Int Arch Occup Environ Health (2005) 78: 253269
DOI 10.1007/s00420-004-0576-4
O R I GI N A L A R T IC L E
Sven Schneider Holger Schmitt Silke Zoller
Marcus Schiltenwolf
Workplace stress, lifestyle and social factors as correlates of back pain:
a representative study of the German working population
Received: 18 May 2004 / Accepted: 9 September 2004 / Published online: 12 April 2005

Springer-Verlag 2005
Abstract Objectives: To investigate the prevalence of
back pain in the German working population and the
relationship between back pain and workplace stresses,
lifestyle and social factors. Methods: The rst National
Health Survey of the Federal Republic of Germany was
carried out between October 1997 and March 1999. It
comprised a representative epidemiological cross-sec-
tional study of the working population, with a total
sample of 3,488 persons between the ages of 18 and 69
years. The participants took part in a medical exami-
nation and answered a self-rating questionnaire. The
relationship between subjective back pain and work-
place stresses and social and lifestyle factors was inves-
tigated with bivariate tests and multiple logistical
regression analyses. Results: The 7-day prevalence for
back pain in the German working population was found
to be 34%, and the 1-year prevalence was 60%. The
odds ratios were signicantly higher in women, persons
of lower socioeconomic status, married and depressed
persons and non-athletes. Carrying heavy loads or
maintaining a single working posture were the most
signicant work-related correlates of back pain, for
members of both the female and male working popula-
tion, while environmental stress and psychological stress
correlated signicantly with back pain in men only.
Conclusions: This study reports the rst representative
epidemiological prevalence data for back pain, and its
correlates and potential risk factors, for the German
working population. To reduce the negative impact of
back pain the most promising behavioural and condi-
tional prevention measures in the workplace would be to
reduce carrying stress and to vary working posture. In
addition, a more active, athletic lifestyle, plus the
S. Schneider (&) H. Schmitt S. Zoller M. Schiltenwolf
Orthopadische Universitatsklinik Heidelberg,
Schlierbacher Landstrasse 200,
69118 Heidelberg, Germany
E-mail: sven.schneider@ok.uni-heidelberg.de
Tel.: +49-6221-969255
Fax: +49-6221-969288
URL: www.orthopaedie.uni-hd.de
avoidance of being overweight, should provide an
additional protective or preventive eect.
Keywords Back pain Low back pain Risk factors
Prevalence Life style
Introduction
Representative data on the prevalence and causes of back
pain in the working population are highly relevant for
medical doctors and public health workers. One issue is
the burgeoning economic impact of the resulting risk of
sick leave (Gobel 2001; Norlund and Waddell 2000).
Another is the fact that the workplaceand lifestyle-
dependent risk factorscan be managed by prevention.
Data on the prevalence of pain and on the prevalence of
known work-related and social risk factors are sought, so
that both behavioural and structural prevention might be
able to play a role. The literature dealing with this sig-
nicant endemic aiction has increased dramatically
over time (Kohlmann 2001; Vingard and Nachemson
2000; Waddell and Waddell 2000), in parallel with the
impact of back pain on health policy and on the econ-
omy. However, no epidemiological study has been car-
ried out, to date, with data representative of the working
population in Germany (Bellach et al. 2000). The avail-
able prevalence and incidence data have been derived
from selective, regionally limited subject populations
(e.g. from Lubeck or Bad Sackingen), from studies with
non-representative sample populations, or from surveys
long out of date (Berger-Schmitt et al. 1996).
It is worth noting that the epidemiological studies of
risk factors for back pain have often not been checked
for spurious correlations, and no causal relationship has
been established.
The German National Health Survey (Bundes-
gesundheitssurvey) has made available the rst repre-
sentative account of the frequency of occurrence of back
pain in the working population across the entire country
254
after the reunion in 1990 (Bellach 1999). These data
included dierentiation with respect to occupational,
socioeconomic and lifestyle-specic correlates and risk
factors. The goals of our present work were: (1) to
investigate these prevalence data (pain prevalence) and
its dierentiation according to certain population seg-
ments, (2) to determine the frequency and patterns of
occurrence of the risk factors known from the clinical
studies (risk factor prevalence) in German workers, and
(3) to explore to what extent the correlates of back pain
can be attributed to the eect of extraneous variables,
using multiple regression models.
Subjects and methods
Subjects and study design
The German National Health Survey was a representa-
tive epidemiological study of the German-speaking
inhabitants of the Federal Republic of Germany. The
study was carried out at the Robert Koch Institute in
Berlin, the central research institution for the Public
Health Service of the German Federal Ministry of
Health, between October 1997 and March 1999. It
comprised a total sample pool of 7,124 people between
the ages of 18 and 79 years who had their primary res-
idence in the region under study and had a response rate
of 61%. Through the use of a weighting procedure for
the individual cases based on age, gender, size of com-
munity, and German state of residence, the results were
representative of the German-speaking resident popu-
lation of the entire country for the year 1998 (for de-
tailed evidence of the representativeness, see Winkler
et al. 1998,; Thefeld et al. 1999). The interviewing and
medical examinations of the participants were carried
out with four mobile inspection teams composed of
doctors and medically trained examiners in 130 locations
within 113 cities (Pottho et al. 1999; Schroeder et al.
1998). The examiners were subjected to regular external
quality control procedures. The participants took part in
a standard medical interview (computer assisted per-
sonal interview, CAPI) as well as a medical examination,
which included blood pressure, pulse, weight, height,
and blood tests. In addition, the participants answered a
self-rating questionnaire composed of 107 questions
covering medical risk factors, health-related behaviour
patterns and medicalsociological items (Bellach et al.
1998). Participants with mobility problems could request
that the interview and examination be held in their
home. This representative sample made up the test
population used in the present study for all participants
between the ages of 1869 years who were employed
full- or part-time or were enrolled in a training pro-
gramme. For the purposes of the present study, partic-
ipants over 69 years of age (n=721), those who were
unemployed at the time of the interview (n=2,183), and
those for whom data sets were incomplete (n=732),
were excluded. After these modications, a weighted
cross-section of data from a total of 3,488 participants
between the ages of 18 and 69 years was available.
Assessment of independent variables
In order to decide which risk factors and correlates of
back pain to include in the empirical data analysis, we
carried out a literature search of the MEDLINE/PubMed
database. The key words low back pain and back
pain (keyword group 1) were used in combination with
risk factor, chronication, chronic, prevention,
predictors, and prevalence (keyword group 2).1
The variables that were appropriate to the present data
set are summarized in Table 6, in the appendix. The
categories of occupational risk factors and personal
risk factors suggested by Waddell were adopted, and
these were further subdivided into socio-structural
factors and lifestyle factors (Waddell 1998). Specically,
the variables were encoded as described below.
Occupational risk factors
Occupational stress factors in the workplace encom-
passed ve dimensions: (1) carrying or postural stress,
(2) environmental factors, (3) mental stress, (4) overtime,
and (5) shift work. The items in the questionnaire were
(1) strenuous physical labour (such as maintaining a
single posture, carrying heavy objects), (2) noise, dust,
gases, fumes, poor air quality, (3) stress in the work-
place (such as time/performance pressure, strict con-
centration, poor working atmosphere), anxiety in the
workplace, (4) overtime, long working hours, and (5)
shift work or night work. The time spent sitting at
work, in a car, and during free time was included sep-
arately for weekdays and holidays, and an average value
for the number of hours per day was obtained. Satis-
faction with the workplace was indicated on a seven
point, equidistant scale.
Personal risk factors
Socio-structural factors
Age was expressed in whole years at the time of the
interview. Since a non-linear eect of age on the risk of
back pain was inferred from several studies, the analysis
was additionally carried out by age category to facilitate
the modelling of a non-linear analysis. The variable
foreigner was dummy coded. The net income of the
respondents was broken down into 13 groups. From this
the monthly per capita equivalent income was calculated
1
For the purposes of this search, we combined a key word from
group 1 with a key word from group 2, using an and statement.
The search was limited to studies reported over the past six cal-
endar years, employed a multiple regression design, and had at
least 100 exclusively adult participants.
 255

Table 1 Univariate evaluation of potential risk factors and correlates of back pain among employed workers. Number
(weighted) = 3,488, of whom 1,997 were men and 1,491 were women. AM arithmetic mean

