Musculoskeletal pain among medical students and its association with perceived stress level: A cross-sectional study
SG Thejaswi, Akhilesh Mukerji, Sunil Baliga, Sundar Kishore Dewan, Anubhav Verma
Department of Orthopaedics, Sikkim Manipal Institute of Medical Sciences, Sikkim, India
|Date of Submission||24-Aug-2022|
|Date of Acceptance||31-Oct-2022|
|Date of Web Publication||28-Apr-2023|
Dr. S G Thejaswi
Department of Orthopaedics, SMIMS, 5th Mile, Tadong, Gangtok - 737 102, Sikkim
Source of Support: None, Conflict of Interest: None
BACKGROUND: Musculoskeletal pain (MSP) is common among medical students across the world. The present study was done to estimate the prevalence of MSP among medical students in the state of Sikkim, India, and to assess perceived stress levels among medical students and its association with MSP.
MATERIALS AND METHOD: A cross-sectional study was carried out at a private medical college in the state of Sikkim, India. Fifty students each from the third, fifth, seventh, and ninth semesters were included in the study. Students were asked to complete a questionnaire that included data regarding lifestyle habits and activities, the modified Nordic scale for MSP, perceived stress score (PSS-10), and Oswestry disability index (ODI) questionnaire.
RESULTS: The majority (73%) of the participants reported one or more episodes of MSP in the past 12 months and 50% of them had pain in the past 7 days. No significant association was found between MSP and lifestyle habits, mean time spent on physical activities and sedentary behavior. The perceived stress level was significantly higher among those with MSP in the past 12 months (19.7 ± 5.6) (P-0.021), as well as in those who had MSP in the past 7 days (20.8 ± 5.5) (P-0.001). Severe pain was significantly associated with a higher perceived stress score (23 ± 5) (P-0.003). Students who had MSP in the past 12 months as well as in past 7 days had a higher quality of life score (9.8 ± 10.6, P-0.039 and 13 ± 10.9, P-0.000, respectively).
CONCLUSION: The majority of our medical students have experienced musculoskeletal pain in the past 12 months, which is significantly associated with perceived stress and quality of life.
Keywords: Medical education, musculoskeletal pain, perceived stress, quality of life
|How to cite this article:|
Thejaswi S G, Mukerji A, Baliga S, Dewan SK, Verma A. Musculoskeletal pain among medical students and its association with perceived stress level: A cross-sectional study. J Edu Health Promot 2023;12:143
|How to cite this URL:|
Thejaswi S G, Mukerji A, Baliga S, Dewan SK, Verma A. Musculoskeletal pain among medical students and its association with perceived stress level: A cross-sectional study. J Edu Health Promot [serial online] 2023 [cited 2023 May 30];12:143. Available from: https://www.jehp.net//text.asp?2023/12/1/143/374760
| Introduction|| |
”Musculoskeletal pain” (MSP) is considered a major cause of chronic pain, and could lead to reduced educational attainment, and absenteeism from university lessons. Various risk factors identified for the development of MSP range from body morphology to lifestyle activities to psychological aspects.,,,Among them, occupation could be considered one of the major contributors to the development of MSP. Healthcare workers, particularly surgeons and interventionists, commonly suffer from musculoskeletal problems. Studies have implicated that low back pain (LBP) among healthcare workers begins before they start working, which brings our attention to the years of their training. Available literature suggests that there is a high prevalence of MSP among medical students.,,,, Undergraduate training for medicos is different in each country. Hence, these results cannot be generalized as a whole. To the best of our knowledge, only two studies have been done related to MSP among medical students in India, and have shown a high prevalence of LBP, and neck pain.
In view of the suspected high prevalence of musculoskeletal problems among medical students, the present study was done to estimate the prevalence of MSP among MBBS students of a private medical college in the state of Sikkim, India. The study aimed to correlate various previously identified risk factors with MSP and to assess perceived stress levels among medical students and its association with MSP.
| Material and Methods|| |
Study design and setting
This cross-sectional study was carried out at a private medical college in the state of Sikkim, India, with an annual intake of 100 students for the course of MBBS. The study aimed at estimating the prevalence of MSP among medical students in Sikkim state and identifying risk factors associated with MSP. We also assessed the perceived stress score (PSS) and quality of life (QoL) among medical students and their association with MSP.
