SPINE Volume 24, Number 23, pp 2497–2505
©1999, Lippincott Williams & Wilkins, Inc.
Personal Risk Factors for First-Time Low Back Pain
Michael A. Adams, PhD,* Anne F. Mannion, PhD,† and Patricia Dolan, PhD*
Study Design. A prospective study of personal risk
factors for first-time low back pain.
Objectives. To construct and validate a multivariate
model to predict low back pain.
Summary of Background Data. Various physical and
psychological factors have been reported to increase the
risk of low back pain, but conflicting results may be at-
tributable to inaccurate “clinical” measures and to poorly
validated statistical models.
Methods. A total of 403 health care workers aged
18 – 40 years volunteered for the study. None had any
history of “serious” back pain requiring medical attention
or time off work. The volunteers completed the following
questionnaires: the modified somatic perception ques-
tionnaire, the Zung depression scale, and the Health Lo-
cus of Control. Anthropometric factors were quantified
using standard techniques. The 3Space Isotrak device
(Polhemus, VT) was used to measure lumbar curvature
and hip and lumbar spine mobility. Leg and back strength
and back muscle fatiguability were measured in func-
tional postures. Postal follow-up questionnaires, sent af-
ter 6, 12, 18, 24, 30, and 36 months, inquired about back
pain, and multivariate logistic regression was used to
identify risk factors at each follow-up.
Results. The response rate fell from 99% at 12 months
to 90% at 36 months, at which time 90 volunteers re-
ported “serious” back pain and 266 reported “any” back
pain. The following were consistent predictors of serious
back pain: reduced range of lumbar lateral bending, a
long back, reduced lumbar lordosis, increased psycholog-
ical distress, and previous nonserious low back pain. Only
the latter three were consistent predictors of “any” back
pain. Physical factors had the most influence in a sub-
population of volunteers who were new to the job.
Conclusions. Personal risk factors explained up to 12%
of first-time low back pain. [Key words: anthropometry,
back pain, mobility, psychometric questionnaires, risk
factors] Spine 1999;24:2497–2505
Recent epidemiologic studies have shown that many
cases of disc degeneration and low back pain (LBP) de-
velop because of patients’ personal characteristics, rather
than patients’ exposure to physical labor.8,9,10,54 Mod-
erate physical labor may even strengthen the
spine,1,34,49,61 and only arduous work significantly in-
creases the risks of LBP.31,45,56,57,61
Personal risk factors may be genetic or may be ac-
quired during the lifetime of the individual. Other factors
such as lumbar mobility may represent an interaction
between genetics and environment. The genetic influence
could involve metabolism (e.g., an abnormal vitamin D
From the *Department of Anatomy, University of Bristol, United King-
dom, and the †Schulthess Klinik, Zurich, Switzerland.
Supported by the Medical Research Council and the Arthritis and
Rheumatism Council (United Kingdom), and by the Schulthess Klinik
Research Fund (Switzerland).
gene60) biochemistry (abnormal collagen), physical fac-
tors (a long back), or psychology (depressive tendencies).
Many previous investigations have concentrated on
physical risk factors such as lumbar posture, mobility,
and anthropometry. Only the more recent studies have
incorporated the important biasing effects of psychoso-
cial factors, which have a profound influence on all as-
pects of LBP behavior, including the reporting of it and
response to treatment.10,15,16,27,41,46
Even when all relevant factors are studied, it may be
difficult to prove that they actually cause LBP, because
personal characteristics such as reduced mobility and de-
pression may themselves be a result of pain and ineffec-
tive treatment. The task of determining cause and effect
can be tackled only in prospective studies that link per-
sonal characteristics with future back pain. Several pro-
spective studies already have been performed,7,9,10,14 but
their inconsistent and variable results may reflect meth-
odologic difficulties. Firstly, if a high proportion of study
patients do not return the questionnaires, then the results
may be applicable only to a self-selected group. Sec-
ondly, the sensitivity of a multivariate analysis to small
risk factors can be reduced by the inclusion of exception-
ally large risk factors such as previous back pain9,10,46 or
an occupation that demands heavy and awkward lift-
ing.31,45,55,56,61 Merely omitting such factors from a
multivariate analysis would exaggerate the importance
of any minor factors that depend on them. Thirdly, in
several large prospective studies, investigators have used
quick but inaccurate “clinical” techniques to measure
physical characteristics such as lumbar mobility and
back muscle fatigability7,9,14 or have relied on individual
questions, rather than validated questionnaires, to assess
psychosocial factors. Fourthly, the authors of most pre-
vious studies were not able to check the reproducibility
of the multivariate statistical model used to identify risk
factors for LBP. Unexpected and possibly chance inter-
actions between variables may suggest a significant risk
factor in a given analysis, even though analyses on sub-
sets of the data or at different time points fail to support
the association.
The purpose of the current study was to overcome
these problems and to evaluate the true relative impor-
tance of physical and psychological personal risk factors
for LBP. Follow-up rates were kept above 90% by using
only volunteers who gave the authors permission to trace
them after any change of address during the 3-year fol-
low-up period. The effects of potential dominant risk
factors were minimized by restricting recruitment to 403
volunteers of similar age and occupation, who had no
previous history of serious LBP. All physical risk factors
2497
2498 Spine • Volume 24 • Number 23 • 1999