Variable Operationalization/coding Hypothetical Men. AM (SD), Women. AM (SD),

relationshipb respectively, respectively, distribution
distribution

Occupational risk factors and correlates

Carrying/postural stressa Dummy at the time of interview 41.58% 34.30%
Environmental factorsa Dummy at the time of interview 39.51% 20.66%
Mental stressa Dummy at the time of interview 61.97% 52.20%
a
Overtime Dummy at the time of interview 55.44% 29.55%
Shift worka Dummy at the time of interview 17.51% 12.52%
Time spent sitting Sitting, in hours per 24 h 7.06 (3.15) 6.79 (2.70)
Satisfaction with the 1= Very dissatised to 7= very satised 5.16 (1.51) 5.24 (1.42)
workplace
Personal risk factors and correlates
Socio-structural factors
Age Measured in whole years 39.98 (11.48) 39.40 (11.16)
Non-Germana Non-German citizenship 5.85% 4.53%
Income Equivalent income/month per person 1276.63 (624.78) 1241.55 (591.56)
in euros according to OECD
Professional position Current professional position
Higher service/management 3.83% 5.07%
Highermiddle service/independent worker 20.87% 17.27%
Qualied clerical worker 7.06% 5.71%
Supervisor/middle service 21.89% 30.59%
Clerical worker 9.10% 10.23%
Skilled labourer 30.50% 24.09%
Unskilled labourer 6.75% 7.04%
Educational status Advanced training degreec
High-school diploma 19.33% 14.19%
Abitur 6.38% 9.52%
Realschul diploma with vocational training 42.18% 44.72%
Hauptschul diploma with vocational training 24.09% 19.82%
Realschul diploma without training 1.87% 3.07%
Hauptschul diploma without training 5.03% 7.56%
No diploma 1.11% 1.11%
Social status Upper class 25.74% 21.89%
Middle class 55.27% 59.76%
Lower class 19.00% 18.36%
Lifestyle factors
Marital status Married 65.05% 60.81%
Separated 5.98% 11.19%
Single 28.44% 25.20%
Widowed 0.52% 2.80%
Social support More than three dependable friends 67.35% 64.67%
Two to three dependable friends 27.78% 28.97%
Fewer than two dependable friends 4.87% 6.36%
Private health insurance Private whole or supplemental insurance 20.05% 16.90%
Depressivity In a depressed mood in the past month 8.98% 15.64%
Leisure time physical More than 4 h/week 9.98% 5.60%
activity 24 h/week 15.17% 12.11%
12 h/week 17.29% 23.29%
Less than 1 h/week 18.71% 19.30%
No sports activity 38.86% 39.70%
Fitnessa No problem climbing three ights 83.93% 65.68%
of stairs
Smoking Smoker (daily consumption) 33.74% 26.67%
Occasional smoker 7.02% 7.58%
(less than daily consumption)
Ex-smoker 24.53% 16.61%
Never smoked 34.70% 49.14%
Height Measurement 177.45 (7.04) 165.03 (6.34)
Weight Measurement 84.30 (12.85) 69.12 (13.19)
BMI Measurement U 26.77 (3.76) 25.40 (4.78)
Underweight (BMI <21.00) 3.82% 15.93%
Normal weight (21 BMI <27.8 60.13% 56.14%
men/<27.3 women)
256
Table 1 (Contd.)
Variable Operationalization/coding
Overweight (BMI 27.8
men/27.3 women)
a
Dummy variable, when the corresponding characteristic present
takes the value 1
b c
The direction of the parameter values: for heightened risk, for
reduced risk, or U for a U-shaped trend for risk of back pain. These
are the stated ones for the dichotomous dummy variables, the
in euros according to the guidelines of the Organisation
for Economic Co-operation and Development (OECD),
with appropriate adjustments made for other household
members. The development of the three additional
sociological dimensions of vertical stratication (pro-
fessional position, education level, and social status)
followed from the suggestion by Winkler (Winkler and
Stolzenberg 1999).
Lifestyle factors
Since the medicalsociological literature views marital
status as one indicator of family support, those who
were married but living separately, as well as those who
were divorced, were placed in the separated category.
In order to consider the scope of other sources of social
support (from an unmarried partner, close friends, etc.)
separately, we established the additional variable of
social support to code for the number of people whose
help the respondent could depend on at any time in an
emergency. Those participants who had either supple-
mental or whole private health insurance were dummy
coded with the value 1 for the variable private health
insurance. The variable depressiveness denoted a
subjective, though non-pathological, depressed mood.
Participants who indicated that they had felt discour-
aged or sad at least sometime within the previous 4
weeks, and were so despondent that they could not lift
their spirits, received a dummy coding of 1. The
question regarding regular sports activity covered a time
frame of 3 months. As an alternative indicator of
physical tness, a dummy variable was created that was
given a coding of 1 when the respondent indicated
that he/she could climb three ights of steps without
being out of breath or breaking into a sweat. For current
tobacco consumption the respondent was categorized as
either a smoker (smokes tobacco daily), an occasional
smoker (smokes less than once per day), an ex-smoker,
or as having never smoked, following the denitions
used in the international WHO-MONICA study (Insti-
tut fur Epidemiologie 1993). The participants height
and weight were measured to one decimal place under
standardized conditions with calibrated instruments,
without outer clothing and shoes. To safeguard against a
possible non-linear relationship, we classied the weight
according to gender-specic limits as follows: normal
Hypothetical Men. AM (SD), Women. AM (SD),
relationshipb respectively, respectively, distribution
distribution
36.05% 27.93%
higher ones with the ordinal variables, and the higher ones with the
quantitative variables
The Abitur examination is taken by German pupils after
approximately 13 years at school, the Realschule after approxi-
mately 10 years and the Hauptschule after approximately 9 years
weight, BMI < 27.8 for men and BMI < 27.3 for wo-
men; overweight, BMI 27.8 for men and BMI 27.3 for
women. To ensure adequate cell occupancy for the
multiple analyses, we dened underweight as a BMI <
21.0. Table 1 summarizes the operationalization of all
variables used, along with their hypothetical association
with back pain.
Assessment of dependent variables
Each of the participants included in the present study had
answered the question of whether they had had back pain
over the 7 days prior to the date of the interview (dummy
coded as: 1= yes; 0= no). Questions regarding the 7-
day prevalence of pain in other locations, such as the
neck, shoulder, hip and legs, were asked separately; in
order to delineate the pain picture clearly, we did not
consider these data further. In addition, participants also
indicated the prevalence of any back pain over a 1-year
period. The decision to favour the 7-day prevalence was
aimed at reducing as much as possible the eect of the
recall bias factor identied by Waddell, since the pain
picture from the most recent 7 days ought to be
remembered well (Waddell 1998). Moreover, when the
responses are collected within this time frame there is a
better overlap between the possible risk factors and the 7-
day prevalence than when the 1-year prevalence is used.
Statistical analysis
The study design and the sample size provided repre-
sentative prevalence data on potential risk factors and
correlates for back pain for the present test population
of interest: employed German citizens between the ages
of 18 and 69 years. First, the descriptive analyses in-
cluded the weighted percentage data as well as the
arithmetic mean the standard deviation (AM SD)
for the interval scale level variables. Next, the question
of whether there was a signicant dierence in pain
prevalence within the individual risk groups was exam-
ined for the nominal and ordinal variables by bivariate
chi-square tests and for the metric variables by t-tests for
independent samples. The underlying alternative
hypotheses were derived from current research and are

presented in Table 1. Finally, multiple logistic regression
analysis was carried out with the dependent variable
back pain within the past week =1, based on the
nominal scale levels of the dependent variables. In order
to implement a procedure with the fewest possible
parameters, we included in the regression analysis only
those variables established as signicant in at least one
of the two gender-specic bivariate analyses. In addi-
tion, variables found to have a similar meaning after a
collinearity diagnosis were excluded, so that collinearity
among the predictors would be reduced. Social status
was chosen as a class indicator. For one thing, this was
the most appropriate and inclusive operationalization of
social class membership, especially for women. For an-
other, it can compensate in the calculation routine for
missing values for income, profession and vocational
training entries. 2 The frequency of participation in sport
was used as an indicator of physical activity and was
assigned to the data for tness, whereas at rst it was
considered suitable for the subsequent recommendations
for prevention. BMI was selected instead of height, since
this was considered to be aetiologically signicant.
Finally, both age and BMI were incorporated into the
multiple regression analysis in categorized form, so that
we could model possible non-linear relationships. In
addition, an r2 value was determined in accordance with
Nagelkerke. The successive inclusion of covariables
from the various risk factor groups provided a rudi-
mentary assessment of their relative importance. The
model quality was in an acceptable range (Hosmer
Lemeshow test). These were all carried out as two-sided
tests with signicance limits P<0.001, P<0.01 and
P<0.05. We took into account gender-specic
aetiological and perceptive processes by conducting all
analyses separately for men and women, using the
statistical program SAS for Windows, version 8.02 (SAS
Institute, Cary, N.C., USA).
Results
Descriptive analyses
One in three workers (34%) had suered from back pain
within the 7 days prior to the interview. The 1-year
prevalence amounted to 60% of all workers. Both 7-day
prevalence (32% vs 38%) and 1-year prevalence (58% vs
62%) were lower for men than for women. Table 1
provides the representative data on the prevalence of the
known and potential risk factors or correlates for back
pain. The clearest dierences between male and female
workers related to workload, social status, physical
condition and smoking: men were much more likely than
2
In order to maintain the representativeness and the sample size, we
did not exclude respondents for whom only the income data were
missing (nweighted=510), so that the appropriate social status
assignment (in our opinion) was used for the class indicator in the
multiple analysis.
257
women to report physical and mental stress at work. For
example, 42% of all male workers responded that they
found it physically arduous to work, due to the need to
maintain a single posture, carrying heavy objects, or for
some other reason (Table 1). In addition, men in the
Federal Republic of Germany generally have a higher
income, higher educational qualications and higher-
ranking positions at work than women, factors which
combine to give a higher social status. Among the other
risk factors, physical activity was of particular note: four
out of ten workers did not engage in any type of sport. A
total of 16% of the female (and 9% of the male) partic-
ipants reported that they had felt despondent, discour-
aged or sad occasionally or often within the previous
month. The measurement variables showed an approxi-
mate normal distribution. The values for no school di-
ploma and widowed were not interpreted in the
present analysis due to the low occupancy in those cells.
Bivariate analyses
The next stage involved a bivariate analysis to examine
whether the risk factors known from the literature were
present in the test population. Subjective strenuous
activity in a single body posture, as well as carrying
heavy loads, was associated with a signicantly higher
risk of back pain (Tables 2 and 3). This was likewise
true for environmental factors (such as noise and the
impact of dust, gases or fumes on breathing air) as well
as for psychological stress in the workplace. Con-
versely, long working hours and night work or shift
work were not accompanied by a higher risk of back
pain. In comparison to their healthy co-workers,
respondents with back pain reported lower satisfaction
with their workplace (Tables 2 and 3). In addition to
these workplace stresses, there were other signicant
dierences observed in ascriptive and socioeconomic
characteristics for both genders: back pain suerers
were older, on average, and had lower social status in
terms of income, profession and education (the so-
called meritocratic triad). Finally, an unfavourable
lifestyle accentuated the risk of developing back pain:
higher morbidity rates were found for people who were
depressed, non-athletic and overweight. On the other
hand, tobacco consumption and health insurance status
had no signicant association with the phenomenon
under investigation. Interesting gender-specic dier-
ences were identied in terms of the following lifestyle
aspects, in that social deprivation (following divorce
and inadequate social support) and overweight corre-
lated with a higher prevalence of back pain in women
only (Tables 2 and 3).
Multiple analyses
We used logistic regression analysis to examine the ex-
tent to which workplace stresses, social factors and
258