Study participants and sampling
The study was carried out in the months of September and October of 2019, keeping in mind the academic calendar, as well as weather conditions of the region. Out of 400 medical students, who were part of the old National Medical Council curriculum for MBBS, a total of 200 students were enrolled in the study. Fifty students each from the third, fifth, seventh, and ninth semesters (referred here on as first-, second-, third-, and fourth-year batches, respectively) with odd roll numbers were included in the study from every batch. Those who gave a history of diagnosed organic cause for MSP such as connective tissue disorder, history of trauma, infective pathology, or presently suffering from any illness were excluded from the study. In such a case, the subsequent roll-numbered student was asked to fill out the questionnaire.
Data collection tool and technique
After obtaining informed written consent, students were asked to complete a pretested, self-administered questionnaire. The questionnaire was prepared in the English language and consisted of 3 sections. Section 1 of the questionnaire was used to obtain basic demographic details of participants and their health behavior activities. The body mass index (BMI) was calculated based on self-reported weight and height and graded as: underweight (<18.5 kg/m2), normal (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obese (>30.0 kg/m2). Lifestyle habits such as coffee/tea intake, tobacco, and alcohol consumption were recorded as never, occasionally (a few days of the week), and regularly (most days of the week). Time spent on physical activities and sedentary activities was recorded as approximate minutes (in multiples of 15) spent in a week.
WHO recommends 150 to 300 min of moderate-intensity physical activities per week, in the form of exercise, sports (indoor/outdoor), yoga, and brisk walking, for young adults. Accordingly, we recorded the approximate amount of time (minutes per week) spent on these activities and summed them together. The total time was considered as “Summed Physical Activity” (SPA) time per week.
Similarly, sedentary behavior is defined as “ any waking behavior characterized by an energy expenditure of ≤1.5 metabolic equivalents (MET) while in the sitting or reclining posture.”, Accordingly, the time spent on sedentary activities such as watching television, using a computer, playing video games, and studying was recorded as minutes per week and was summed up to obtain “summed sedentary behavior” (SSB) time per week.
In Section 2, a modified Nordic scale questionnaire was used to record information regarding MSP. Participants had to answer about the presence of pain in the upper or lower extremities and spine area, in the past 12 months and in past 7 days. Pain intensity was evaluated by a “10-point visual analog scale” (VAS). Mean VAS values were calculated to form an overall pain score. Visual analog scale scores were categorized as “no pain” for scores equal to 0, while scores between 1–4, 5–7, and 8–10 represented as “mild,” “moderate,” and “severe” pain, respectively.
Perceived stress was analyzed using the perceived stress scale (PSS-10), originally developed by Cohen S. The PSS-10 questionnaire has 10 questions and assesses psychological stress levels as perceived by the participants over the past 4 weeks. Total scores on the PSS range from 0 to 40 and were interpreted as “low stress” (0 to13), “moderate stress” (14 to 26) and “high stress” (27 to 40).
To assess the quality of life (QoL), the Oswestry disability index (ODI) questionnaire was used. Oswestry disability index (ODI) is considered as the gold standard to assess limitations in life caused by low back pain. Total scores were interpreted as a minimal disability (0–20), moderate disability (21–40), severe disability (41–60), and crippled (61–80). Patients with scores above 81 were considered as either bed-bound or exaggerating their symptoms.
Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 20 (IBM Corp, Armonk, NY, USA). For categorical variables, frequency and percentage were calculated with a 95% confidence interval (CI). Mean and standard deviation (SD) were calculated for continuous data. The Chi-square test was used to compare categorical data (likelihood ratio and Fisher's test were used where applicable). Means were compared using “independent t test” and “One-way ANOVA test” for normally distributed data, and nonparametric independent tests such as “Mann–Whitney U test” and “Kruskal–Wallis test” were used for non-normally distributed data. For all analyses, a P value of <0.05 was considered statistically significant.
