively in sporting activ-
ities on a regular basis, avoiding heavy occupational
activities, and being more active during leisure time.
These factors lead to lower back morbidity, as was re-
ported before (16). Similarly to our results, there is pre-
vious evidence of smokers facing increased risk of suf-
fering from LBP (15).
The role of sporting activity participation was further eval-
uated according to the type of sporting activity defined by level
of energy expenditure. Although the sociodemographic profile
of those involved in high energy sports differed from that of
those involved in moderate and low energy sports (e.g., more
males, younger, and presented better perception of general
health and higher SAI), they did not differ fromeach other with
regard to LBP prevalence. Therefore, our baseline assumption
that different sporting activities might relate differently to LBP
prevalence was not confirmed.
We employed several methodological strategies to enhance
the validity of the findings. The population (70%response rate)
represents a target population of all adult inhabitants, age
2270, of a defined community. Respondents and nonrespon-
dents were compared for LBP prevalence, age, and gender.
Age differences, although statistical significant, are irrelevant
in the context of LBP. Last but not least, the terms LBP and
sporting activities were clearly defined and evaluated by reli-
able and validated measures (3,9,19,21).
The limitations of this study include the use of self-
administered questionnaires, which requires a certain
level of education. That should be taken into consider-
ation especially because the proportion of low-educated
participants is lower than that of the general population
(10). A slightly excessive prevalence of LBP is expected
in this study compared with the target population for two
reasons. First, because women were more likely to re-
spond, as was demonstrated before (3), and, second, because
respondents reported a higher prevalence of LBP. Data regard-
ing nonrespondents to the cross-sectional survey was available
TABLE 8. Selected characteristics of study sample and sporting activities categoriesMeans and frequency (N 2000).
Total Active
Low Energy
Activities
#
Moderate
Energy
Activities
##
High Energy
Activities
###
Significance
All N, % 975, 100 155, 15.9 550, 56.4 270, 27.7
Age (yr) Mean, 95% CI 45.1, 44.445.7 47.6, 46.049.2 46.5, 45.747.3 40.4, 39.141.6 **
Perception of general health Mean, 95% CI 82.0, 81.083.0 82.6, 80.684.5 79.6, 78.181.1 86.3, 84.987.8 **
Gender (M) M, N, % 435, 44.6 24, 15.5 227, 41.3 184, 68.1 **
F 540, 55.4 131, 84.5 323, 58.7 86, 31.9
LBP during past month Yes, N, % 266, 27.3 48, 31.0 157, 28.5 61, 22.9 NS
No 709, 72.7 107, 69.0 393, 71.5 209, 77.4
LBP during past year Yes, N, % 445, 45.6 69, 44.5 264, 48.0 112, 41.5 NS
No 530, 54.4 86, 55.5 286, 52.0 158, 58.5
Means and 95% confidence intervals (95% CI) were estimated by t-tests. Differences between categories were estimated by chi-square tests.
#
e.g., Gymnastics, yoga;
##
e.g., walking, swimming, fitness room;
###
e.g., jogging, aerobic activities, playing basketball or soccer.
** Statistically significant at the level of P 0.0001.
TABLE 9. Selected characteristics associated with low back pain prevalence among
adult population in a single town in Israel.
Characteristics
LBP during the
Past Month
LBP during the
Past Year
OR 95% CI OR 95% CI
Occupation Activity Index 1.8 1.42.3 1.6 1.22.2
Perception of general health (increase
in 10 on 100 scale)
0.7 0.680.78 0.8 0.70.8
Age (increase in 10 yr) 1.2 1.021.48
Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated by logistic
regression analysis.
The variables removed from the model were: education, smoking, work status,
work satisfaction, leisure and sporting activities indices, participating in regular
sporting activities, and type of sporting activity.
14 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org
from less than 50% of this group. The sociodemographic
characteristics of the population differ from those of the gen-
eral population in Israel, and therefore any attempt to extrap-
olate them to other populations interpretations should be car-
ried out carefully.
CONCLUSIONS
The results support previous evidence of indirect associ-
ation between LBP and sports physical activities (1) and of
direct association between LBP prevalence and physical
load during work (1,13). There are several shared charac-
teristics between those who participate in regular sport
physical activities and those free of LBP. Both groups report
higher perception of general health and are involved in
fewer occupational physical activities. These characteristics
can be considered as markers of a healthy life. Whether LBP
severity is the cause of less frequent sporting activity rather
the opposite effect is not clear. However, considering the
overall, well-known benefits of sporting activities and our
results, it seems that LBP patients, as the general population,
should be encouraged to participate in regular sporting ac-
tivities regardless of its type.
The study was partially supported by grants from the Israeli
Sports and Physical Education Authorities, Ministry of Education,
Culture, and Sport.
The College of Judea and Samaria granted publication fee.
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TABLE 10. Selected characteristics associated with LBP severity among adult population in a single town in Israel.
Selected Characteristics
Pain Measures
Pain Severity Scale
(range 110)
Roland and Morris
Disability Scale Symptoms Frequency Index
Symptoms
Bothersomeness Index
Beta 95% CI Beta 95% CI Beta 95% CI Beta 95% CI
Sport Activity Index 0.09 0.1 to 0.02 0.08 0.14 to 0.02 0.06 0.1 to 0.005
Perception of general health (decrease
in 10 on a 100 continuum scale)
0.3 0.5 to 0.1 1.06 1.3 to 0.8 0.6 0.8 to 0.4 0.7 0.1 to 0.4
Education (decrease in 3 schooling yr) 0.3 0.5 to 0.1 0.8 1.2 to 0.3 0.5 0.8 to 0.2 0.7 1.1 to 0.3
Increased age (Increase in 10 yr) 0.6 0.2 to 1.14
Beta coefficients (Beta) and 95% confidence intervals (95% CI) were estimated by regression analysis.
The variables removed from the model were: Gender, work status, work satisfaction, leisure, and occupational activities indices.
PHYSICAL ACTIVITIES AND LOW BACK PAIN Medicine & Science in Sports & Exercise

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