Table 2 Seven-day prevalence of back pain among employed workers according to potential risk factors and correlatesmen (n=1,997)

Variable Men AM (SD), respectively, Test value/degrees of

proportion (%) freedom/signicance level

With back pain Without back pain

Occupational risk factors and correlates

Carrying/postural stress
Yes 38.82 61.18 v2=33.15 df=1 P<0.001***
No 26.65 73.35
Environmental factors
Yes 38.28 61.72 v2=25.95 df=1 P<0.001***
No 27.42 72.58
Mental stress
Yes 35.13 64.87 v2=17.51 df=1 P<0.001***
No 26.15 73.85
Overtime
Yes 32.67 67.33 v2=1.05 df=1 P=0.305
No 30.52 69.48
Shift work
Yes 34.89 65.11 v2=1.98 df=1 P=0.159
No 31.04 68.96
Time spent sitting 6.83 (3.14) 7.16 (1.35) t=2.15 df=1,950 P=0.031*
Satisfaction with the workplace 4.85 (1.70) 5.31 (1.39) t=6.29 df=1,950 P<0.001***
Personal risk factors and correlates
Socio-structural factors
Age 41.32 (12.01) 39.35 (11.17) t= 3.58 df=1,950 P<0.001***
6069 years 40.73 59.27
5059 years 39.17 60.83
4049 years 32.62 67.38
3039 years 26.97 73.03
1829 years 29.18 70.82
Non-German
Yes 36.66 63.34 v2=1.40 df=1 P=0.236
No 29.57 64.58
Income 1231.30 (586.61) 1297.30 (640.63) t=2.04 df=1670 P=0.041*
Professional position v2=32.60 df=6 P<0.001***
Higher service/management 33.20 66.80
Highermiddle service/independent worker 22.33 77.67
Qualied clerical worker 30.07 69.93
Supervisor/middle service 29.53 70.47
Clerical worker 41.22 58.78
Skilled labourer 35.67 64.33
Unskilled labourer 37.98 62.02
Educational statusa v2=42.30 df=6 P<0.025*
High-school diploma 20.50 79.50
Abitur 24.32 75.68
Realschul diploma with vocational training 33.79 66.21
Hauptschul diploma with vocational training 36.78 63.22
Realschul diploma without training 24.39 75.61
Hauptschul diploma without training 45.16 54.84
No diploma 32.07 67.93
Social status v2=23.07 df=2 P<0.001***
Upper class 23.76 76.24
Middle class 33.28 66.72
Lower class 37.94 62.06
Lifestyle factors
Marital status v2=6.40 df=3 P=0.094
Married 33.55 66.45
Separated 27.98 72.02
Single 28.15 71.85
Widowed 39.41 60.59
Social support v2=1.67 df=2 P=0.434
More than three dependable friends 30.79 69.21
Two to three dependable friends 33.78 66.22
Fewer than two dependable friends 32.72 67.28
Private health insurance
Yes 29.77 70.23 v2=0.87 df=1 P=0.350
No 32.20 67.80
 259

Table 2 (Contd.)

Variable Men AM (SD), respectively, Test value/degrees of

proportion (%) freedom/signicance level

With back pain Without back pain

Depressivity
Yes 43.99 56.01 v2=13.70 df=1 P<0.001***
No 30.50 69.50
Leisure time physical activity (LTPA) v2=12.12 df=4 P=0.017*
More than 4 h/week 28.50 71.50
24 h/week 25.25 74.75
12 h/week 32.59 67.41
Less than 1 h/week 30.23 69.77
No sports activity 35.39 64.61
Fitness
Yes 30.26 69.74 v2=10.19 df=1 P=0.001**
No 39.31 60.69
2
Smoking v =5.57 df=3 P=0.135
Smoker 32.58% 67.42%
Occasional smoker 31.40% 68.60%
Ex-smoker 34.93% 65.07%
Never smoked 28.66% 71.34%
Height 177.28 (7.08) 177.52 (7.03) t=0.71 df=1950 P=0.478
Weight 84.71 (13.15) 84.11 (12.70) t= 0.96 df=1950 P=0.336
BMI 26.94 (3.82) 26.69 (3.73) t= 1.42 df=1950 P=0.156
Underweight
Yes 36.11% 63.89% v2=0.71 df=1 P=0.400
No 31.54% 68.46%
Overweight
Yes 34.11% 65.89% v2=2.98 df=1 P=0.084
No 30.36% 69.64%

***P<0.001, **P<0.01, *P<0.05

a
The Abitur examination is taken by German pupils after approximately 13 years at school, the Realschule after approximately 10 years
and the Hauptschule after approximately 9 years

individual lifestyle per se were relevant to morbidity, and
whether individual bivariate eects were changed when
further variables were introduced and held constant.
Next, we investigated the signicance exclusive of the
workplace conditions (Tables 4 and 5), in order to be
able to calculate the relative signicance of risk sources
separately at a later stage. Consistent with the hypoth-
eses, model 1 showed a 52% higher risk of back pain for
male labourers (Table 4). The odds ratio for female
respondents with carrying and postural stress was the
most signicant, at 1.65, in comparison to the remaining
female employees, with a risk dened as 1.00 (Table 5).
In contrast, the mental stress had a negative eect only
for male employees. Satisfaction with the workplace was
signicantly higher for the healthy employees.
Age and social status were included in model 2 so
that we could analyse the extent to which social factors
had an eect on the risk of back pain (Tables 4 and 5).
Both categories were shown to be relevant to morbidity.
The age group-specic pattern of risk already known
from the bivariate analyses was mirrored when the social
class-specic risk distribution was considered. In both
tables model 3 served to explore lifestyle themes. Par-
ticipants classied as depressive showed higher risk of
back pain (men: +78%, women: +157%), and the risk
was reduced by 34% for physically active men and by
31% for physically active women [leisure time physical
activity (LTPA) 24 h/week]. Finally, model 4 assessed
the signicance of all factors acting together simulta-
neously.
Discussion
Validity and limitations of data
The data quality and the representativeness of the Ger-
man National Health Survey of 1998 has been subjected
to intensive internal and external quality management
testing (Pottho et al. 1999; Thefeld et al. 1999; Winkler
et al. 1998). The advantages and disadvantages of large
epidemiological studies in comparison to longitudinal
and classical experimental studies have been discussed at
length (Beaglehole et al. 1993; Bortz 1985; Brown et al.
2000; Trampisch et al. 2000).
The goal of this study was to survey subjective pain
experiences. However, it is worth noting that back pain
can be caused by a variety of factors (including non-
pathological ones). There is an unequivocal dierential
diagnosis only in a small proportion of back pain cases
(Hildebrandt et al. 2000). The investigation of back
pain within the previous 7 days was thus based upon
the self reports of the respondents. This was considered
to be the most valid operationalization procedure for the
present study, in view of the fact that the phenomena
under investigation involve non-specic or idiopathic
260

Table 3 Seven day prevalence of back pain among employed workers according to potential risk factors and correlateswomen
(n=1,491)