Ethical clearance was obtained by the institutional ethics committee (SMIMS IEC Registration No: IEC/522/19-58).
| Results|| |
Out of the 200 distributed questionnaires, 199 were completely filled. The mean (± SD) age of the participating students was 21.16 ± 3 years. Of the 199 participants, 109 (55%) were females and 90 (45%) were males. The mean (± SD) BMI of participants was 22.1 ± 3 kg/m2. [Table 1].
Comparison between MBBS batches
On comparing students of different batches of MBBS, [Table 2] it was seen that the BMI of third-year students (23.5 ± 3) was marginally better as compared to other batches; however, it was not significant (P-0.061). Interestingly, it was noted that first-year students spent more time on physical activities (117 ± 72 min/week), whereas final-year students significantly spent the least (67 ± 67 min/week) (P-0.006). The time spent on “summed sedentary behavior” by students as a whole was 1275 ± 726 min/week, which did not differ significantly among different batches (P-0.346). There was no significant difference among batches, with respect to lifestyle habits such as caffeine intake, smoking habits, or alcohol intake.
Musculoskeletal pain among participants and factors associated
The majority of participants (n = 171, 86%) responded as having one or more episodes of MSP in the past 12 months and 85 (50%) of them had pain in the past 7 days. Among those who reported MSP, 57% were females, with no significant difference between genders (P-0.232). There was no statistical difference in the occurrence of MSP among the different batches of MBBS (P-0.443). The majority (70%) of the symptomatic students complained of pain in multiple areas. No significant association was found between MSP and lifestyle habits [Table 1], physical activities or sedentary behavior [Table 3].
The perceived stress level of students was assessed using the PSS-10 score [Table 4]. The mean stress score of participants was 19.3 ± 5.6. Perceived stress scores were significantly higher among female students (20.2 ± 5.7) as compared to male students (18.3 ± 5.3) (P-0.018). The perceived stress level was significantly higher among those who had MSP in the past 12 months (19.7 ± 5.6) (P-0.021), as well as those who had MSP in the past 7 days (20.8 ± 5.5) (P-0.001). Severe pain was significantly associated with a higher PSS score (23 ± 5) (P-0.003). Although there was no significant change in stress scores among students of different batches, it was noted that the mean PSS score across batches was in the range of moderate stress level, with second-year and final-year students having higher PSS scores [Table 2].
|Table 4: Correlation between musculoskeletal pain and perceived stress scale score and quality of life score|
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To assess quality of life (QoL), the Oswestry disability index (ODI) was used, with a higher grade suggesting progressively restricted mobility. The mean QoL score was significantly higher among those who had MSP in the past 12 months [9.8 ± 10.6 (P-0.039)] and in those who had pain in the past 7 days [13 ± 10.9 (P-0.000)]. Similarly, students with severe pain had a considerably poorer QoL (31.4 ± 13.5, P-0.000) [Table 4]. Although final-year students had relatively higher QoL scores, there was no significant difference in the quality of life among students of different batches [Table 2].
| Discussion|| |
Our study showed that 73% of the students had experienced one or more episodes of MSP in the past 12 months, and almost 50% of them had acute pain.
Various studies have been done to assess the burden of musculoskeletal problems among medical students in countries across the world.,,,,,,,,,, Unfortunately, till now only a couple of studies have been done in this regard in India. One of them reported that 48% of the study group at one of the medical colleges in New Delhi had low back pain (LBP) in a span of 12 months, and the other reported that 58% of the study group had neck pain. Although these studies were assessing symptoms related to a particular area (i.e., low back pain and pain in the neck, respectively), these are the only studies available to compare our present study. As our study considered symptoms in all the musculoskeletal areas, it showed a higher (73%) prevalence of MSP in the past 12 months, which is similar to studies conducted on medical students in Saudi Arabia (85%), China (67%), and Malaysia (65%).
