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Eur Spine J (2007) 16:283298

DOI 10.1007/s00586-006-0143-7

O R I G I N A L A RT I C L E

Association between sitting and occupational LBP


Angela Maria Lis Katia M. Black Hayley Korn
Margareta Nordin

Received: 16 January 2005 / Accepted: 31 March 2005 / Published online: Published online: 31 May 2006
 Springer-Verlag 2006

Abstract Low back pain (LBP) has been identified as awkward postures were analyzed as co-exposure fac-
one of the most costly disorders among the worldwide tors. WBV while sitting was also independently asso-
working population. Sitting has been associated with ciated with non-specific LBP and sciatica. Vibration
risk of developing LBP. The purpose of this literature dose, as well as vibration magnitude and duration of
review is to assemble and describe evidence of research exposure, were associated with LBP in all occupations.
on the association between sitting and the presence of Exposure duration was associated with LBP to a
LBP. The systematic literature review was restricted to greater extent than vibration magnitude. However, for
those occupations that require sitting for more than the presence of sciatica, this difference was not found.
half of working time and where workers have physical Awkward posture was also independently associated
co-exposure factors such as whole body vibration with the presence of LBP and/or sciatica. The risk ef-
(WBV) and/or awkward postures. Twenty-five studies fect of prolonged sitting increased significantly when
were carefully selected and critically reviewed, and a the factors of WBV and awkward postures were com-
model was developed to describe the relationships bined. Sitting by itself does not increase the risk of
between these factors. Sitting alone was not associated LBP. However, sitting for more than half a workday, in
with the risk of developing LBP. However, when the combination with WBV and/or awkward postures,
co-exposure factors of WBV and awkward postures does increase the likelihood of having LBP and/or
were added to the analysis, the risk of LBP increased sciatica, and it is the combination of those risk factors,
fourfold. The occupational group that showed the which leads to the greatest increase in LBP.
strongest association with LBP was Helicopter Pilots
(OR=9.0, 90% CI 4.916.4). For all studied occupa- Keywords Sitting LBP Sciatica Epidemiology
tions, the odds ratio (OR) increased when WBV and/or Review

A. M. Lis (&) M. Nordin Introduction


Occupational and Industrial Orthopaedic Center,
New York, NY, USA
e-mail: al96@nyu.edu Low back pain (LBP) is an important public health
problem in all industrialized countries. It remains the
A. M. Lis M. Nordin leading cause of disability in persons younger than
NYU Hospital for Joint Diseases, New York, NY, USA
45 years old and comprises approximately 40% of all
K. M. Black H. Korn compensation claims in the United States [17, 19, 42,
Program of Ergonomics and Biomechanics, 46, 78]. More than one-quarter of the working popu-
New York, NY, USA lation is affected by LBP each year [35], with a lifetime
prevalence of 6080% [21, 35] and a large percentage
K. M. Black H. Korn
Graduate School of Arts and Science (GSAS), of LBP claims for long durations (more than 90
New York University, New York, NY, USA workdays lost) [55].

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Approximately one-third of American workers are sitting and found that, in fact, it can be lower in sitting
in jobs that contribute to an increased risk of devel- than in erect standing. Another hypothesis is that pro-
oping back disorders, although the causes of lumbar longed static sitting postures may have a negative effect
disorders are complex and difficult to identify [57]. This on the nutrition of the intervertebral disc [47]. Thus, a
situation is similar in Great Britain, where the average constantly changing position may promote the flow of
estimated year-prevalence derived from British popu- fluid (nutrition) to the disc [75].
lation surveys is 38% [61, 77]. The purpose of this paper is to review the more
Because of the potential economic and social ben- recent literature that examines the association between
efits to be gained from reducing the magnitude of LBP sitting and the report of LBP among working popula-
in industry, many investigations have focused their tions. This review also intends to identify if there is an
attention on the factors that lead to injury, particularly interaction between occupational LBP/sciatica and
on those activities and events associated with the onset sitting in combination with WBV and/or awkward
of symptoms [67]. The major thrust of research about postures. The importance of this association cannot be
LBP has been to identify occupational risk factors underestimated. Understanding the risk factors for
associated with its presence and occurrence [58]. LBP and sciatica can lead to prevention programs that
With the rapid development of modern technology, have the potential to mitigate the high prevalence rates
sitting has now become the most common posture in of occupational LBP. Although other factors (i.e.,
todays workplace [38]. Reinecke et al. [66] reports physiological and psychosocial) may also be important,
that three-quarters of all workers in industrialized they are not the focus of this paper.
countries have sedentary jobs that require sitting for For this review, sitting is defined as a sustained up-
long periods. For many activities, however, sitting can right trunk posture with limited possibilities to change
be a less straining posture than standing [32]. Both posture or position [16, 30]. LBP is represented here by
postures are commonly used, and have advantages and reported or examined ache, pain, stiffness, or discom-
disadvantages depending on the task to be performed. fort in the lumbar spine [9]. Sciatic pain is considered a
In this review, sitting is discussed in the context of reported or examined radiating pain extending below
Western standards. Sitting is described as an erect the knee in one or both legs [9]. Workers in occupa-
posture in which the head and trunk are vertical, the tions who performed tasks while sitting may also be
lower legs are bent at about 90 at the hips and knees, exposed to WBV and/or awkward posture, and these
and the feet are firmly placed on the floor [16]. The exposures are independently analyzed in the literature.
concept of sitting is very different in non-Western Awkward posture represents a non-neutral trunk pos-
societies. In India and Southeast Asia, for example, it is ture (i.e., bending forward and/or twisting of the trunk)
still common to see workers sitting cross-legged on the [10, 12, 25, 30, 51]. Postural load [7] and unfavor-
ground, squatting (knees bent severely, the thighs close able posture [49] are terms used in the literature that
to the trunk, and weight concentrated on the heels), or refer to awkward posture. WBV is present when the
kneeling [32]. Although common, these variations of body receives continuous vibration transmitted from
sitting are not discussed in this review. the seat over a period of time [7, 9].
The existence of the relationship between workplace This systematic review seeks to examine the asso-
factors and the occurrence of LBP has long been rec- ciation between the presence and/or occurrence of
ognized [1, 3, 13, 29]. Among the occupational expo- LBP and sciatica among occupational groups in which
sures identified, sitting is commonly cited as a risk the seated posture is the major physical requirement
factor in the literature, in addition to heavy physical for the work. The following questions were considered:
work, heavy or frequent lifting, non-neutral postures (1) Is there evidence in the recent epidemiological
(i.e., trunk rotation, forward bending), pushing and literature for an association between occupational
pulling, and exposure to whole body vibration (WBV) groups exposed to sitting and reported LBP?, (2) Is
(i.e., motor vehicle driving) [12, 20, 25, 31, 35, 37, 39, there evidence in the recent epidemiological literature
47, 51, 53, 76, 79]. of an association between exposure to WBV while
Laboratory studies have focused on biomechanical sitting and reported LBP?, (3) Is there evidence in the
hypotheses to explain the association between sitting recent epidemiological literature for an association
and LBP [45, 47, 56, 74, 80]. The literature on this subject between awkward posture while sitting and reported
is extensive, but the evidence is somewhat contradictory. LBP?, and (4) Is there evidence in the recent epide-
It has been shown that intradiscal pressure is increased in miological literature for an association between the
the sitting posture [56]. In a more recent investigation, combined effect (both WBV and awkward posture)
Wilke et al. [80] reevaluated the intradiscal pressure in while sitting and reported LBP?