Variable Women AM (SD), respectively, Test value/degrees of

proportion freedom/signicance level

With back pain Without back pain

Occupational risk factors and correlates

Carrying/postural stress
Yes 46.46% 53.54% v2=24.09 df=1 P<0.001***
No 33.47% 66.53%
Environmental factors
Yes 45.58% 54.42% v2=9.67 df=1 P=0.002**
No 35.93% 64.07%
Mental stress
Yes 40.35% 59.65% v2=4.06 df=1 P=0.044*
No 35.28% 64.72%
Overtime
Yes 38.81% 61.19% v2=0.21 df=1 P=0.648
No 37.55% 62.45%
Shift work
Yes 40.54% 59.46% v2=0.62 df=1 P=0.431
No 37.55% 62.45%
Time spent sitting 6.73 (2.75) 6.82 (2.67) t=0.59 df=1561 P=0.555
Satisfaction with the workplace 5.10 (1.43) 5.34 (1.40) t=3.19 df=1561 P=0.001**
Personal risk factors and correlates
Socio-structural factors
Age 40.09 (11.55) 38.98 (10.91) t= 1.86 df=1561 P=0.063
6069 years 33.40% 66.60%
5059 years 44.33% 55.67%
4049 years 37.48% 62.52%
3039 years 36.25% 63.75%
1829 years 35.96% 64.05%
Non-German
Yes 46.73% 53.27% v2=2.34 df=1 P=0.126
No 37.51% 62.49%
Income 1197.40 (593.27) 1269.50 (589.25) t=2.10 df=1303 P=0.036*
Professional position v2=3.69 df=6 P=0.718
Higher service/management 37.52% 62.48%
Highermiddle service/independent worker 34.86% 65.14%
Qualied clerical worker 40.09% 59.91%
Supervisor/middle service 36.33% 63.67%
Clerical worker 38.07% 61.93%
Skilled labourer 40.09% 59.91%
Unskilled labourer 43.29% 56.71%
Educational statusa v2=14.49 df=6 p=0.025*
High-school diploma 33.94% 66.06%
Abitur 27.72% 72.28%
Realschul diploma with vocational training 38.30% 61.70%
Hauptschul diploma with vocational training 42.33% 57.67%
Realschul diploma without training 37.28% 62.72%
Hauptschul diploma without training 41.40% 58.60%
No diploma 60.87% 39.13%
Social status v2=8.24 df=2 P=0.016*
Upper class 34.18% 65.82%
Middle class 37.08% 62.92%
Lower class 45.13% 54.87%
Lifestyle factors
Marital status v2=9.87 df=3 P=0.020*
Married 38.66% 61.34%
Separated 46.09% 53.91%
Single 32.38% 67.62%
Widowed 39.08% 60.92%
Social support v2=11.81 df=2 P=0.003**
More than three dependable friends 35.18% 64.82%
Two to three dependable friends 41.21% 58.79%
Fewer than two dependable friends 50.85% 49.15%
Private health insurance
Yes 33.23% 66.77% v2=2.84 df=1 P=0.092
No 38.88% 61.12%
 261

Table 3 (Contd.)

Variable Women AM (SD), respectively, Test value/degrees of

proportion freedom/signicance level

With back pain Without back pain

Depressivity
Yes 58.33% 41.67% v2=48.94 df=1 P<0.001***
No 34.14% 65.86%
Leisure time physical activity (LTPA) v2=16.47 df=4 P=0.003**
More than 4 h/week 33.07% 66.93%
24 h/week 29.98% 70.02%
12 h/week 33.50% 66.50%
Less than 1 h/week 38.14% 61.86%
No sports activity 43.53% 56.47%
Fitness
Yes 31.33% 68.67% v2=52.63 df=1 P<0.001***
No 50.53% 49.47%
Personal risk factors and correlates
Lifestyle factors
Smoking v2=5.70 df=3 P=0.127
Smoker 42.08% 57.92%
Occasional smoker 39.68% 60.32%
Ex-smoker 38.89% 61.11%
Never smoked 35.07% 64.93%
Height 164.56 (6.27) 165.31 (6.36) t=2.22 df=1561 P=0.026*
Weight 70.43 (13.91) 68.33 (12.68) t= 3.00 df=1561 P=0.0028**
BMI 26.03 (5.12) 25.02 (4.53) t= 3.98 df=1561 P<0.001***
Underweight
Yes 33.64% 66.36% v2=2.21 df=1 P=0.137
No 38.74% 61.26%
Overweight
Yes 46.34% 53.66% v2=17.38 df=1 P<0.001***
No 34.66% 65.34%

***P<0.001, **P<0.01, *P<0.05

a
The Abitur examination is taken by German pupils after approximately 13 years at school, the Realschule after approximately 10 years
and the Hauptschule after approximately 9 years

symptoms that are predominantly empirical. Finally, a
number of hypotheses refer to subjective experiences of
pain and not to specic pains that have a unique clinical
denition. Vingard et al. validated self-reported back
pain by objective diagnostic procedures in a population-
based case-referent study and concluded that self-re-
ports of pain may be sucient enough for classifying
subjects in epidemiologic studies (Vingard et al. 2000).
However, the fact that the entire study is based on self-
reported questionnaire data is problematic for another
reason: Firstly, a desirability bias may have prevailed,
which would have prompted the respondents to down-
play socially sanctioned behaviour such as excessive
alcohol intake and smoking (Hagen et al. 2002). Sec-
ondly, there is always a risk of recall bias for many of the
particulars investigated (Kovacs et al. 2003). Johnston
et al. (2003) and Byrns et al. (2002) pointed out that
people with back pain may be more likely than pain-free
respondents to report specic potential factors or exag-
gerate their importance [such as stress at work or low job
satisfaction (Johnston et al. 2003)] if more attention is
being paid to specic possible causes and may tend, ret-
rospectively, to attribute symptoms to causes that have
been singled out beforehand. It is impossible to quantify
the extent of such potential sources of bias ex ante for the
study presented here.
Another point worthy of further consideration is the
participation rate of 61.4%, which is above that of other
current questionnaire-based back pain studies [with
participation rates ranging from 36%59% (Cassidy
et al. 1998; Cote et al. 2001; Croft et al. 1999; Failde
et al. 2000; Hellsing and Bryngelsson 2000)] for the total
dataset, despite a conservative denition of what con-
stitutes participation. Half of the non-participants
were prepared to provide basic health information and
socioeconomic data for a non-respondent analysis.
According to the data provided, non-participants and
participants did not dier with regard to age, gender
ratio, smoking or health, but non-participants were
more likely to have lower educational qualications
(Thefeld et al. 1999). Exclusion of the population that
was over 69 years of age (n=721) and those not engaged
in paid work (n=2,183) is qualitatively neutral. It was
necessary to exclude 732 incomplete datasets for statis-
tical reasons. This is a quality problem if there is reason
to suppose that, for instance, people with back pain or
individual sectors of the population studied separately
by us lled out the questionnaires signicantly more
frequently or signicantly less frequently than other
segments. The gross sample population knew that the
survey was about health issues, so it is possible that
people with health problems would have been more
262

Table 4 Multiple logistic regression model for back pain among employed workersmen. Dependent variable: dummy variable back pain
in the previous 7 days. LTPA leisure time physical activity

Variable Odds ratios (95% CI)

Model 1: occupational Model 2: socio-structural Model 3: lifestyle Model 4:

factors factors factors combined model

Carrying/postural stress 1.52 (1.21; 1.90)*** 1.45 (1.14; 1.84)**

Environmental factors 1.27 (1.02; 1.59)* 1.26 (1.01; 1.58)*
Mental stress 1.35 (1.09; 1.66)** 1.37 (1.11; 1.70)**
Sitting 1.00 (0.97; 1.04) 1.01 (0.97; 1.04)
Satisfaction with the workplace 0.85 (0.80; 0.91)*** 0.87 (0.81; 0.93)***
Age 3039 yearsa 1.00 (0.75; 1.33) 0.91 (0.66; 1.27)
Age 4049 years 1.37 (1.02; 1.83)* 1.17 (0.81; 1.70)
Age 5059 years 1.87 (1.37; 2.54)*** 1.70 (1.15; 2.51)**
Age 6069 years 1.85 (1.10; 3.10)* 1.95 (1.09; 3.50)*
Social statusb
Middle class 0.83 (0.65; 1.06) 0.90 (0.69; 1.17)
Upper class 0.47 (0.35; 0.63)*** 0.64 (0.45; 0.90)*
Marital statusc
Separated 0.72 (0.47; 1.10) 0.73 (0.47; 1.12)
Single 0.79 (0.63; 1.00)* 0.86 (0.65; 1.15)
Widowed 1.24 (0.35; 4.39) 0.88 (0.24; 3.23)
Social supportd
Two to three dependable friends 1.06 (0.67; 0.69) 1.11 (0.69; 1.79)
More than four dependable friends 0.97 (0.62; 1.51) 1.12 (0.71; 1.78)
Depressivity 1.78 (1.29; 2.44)*** 1.38 (0.99; 1.93)
LTPAe
More than 4 h/week 0.81 (0.57; 1.15) 1.07 (0.74; 1.54)
24 h/week 0.66 (0.49; 0.89)** 0.84 (0.61; 1.15)
12 h/week 0.94 (0.71; 1.23) 1.18 (0.89; 1.57)
Less than 1 h/week 0.80 (0.62; 1.05) 0.99 (0.75; 1.31)
BMI f
Underweight 1.29 (0.78; 2.11) 1.26 (0.75; 2.09)
Overweight 1.12 (0.91; 1.38) 1.08 (0.87; 1.34)
Interceptg 0.44 0.71*** 0.65** 0.67
r2 adjustedh 5.53 3,54 2,35 8,74
n 1,997 1,997 1,997 1,997
e
***P<0.001, **P<0.01, *P<0.05 Reference category: no sports activity
a f
Reference category: 1829 years Reference category: normal weight
b g
Reference category: lower class b coecients
c h 2
Reference category: married r according to Nagelkerke
d
Reference category: fewer than two dependable friends