were measured by using precise quantitative techniques,

and five validated questionnaires were used to evaluate
psychological characteristics. The statistical model was
validated at five time points and on various subpopula-
tions. With these checkpoints, the authors hoped to
avoid the difficulties that beset previous investigations.

Methods
Study Design. Healthy volunteers were recruited into a pro-
spective study of risk factors for LBP. On entering the study,
each volunteer underwent a functional assessment that in-
cluded anthropometry and measures of strength, endurance,
mobility, and posture. Five psychometric questionnaires were
completed at the time of entry and at 6, 12, 18, 24, 30, and 36
months thereafter. Accompanying questionnaires asked about
any back-related pain experienced in the previous 6 months.
Various multiple logistic regression models were used to iden-
tify risk factors for future LBP.

Study Population. A total of 403 health care workers volun-

teered for the study. Most were nurses, but physiotherapists,
health care assistants, radiographers, and other therapists were
included. There were 371 women and 32 men. The numbers of
men and women simply reflect the numbers who volun-
teered—no deliberate selection bias was used. Only those aged
between 18 and 40 years were admitted (average age on entry,
27 years). None had any history of “serious” LBP (defined as
LBP requiring medical attention or time off work), but when
prompted, 141 volunteers recalled having experienced “nonse-
rious” LBP. Throughout the study, “back pain” was taken to
include symptoms from the region of the back between L1 and
the gluteal folds. Further details of the study population and
recruitment methods have been reported previously.41 No vol-
unteers were known to be pregnant at the time of the func-
tional assessment.
Functional Assessment. This evaluation lasted approxi-
mately 2 to 3 hours. To generate interest in the study, the
authors explained each test thoroughly and gave a verbal sum-
mary of each person’s performance in relation to the average.
Refreshments were offered and expenses reimbursed, but no
other payments were made. Recruitment and testing of the 403
volunteers took 30 months.
Back Muscle Strength. For this assessment, volunteers were
asked to adopt a “functional” stooped posture and to pull
upward with maximum force on a load cell attached to the
floor, for a period of 3 seconds.23,40
Quadriceps Strength. To assess this strength, the volunteer
was asked to flex the knee of the dominant leg by 90° while
sitting in a Tornvall chair.39
Back Muscle Fatiguability. The Biering-Sorensen test was
used to determine fatiguability. The volunteer lay prone on the
edge of a couch, with the torso unsupported, and attempted to
maintain the trunk in a horizontal position for as long as pos-
sible. This test is widely used,9,35 but it does not simulate pro-
longed physical labor, because the back muscles are not loaded
severely, and the lumbar lordosis is preserved or exaggerated.
Therefore, an additional fatigue test was devised in which vol-
unteers adopted a standardized stooped position and pulled up
on a floor-mounted load cell with 80% of their previously
Figure 1. “Sacral angle” (Ø) was the angle between the vertical
and the tangent to the skin surface at S1–S2. Lumbar curvature, or
lordosis, was the angle (u) between the tangent to the skin surface
at L1 and the tangent at S1–S2.
measured maximal strength for up to 20 seconds. Fatiguability
was quantified from the endurance time (in the Biering-
Sorensen test only) and from the rate of change of median
frequency of the electromyographic signal from the erector spi-
nae muscles at T10 and L3.23,40,59
Lumbar Lordosis and the Ranges of Lumbar Flexion, Ex-
tension, and Lateral Bending. These values were measured us-
ing the 3Space Isotrak device (Polhemus, VT).19 A source of
pulsed electromagnetic waves was attached to the skin surface
overlying the sacrum, and a sensor of these waves was attached
to the back overlying the L1 spinous process (Figure 1). The
Isotrak then recorded the angle between source and sensor in
the sagittal and frontal planes at 28 Hz. This angle is the lum-
bar lordosis, and the change in this angle between erect stand-
ing and extreme full flexion (measured while standing and
while sitting with the legs out straight to find a true maximum)
is the lumbar range of flexion. Ranges of movement in exten-
sion (standing and lying prone) and side-to-side lateral bending
(standing) were similarly quantified. In all cases, the volunteers
had several attempts to reach an extreme position, and the
maximum value was noted. The range of lumbar flexion move-
ment also was measured by using the modified Schober (skin-
stretching) test.7
Sacral Inclination and the Ranges of Hip Flexion and Ex-
tension. The sacral angle is defined in Figure 1. It was measured
by comparing the angle between the Isotrak source, mounted
on the sacrum, and the sensor, which was attached to a vertical
surface. Measurements were repeated with the volunteer in the
standing fully flexed and fully extended postures, to obtain the
range of hip flexion and extension, respectively.19,22
Peak Spinal Loading During Standardized Lifts. Peak spinal
loading was quantified21 to measure each volunteer’s “clumsi-