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Eur Spine J (2007) 16:283298 285

Methodology 10, 14, 15, 20, 22, 24, 31, 3739, 41, 43, 44, 48, 49, 53, 62,
69, 76].
Using MEDLINE (US National Library of Medicine),
HEALTHSTAR, and CINAHL as the principal data-
bases, studies published between 1990 and May of 2004 Results
were retrieved. The primary keywords used were LBP
and sitting. The secondary keywords used were WBV, LBP
static posture, occupational back pain, awkward pos-
ture, sedentary occupation, trunk twisting, and sciatica. Figure 1 depicts the results of studies undertaken be-
Several specific occupations such as different forms of tween 1990 and 2004 that measured the annual prev-
professional driving that require a combination of sit- alence rates of LBP among occupational groups that
ting and WBV or awkward postures were also re- are required to sit for more than half of their work-
viewed. Reference lists of studies retrieved were time. The estimated annual prevalence rate of LBP in
carefully screened in order to locate additional papers. the general population of Europe was used for com-
Articles written only in English were included, and a parison [61, 77]. European population data was chosen
total of 155 studies were identified. as a comparison group because 72% of the studies
Those studies that described the presence and/or reviewed were conducted in Europe. The average age
occurrence of reported or examined LBP in occupa- of the populations listed in Fig. 1 was 3050 years old
tional groups in which the major physical requirement and most of the workers were male. In general, the
is sitting (calculated as sitting for more than half of figure shows a higher annual prevalence rate for those
work-time) were included. Job titles were also used as occupational groups that spend more than half their
the selection criteria to identify those occupations in working day in a sitting position. Commercial travelers
which the worker is required to sit for a major part of [62] and office workers (in control groups) [7, 14]
the day. If there was doubt about the amount of sitting showed a lower prevalence rate (25%) than the aver-
required for a specific occupation, ONET, the US age of annual prevalence rate (38%) found in the
Department of Labors Occupational Information compared European general population [61, 77].
Network, was consulted [59]. Forty-one publications Tractor drivers reported the highest annual prevalence
met this criterion and were reviewed using a Critical rate, with almost two times the annual prevalence rate
Appraisal form [65]. (72%) of the general population [14].
Quality criteria were established for inclusion and Twenty-four publications were selected according to
carefully analyzed by the authors. The criteria were: a specific criteria for a more detailed review of the
clear definition of LBP and/or sciatica; a control group association between presence and/or occurrence of
(if applicable) that is well described and relevant LBP and occupational groups in which sitting is the
(consisting of similar or internal groups subjected to major physical requirement. Seventeen of these studies
less exposure to sitting); a response rate reported if a were conducted in Europe, [47, 9, 10, 14, 20, 22, 43, 44,
questionnaire was used to gather data; exposure de- 48, 49, 54, 62, 72, 76], one was conducted in Asia [15],
scribed or at least graded; and a statistical measure of one was conducted in Israel, [69] three were conducted
association (OR or Risk Ratio). in Canada, [31, 39, 41] and two were conducted in the
After applying the evaluation criteria, 17 articles US [24, 37]. The studies yielded different types of
were excluded from the final review. Of the 17 articles, prevalence estimates (i.e., point, period, lifetime);
5 articles were experimental studies [27, 36, 38, 50, 66] however, in the majority of studies, the OR for annual
and 12 articles were observational studies [11, 12, 26, prevalence was provided. For the papers that reported
28, 3335, 47, 52, 63, 70, 73]. The main exclusion cri- a significant association but did not report an OR, if
teria pertained to the lack of a statistical measure of enough information was available, an OR was calcu-
association. Ten of the 12 observational studies were lated so that all papers could be compared using the
excluded for this reason [11, 26, 28, 3335, 47, 52, 63, same measure of association. In general, the definition
70]. Two epidemiological studies were excluded, one for LBP was consistent with the definition for sciatica.
because of small sample size [12] and one because the Most authors described how data had been collected
focus was placed on psychosocial factors rather than on and attempted to categorize participants as exposed/
physical work-related factors while sitting [73]. non-exposed, or even to quantify their exposure. It
The remaining 24 publications were critically should be noted that for all the studies analyzed, the
reviewed to measure the possible associations between parameter that indicates the greatest exposure (mag-
sitting at work and reported LBP or sciatica [47, 9, nitude or duration) was selected by the authors for