willing to complete the questionnaires. However,
because of the numerous other conditions included in
the survey (ranging from allergies to venous thrombo-
sis), the study participants would not have been aware of
the specic issue on which this study was focused.
Likewise, it is equally hard to judge whether people with
back pain might have been more likely to submit
incomplete forms because of their health problems.
These two eects would be inclined to cancel each other
out to an extent, and the non-respondent analysis gives
us no grounds to assume a greater bias than in other
cross-sectional studies (Thefeld et al. 1999).
Main results
Gender dierences
It is known from both German and international studies
that women suer more pains than men in almost all
areas of the body (Kohlmann 2001). This also applies to
back pain (Waddell 1998), as corroborated by our
studies (Schiltenwolf and Neubauer 2002). The reasons
for this are still unclear, since in other studies, as well as
the present one, women generally experience more
favourable working conditions. Women report less
stress in all aspects relating to the workplace, both
physical and mental (Table 1). They exhibit a healthier
lifestyle, more favourable risk and prevention behav-
iour, and consequently a longer life expectancy. Several
mechanisms (gender role expectancies, cognitiveaec-
tive, familial and hormonal factors) have been proposed
to explain gender dierences in back pain (Fillingim
2000; Kohlmann 2001; Schneider 2002; Waddell 1998).
Complex psychosocial workplace factors that have not
been measured may combine to cause higher levels of
psychological workplace-related stress and a higher
prevalence of pain in women. Subjective perception of
social support at work and a combination of high psy-
chological demands and low decision latitude are known
to inuence the subjective perception of pain in a gen-
der-specic fashion (Rollman and Lautenbacher 2001;
Vingard and Nachemson 2000).
 263

Table 5 Multiple logistic regression model for back pain among employed workerswomen. Dependent variable: dummy variable back
pain in the previous 7 days.LTPA leisure time physical activity

Variable Odds ratios (95% CI)

Model 1: occupational Model 2: socio-structural Model 3: lifestyle Model 4: combined

factors factors factors model

Carrying/postural stress 1.65 (1.30; 2.10)*** 1.50 (1.16; 1.94)**

Environmental factors 1.26 (0.96; 1.64) 1.23 (0.93; 1.62)
Mental stress 1.04 (0.84; 1.31) 1.07 (0.85; 1.35)
Sitting 1.02 (0.98; 1.06) 1.01 (0.97; 1.06)
Satisfaction with the workplace 0.91 (0.84; 0.98) * 0.96 (0.89; 1.04)
Age 3039 yearsa 1.04 (0.78; 1.40) 0.79 (0.55; 1.12)
Age 4049 years 1.10 (0.81; 1.50) 0.76 (0.51; 1.12)
Age 5059 years 1.46 (1.05; 2.02)* 0.99 (0.65; 1.50)
Age 6069 years 0.85 (0.44; 1.64) 0.57 (0.27; 1.18)
Social statusb
Middle class 0.72 (0.54; 0.95)* 0.90 (0.67; 1.21)
Upper class 0.61 (0.44; 0.86)** 1.02 (0.70; 1.49)
Marital statusc
Separated 1.26 (0.90; 1.78) 1.24 (0.87; 1.77)
Single 0.83 (0.64; 1.09) 0.70 (0.50; 0.99)*
Widowed 0.90 (0.47; 1.75) 0.84 (0.42; 1.68)
Social supportd
Two to three dependable friends 0.77 (0.48; 1.22) 0.77 (0.48; 1.24)
More than four dependable friends 0.64 (0.41; 1.00) 0.66 (0.42; 1.04)
Depressivity 2.57 (1.92; 3.45)*** 2.43 (1.80; 3.29)***
LTPAe
More than 4 h/week 0.77 (0.47; 1.27) 0.81 (0.48; 1.35)
24 h/week 0.69 (0.48; 1.00)* 0.72 (0.49; 1.04)
12 h/week 0.75 (0.57; 1.00)* 0.78 (0.58; 1.05)
Less than 1 h/week 0.91 (0.67; 1.22) 0.94 (0.69; 1.27)
BMIf
Underweight 1.03 (0.75; 1.41) 1.04 (0.76; 1.43)
Overweight 1.57 (1.23; 2.02)*** 1.51 (1.16; 1.95)**
Interceptg 0.35 0.29 0.26 0.11
r2 adjustedh 3,13 1,32 7,36 9,53
n 1,491 1,491 1,491 1,491
e
***P<0.001, **P<0.01, *P<0.05 Reference category: no sports activity
a f
Reference category: 1829 years Reference category: normal weight
b g
Reference category: lower class b coecients
c h 2
Reference category: married r according to Nagelkerke
d
Reference category: fewer than two dependable friends

Occupational risk factors Moreover, it accentuates both a decrease in the

The present study permits a possible dierentiation to
be made of the stress levels in various occupations.
Beginning with physical stress, the eects of a sub-
jectively perceived single posture and of carrying heavy
loads are the most common occupation-dependent risk
factors for back problems (Hasenbring 2001; Vingard
and Nachemson 2000). At the same time, the biome-
chanical mechanisms responsible are still a subject of
debate (Waddell 1998). In the present study, the var-
iable carrying and postural stress encompassed both
these eects. Although further qualitative and quanti-
tative dierentiation of these activities was not possi-
ble, our data led us to the conclusion that such
perceived bodily stress was the most important occu-
pational risk factor. However, a sedentary work habit
as a causative factor in back pain has been disputed. It
is known from in vivo measurements of intra-disc
pressure that non-physiological, forward-bent sitting
leads to strong compression of the intervertebral discs.
nutritive processes of the intervertebral disc cartilage
tissue and also an adverse, site-specic muscular
reaction. Deleterious sitting postures were conrmed
as risk factors for specic as well as non-specic back
pain in a longitudinal study (Hasenbring 2001). The
perceived pains may have a predominantly muscular
origin, since the load and pressure relationship in sit-
ting was insucient to explain the intervertebral disc
damage for some authors. Thus, Waddell argues that
sitting may only exacerbate existing symptoms, rather
than cause them (Waddell 1998). The bivariate anal-
yses (Tables 2 and 3) show that employees without
back pain spend more of their day sitting, on average.
Thus, the contention that longer time spent sitting
leads to back pain perhaps falls short. Certainly, the
specics of the sitting posture are important, as is the
time spent sitting in proportion to alternative body
postures [physically arduous work (Hartvigsen et al.
2001)]. This may explain why, in the multiple analysis,
the signicance of a sitting posture becomes negligible
264
and the physical stress factors (models 1 and 4) appear
to be much more important.
Numerous studies have described the health eects of
workplace environmental factors, such as harmful
physical, chemical and biological agents. The predomi-
nant eect recognized is hearing impairment, and others
include damage to the respiratory pathways and internal
organs (Bannasch 1987; Becker 1998; Duch and So-
kolowska 1990; Oppolzer 1994). An inuence of these
environmental factors on the prevalence of back pain
has not been reported in the literature to date. In the
present study population, however, a relationship be-
tween environmental factors (noise, poor air quality)
and the occurrence of back pain was found to be sig-
nicant (Tables 2 and 3). If environmental factors have
an indirect eect (some kind of noise-dependent mus-
cular reaction), this would obviously be perceived
unconsciously, e.g. as mental stress. Moreover, the
importance of mental stress for the back pain phe-
nomenon under investigation is extremely complex.
Hasenbring has argued that the continuous or repetitive
occurrence of emotional distress is accompanied by
heightened muscular activity in the lumbar erector
muscles of the back (Hasenbring et al. 2001). On the
other hand, mental distress is more likely to favour a
predisposition to perceive and comment on non-specic
back pain over the pathological development of specic
back pains (Waddell 1998). In addition, there is the
fundamentally bi-directional relationship between
occupational stress and back pain to be considered,
which can be understood as a stress reaction on the one
hand and as a stressor on the other (Institut fur Epide-
miologie 1993; Schneider 2002; Vingard and Nachemson
2000), with cause and eect leading to a vicious circle.
Josephson and Vingard also considered shift work to be
a potential stressor, since it has negative eects on the
quantity and quality of sleep, which can elevate muscle
tension and thus favour back pain (Josephson and
Vingard 1998). However, the empirical results reported
by those authors provide just as little support for this
contention as do our own: (night) shift work as a po-
tential stress-inducing factor has no inuence on the
occurrence of back pain.
In many studies, a negative relationship has been
reported between satisfaction with the workplace and
back pain (Schiltenwolf and Neubauer 2002; Vingard
and Nachemson 2000). As with the stress reports, the
subjective satisfaction with the workplace should be
interpreted not as a predictor, but merely as a correlate
of back pain (Waddell and Waddell 2000). Given the
fact that job satisfaction has been shown to be a sig-
nicant predictor of subsequent back pain in prospective
studies, two underlying mechanisms have been postu-
lated: for one, it is possible that low job satisfaction and
subjective pain are both expressions of low satisfaction
with life in general (constituting a confounder eect).
For another, low job satisfaction may help to aggravate
back pain when it occurs [constituting a moderator eect
(Latza et al. 2002; Papageorgiou et al. 1998)].
The overall eect of workplace conditions is more
likely to be underestimated in our study. It was known
from the prevalence data for the entire population that
gainfully employed workers generally enjoy better health
and, in particular, have a lower incidence of back pain,
than do the unemployed. This observation was also
supported by further analyses of our data. This healthy
worker eect translates to a selection mechanism based
on unsuitability for work or employment. This is one of
the key problems of any cross-sectional study and tends
to result in an underestimation of workplace-related risk
factors (Byrns et al. 2002; Cole et al. 2001; Harkness
et al. 2003; Hartvigsen et al. 2001; Krause et al. 1998;
Levangie 1999; Masset et al. 1998). This excludes certain
back pain suerers from the study population, either by
virtue of their being unemployed or by their changing
jobs in-house or externally due to past experiences of
stress (Devereux et al. 1999; Levangie 1999).
Personal risk factors
It is known from medical studies of varying design that
the prevalence of back pain reaches a maximum in
middle age and drops o to a certain extent thereafter.
Clinical studies show a peak at around 40 years (Failde
et al. 2000), while in epidemiological studies it occurs at
around 50 years (Waddell 1998). In addition to the
healthy worker eect mentioned above, the reasons
for a decrease in the frequency of symptoms with age
might be a higher tolerance of pain, as well as an in-
creased ability to delegate those activities which are
stressful to the back (Failde et al. 2000; Krause et al.
1998). Furthermore, it is known that some aspects of
lifestyle, such as sports, social contact, and healthy
nutritional habits, have a negative age-dependence
(Schneider 2002). Our investigation of German workers
likewise supports such a prevalence pattern. The 50- to
59-year-olds in our population complained most fre-
quently of back pains (Table 4, model 2, odds ratio 1.87;
Table 5, model 2, odds ratio 1.46). If occupational and
lifestyle variables are held constant, the age eect is less
in both men and women. This suggested that the age
eect was actually due to the age-associated occupa-
tional and lifestyle variables.
We had anticipated a higher pain prevalence among
workers with foreign citizenship, as a result of socio-
economic deprivation, working in the primary and sec-
ondary sectors, and dierences in access to health care.
Despite our nding of signicantly higher physical
workplace stress for these sub-groups (data not shown),
Table 2 shows no association with reports of back pain.
Depending on how social class membership is oper-
ationalized, the results of empirical studies on the neg-
ative relationship between indicators of occupation,
education and income on the one hand, and back pain
prevalence on the other, show a pronounced conformity.
Studies carried out in the USA, Great Britain, Denmark,
Canada and Sweden led to the same nding. This eect