ness” during simple manual handling tasks. Details of these
experiments will be reported elsewhere.
Anthropometry. Measurements were made using standard
physiologic techniques. They included the length of trunk and
limbs, body weight and height, body mass index (weight/
height2), and body fat from skinfold measurements.
Psychological Factors. Five validated psychometric ques-
tionnaires were used, as justified previously.41 These were: the
modified somatic perception questionnaire (MSPQ18,37), the
Zung depression scale (ZUNG67), and the Health Locus of
Control (HLC64) which is divided into three subsections con-
cerned with “internal” factors (IHLC), “powerful others”
(PHLC), and “chance” (CHLC). These questionnaires were
chosen because they assess personal characteristics such as de-
pressive feelings and anxiety, rather than work-related factors,
and because they are all suitable for use by nonspecialists.
Scores from the MSPQ and the ZUNG questionnaires can be
added together to provide a total score (MSPQ 1 ZUNG),
which has a particularly high specificity and sensitivity for pre-
dicting psychological disturbance in LBP.28,38 The psychomet-
ric scores used in the final analysis were those obtained at the
initial assessment.
The five psychometric questionnaires were sent to each vol-
unteer as soon as they volunteered. Forms were checked for
completeness when they were brought to the functional assess-
ment. If necessary, advice was given concerning the completion
of future questionnaires. Subsequently, all five psychological
questionnaires were sent and returned by post every 6 months.
An accompanying questionnaire asked about any back-related
pain experienced during the previous 6 months, including de-
tails of any medical consultations and time taken off work.
Returned questionnaires were checked, and scores were en-
tered into a database. If questionnaires were not returned or
were incomplete, then the volunteer was contacted repeatedly
on the telephone or by letter until a response was forthcoming.
Even if a questionnaire was not returned, the volunteer was
pursued with equal vigor at the next 6-month interval.
Statistical Methods. The ability of each measured factor to
predict either serious or “any” LBP (i.e., serious or nonserious)
was assessed by univariate linear logistic regression. Univariate
analyses were repeated using data from each of the five fol-
low-up questionnaires to identify consistent risk factors for
LBP. The independence of variables was assessed using corre-
lation analysis, and the linearity of risk associated with certain
variables was checked by comparing subsets of their range.
Additional univariate analyses were performed on various sub-
sets of the study group. Results from the univariate analyses
were used to construct multiple regression models for predict-
ing LBP, using stepwise forward multiple logistic regression.
Results were defined as significant at P , 0.05, P , 0.01, or P
, 0.001.
Results
Response Rates and Incidence of Low Back Pain
The follow-up response fell from 99% at 12 months to
90% at 36 months. The number of volunteers reporting
serious LBP increased from 46 to 90 at these times, and
those reporting “any” LBP increased from 159 to 266.
There were no significant differences between men
and women.
Personal Risk Factors • Adams et al 2499
Cross-sectional Data
Details of the physical and psychological measurements
on the 403 healthy volunteers will be published sepa-
rately. A summary can be obtained from the authors.
Univariate Analyses
These revealed several consistent predictors of LBP, in-
cluding the sum of the scores from the MSPQ and ZUNG
questionnaires, which was the best psychometric predic-
tor (Table 1). Physical characteristics such as a pro-
nounced lordosis, a short back, and a large range of
lateral bending reduced the risk of serious LBP, but not
of “any” LBP. Conversely, increasing age and the num-
ber of years spent working in health care both tended to
reduce the risk of “any” back pain, but had little effect on
serious LBP. Being a qualified (and therefore experi-
enced) nurse or physiotherapist reduced the risk of seri-
ous LBP, but otherwise occupational categories had little
effect, possibly because most volunteers were involved in
similar work. Variables that consistently failed to predict
LBP of any description included: back strength, leg
strength, body weight, arm length, leg length, Schober
value, hip mobility, clinical hypermobility, IHLC, and
PHLC. Lumbar sagittal mobility, body height, smoking
status, and pregnancy during the 3-year follow-up pe-
riod were of variable significance. Most risk factors be-
came more significant with increasing follow-up time,
presumably because of the greater numbers of volunteers
with LBP, but several risk factors, including trunk length
and lumbar lordosis, were more significant at 12 months.
Correlations Between Variables
Despite the narrow age range of the population, the
range of lumbar extension (P , 0.001) and that of lateral
bending (P , 0.01) decreased with age, whereas back
muscle strength and endurance capacity increased (P ,
0.05). Some other variables were obviously highly corre-
lated, such as trunk length and body height (P , 0.001),
back muscle strength and fatigability (P , 0.05), and
lumbar lordosis and sacral angle when standing (P ,
0.001). Schober value (a measure of skin stretching) was
related to the lumbar range of flexion (P , 0.001) but
accounted for less than 9% of it, perhaps because it was
influenced by other factors such as trunk length (P ,
0.01). The generally small interactions between physical
and psychometric variables have been described previ-
ously.41
Multivariate Models
For each of the five follow-up times, stepwise forward
multiple regression models were constructed from all
those variables that were significant predictors of LBP at
two or more time points and that were not correlated to
each other. Age and gender also were entered. The best
models for all volunteers combined are summarized in
Table 2. The best predictors of serious LBP were reduced
range of lumbar lateral bending, reduced lumbar lordo-
sis, a long back, increased psychological distress (as in-
dicated by the combined MSPQ 1 ZUNG score), and
2500 Spine • Volume 24 • Number 23 • 1999