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Fig. 1 Annual prevalence of Annual Prevalence of LBP found in studies on occupations required to sit
LBP found in studies of
occupations where sitting is for more than half of work-time
required for more than half of 100%
work-time Index Group Control Group
75%

LBP (%)
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Occupational Group

each of the factors described. For instance, Bovenzi almost null association between professional driving
and Betta [7] provided the OR for three parameters of and LBP [6, 53].
the exposure vibration duration such as 515, 1625, Nine studies showed a non-significant association
and greater than 25 years. The later parameter (OR= 1.4 and CI including 1) between sitting and
(>25 years) was selected for this review. LBP was self- LBP [20, 31, 3739, 41, 43, 53, 76]. For instance, when
reported in all the publications reviewed, with the dental hygienists were compared with a control group
exception of two that used a medical examination [22, of dental assistants, a small protective effect was evi-
69]. dent (OR=0.9, 95% CI 0.61.4) [41], and when dentists
Table 1 shows the OR for LBP in the occupational were compared with office workers, no association was
groups in which sitting is the major physical require- found (OR=1, 95% CI 0.51.9) [38].
ment (accounts for more than half of work-time). The Two studies [43, 62] evaluated the effect of extended
occupational group that demonstrated the strongest daily periods of driving (>4 h/day and >5 h/day). Each
association between sitting and reported LBP was study found OR > 1 (0.52.7) and OR=3.7 (0.914),
helicopter pilots [4] (OR=9.0, 90% CI 4.916.4), com- respectively; however, the P value was not significant
pared with a control group of non-flying officers. Crane in any of the studies (P>0.05). Working in a seated
operators also presented a high OR [14]; they had 3.29 position among steel industry workers produced a
times (95% CI 1.527.12) the risk of reporting LBP slight increase in the OR of LBP (OR=1.46, P=0.09);
than office workers. Bus drivers were the subject of two however, the OR was not significant [49]. In the Danish
separate studies. Although the OR in both studies was Twin Registry, sitting has a slight protective effect
not equal, both studies showed a positive association (OR=0.95, 95% CI 0.81.14). In fact, previous studies
between sitting and reported LBP (1.5) [9, 44]. In fact, conducted on populations in Sweden and Canada also
Bovenzi and Zadini [9] reported an OR of 2.57 (95% found that sitting did not increase the odds of LBP [31,
CI 1.524.35) while Magnusson et al. [44] reported an 39, 76].
OR of 1.79 (95% CI 1.162.75). Overall, the average OR for LBP in the occupations
However, results for the association between sitting presented in Table 1 was 1.99. However, almost half
and LBP in professional drivers (automobile, bus, the ORs factored in were not significant, weakening
tractor or truck drivers) are somewhat controversial. the supposed effect of sitting [6, 20, 36, 37, 39, 41, 43,
Four out of six studies showed a moderate positive 53, 62, 76].
association (average OR=2.1) between sitting and LBP Currently, the evidence is controversial in finding an
[7, 9, 22, 44]. The remaining two studies found an association between sitting and occupational LBP. In

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Table 1 Association between the presence of LBP and occupations requiring sitting for >1/2 of working time
Study Study design Study population Outcome Exposure Risk indicator OR Adjusted for
(95% CI or P value)

Bongers Cross-sectional Helicopter pilots LBP Pilot a helicopter OR=9.0 (4.916.4)a Age, height, weight, climate,
et al. [4] cohort (n=133) Non-flying bending forward, twisted
officers (n=228) posture and mental stress
Boshuizen Cross-sectional Truck and tractor drivers LBP Drive a tractor or a OR=1.39 (0.712.7)a Age
et al. [6] cohort (n=196) Blue-collar truck
workers (n=107)
Eur Spine J (2007) 16:283298

Bovenzi and Cross-sectional Tractor drivers LBP (previous Drive a tractor OR=2.39 (1.573.66) Age, BMI, education, sport
Betta [7] cohort (n=1,155) Office 12 months) activity, car driving, marital
workers (n=220) status, mental stress,
climate, history of trauma
and postural load
Bovenzi and Cross-sectional Bus drivers LBP (previous Drive a bus OR=2.57 (1.524.35) Age, awkward posture, BMI,
Zadini [9] cohort (n=234) Maintenance 12 months) mental load, education,
workers (n=125) smoking, sport activity and
previous jobs at risk for
LBP
Burdorf Cross-sectional Crane operators (n=94) LBP (previous Crane operator OR=3.29 (1.527.12) Age, individual
et al. [14] and Straddle-carrier 12 months) Straddle-carrier OR=2.51 (1.175.38) characteristics, work-
drivers (n=95) office driver related risk factors in
workers (n=86) previous jobs and work-
related risk factors
pertaining to the current job
Heliovaara Cross-sectional Professional drivers Unspecified LB Occupational OR=1.83 (1.123.0)a Sex, age, body height, BMI,
et al. [22] cohort (n=310) Non- syndromeb vehicle driving previous trauma, physical
professional drivers and mental stress, smoking,
(n=5,363) alcohol consumption, no. of
births (women)
Liss et al. [41] Cross-sectional Dental hygienists LBP (previous Work as a dental OR=0.9 (0.61.4) Age
n=950) Dental 12 months) hygienist
assistants (n=108)
MacFarlane Longitudinal Workforce population of Occurrence of LBP Drive a car (> 4 h/ OR=1.1 (0.52.7) Age
et al. [43] cohort Northwest England (1 year follow-up) day)
(population- (n=1,412)
based)
Magnusson Cross-sectional Bus drivers (n=111) LBP (previous Drive a bus or OR=1.79 (1.162.75) None
et al. [44] cohort Truck drivers 12 months) truck
(n=117) Sedentary
workers (n=137)
Masset and Cross- sectional Steel industry workers LBP (previous Work in a seated OR=1.46 (P=0.09) Vehicle driving, efforts with
Malchaire [49] (n=618) 12 months) position the shoulders
Moen and Cross-sectional Dentists (n=96) Dental LBP (employment Being a dentist OR=1.0 (0.51.9) None
Bjorvatn [54] auxiliaries (n=83) and period)
Office workers (n=25)
287