A sedentary lifestyle, in common perception, has always been linked to several health problems. However, the link between sedentary behavior and MSP remains uncertain. Systematic reviews and meta-analysis reports on this topic are contradictory. In their meta-analysis, Baradaran Mahdavi et al. concluded that “sedentary behavior” is associated with a moderate increase in the risk of LBP, whereas Alzahrani H et al., in their meta-analyses, indicated no relation between sedentary behavior of different durations as a risk factor for LBP. Similarly, in our study, we did not find a significant association between “summed sedentary behavior” time and MSP, much like other studies on MSP in medical students.,,
WHO recommends 150 to 300 min per week of moderate physical activities for adults. It was noted that on average our students spent 88 ± 74 min on SPA in a week, which is less than the WHO recommended time. IC Benlidayi et al., in their study comparing MSP between medical and dental students, recorded 2.1 ± 3.3 hours per week of exercise in medical students. Compared to this, our students are spending lesser time in such activities. Although we did not find any significant correlation between SPA time and the presence of MSP, this is a matter of concern. The correlation between “regular exercise” and musculoskeletal-related problems is contradictory. Amelot et al., in their study, suggest that at least 30 min walking per day reduces the occurrence of LBP. Similarly, Behera et al., in their study, showed a lower prevalence of neck pain among those who did regular exercise, whereas few other studies did not find a significant association between exercise and MSP.,,, The lack of a proper description of “regular exercise” and its quantification in these studies might be the reason for discrepancies in the correlation between MSP and physical activities.
Musculoskeletal pain and its relation with perceived stress and quality of life
Perceived stress score among our students was in the range of moderate stress level (19.3 ± 5.6). Studies done in the southern part of India to assess psychological stress levels among medical students using the same scale as ours have recorded a higher mean PSS score of 25.64 ± 5.44 and 27.53 ± 7.01., Grossly, it appears that our students are relatively less stressed than students of other regions in India. But the fact that in general, medical students are having higher stress levels cannot be ignored. Previous studies have pointed out the vastness of the academic curriculum, fear of failure or poor performance in the examination, lack of recreation, loneliness, and family problems as major contributors to increased stress levels among medical students.,,
Although there was no significant change in mean PSS score between different batches of students, in our study, it was seen that the second-year students and final-year students scored higher on the stress scale, which is similar to other studies done in India.,, It was also noted that PSS score was significantly higher among female students as compared to males, similar to other studies.,
There was a strong association between MSP and perceived stress levels among students in our study, similar to other studies.,,, Studies have attributed this positive correlation between MSP and perceived stress to an increase in muscle tension by psychological stress, especially in central body areas such as the neck and shoulder, thus increasing the risk of musculoskeletal disorders., However, Hendi et al., in their study on MSP and its correlation with stress among medical students, found no significant correlation between the two.
Pain in any form and region can have implications on QoL. Although previous studies have not assessed the QoL using the same scale as our study, Amelot et al. noted that LBP had a very significant repercussion on the daily personal schoolwork, the quality of sleep, and personal life of students. Similarly, we found that QoL scores were significantly high (poor QoL) among those who had MSP. It was also strongly correlated with the intensity of pain and pain in the past 7 days.
Strengths of the study
The newly formed National Medical Council, India, implemented competency-based undergraduate curriculum from the year 2019. Hence, to the best of our knowledge, this would be the only study available to compare the development of MSP among medical students of old and new curricula and to compare the relation between MSP and perceived stress, as no such studies are available in India at present.
The study used the time spent on activities and considered summed physical activities and summed sedentary behavior time, instead of using an ordinal scale, which would be ambiguous, as no definitive criteria are available for “occasional,” “regular.” The study used gold standard scales in measuring perceived stress levels and quality of life. The above-mentioned changes in our methodology indeed have been mentioned as limitations in other studies done on the same subject.,,,
Limitations and recommendation
The risk of response bias and recall bias are major limitations of our study, as we mainly recorded events of the past year. The study is from the only medical college present in the state, which may limit the generalization of results elsewhere in the country. The study did not record the number of episodes of MSP among participants. The cross-sectional design of the study prevents us from establishing a cause–effect relationship. Prospective studies using better study design are to be encouraged in the future to circumvent this problem.
| Conclusion|| |
The majority of our medical students have experienced musculoskeletal pain in the past 12 months, which is significantly associated with perceived stress and quality of life. Although no significant association was found between a sedentary lifestyle, physical activities, and musculoskeletal pain, better lifestyle habits are to be encouraged among students. Multicentric prospective studies are needed in India to tackle this issue in the future.