Table 1. Results of Univariate Analyses Indicating Risk ceptably linear). For example, reducing lumbar range of
Factors for Low Back Pain (LBP) lateral bending by 2 standard deviations would (for a
student nurse) increase the risk of serious LBP by 550%
12 months 36 months
(odds ratio 5 6.5).
Serious Any Serious Any
Variable LBP (P) LBP (P) LBP (P) LBP (P) Discussion

Age 0.721 (0.042)* 0.283 (0.073) The purpose of the study was to assess the relative im-
Women (vs. men) (0.016)* 0.897 (0.093) 0.993 portance of physical and psychological risk factors for
Previous LBP (0.011)* (,0.001)* (,0.001)* (,0.001)* first-time LBP, while avoiding the methodologic difficul-
Smoking 0.861 0.203 (0.072) (0.117)
Years in occupation 0.245 (0.002)* 0.363 (0.025)* ties that have beset previous investigations. The high sta-
Qualified nurse (0.011)* 0.261 (0.034)* 0.318 tistical significance and robustness of the multivariate
Qualified physiotherapist 0.267 0.522 (0.033)* 0.215 models (Table 2) suggest that this objective has been
CHLC (0.050)* 0.731 (0.061) 0.310
MSPQ 0.788 ,0.001* 0.155 ,0.001* achieved. Evidently, a long, stiff, or flat back appears to
ZUNG 0.082 0.028* 0.010* 0.014* predispose one to LBP, as do certain psychological fac-
MSPQ1ZUNG 0.090 0.001* 0.006* ,0.001* tors and previous LBP. The following sections will con-
Height 0.017* 0.428 0.129 0.874
Trunk length 0.008* 0.492 0.037* 0.633 sider the validity of the techniques used and the range of
Fat-free body mass 0.050* 0.600 0.133 0.761 applicability of the results obtained. Each identified risk
Sacral angle—standing (0.004)* 0.800 (0.019)* 0.157 factor will be discussed in turn, and the final section will
Sacral angle—full flexion 0.146 0.197 (0.029)* 0.237
Lumbar lordosis—standing (0.002)* (0.048)* (0.027)* 0.144 tackle the question: What did cause back pain in most of
Lumbar ROE (0.770) 0.310 0.576 0.971 the volunteers?
Lumbar ROF 0.131 0.462 0.252 0.170
Lumbar ROLF (0.012)* 0.279 (0.007)* 0.290
Modified Schober 0.846 0.946 0.619 0.405
Validity of Techniques
Back muscle endurance time (0.133) 0.486 (0.010)* (0.058) The use of self-reported pain as the outcome measure is
MF-gradient (max) 0.200 0.739 0.113 0.956 justified by a recent study in which 120 of 131 individu-
* Significant. als who reported previous LBP in a postal questionnaire
Serious LBP 5 required medical attention or time off work; Any LBP 5 could gave the same response 12 months later.65 Furthermore,
be serious or not. Previous LBP 5 an episode of nonserious LBP prior to
entering the study; ROE 5 range of sagittal extension; ROF 5 range of sagittal the reliability of self-reported LBP increases when the
flexion; ROLF 5 range of lateral flexion; MF 5 median frequency. pain is recent. The volunteers in the current study re-
Note: Values in parentheses indicate a negative association.
ported pain during the previous 6 months, so the average
elapsed time between pain onset and reporting was only
3 months.
previous nonserious LBP. This last factor dominated the The five psychometric questionnaires have been vali-
prediction of “any” LBP. dated and were devised for use by nonspecialists. Each
Similar results were obtained if women were ana- volunteer completed each questionnaire on seven sepa-
lyzed as a separate group (Table 2). Results among the rate occasions during their 3-year involvement with the
men were qualitatively similar, but few predictors study, and a preliminary assessment showed that re-
reached significance because of the small numbers (not peated scores were reproducible over long periods.41
shown in Table 2). A separate analysis was performed Techniques used to measure the physical risk fac-
on the 130 student nurses in the study, because they tors have been evaluated previously. When mounted
were very homogenous for age, occupation, and job on the back as described above, Isotrak measurements
experience, yet were required to perform the same are reproducible,19 and when used to quantify the
work as the more experienced nurses. Within this range of lumbar flexion movement, they provide mean
group, there was a greatly increased influence (as in- values and standard deviations similar to those ob-
dicated by R2) from the physical factors such as trunk tained using bilateral radiographs.24,47 This suggests
length and lumbar mobility on future serious LBP (Ta- that the Isotrack measurements in the current study do
ble 2). Finally, a separate analysis was performed on not contain larger, systematic errors. Random errors
those 262 volunteers who did not report any previous may arise from small skin movements, but these will
nonserious LBP when they entered the study. Remov- serve only to reduce statistical correlations with future
ing this important risk factor caused age to become LBP. Isotrak measurements of lateral bending have not
significant; increasing age tended to protect this subset been validated against radiographs because of the dif-
of volunteers from LBP. ficulty in obtaining ethical committee approval for ra-
Table 3 summarizes the most important results, which diation exposure. Muscles are strongest when
were evaluated at the central time point (24 months) stretched slightly from their resting position, so back
when response rates were still almost 100%. The odds muscle strength and fatiguability need to be measured
ratios quoted in this table show the increased risk of LBP in a moderately flexed functional posture if they are to
associated with changing the predictor variable from the be applicable to real life. The current authors’ electro-
mean value minus 1 standard deviation to the mean plus myographic techniques for quantifying muscle fatigue
1 standard deviation (within this range, the risk was ac- have been validated extensively, 23,40 and a recent
 Personal Risk Factors • Adams et al 2501