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288

Table 1 continued

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Study Study design Study population Outcome Exposure Risk indicator OR Adjusted for
(95% CI or P value)

Rotgoltz Cross-sectional Pharmaceutical factory LBP (previous Work in sitting OR=1.97 (1.372.81) Age and sex
et al. [69] workers (n=208) 12 months) position (packing,
laboratories and
offices)
Pietri et al. [62] Longitudinal Commercial travelers LBP (previous Drive a car ( < 5 h/ OR=2.1 (1.33.4) None
cohort (n=1,719) 12 months) day)
1st episode of LBP Drive a car (>5 h/ OR=3.7 (0.914.0) None
(in 1 year follow- day)
up)
Hartvigsen Twin-control Danish Twin Registry LBP Sitting only 0.95 (0.81.14) None
et al. [20]
Vingard Case-control Those living in the LBP Sitting > 5 h/day RR men: 1.1 (0.71.7); Age, gender
et al. [76] municipality of women: 0.7 (0.41.1)
Norrtalje, Sweden and
who sought care
treatment for LBP
Kopec Cohort Canadian National LBP Sitting only 1 (referent) Adjusted sample to match
et al. [31] Population Health the Canadian population
Survey
Miyamoto Cross-sectional Truck Drivers from a LBP Sitting only 1.3 (0.62.7) Age, height, weight, BMI,
et al. [53] large chemical industry working period
company in Toyko
Levangie [37] Case-control Patients referred to LBP Sitting < 4 h-referent Geographic distribution,
physical therapists for 46 h: 1.54 (0.812.91) socioeconomic group,
treatment of LBP 68 h: 0.71 (0.371.35) health care access,
(n=150) patients being >9 h: 1.42 (0.732.78) willingness to seek medical
treated by phys attention
therapists for an
unrelated problem
(n=138)
Liira et al. [39] Cross-sectional All residents outside LBP Sitting 1.08 (0.711.63) Sex, age, smoking
institutions and Indian
reservations in Ontario,
Canada with White
Collar Occupations
a
90% Confidence interval
b
Unspecified low back syndrome was defined by the authors as low back diagnoses other than sciatica (i.e., spondylolisthesis, spondyloarthosis, chronic muscular pain and
others)
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Eur Spine J (2007) 16:283298 289

fact, the more recent studies (19952004) almost (trunk flexed, bent, and twisted) in drivers of Road
unanimously found no association between sitting Washing Vehicles increased the OR of LBP to 10.59.
alone and LBP [20, 31, 3739, 41, 43, 53, 76]. As indicated in Table 4, only one study measured
Table 2 summarizes the studies that examine the associations for reported LBP and for the combined
association between the presence and/or occurrence of effects of exposure to WBV and awkward postures.
LBP and exposure to WBV among occupations that This study was done by Bovenzi and Betta, [7] who also
require sitting for more than half of working time. All looked at agricultural tractor drivers exposed to WBV
studies used vibration dose as the exposure measured; and the association of postural stress with the occur-
however, some studies also provided the OR for rence of chronic LBP. The tractor drivers were 4.56
vibration magnitude [5, 7, 9] and/or duration [4, 5, 7, 9]. times (95% CI 2.598.03) more likely to report LBP
To calculate vibration dose, the studies used the for- compared with the control group. Bovenzi and Betta
mula S a2i . tI, where ai is the estimated vector sum of [7] categorized postural stress by rating the workers
accelerations measured on the vehicle and tI is the time perception of the frequency and duration of each
in years (or hours in the case of helicopter pilots). In all posture. They calculated the frequency using a five-
studies, vibration measurements on the vehicles were item index scale assigning a value from 0 (never) to 4
performed according to the recommendations of the (very often). Following this step, a mean value was
international standard ISO 2631-1 [23]. Seven of the used to determine the duration by calculating the
nine studies included in Table 2 showed a positive postural indices during a typical workday. Finally, they
association between LBP and exposure to WBV [47, categorized the average postural load into one of the
9, 15, 39]. The occupational group that shows the four grades described on the table (mild = 00.99,
strongest association between LBP and vibration dose moderate = 11.99, hard = 22.99, and very hard = 3
is helicopter pilots, with OR=6.6 (90% CI 2.915.1). It 4). The results of this study show that after combining
is noteworthy that this was the only occupational group the exposure factors, the risk of the occurrence of
that used total hours as a measurement for duration of chronic LBP increases as vibration dose and postural
exposure because pilots systematically document their load increase. In fact, the risk for chronic back pain
flight hours in a flight log. Both the magnitude and the increases more than threefold compared with the
duration were positively associated with LBP. How- unexposed group (office workers).
ever, duration had a stronger impact on increasing the
risk of LBP in each of the studies (OR>2.5) [5, 7, 9]. Sciatica
One study, conducted by Liira [39], showed a small
association between the presence of LBP and the A parallel literature review was conducted to find the
duration of the WBV (OR=1.71). In Chens study, association between sitting for more than half of
when the analysis of the doseresponse of WBV was the work-time and the presence of sciatica. Using the
conducted, the results showed an increase in the risk of inclusion criteria mentioned earlier, five studies were
LBP of 3.7 as the daily vibration dose was increased included [4, 6, 7, 9, 24]. These studies collected infor-
[15]. mation about the prevalence of sciatica using ques-
Table 3 summarizes the studies that examine the tionnaires that asked about the presence of back pain
association between the presence and/or occurrence with radiation to a leg [24]. Table 5 describes the
of LBP and exposure to awkward posture among prevalence of sciatica in occupations where sitting is
occupations that require sitting for more than half of the major physical requirement with co-exposure fac-
work-time. Four studies [7, 9, 10, 48] were included in tors such as WBV and awkward postures. The preva-
Table 3. Bovenzi and Zadini [9] showed that the lence rates for reported sciatica in all the occupations
reporting of LBP increased when exposure to awkward analyzed were two to three times (OR ranging from
postures increased (OR=2.29, 95% CI 1.224.29) for 1.16 to 3.9, 95% CI 0.628.71) higher than their cor-
bus drivers when compared with maintenance workers. respondent control groups. However, the prevalence of
With exposure to frequent awkward postures, Bovenzi LBP as mentioned above was much higher for all
and Betta [7] found that tractor drivers are almost five occupations compared with the prevalence of sciatica
times more likely to report LBP than office workers. pain, except for crane operators [4] (50% prevalence of
Bridger [10] showed that sitting forward (as opposed LBP versus a 61% prevalence of sciatica pain).
to sitting up straight) resulted in a large increase in Table 6 shows the association between the presence
LBP (OR=6.02), and that further increments resulted of sciatica pain and sitting for more than half of
in smaller increases in the OR (3.15) of LBP. Mas- working time. The occupational groups that presented
saccesi [48] showed that exposure to awkward posture the strongest association of sitting and reported LBP