nds a basis in poorer medical care, unhealthy working
conditions and an adverse lifestyle experienced by the
members of lower social classes (Gobel 2001; Hasen-
bring 2001; Schneider 2003; Waddell 1998; Waddell and
Waddell 2000). The odds ratio for social class indicators
is signicantly reduced for both genders (Tables 4 and 5,
model 4 compared with model 2). It has been clearly
shown in numerous morbidity studies that, to a large
extent, social class indicators merely represent proxy
variables for workplace and lifestyle factors.
Lifestyle factors
Little attention has been paid to the impact of the social
support factor on the occurrence of back pain, opera-
tionalized here with marital status and support group of
dependable friends. It is conceivable that overprotecting
partners and dependable friends can encourage the
perception of pain in the sense of social or operant
learning, e.g. in so-called pain families (Flor and Bir-
baumer 2001; Linton 2000). On the other hand, the
absence of social support acts as a stressor, and the
perception of pain can be subjectively dramatized be-
cause of the missing emotional and instrumental help
[the so-called buering eect (Klein et al. 2002; Krist-
jansdottir and Rhee 2002)]. In view of the conicting
results for men and women in our empirical analysis,
only a minor relevance and an unclear direction of the
eect of social network can be discerned.
However, the relationship between depressivity and
rst occurrence of the chronication of back pain has
been shown many times. This relationship exists, even
for mild forms of depressivity, and is not limited to
psychiatric cases. It is presumed that the resulting pas-
sive withdrawal behaviour can foster an atrophy of the
musculature in addition to a perceptive focusing on the
resulting pains (Flor and Birbaumer 2001; Hasenbring
et al. 2001). Our analyses operate with a similarly broad
denition and substantiate the known correla-
tionsespecially the odds ratios for women. It is con-
ceivable that the experiences of pain themselves can be
causes of the depressed mood (Hurwitz and Morgen-
stern 1999; Schiltenwolf and Neubauer 2002).
The eect of athletic leisure activities is complex:
aside from the risk of injury, both a physically and
psychologically protective impact has been ascribed to
sport. The training eect is divided into direct aspects
(increase in muscular endurance, strength, exibility and
agility) and indirect aspects (overall mood, social con-
tact and lifestyle) (Vuori 2001). A further indirect eect
is the sport-induced elevation of the pain threshold
through the release of endorphins. However, it was re-
ported by Failde et al. (2000) and Harreby et al (2001)
that the fundamental protective eect of sport activity
does not appear to hold true for high-intensity, daily
training. This can be replicated: athletes with a weekly
training eort of over 4 h report back pains more fre-
quently than do those who train for 24 h (Tables 2 and
265
3). It appears that too short a regeneration phase and an
overtraining eect, as well as an elevated risk of over-
stress and injury, likewise play a role as secondary sports
eects (secondary eect of illness as a stress moderator,
causal attribution, etc.).
The health-damaging eect of smoking in connection
with back pains is disputed. Certainly, smoking has an
inuence on the circulatory system, on the blood pH,
and on the maintenance of the intervertebral discs as a
cause of disc degeneration. However, since no strict
doseresponse eect was demonstrated in large, con-
founder-controlled cross-sectional studies, a number of
authors have argued that the relationship reported in
some studies between smoking and back pain is a spu-
rious correlation, in which tobacco consumption is
associated with an unhealthy lifestyle (with respect to
sport, nutrition, relaxation etc.) and mental stress
(Kristjansdottir and Rhee 2002; Leboeuf-Yde 2000;
Nachemson and Vingard 2000). In this cross-sectional
study, as in a previous, prospective longitudinal study by
our research group (Schiltenwolf and Neubauer 2002),
no relationship exists between smoking and back pain,
even without our controlling the potential behaviour-
and occupation-related confounders, and despite the
scope of the study sample (Table 2).
Overweight, especially abdominal adiposity, can lead
to inordinate stress on the entire spinal column and on
the lower extremities as the centre of gravity becomes
more ventral in an upright gait. Orthopaedic symptoms
(back pain, arthrosis) are exacerbated by concurrent
metabolic factors (Leboeuf-Yde 2000; Vezyroglou et al.
1996). While the inuence of body weight and BMI on
the occurrence of back pain has been well researched,
height, per se, has seldom been examined as a predictor.
Moreover, the body of research on these biometric fac-
tors is inconsistent (Leboeuf-Yde 2000; Masset et al.
1998; Nachemson and Vingard 2000). A few studies re-
ported a higher risk of injury for heavy participants,
while others obtained negative or non-signicant results
(Nachemson and Vingard 2000; Waddell 1998). Our
data support a negative relationship for height and a
positive one for overweight for female workforce mem-
bers only. This may be attributable to the higher body
fat ratio and lower ratio of spine-supporting muscle in
women versus men of the same weight.
Generalizability of results
Based on the large number of participants and the rep-
resentativeness of the sample, this study has sucient
generalizability for the results to be applied to the
working population of any culturally similar group. As
expected, the 7-day and 12-month prevalence values are
slightly smaller for workers than for the total German
population (Kohlmann 2001; Kohlmann et al. 1998;
Raspe et al. 1990). Thus, the reported prevalences
should also be suitable for international data (Cassidy
et al. 1998; Waddell 1998).
266

Not being able to exclude the healthy worker eect carrying stress by taking regular breaks, by reducing
leads us to the conclusion that the impact (signicance
and scope) of the risk factors and the inuencing vari-
ables was actually underestimated. For this reason, it
would be interesting to carry out further analyses in a
sample that included the unemployed. Furthermore, in a
study of 1,514 British workers, Devereux et al. con-
cluded that the odds ratios were elevated when only
chronic courses were included instead of the 7-day pre-
valences (Devereux et al. 1999). The present interview
data do not permit us to make a dierentiation between
acute and chronic pain.
In summary, this epidemiological study provides
current and valid data on the prevalence of back pain for
various groups within the population across Germany.
In addition to the physical aspects of lifting and carrying
stress, there are also indirect causal factors for back pain,
such as mental stress and environmental factors in the
workplace. Based on the present ndings, future pre-
ventive measures for back pain should focus on two
areas. First, employees should decrease their lifting and
Table 6 Possible risk factors for back pain selected by analysis of
the literature. Only those variables with a counterpart in the data
set used are shown. When several analyses are reported from one
their work pace, by dividing up the movement of loads,
and by changing individual tasks frequently. To this end,
technical improvements, such as the use of lifters,
transporters and height-adjustable work equipment,
should serve to reduce risks. A load handling directive
has been in force in Germany since 1996, which can serve
as an operational model. Second, a more active, athletic
lifestyle plus the avoidance of being overweight should
provide an additional protective or preventive eect.
Acknowledgements Special thanks are due to Dr. Heribert Stolzen-
berg, Robert-Koch Institute of Berlin, for the preparation of the data
sets. We also wish to thank Gwendolyn Schmitt and Christian Hauf
for their assistance in the treatment of the data. This publication was
supported by a grant of the research fund of the Department of
Orthopaedic Surgery, University of Heidelberg, Germany.
Appendix
source, the data refer to the multiple analysis with the largest test
population. M signicant only for men, F signicant only for wo-
men