Table 2. Results of Multivariate Analyses Indicating Risk Factors for Low Back Pain (LBP) in Different Groups
of Subjects
12 months 18 months 24 months 30 months 36 months
(R2 %) (R2 %) (R2 %) (R2 %) (R2 %)

Serious LBP (all subjects) n 5 386

Previous LBP 1.2* 1.6† 1.8† 2.6‡ 2.7‡
MSPQ1ZUNG 1.3* 0.8* 1.5† 0.9*
Trunk length 0.7* 0.5* 0.7*
Lumbar lordosis (2.0†) (0.7*) (0.7*) (1.2*) (0.9*)
Lumbar ROLF (1.4*) (1.8†) (2.1†) (1.5†) (1.4†)
Any LBP (all subjects) n 5 386
Age (0.9†) (0.8*) (0.6*) (0.9*) (0.8*)
Previous LBP 3.5‡ 4.3‡ 6.0‡ 4.9‡ 4.0‡
MSPQ1ZUNG 0.6* 0.8* 0.6* 1.3† 1.4†
Lumbar lordosis (0.6*) (2.0‡) (1.0†) (0.6*)
Serious LBP (women) n 5 355
Previous LBP 1.5* 1.3* 3.0‡ 2.8‡ 3.1‡
MSPQ1ZUNG 1.0* 1.0* 0.5*
Trunk length 0.9*
Lumbar lordosis (1.7*) (0.6*) (0.7*) (0.5*)
Lumbar ROLF (2.0†) (2.3†) (2.3†) (1.5†) (1.4†)
Serious LBP (no previous LBP) n 5 248
MSPQ1ZUNG 2.3†
Lumbar lordosis (1.7*) (1.4*) (2.1*) (1.8*)
Lumbar ROLF (2.8*) (3.5†) (2.0*) (1.5*) (2.1†)
Age (1.7*) (2.0*) (1.3*)
Serious LBP (students) n 5 125
Trunk length 6.4† 4.2† 6.3† 2.2*
Lumbar lordosis (2.4*)
Lumbar ROLF (2.8*) (5.3†) (3.6*) (2.3*)
Lumbar ROF (2.1*)
* P , 0.05.
† P , 0.01.
‡ P , 0.001.
R2 5 the % of reports of LBP that are attributable to each risk factor; Serious LBP 5 required medical attention or time off work; Any LBP 5 could be serious
or not; Previous LBP 5 an episode of nonserious LBP prior to entering the study; No previous LBP 5 those subjects who, on entry into the study, had no
recollection of having suffered from any LBP in the past; Lumbar lordosis 5 lordosis in standing; ROLF 5 range of lateral flexion; ROF 5 range of sagittal flexion;
n 5 total number of subjects included in model at 12 months follow up.
Note: Values in parentheses indicate a negative association.