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290

Table 2 Association between the presence of LBP and exposure to whole body vibration among occupations that require sitting for >1/2 of working time
Study Study design Study group Control Outcome Vibration dose, Risk indicator OR Confounders adjusted for

123
group magnitude and/or (95% CI)
duration

Bongers Cross-sectional Helicopter pilots Non-flying LBP Duration: Total flight OR=13.4 (5.732.0)a Age, height, weight, climate,
et al. [4] cohort (n=133) air force time/>4,000 h bending forward, twisted
officers Dose: >8001,200 m2 h/s4 OR=6.6 (2.915.1)a posture and mental stress
(n=228)
Boshuizen Longitudinal Tractor drivers Agricultural LBP Magnitude: >0.7 m/s2 OR=2.10 (1.074.1)a Duration of exposure, age,
et al. [5] cohort (n=450) workers Duration:>10 years OR=3.6 (1.2111)a height, weight, smoking,
(n=110) Dose: >5 year m2/s4 OR=2.8 (1.645.0)a twisting, lifting, mental stress,
employing company
Boshuizen Cross-sectional Truck and tractor Blue-collar LBP Dose: 15 year m2/s4 OR=1.96 (1.033.7)a Age, mental stress, no. of years
et al. [6] cohort drivers (n=196) workers lifting + twisting, no. of times/
(n=107) day lifting + twisting, body
height, smoking, prolonged
sitting and time spent looking
backward
Bovenzi and Cross-sectional Bus drivers (n=234) Maintenance LBP Magnitude: >0.60 m/s2 OR=1.76 (0.863.58) Age, awkward posture, BMI,
Zadini [9] cohort workers (previous Duration: >15 years OR=2.90 (1.545.46) mental load, education,
(n=125) 12 months) Dose: >4.5 years m2/s4 OR=2.63 (1.355.12) smoking, sport activity and
previous jobs at risk for LBP
Bovenzi and Cross-sectional Tractor drivers Office LBP Magnitude: >1.25 m/s2 OR=2.29 (1.433.68) Age, BMI, education, sport
Betta [7] cohort (n=1,155) workers (previous Duration: >25 years OR=2.74 (1.694.45) activity, car driving, marital
(n=220) 12 months) Dose: >30 years m2/s4 OR=2.36 (1.483.74) status, mental stress, climate,
history of trauma and postural
load
Magnusson Cross-sectional Bus drivers (n=111) Sedentary LBP Bus drivers: OR=2.0 (0.984.1) None
et al. [44] cohort Truck drivers (n=117) workers (previous Dose: 48.18 years m2/s4
(n=137) 12 months) Truck drivers: Dose:
79.97 years m2/s4
Chen et al. Cross-sectional Taxi drivers N/A-general LBP Increment of daily 3.7 (1.112.2) Age, body mass index,
[15] population vibration exposure by professional seniority,
each m2/s4 h registration type, seat
inclination, vehicle engine size,
use of lumbar support
Liira et al. Cross-sectional All Residents outside Those from LBP Duration: always or often 1.71 (1.092.67) Sex, age, smoking
[39] institutions and the same (at least several hours
Indian reservations population per day)
in Ontario, Canada who were
with White Collar not
Occupations that exposed to
were exposed to WBV
WBV
a
90% Confidence interval
Eur Spine J (2007) 16:283298
Eur Spine J (2007) 16:283298 291

Table 3 Association between the presence of LBP and awkward posture among occupations that require sitting for >1/2 of working
time
Study Study design Study population Outcome Exposure Risk Adjusted for
indicator
OR (95%CI)

Bovenzi and Cross-sectional Bus drivers LBP Awkward postures OR=2.29 None
Zadini [9] cohort (n=234) Main- (previous (1.224.29)
tenance workers 12 months)
(n=125)
Bovenzi and Cross-sectional Tractor drivers LBP Awkward posture OR=4.56 Age, BMI, education,
Betta [7] cohort (n=1,155) Office (12 month (2.598.03) sport activity, car
workers (n=220) prevalence) driving, marital status,
mental stress, climatic
conditions, back trauma
and total vibration dose
Bridger Cross-sectional Navy helicopter LBP For VFF, slightly 6.02 None (but there were no
et al. [10] pilots forward posture (P < 0.01)a significant differences
vs. sitting up based on other
straight variables)
For IF, sitting 3.15
noticeably (P < 0.05)a
forward vs. sitting
slightly forward
Massaccesi Cross-sectional Drivers of road LBP Awkward posture 10.59a None
et al. [48] washing vehicles
(sitting in an
awkward posture)
(n=38) Drivers
of rubbish
collection vehicles
(sitting in a
standard posture)
(n=39)
a
OR was not reported in the paper, but enough information was given to calculate the OR