Correlates/possible Empirical ndings

risk factors
Variable Positive relationship Negative relationship No relationship (P>0.05)

Occupational risk factors

Carrying/postural stress
Environmental factors
Mental stress
Overtime work
Shift work
Time spent sitting
Satisfaction with
the workplace
Barnekow-Bergkvist et al. (1998), Krause et al. (1998),
Cole et al. (2001), Levangie (1999),
Devereux et al. (1999), Thorbjornsson et al. (2000) (M),
Hartvigsen et al. (2001), Vingard et al. (2000)
Heistaro et al. (1998),
Hoogendoorn et al. (2000),
Josephson and Vingard (1998),
Kerr et al. (2001),
Lee et al. (2001),
Masset et al. (1998),
Myers et al. (1999),
Nourbakhsh et al. (2001),
Thorbjornsson et al. (2000) (F),
Guo (2002),
Hellsing and Bryngelsson (2000),
Hoozemans et al. (2002)
Cole et al. (2001), Cole et al. (2001) (M)
Devereux et al. (1999),
Krause et al. (1998) (F),
Hoozemans et al. (2002),
Kerr et al. (2001),
Yip et al. (2001)
Krause et al. (1998),
Thorbjornsson et al. (2000) (M)
Josephson and Vingard (1998),
Krause et al. (1998)
Levangie (1999),
Nourbakhsh et al. (2001),
Thorbjornsson (2000)
Kerr et al. (2001) Krause et al. (1998), Vingard et al. (2000)
Papageorgiou et al. (1998),
Schiltenwolf and
Neubauer (2002),
van Poppel et al. (1998)

Table 6 (Contd.)
Correlates/possible Empirical ndings
risk factors
Variable Positive relationship
Personal risk factors
Socio-structural factors
Age Guo (2002),
Heistaro et al. (1998),
Lee et al. (2001)a,
Leboeuf-Yde et al. (1998),
Omokhodion and Sanya (2003),
Santos-Eggimann et al. (2000)
Women Cassidy et al. (1998),
Failde et al. (2000),
Heistaro et al. (1998),
Kovacs et al. (2003),
Omokhodion et al. (2000),
Santos-Eggimann et al. (2000),
Schiltenwolf and Neubauer (2002)
Foreigner
Income
Professional position
Educational status Kerr et al. (2001),
Kovacs et al. (2003)
Social status
Lifestyle factors
Marital status (married) Lee et al. (2001)
Social support Kerr et al. (2001),
Lee et al. (2001)
Private health insurance
Depressivity Adams et al. (1999),
Schiltenwolf and
Neubauer (2002)
Leisure time Croft et al. (1999),
physical activity Kovacs et al. (2003) (F),
Mortimer et al. (2001) (F)
Smoking Heistaro et al. (1998),
Leboeuf-Yde et al. (1998),
Levangie (1999),
Omokhodion and Sanya (2003)
Height Lee et al. (2001)
Weight
BMI Heistaro et al. (1998),
Hellsing and Bryngelsson (2000),
Kerr et al. (2001),
Myers et al. (1999) (M),
Mortimer et al. (2001)
267
Negative relationship No relationship (P>0.05)
Adams et al. (1999), Devereux et al. (1999),
Krause et al. (1998), Failde et al. (2000),
Stevenson et al. (2001) Hoozemans et al. (2002),
Kerr et al. (2001),
Myers et al. (1999),
Nourbakhsh et al. (2001),
Omokhodion et al. (2000),
van Poppel et al. (1998)
Omokhodion and Devereux et al. (1999),
Sanya (2003) Hoozemans et al. (2002),
Krause et al. (1998),
Leboeuf-Yde et al. (1998)
Heistaro et al. (1998)
Failde et al. (2000)
Heistaro et al. (1998),
Schiltenwolf and
Neubauer (2002)
Kerr et al. (2001),
Yip et al. (2001)
Stevenson et al. (2001), Cole et al. (2001)
Yip et al. (2001) Josephson and Vingard (1998),
Krause et al. (1998),
Thorbjornsson et al. (2000) (M)
Taimela et al. (2000)
Brown et al. (2000), Levangie (1999),
Failde et al. (2000), Mortimer et al. (2001),
Hagen et al. (2000), Taimela et al. (2000) (F)
Heistaro et al. (1998),
Hildebrandt et al. (2000),
Lonn et al. (1999),
Nourbakhsh et al. (2001),
Stevenson et al. (2001)
Josephson and Vingard (1998),
Kerr et al. (2001),
Thorbjornsson et al. (2000) (F),
Mortimer et al. (2001),
Omokhodion et al. (2000)
Brown et al. (1998),
Hellsing and Bryngelsson (2000),
Nourbakhsh et al. (2001)
Masset et al. (1998) Brown et al. (1998),
Croft et al. (1999),
Lee et al. (2001),
Nourbakhsh et al. (2001)
Failde et al. (2000),
Levangie (1999),
Mortimer et al. (2001) (F),
Brown et al. (1998)
268
References
Adams MA, Mannion AF, Dolan P (1999) Personal risk factors for
rst-time low back pain. Spine 24:24972505
Bannasch P (1987) Cancer risks. Strategies for elimination.
Springer, Berlin Heidelberg New York
Barnekow-Bergkvist M, Hedberg GE, Janlert U, Jansson E (1998)
Determinants of self-reported neck-shoulder and low back
symptoms in a general population. Spine 23:235243
Beaglehole R, Bonita R, Kjellstrom T (1993) Basic epidemiology.
World Health Organization, Geneva
Becker R (1998) Bildung und Lebenserwartung in Deutschland. Z
Soziol 27:133150
Bellach BM (1999) The 1998 Federal Health Survey. Experiences,
results, perspectives. Gesundheitswesen 61:S55S56
Bellach BM, Knopf H, Thefeld W (1998) The German health
survey 1997/98. Gesundheitswesen 60:5968
Bellach BM, Ellert U, Radoschewski M (2000) Epidemiologie des
Schmerzes - Ergebnisse des Bundes-Gesundheitssurveys 1998
[Pain epidemiology in Germany - results of the national health
interview and examination survey 1998]. Bundesgesundheitsbl-
att 6:424431
Berger-Schmitt R, Kohlmann T, Raspe H (1996) Backache in East
and West Germany. Gesundheitswesen 58:519524
Bortz J (1985) Lehrbuch der Statistik fur Sozialwissenschaftler.
Springer, Berlin Heidelberg New York
Brown JJ, Wells GA, Trottier AJ, Bonneau J, Ferris B (1998) Back
pain in a large Canadian police force. Spine 23:821827
Brown WJ, Mishra G, Lee C, Bauman A (2000) Leisure time
physical activity in Australian women: relationship with well
being and symptoms. Res Q Exerc Sport 71:206216
Byrns G, Agnew J, Curbow B (2002) Attributions, stress, and work-
related low back pain. Appl Occup Environ Hyg 17:752764
Cassidy JD, Carroll LJ, Cote P (1998) The Saskatchewan health
and back pain survey. The prevalence of low back pain and
related disability in Saskatchewan adults. Spine 23:18601866
Cole DC, Ibrahim SA, Shannon HS, Scott F, Eyles J (2001) Work
correlates of back problems and activity restriction due to
musculoskeletal disorders in the Canadian national population
health survey (NPHS) 19941995 data. Occup Environ Med
58:728734
Cote P, Cassidy JD, Carroll L (2001) The treatment of neck and
low back pain: who seeks care? Who goes where? Med Care
39:956967
Croft PR, Papageorgiou AC, Thomas E, Macfarlane GJ, Silman
AJ (1999) Short-term physical risk factors for new episodes of
low back pain. Prospective evidence from the South Manchester
back pain study. Spine 24:15561561
Devereux JJ, Buckle PW, Vlachonikolis IG (1999) Interactions
between physical and psychosocial risk factors at work increase
the risk of back disorders: an epidemiological approach. Occup
Environ Med 56:343353
Duch D, Sokolowska M (1990) Health inequalities in Poland. Soc
Sci Med 31:343350
Failde I, Gonzalez JL, Novalbos JP, Casais F, Marin J, Elorza J
(2000) Psychological and occupational predictive factors for
back pain among employees of a university hospital in southern
Spain. Occup Med (Lond) 50:591596
Fillingim RB (2000) Sex, gender, and pain: women and men really
are dierent. Curr Rev Pain 4:2430
Flor H, Birbaumer N (2001) Verhaltensmedizinische Grundlagen.
In: Jurna I, Zenz M (eds) Lehrbuch der Schmerztherapie.
Wissenschaftliche Verlagsgesellschaft, Stuttgart, pp 197208
Gobel H (2001) Epidemiologie und Kosten chronischer Schmerzen.
Spezische und unspezische Ruckenschmerzen. Schmerz
15:9298
Guo HR (2002) Working hours spent on repeated activities and
prevalence of back pain. Occup Environ Med 59:680688
Hagen EM, Eriksen HR, Ursin H (2000) Does early intervention
with a light mobilization program reduce long-term sick leave
for low back pain? Spine 25:19731976
Hagen KB, Tambs K, Bjerkedal T (2002) A prospective cohort
study of risk factors for disability retirement because of back
pain in the general working population. Spine 27:17901796
Harkness EF, Macfarlane GJ, Nahit ES, Silman AJ, McBeth J (2003)
Risk factors for new-onset low back pain amongst cohorts of
newly employed workers. Rheumatology (Oxford) 42:959968
Harreby MS, Nygaard B, Jessen TT, Larsen E, Storr-Paulsen A,
Lindahl A, et al (2001) Risk factors for low back pain among
1,389 pupils in the 8th and 9th grade. An epidemiologic study.
Ugeskr Laeger 163:282286
Hartvigsen J, Bakketeig LS, Leboeuf-Yde C, Engberg M, Laurit-
zen T (2001) The association between physical workload and
low back pain clouded by the healthy worker eect: popu-
lation-based cross-sectional and 5-year prospective question-
naire study. Spine 26:17881792
Hasenbring M (2001) Biopsychosoziale Grundlagen der Chroni-
zierung am Beispiel von Ruckenschmerzen. In: Zenz M, Jurna I
(eds) Lehrbuch der Schmerztherapie. Wissenschaftliche Ver-
lagsgesellschaft, Stuttgart, pp 185196
Hasenbring M, Hallner D, Klasen B (2001) Psychological mecha-
nisms in the transition from acute to chronic pain: over- or
underrated. Schmerz 15:442447
Heistaro S, Vartiainen E, Heliovaara M, Puska P (1998) Trends of
back pain in eastern Finland, 19721992, in relation to socio-
economic status and behavioral risk factors. Am J Epidemiol
148:671682
Hellsing AL, Bryngelsson IL (2000) Predictors of musculoskeletal
pain in men: a twenty-year follow-up from examination at
enlistment. Spine 25:30803086
Hildebrandt VH, Bongers PM, Dul J, van Dijk FJ, Kemper HC
(2000) The relationship between leisure time, physical activities
and musculoskeletal symptoms and disability in worker popu-
lations. Int Arch Occup Environ Health 73:507518
Hoogendoorn WE, Bongers PM, de Vet HC, Douwes M, Koes
BW, Miedema MC, et al (2000) Flexion and rotation of the
trunk and lifting at work are risk factors for low back pain:
results of a prospective cohort study. Spine 25:30873092
Hoozemans MJ, van der Beek AJ, Frings-Dresen MH, van der
Woude LH, van Dijk FJ (2002) Pushing and pulling in associ-
ation with low back and shoulder complaints. Occup Environ
Med 59:696702
Hurwitz EL, Morgenstern H (1999) Cross-sectional associations of
asthma, hay fever, and other allergies with major depression
and low-back pain among adults aged 2039 years in the Uni-
ted States. Am J Epidemiol 150:11071116
Institut fur Epidemiologie (1993) MONICA-Projekt Region
Augsburg. Herz-Kreislaufstudie der Weltgesundheitsorganisa-
tion (WHO). Data-Book. Trends in cardiovascular risk factors
from survey 1984/85 to survey 1989/90. Munchen
Johnston JM, Landsittel DP, Nelson NA, Gardner LI, Wassell JT
(2003) Stressful psychosocial work environment increases risk
for back pain among retail material handlers. Am J Ind Med
43:179187
Josephson M, Vingard E (1998) Workplace factors and care seek-
ing for low-back pain among female nursing personnel. MU-
SIC-Norrtalje Study Group. Scand J Work Environ Health
24:465472
Kerr MS, Frank JW, Shannon HS, Norman RW, Wells RP, Neu-
mann WP, et al (2001) Biomechanical and psychosocial risk fac-
tors for low back pain at work. Am J Public Health 91:10691075
Klein T, Lowel H, Schneider S, Zimmermann M (2002) Social rela-
tionships, stress and mortality. Z Gerontol Geriatr 35:441449
Kohlmann T (2001) Bevolkerungsbezogene Epidemiologie am
Beispiel chronischer Ruckenschmerzen. In: Jurna I, Zenz M
(eds) Lehrbuch der Schmerztherapie. Wissenschaftliche Ver-
lagsgesellschaft, Stuttgart, pp 221229
Kohlmann T, Deck R, Klockgether R (1998) Ruckenschmerzen in
der Lubecker Bevolkerung. Z Rheumatol 57:238240
Kovacs FM, Gestoso M, Gil del Real MT, Lopez J, Mufraggi N,
Ignacio MJ (2003) Risk factors for non-specic low back pain
in schoolchildren and their parents: a population based study.
Pain 103:259268