TMA Pai Seed grant-student project. Ethical clearance was obtained by the institutional ethics committee (SMIMS IEC Registration No: IEC/522/19-58).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Buckle P. Ergonomics and musculoskeletal disorders: Overview. Occup Med (Lond) 2005;55:164–7.
Dighriri YH, Akkur MA, Alharbi SA, Madkhali NA, Matabi KI, Mahfouz MS. Prevalence and associated factors of neck, shoulder, and low-back pains among medical students at Jazan University, Saudi Arabia: A cross-sectional study. J Family Med Prim Care 2019;8:3826–31.
] [Full text]
Dionne CE, Laurin D, Desrosiers T, Abdous B, Le Sage N, Frenette J, et al
. Vitamin C is not the missing link between cigarette smoking and spinal Pain. Spine (Phila Pa 1976) 2018;43:E712–21.
Hafner ND, Milek DM, Fikfak MD. Hospital staff's risk of developing musculoskeletal disorders, especially low back pain. Zdr Varst 2018;57:133–9.
Mehrdad R Md Mph, Shams-Hosseini NS Md, Aghdaei S Md, Yousefian M Md. Prevalence of low back pain in health care workers and comparison with other occupational categories in Iran: A systematic review. Iran J Med Sci 2016;41:467–78.
Al Amer HS. Low back pain prevalence and risk factors among health workers in Saudi Arabia: A systematic review and meta-analysis. J Occup Health 2020;62:e12155.
Epstein S, Sparer EH, Tran BN, Ruan QZ, Dennerlein JT, Singhal D, et al
. Prevalence of work-related musculoskeletal disorders among surgeons and interventionalists: A systematic review and meta-analysis. JAMA Surg 2018;153:e174947.
Karahan A, Kav S, Abbasoglu A, Dogan N. Low back pain: Prevalence and associated risk factors among hospital staff. J Adv Nurs 2009;65:516–24.
Tavares C, Salvi CS, Nisihara R, Skare T. Low back pain in Brazilian medical students: A cross-sectional study in 629 individuals. Clin Rheumatol 2019;38:939–42.
Algarni AD, Al-Saran Y, Al-Moawi A, Bin Dous A, Al-Ahaideb A, Kachanathu SJ. The prevalence of and factors associated with neck, shoulder, and low-back pains among medical students at university hospitals in central Saudi Arabia. Pain Res Treat 2017;2017:1235706.
Aggarwal N, Anand T, Kishore J, Ingle GK. Low back pain and associated risk factors among undergraduate students of a medical college in Delhi. Educ Health (Abingdon) 2013;26:103–8.
Behera P, Majumdar A, Revadi G, Santoshi JA, Nagar V, Mishra N. Neck pain among undergraduate medical students in a premier institute of central India: A cross-sectional study of prevalence and associated factors. J Family Med Prim Care 2020;9:3574–81. [Full text]
Amelot A, Mathon B, Haddad R, Renault MC, Duguet A, Steichen O. Low back pain among medical students: A Burden and an impact to consider! Spine (Phila Pa 1976) 2019;44:1390–5.
Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000;894:i-xii, 1–253.
Available from: www.who.int/news-room/fact-sheets/detail/physical-activity. [Last accessed on 02 May 2022].
Sedentary Behaviour Research Network. Letter to the editor: Standardized use of the terms “sedentary” and “sedentary behaviours”. Appl Physiol Nutr Metab 2012;37:540-2.
Owen N, Sparling PB, Healy GN, Dunstan DW, Matthews CE. Sedentary behavior: Emerging evidence for a new health risk. Mayo Clin Proc 2010;85:1138-41.
Kuorinka I, Jonsson B, Kilbom A, Vinterberg H, Biering-Sørensen F, Andersson G, et al
. Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl Ergon 1987;18:233-7.
Available from: www.cmu.edu/dietrich/psychology/stress-immunity-disease-lab/scales/html/pss.html. [Last accessed on 02 May 2022]
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385–96.
Available from: www.das.nh.gov/wellness/docs/percieved%20stress%20scale.pdf. [Last accessed on 02 May 2022].