were subway train operators [24] and tractor drivers Table 6 were exposed to other factors such as WBV
[7], with an OR of 3.9 (95% CI 1.78.6) and an OR of and awkward postures, these groups will be analyzed
3.9 (95% CI 1.758.71), respectively. Taking into independently below.
account that the occupational groups presented in Table 7 shows the association between vibration
magnitude, duration of vibration exposure, and total
vibration dose while sitting with sciatica pain. An
Table 4 Association between the combined effects of vibration overall positive association was found between sciatica
dose (years m2/s4)/postural load and the occurrence of chronic pain and WBV when the OR was greater than or equal
LBP to 1.5 (OR1.5). There was a significant trend of in-
Total Postural load (grades)a creased reported presence of sciatica with increased
vibration vibration dose expressed as a variable derived from the
dose 1 2 3 4
(Mild) (Moderate) (Hard) (Very hard) duration of exposure and the magnitude of the expo-
(years m2/s4)
sure.
5 OR=1.29 OR=1.79 OR=2.50 OR=3.48 Helicopter pilots with a vibration dose greater than
10 OR=1.41 OR=1.96 OR=2.73 OR=3.79 1,200 m2 h/s4 were 5.6 times more likely to have sci-
20 OR=1.55 OR=2.15 OR=2.99 OR=4.16
atica pain [4]. At the same time, tractor drivers with a
30 OR=1.63 OR=2.27 OR=3.16 OR=4.39
40 OR=1.70 OR=2.36 OR=3.29 OR=4.58 vibration dose greater than 30 years m2/s4 were 4.14
times more likely to develop sciatica pain compared
Modified from Bovenzi and Betta [7]. Low-back disorders in
agricultural tractor drivers exposed to whole-body vibration and
with office workers [7]. In contrast with LBP without
postural stress sciatica, the magnitude of vibration presents a greater
a
OR adjusted for age, BMI, education, sport activity, car driving, risk for having sciatica pain when compared with
marital status, mental stress, climatic conditions and back trauma exposure to long-term vibration [5, 7, 9]. For instance,

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292 Eur Spine J (2007) 16:283298

Table 5 Sciatica prevalence in occupations that require sitting Discussion


for >1/2 of working time
Occupational groups Sciatica (%) The prevalence rates of LBP have been affecting the
economy of industrialized countries in many ways [17,
Crane operators 61
Office workers [14] 27
19]. As was described in Fig. 1, the prevalence rate of
Helicopter pilots 12 reported LBP in those occupations that require the
Non-flying officers [4] 6 worker to sit for the majority of a working day is sig-
Subway train operators 22 nificantly higher than the prevalence rate of the gen-
Tower operators [24] 8
Tractor drivers 16
eral population [61, 77]. Physical factors, psychosocial
Office workers [7] 4 factors, and individual characteristics contributed to
these findings [12, 25, 47, 67, 79], but only the physical
factors will be discussed here.
Bovenzi and Zadini [9] found a greater associa-
tion between exposure to a vibration magnitude of Sitting
0.60 m/s2 and sciatica (OR=2.26, 95% CI 1.44.49),
than compared with exposure to a vibration duration of Sitting has been a complex topic for researchers of
more than 15 years (OR=2.06, 95% CI 0.934.53). LBP. For many years, the sitting position has been
Only two studies investigated the independent identified as one of the major risk factors for devel-
association of awkward postures while sitting with oping LBP [29, 45]. Nachemson and Elfstrom found
the presence of sciatica (Table 8). Although the OR that body position affects the magnitude of the loads
was higher than 2 in each study, Bovenzi and Betta on the lumbar spine, and that the magnitude of the
[7] found that the association was not significant loads increases markedly when sitting is compared with
(95% CI 0.687.61). In Bovenzi and Zandini [9], the upright standing and well-supported reclining [39].
confidence interval was not provided, so it is not This finding created much controversy, and while some
included in the calculation. However, it seems that subsequent lab studies supported this finding [2, 36],
awkward posture at work was associated with the others have found different results [47, 80]. For in-
presence of back pain with radiation to a leg to a stance, the conclusions of Wilke et al. reevaluate the
lesser extent than WBV. assumption that there is an increased presence of

Table 6 Association between the presence of sciatica pain and occupations that require sitting for >1/2 of working time
Study Study design Study population Outcome Exposure Risk indicator Adjusted for
(95% CI)

Bongers Cross- Helicopters pilots Sciatica Pilot a OR=3.3 Age, height, weight,
et al. [4] sectional (n=133) Non-flying helicopter (4.916.4)a climate, bending
cohort officers (n=228) forward, twisted posture
and mental stress
Boshui- Cross- Truck and tractor drivers Sciatica Drive a tractor OR=1.16 Age
zen sectional (n=196) Blue-collar or a truck (0.622.2)a
et al. [6] cohort workers (n=107)
Bovenzi Cross- Tractor drivers Sciatica Drive a tractor OR=3.9 Age, BMI, education,
et al. [7] sectional (n=1,155) Office (1.758.71) sport activity, car
cohort workers (n=220) driving, marital status,
mental stress, climate,
history of trauma and
postural load
Bovenzi Cross- Bus drivers Sciatica Drive a bus OR=2.57 Age, awkward posture,
and sectional (n=234) Maintenance (previous (1.524.35) BMI, mental load,
Zadini cohort workers (n=125) 12 months) education, smoking,
[9] sport activity and
previous jobs at risk for
LBP
Johan- Cross- Subway train operators Sciatica Operate a OR=3.9 Age, gender, job title and
ning sectional (n=492) Tower (previous subway train (1.78.6) employment duration
[24] operators (n=92) 12 months)
a
90% Confidence interval

123
Eur Spine J (2007) 16:283298 293

Table 7 Association between the presence of sciatica pain and exposure to whole body vibration among occupations that require
sitting for >1/2 of working time
Study Study design Study group Control Outcome Vibration dose, Risk indicator Confounders
group magnitude and/ OR (95% CI) adjusted for
or duration