study has confirmed that a decline in median frequency Repeated contacts with the volunteers and the very
does reflect a real loss of maximal force-generating fact that they were volunteers could have resulted in a
capacity, or “fatigue.”39 well-motivated and self-selected group. However, the
fact that the annual incidence of serious LBP in the first
Generalizability of Results
12 months of the current study (13%) was similar to the
This study focused on healthy volunteers of similar age
16% reported previously in a large prospective study on
and occupation to prevent the regression model from
a general population9 suggests that this was not the case.
being dominated by previous LBP, age, and occupation
It may not be valid to compare incidence rates with those
loading. However, this makes it more difficult to extrap-
from previous studies on nurses, because the volunteers
olate to other ages and occupations. Each of the risk
in the current study benefited from the recent introduc-
factors considered in Tables 1 and 2 may be more or less
tion of manual handling aids to counter the previously
important at predicting LBP in heavy laborers, office
reported high incidence of LBP in the profes-
workers, or retired people. The influence of physical risk
sion.32,48,62,66
factors such as trunk length and ranges of lumbar move-
Male and female data were pooled because gender
ment probably can be explained in terms of increased
had only a marginal influence on future LBP (Table 2)
mechanical loading on certain spinal tissues (see below),
and because pooling the results increased the range of
so these factors might be expected to have more influence
several predictor variables such as body weight and
in occupations that are physically demanding. Similarly,
height. Results were very similar among women, which
psychological factors may predict more LBP in mentally
suggests that the inclusion of men could not have dis-
stressful occupations.
torted the model. Although the data on men showed a
A closely-related problem is that the homogeneity of
few similar trends, there were too few men to identify
the current study population may have restricted the
any real gender differences in these risk factors.
range of certain predictor variables, such as strength and
lumbar mobility, and may have made it more difficult for Predictors of First-Time Low Back Pain
them to influence future LBP. R2 values for these factors Several factors unexpectedly failed to reach significance.
may be higher in the general population. The effect of smoking is dose-related,17 and the volun-
2502 Spine • Volume 24 • Number 23 • 1999

Table 3. Relative Risks of Serious Low Back Pain (LBP) for the 24-months Follow-up Data
Serious LBP (all subjects) 24 months (n 5 382) Serious LBP (students) 24 months (n 5 125)
2 2
R % OR 95% CI R % OR 95% CI

Previous LBP 1.8* 2.3 1.3–4.0

MSPQ1ZUNG 0.8† 1.3 1.0–1.5
Trunk length 0.7† 1.9 1.1–3.3 6.3* 4.7 1.7–13.1
Lumbar lordosis 0.7† (1.8) 1.0–3.2
Lumbar ROLF 2.1* (2.5) 1.4–4.5 5.3* (6.5) 2.0–20.8

Total 6.1% 11.6%

* P , 0.01.
† P , 0.05.
CI 5 confidence interval; Lumbar lordosis 5 lordosis in standing; ROLF 5 range of lateral flexion; n 5 total number of subjects included in model.
Note: For continuous variables, the odds ratio (OR) represents the increased risk associated with increasing the variable from the mean less one SD to the mean
plus one SD. Where the association is negative (OR in parentheses), the risk is for reducing the variable by this amount. For example, for student nurses, increasing
trunk length by two SD increases the risk of LBP by a factor of 4.7 (i.e., by 370%).