Fairbank JC, Pynsent PB. The Oswestry disability index. Spine (Phila Pa 1976) 2000;25:2940–52.
Available from: www.rehab.msu.edu/_files/_docs/Oswestry_Low_Back_Disability.pdf. [Last accessed on 02 May 2022].
D. R. Smith and P. A. Leggat (2007) Prevalence and Distribution of Musculoskeletal Pain Among Australian Medical Students, Journal of Musculoskeletal Pain, 15:4, 39-46, DOI: 10.1300/J094v15n04_05.
Smith DR, Wei N, Ishitake T, Wang RS. Musculoskeletal disorders among Chinese medical students. Kurume Med J 2005;52:139–46.
Coskun Benlidayi I, Al-Bayati Z, Guzel R, Sarpel T. Neither got a good bill of musculoskeletal health: A comparative study among medical and dental students. Acta Clin Belg 2019;74:110–4.
Ilic I, Milicic V, Grujicic S, Zivanovic Macuzic I, Kocic S, Ilic MD. Prevalence and correlates of low back pain among undergraduate medical students in Serbia, a cross-sectional study. PeerJ 2021;9:e11055.
Haroon H, Mehmood S, Imtiaz F, Ali SA, Sarfraz M. Musculoskeletal pain and its associated risk factors among medical students of a public sector University in Karachi, Pakistan. J Pak Med Assoc 2018;68:682–8.
Alshagga MA, Nimer AR, Yan LP, Ibrahim IA, Al-Ghamdi SS, Radman Al-Dubai SA. Prevalence and factors associated with neck, shoulder and low back pains among medical students in a Malaysian Medical College. BMC Res Notes 2013;6:244.
Baradaran Mahdavi S, Riahi R, Vahdatpour B, Kelishadi R. Association between sedentary behavior and low back pain; A systematic review and meta-analysis. Health Promot Perspect 2021;11:393–410.
Alzahrani H, Alshehri MA, Alzhrani M, Alshehri YS, Al Attar WSA. The association between sedentary behavior and low back pain in adults: A systematic review and meta-analysis of longitudinal studies. PeerJ 2022;10:e13127.
Chen SM, Liu MF, Cook J, Bass S, Lo SK. Sedentary lifestyle as a risk factor for low back pain: A systematic review. Int Arch Occup Environ Health 2009;82:797–806.
Anuradha R, Dutta R, Raja JD, Sivaprakasam P, Patil AB. Stress and stressors among medical undergraduate students: A cross-sectional study in a private medical college in Tamil Nadu. Indian J Community Med 2017;42:222–5.
] [Full text]
Brahmbhatt KR, Nadeera VP, Prasanna KS, Jayram S. Perceived stress and sources of stress among medical undergraduates in a private medical college in Mangalore, India. Int J Biomed Adv Res 2013;4:128–36.
Sreeramareddy CT, Shankar PR, Binu VS, Mukhopadhyay C, Ray B, Menezes RG. Psychological morbidity, sources of stress and coping strategies among undergraduate medical students of Nepal. BMC Med Educ 2007;7:26.
Satheesh BC, Prithviraj R, Prakasam PS. A study of perceived stress among undergraduate medical students of a private medical college in Tamil Nadu. Int J Sci Res 2015;4:994–7.
Tantawy SA, Abdul Rahman A, Abdul Ameer M. The relationship between the development of musculoskeletal disorders, body mass index, and academic stress in Bahraini University students. Korean J Pain 2017;30:126–33.
Sjøgaard G, Lundberg U, Kadefors R. The role of muscle activity and mental load in the development of pain and degenerative processes at the muscle cell level during computer work. Eur J Appl Physiol 2000;83:99–105.
Westgaard RH, Jensen C, Hansen K. Individual and work-related risk factors associated with symptoms of musculoskeletal complaints. Int Arch Occup Environ Health 1993;64:405–13.
Hendi OM, Alturkistani LH, Bajaber AS, Alhamoud MA, Mahmoud Mahfouz ME. Prevalence of musculoskeletal disorder and its relation to stress among medical student at Taif University, Saudi Arabia. Int J Prev Med 2021;12:98. [Full text]
[Table 1], [Table 2], [Table 3], [Table 4]