Bongers Cross- Helicopter Non-flying Sciatica Duration: Total OR=3.3 Age, height, weight,
et al. [4] sectional pilots air force flight time/ (1.010.4)a climate, bending
cohort (n=133) officers > 4,000 h forward, twisted
(n=228) Dose: OR=5.6 posture and mental
>1,200 m2 h/s4 (1.521.2)a stress
Boshuizen Longitudinal Tractor Agricultural Sciatica Magnitude: OR=1.60 Duration of exposure,
et al. [5] cohort drivers workers >0.7 m/s2 (0.713.6)a age, height, weight,
(n=450) (n=110) Duration: OR=1.42 smoking, twisting,
> 10 years (0.405.1)a lifting, mental stress,
Dose: > 5 year OR=1.59 employing company
m2/s4 (0.843.0)a
Bovenzi and Cross- Bus drivers Maintenance Sciatica Magnitude: OR=2.26 Age, awkward
Zadini [9] sectional (n=234) workers (previous >0.60 m/s2 (1.44.49) posture, BMI, mental
cohort (n=125) 12 months) Duration: OR=2.06 load, education,
>15 years (0.934.53) smoking, sport
Dose: OR=2.28 activity and previous
>4.5 years m2/ (1.194.35) jobs at risk for LBP
s4
Bovenzi and Cross- Tractor Office LBP Magnitude OR=3.65 Age, BMI, education,
Betta [7] sectional drivers workers (previous >1.25 m/s2 (1.568.53) sport activity, car
cohort (n=1155) (n=220) 12 months) Duration OR=4.46 driving, marital
>25 years (1.8610.7) status, mental stress,
Dose >30 years OR=4.14 climate, history of
m2/s4 (1.189.61) trauma and postural
load
a
90% Confidence interval

higher intradiscal pressure while sitting as opposed to among more strenuous occupations, Lee et al. reported
erect standing [80]. In fact, Rohlmann et al. reports that this group had the highest hospitalization rate for
that intradiscal pressure is up to 10% less when LBP, indicating that when low back injuries occur
standing [68]. Some studies have reported ORs as low among persons in these occupations, these injuries tend
as 0.7 for occupations in which the major physical to be more severe [35]. Hence, the risk of prolonged
requirement is sitting, indicating that people in these sitting in the workplace should not be overlooked. A
occupations may actually have a lower risk of LBP definitive experimental conclusion about the effect of
than in other occupations [37, 76]. However, although sitting on LBP has yet to be confirmed. However, the
the rate of LBP among occupations requiring extended majority of the literature reviewed for this paper has
periods of sitting may not be as high as the rate of LBP shown that sitting by itself does not imply a markedly

Table 8 Association between the presence of sciatica pain and exposure to awkward postures among occupations that require sitting
for >1/2 of working time
Study Study Study population Outcome Exposure Risk indicator Adjusted for
design OR (95%CI)

Bovenzi and Cross- Bus drivers Sciatica Awkward OR=2.44 None


Zadini [9] sectional (n=234) Main- (previous postures
cohort tenance workers 12 months)
(n=125)
Bovenzi and Cross- Tractor drivers Sciatica Awkward OR=2.27 Age, BMI, education, sport
Betta [7] sectional (n=1,155) Of- (12 month postures (0.687.61) activity, car driving, marital
cohort fice workers prevalence) status, mental stress,
(n=220) climatic conditions, back
trauma, and total vibration
dose

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294 Eur Spine J (2007) 16:283298

increased association with the presence and/or occur- effect. As the duration of exposure increases, the risk
rence of reported or examined LBP. In fact, a consid- of LBP increases. Bovenzi and Betta [7] found that
erably stronger association was found only when the prolonged tractor driving and exposure to WBV were
occupational groups studied were exposed to WBV the factors most associated with chronic LBP and sick
and/or awkward postures while sitting [47, 9, 10, 15, leave. They suggested an excessive accumulated
39, 48]. It is still unknown if other confounders as vibration dose effect as the main reason, which is in
psychosocial factors may affect the strength of the agreement with the Boshuizen findings [6]. However,
association between sitting alone and LBP. in the case of sciatica the pattern is not the same. The
duration of the exposure was constantly related to
Sitting and exposure to WBV sciatica to a lesser extent than vibration magnitude for
all the occupations [5, 9]. The reasons for such results
One of the major co-exposure factors for all the are not clear. Moreover, it is important to understand
occupations analyzed was WBV. There is a clear that in both cases either duration or magnitude were
indication of an increased risk of reported LBP and/or positively associated with the presence of reported
sciatica in occupations with exposure to WBV while LBP or sciatica symptoms. It is also important to take
sitting, mostly in professional driving occupations [4, 6 into account that the recommended ISO standards did
9, 12, 15, 22]. Many authors have carefully reviewed the not reveal any preventive health effect. Even with
risk effect expressed as increased associations from following ISO recommendations, the levels of vibra-
exposure to WBV and LBP, and have concluded that tion magnitude to which most drivers are exposed
there is indeed an association between WBV and LBP seems to be higher than the recommended maximum
[8, 18, 40, 60]. However, there is limited evidence level of exposure, especially when exposed for long
regarding a doseresponse relationship. There are periods of time. Many authors argue that these rec-
many confounding factors that interfere with the rela- ommendations should be reviewed [4, 6, 7].
tionship between LBP and WBV exposure. A workers
age, duration of exposure, history of LBP, previous Sitting and awkward posture
exposure, and even posture while being exposed to
WBV seems to affect that relationship [4, 6, 9, 60, 71]. It has been postulated that sustained awkward seating
Chen et al. [15] found that daily increments of the posture (lordosed or kyphosed, overly arched, or
vibration dose by each m2/s4-hour resulted in an in- slouched) can result in higher intradiscal pressure and
crease in the OR of LBP by 3.7 even after controlling may be injurious to spinal postural health [64].
for age and professional seniority, which is almost Therefore, awkward postures while sitting have been
analogous to duration of exposure [15]. described as possible risk factors for the presence of
Even though the number of studies that use control LBP [12, 25, 30, 71, 80]. Many experimental studies [2,
and exposure groups to analyze the association be- 30] have demonstrated that postural changes affect
tween LBP and WBV is limited, there is strong evi- spinal loads. Keyserling et al. [30] used a computer-
dence of a major association between WBV while aided system to investigate trunk posture during work
sitting and LBP/sciatica [47, 9]. For instance, occu- by measuring the time spent in neutral and non-neutral
pational groups such as helicopter pilots have shown a postures. Their results suggested that by controlling
very high OR (OR=6.6, 90% CI 2.915.1) for a vibra- non-neutral trunk posture, the risk of developing back
tion-dose exposure greater than 800 m2 h/s4 after pain on industrial jobs can be reduced. Non-industrial
adjusting for awkward postures [4]. Only one study [12] occupations such as professional drivers, dentists, and
did not find an association between sitting plus WBV helicopter pilots are also potentially exposed to awk-
and LBP; however, the low response rate in that study ward postures. However, only four epidemiological
compromised its quality. Therefore, this does not affect studies showed the associated risk of being exposed to
the conclusion that there is a strong relationship be- awkward postures and having LBP and/or sciatica [7, 9,
tween sitting plus WBV and LBP. 10, 48]. The results of these studies confirms that in the
In addition to dose, the magnitude and duration of case of bus drivers [9], tractor drivers [7], road washing
exposure have also been found to be important expo- vehicle [48] drivers, and helicopter pilots [10], the risk
sure factors for the presence of occupational LBP and of having LBP increases due to awkward posture while
sciatica. The articles reviewed showed that the dura- driving. The Road Washing Vehicle drivers have the
tion of the exposure had a slightly stronger association highest OR of all the occupations (OR=10.59) [48]. It
with the presence of LBP than did magnitude of may be important to note that these drivers are ex-
vibration [5, 7, 9]. This finding suggests a cumulative posed to trunk flexion, bending, and twisting, whereas