teers in the current study may not have smoked many
cigarettes per day. Age and occupational category may
have had little influence, because all volunteers were
aged 18 – 40 years and worked in similar occupations.
Previous Low Back Pain. This has been a dominant risk
factor in several previous investigations,7,9,10 and it pre-
vailed again in the current study, even though the previ-
ous pain recalled by volunteers in this study was too
trivial to require medical attention or even time off work.
This association may be attributable to the cyclic nature
of LBP. Also, it is possible that individuals who were
prepared to report such trivial LBP on entry to the study
were also more prepared to report pain that occurred
during the 3-year follow-up period. When those report-
ing previous LBP were excluded from the analysis (Table
2), the risk of LBP declined with increasing age.
Psychological Factors. The MSPQ 1 ZUNG was a major
predictor of serious back pain, and several psychometric
scores predicted “any” back pain in the univariate anal-
yses (Table 1). The generally higher significance levels for
“any” LBP may be attributable to the higher number of
people who reported it, or it may reflect a greater psy-
chological involvement in the reporting of minor ail-
ments.10 The current authors previously have suggested
that future first-time back pain can best be predicted by
means of two questionnaires, the ZUNG and the
MSPQ.41 The latter is better for predicting relatively
nonserious back pain whereas the combined score is best
for predicting more serious back pain. The data for seri-
ous back pain in Table 2 are comparable with those of
the Boeing study,10 in which the authors found that med-
ical history (including previous back pain) predicted
3.3% of future back injury reports, and that psycholog-
ical factors explained 1.9% of them. Of the psychomet-
ric scores, only the MSPQ was changed (slightly) by a
first attack of serious back pain, and none was changed
by a first attack of “any” back pain,41 so it seems likely
that a high MSPQ 1 ZUNG score is a true predictor of
future LBP, rather than a consequence of previous non-
serious LBP.
Although psychological factors are not very impor-
tant predictors of first-time LBP, they do explain how
people respond to their pain, e.g., by seeking treatment,
and how they improve. Questionnaires concerning fear-
avoidance beliefs63 are particularly good at identifying
patients whose LBP is likely to become chronic,12,62 and
it remains to be seen whether these or other question-
naires can explain more first-time LBP than the question-
naires used in the current study.
Lumbar Mobility. Intuitively, one would suspect that a
supple back should be more difficult to injure in bending,
and a study on healthy volunteers performing simple
bending tasks in the laboratory has confirmed that sup-
ple individuals subject their lumbar spine to bending mo-
ments that are lower than those of stiff individuals.19
These previous results referred to sagittal-plane flexion,
whereas in the current study the greatest risk for LBP was
associated with poor lumbar mobility in the frontal
plane (i.e., a reduced range of lateral bending). This may
be attributable to the increased stiffness of the lumbar
spine in the frontal plane compared with that in the sag-
ittal plane.52 Many bending movements incorporate a
mixture of forward and lateral flexion,25 and the in-
creased risk of disc injury under these circumstances has
been demonstrated by cadaveric experiments,3,4 mathe-
matical models,53 and epidemiologic studies.25,42 In the
current study, the ranges of lumbar motion in the two
planes were so highly correlated (P , 0.001) that only
the range of lateral bending was included in most multi-
variate models.
Previous retrospective surveys have linked stiff backs
with LBP,13 whereas prospective studies have yielded in-
conclusive or contradictory results,7,9 which may well be
attributable to the use of the Schober (skin stretching)
test to measure mobility. A study claiming a high corre-
lation between Schober measurements and the angular
rotation of vertebrae is seriously flawed because it in-
cludes healthy volunteers and patients with ankylosing
spondylitis in a single population for the purposes of
statistical correlation.36 In fact, the Schober test never