123
Eur Spine J (2007) 16:283298 295

the other occupational groups are exposed to only one awkward posture). The association increased when
of these factors. Hence, flexion, bending, and twisting postural load was analyzed adjusting for vibration dose
may be more detrimental than only flexion. The (OR=4.56, 95% CI 2.598.03).
question to be asked in this case is if the observed A model was constructed based on WBV and awk-
adverse effects of driving in these studies should be ward postures (Fig. 2). The model aims to describe
attributed to the exposure to awkward posture alone or how the risk effect of prolonged sitting increases sig-
to a combination of prolonged sitting, twisting, and nificantly as other co-exposure factors (in this case
bending postures, once sitting per se was not investi- WBV and awkward postures) play a role. As such, just
gated. the fact of sitting probably does not present a risk until
the worker is exposed to a certain level of WBV and/or
A proposed model an awkward posture. When these co-exposure factors
are combined, the risk for reporting LBP and/or sci-
The literature reviewed has indicated an increased risk atica increases (Fig. 2). Bovenzi and Betta [7] tried to
of LBP and sciatica for individuals in those occupations demonstrate this finding after analyzing the combined
that require prolonged sitting (defined as sitting for effect of postural load and total vibration dose. They
more than half of a working day). However, the risk found, as mentioned above (Table 4), that the combi-
increases after combining factors such as WBV and nation of vibration dose and postural load increases the
awkward postures. In fact, for all the occupations risk of reporting LBP. In fact, there was a linear trend
studied, these co-exposure factors were the variables of increasing prevalence of LBP as the combined effect
that led to a significantly increased risk. The fact of increases, perhaps demonstrating a doseresponse
being seated for an extended period does not signifi- relationship.
cantly demonstrate an impressive risk of having LBP It could be argued that this model has many limi-
and/or sciatica. Bovenzi and Betta [7] compared a tations due to the fact that LBP is multi-factorial in its
group of agricultural tractor drivers with a group of origin. Through this literature review, some physical
office workers. Both groups were exposed to static load (mechanical) factors (WBV, awkward posture, and a
due to prolonged sitting. However, only the tractor combination of both) were identified that are associ-
drivers group was exposed to the combined factors of ated with the occupations performed while sitting.
WBV and awkward posture. They found that tractor However studies have shown that there are other risk
drivers were 2.39 times more likely to report LBP than factors for LBP to which workers are exposed during
office workers (OR=2.39, 95% CI 1.573.66). The the time period when they are sitting or not sitting,
association was similar (OR=2.36, 95% CI 1.483.74) such as manual material handling or lifting activities, or
when they looked at WBV while sitting (adjusted for psychosocial factors.

Fig. 2 The risk for having low


back pain while sitting
increases significantly as the
combination of physical
factors such as exposure to
whole body vibration and SITTING + AWKWARD POSTURES + WBV
awkward posture plays an
additive effect
Risk for having LBP

SITTING + SITTING +
WHOLE BODY VIBRATION AWKWARD POSTURE

SITTING

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296 Eur Spine J (2007) 16:283298

Summary groups exposed to awkward postures while sitting


have an increased risk of having LBP. However,
No previous research has been reported that investi- further research is needed on this topic due to the
gated the sitting posture with respect to LBP and sciatica lack of valid and reliable instruments for its mea-
in a manner similar to this literature review, so no direct surement.
comparisons can be made. However, it could be argued The interaction of factors such as sitting, WBV, and
that the conclusions of this paper, as well as of this awkward posture should also be carefully analyzed
model, have some limitations due to the fact that LBP is in terms not only of their association with LBP, but
multi-factorial in its origin. Through this literature re- also of their doseresponse.
view, an association was made between some work-re- Awkward posture and WBV have been previously
lated factors while sitting (WBV, awkward posture, and associated with LBP, even without sitting. Further
the combination of both) and reported LBP and sciatica. research should be conducted to probe if sitting
A quantitative determination of how much exposure to adds to the risk of LBP.
these risk factors (WBV and awkward posture) would
alter the risk of occupational-related LBP was not con-
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