has been shown to be a good measure of the range of
angular movement of lumbar vertebrae during flexion.
Lumbar Lordosis. A lordotic lumbar spine acts as a
shock-absorber during locomotion, in a manner similar
to that of a thin metal rod that is bent to form a helical
spring. In both cases, the curved shape allows the loaded
structure to bend, and this in turn allows it to absorb
more strain energy than if it were simply compressed. In
the case of the lumbar spine, even more energy may be
absorbed by muscles and their tendons as they attempt to
resist changes in lordosis. This shock-absorbing function
of a lordosis may explain why it appears to protect
against future LBP. Other mechanisms have been pro-
posed to explain how a lordosis might reduce spinal
loading during manual handling,51,58 but they are of
doubtful relevance because it is impossible to lift an ob-
ject from the ground without flattening the lower back
and stretching the lumbodorsal fascia.21,22 In the current
study, lumbar lordosis was inversely correlated to range
of extension (P , 0.05) and positively correlated to
range of flexion (P , 0.001), suggesting that a particu-
larly lordotic posture is equivalent to standing in a posi-
tion closer to full extension than is normal. This may
explain in part the protective effect of a pronounced lor-
dosis, because increases in lordosis are associated with
reduced intradiscal pressures6 and with a transfer of
loading from the nucleus to the posterior anulus and
apophyseal joints.5
Trunk Length. When objects are lifted from the floor, a
long back would tend to keep both object and upper
body weight further from the center of rotation in the
intervertebral discs. The back muscles would have to
work harder, and the discs would be compressed more
severely. This may explain why individuals with a long
trunk (or body—the two are closely related) were predis-
posed to low back problems in the current and previous
studies.11,29,30,33 The influence of external levers, such as
trunk length, may be mirrored by a similar influence
from the length of internal levers, such as the spinous
processes. The inherited length of internal and external
levers may explain in part the strong influence of genetics
on back pain50 and disc degeneration.8
Back Muscle Strength and Fatigability. The results of this
study confirm those in previous reports that back muscle
strength has little influence on LBP,9,33,44 whereas the
rate at which the muscles fatigue does have some ef-
fect.9,35 This influence may be explained in terms of the
protection offered the spine by the back muscles during
repetitive or sustained exertions. Fatigable muscles soon
lose their ability to generate maximal force, and this may
leave the underlying spine more vulnerable to bending
injury20 or to excessive “creep” in sustained postures.43
Typical fatigue tests involve a combination of physical,
metabolic, and psychological factors that can be difficult
to untangle, and several variable factors can influence the
rate of decrease in the electromyographic median fre-
Personal Risk Factors • Adams et al 2503
quency.23,40 In future work, the current authors will an-
alyze electromyographic data in more detail to determine
which aspects of the fatigue tests best predicts LBP.
What Caused Most of the Back Pain?
Although several personal characteristics were highly
significant predictors of future back pain, the R2 values
(Table 3) indicate that they explained less than 12% of it.
Either these factors play only a minor role in helping to
determine when most young people first report back
pain, or else they play a decisive role, but only in a small
minority of people. A risk factor can be highly significant
(small P value) but unimportant (low R2 value) if it is
rare in the population studied, but has a decisive effect
when it does occur. As discussed above, the personal
factors included in the current study might have pre-
dicted more LBP in physically or mentally stressful occu-
pations, especially if a more variable group of individuals
had been considered.
Nevertheless, less than 12% of the volunteers studied
could attribute their back pain to any of the psycholog-
ical or physical risk factors considered. What, then,
caused LBP in the remainder? Some might have been
attributable to personal risk factors not considered in
this study, such as a deleterious gene for vitamin D60 or
collagen, short internal lever-arms for the back muscles,
or specific work-related factors such as job satisfaction,
which were not assessed in this study’s question-
naires.10,46 Also, purely random accidents and emergen-
cies may have played a part, especially among nurses
who deal with unpredictable loads (patients), or who
have poor handling skills.62 Chance quarrels with col-
leagues may similarly precipitate pain with a high psy-
chosomatic component.
Despite these possibilities, it is becoming apparent
that there are no simple explanations for LBP, only a
large number of interacting causes that must be identified
and pieced together like a jig-saw puzzle. As far as rela-
tively trivial LBP is concerned, the effort to pursue these
causes may simply not be worthwhile, because the failure
of all the physical factors to predict “any” LBP in the
current study (Table 2) surely indicates that mechanical
influences in the reporting of such pain are negligible. In
this sense, mechanical influences would include any met-
abolic or biochemical factors that might weaken tissues
and leave them more vulnerable to injury. Perhaps the
problem of nonserious LBP should be left to psycholo-
gists and work managers.
As far as serious LBP is concerned, the results of the
current study offer some encouragement to those who
seek to understand it in mechanistic terms. The posses-
sion of a long, flat, or stiff back substantially increases
the risk of serious LBP, and it is difficult to explain this in
other than mechanical terms. Furthermore, the finding
that these factors have a much greater influence in stu-
dent nurses who are new to the job (Table 3) provides
additional insight into the role of mechanical loading in
LBP. It suggests that recent increases in physical activity
2504 Spine • Volume 24 • Number 23 • 1999
are more likely to lead to LBP than a high but constant
level of activity. Previously, the current authors have ar-
gued that sudden increases in physical activity can make
the large avascular discs the “weak link” in a rapidly
strengthening spine, which is loaded with increasing se-
verity by its own strengthening muscles.1 This hypothesis
has received some support from the recent evidence that
student nurses experience more back pain during their
first year working on the wards.32 The results of the
current study lend further support to the hypothesis, be-
cause they suggest that the increased LBP in young nurses
is associated with mechanical factors.
Conclusions
1. In multivariate analyses, none of the physical risk
factors was an important predictor of “any” LBP. It
may not be possible to explain trivial LBP in mechan-
ical terms, at least in young health care workers.
2. The following were consistent predictors of serious
first-time LBP: reduced lumbar mobility, reduced
lumbar lordosis, a long back, increased psychological
distress, and previous nonserious LBP.
3. Up to 12% of serious LBP could be explained by
various combinations of the physical and psycholog-
ical factors considered in the current study. Other fac-
tors may be more important, and the factors consid-
ered in this study may have more influence in other
populations and work environments.
4. Serious LBP was more common among those who
were new to the job, and the influence of physical risk
factors was much greater in this group.
Acknowledgments
The authors thank Christine Standell for helping with all
aspects of this work, and Tony Hughes for statisti-
cal advice.
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Address reprint requests to
Michael A. Adams, PhD
University of Bristol, Department of Anatomy
Southwell Street, Bristol BS2 8EJ
United Kingdom
E-mail: M.A.Adams@bris.ac.uk.