Krause N, Ragland DR, Fisher JM, Syme SL (1998) Psychosocial
job factors, physical workload, and incidence of work-related
spinal injury: a 5-year prospective study of urban transit
operators. Spine 23:25072516
Kristjansdottir G, Rhee H (2002) Risk factors of back pain fre-
quency in schoolchildren: a search for explanations to a public
health problem. Acta Paediatr 91:849854
Latza U, Pfahlberg A, Gefeller O (2002) Impact of repetitive
manual materials handling and psychosocial work factors on
the future prevalence of chronic low-back pain among con-
struction workers. Scand J Work Environ Health 28:314323
Leboeuf-Yde C (2000) Body weight and low back pain. A sys-
tematic literature review of 56 journal articles reporting on 65
epidemiologic studies. Spine 25:226237
Leboeuf-Yde C, Kyvik KO, Bruun NH (1998) Low back pain and
lifestyle. Part I: Smoking. Information from a population-based
sample of 29,424 twins. Spine 23:22072213
Lee P, Helewa A, Goldsmith CH, Smythe HA, Stitt LW (2001)
Low back pain: prevalence and risk factors in an industrial
setting. J Rheumatol 28:346351
Levangie PK (1999) Association of low back pain with self-re-
ported risk factors among patients seeking physical therapy
services. Phys Ther 79:757766
Linton SJ (2000) Psychological risk factors for neck and back pain.
In: Nachemson AL, Jonsson E (eds) Neck and back pain: the
scientic evidence of causes, diagnosis, and treatment. Lippin-
cott Williams & Wilkins, Philadelphia, pp 5778
Lonn JH, Glomsrod B, Soukup MG, Bo K, Larsen S (1999) Active
back school: prophylactic management for low back pain. A
randomized, controlled, 1-year follow-up study. Spine 24:865
871
Masset DF, Piette AG, Malchaire JB (1998) Relation between
functional characteristics of the trunk and the occurrence of low
back pain. Associated risk factors. Spine 23:359365
Mortimer M, Wiktorin C, Pernol G, Svensson H, Vingard E (2001)
Sports activities, body weight and smoking in relation to low-
back pain: a population-based case-referent study. Scand J Med
Sci Sports 11:178184
Myers AH, Baker SP, Li G, Smith GS, Wiker S, Liang KY, et al
(1999) Back injury in municipal workers: a casecontrol study.
Am J Public Health 89:10361041
Nachemson A, Vingard E (2000) Inuences of individual factors
and smoking on neck and low back pain. In: Nachemson AL,
Jonsson E (eds) Neck and back pain: the scientic evidence of
causes, diagnosis, and treatment. Lippincott Williams & Wilk-
ins, Philadelphia, pp 7995
Norlund AE, Waddell G (2000) Cost of back pain in some OECD
countries. In: Nachemson AL, Jonsson E (eds) Neck and back
pain. Lippincott Williams & Wilkins, Philadelphia, pp 421426
Nourbakhsh MR, Moussavi SJ, Salavati M (2001) Eects of life-
style and work-related physical activity on the degree of lumbar
lordosis and chronic low back pain in a Middle East popula-
tion. J Spinal Disord 14:283292
Omokhodion FO, Sanya AO (2003) Risk factors for low back pain
among oce workers in Ibadan, Southwest Nigeria. Occup
Med (Lond) 53:287289
Omokhodion FO, Umar US, Ogunnowo BE (2000) Prevalence of
low back pain among sta in a rural hospital in Nigeria. Occup
Med (Lond) 50:107110
Oppolzer A (1994) Die Arbeitswelt als Ursache gesundheitlicher
Ungleichheit. In: Mielck A (ed) Krankheit und soziale Ungl-
eichheit: Ergebnisse der sozialepidemiologischen Forschung in
Deutschland. Leske + Budrich, Opladen, pp 125166
Papageorgiou AC, Croft PR, Thomas E, Silman AJ, Macfarlane
GJ (1998) Psychosocial risks for low back pain: are these related
to work? Ann Rheum Dis 57:500502
Pottho P, Schroeder E, Reis U, Klamert A (1999) Process and
results of eld work concerning the Federal health survey.
Gesundheitswesen 61:6267
Raspe H, Wasmus A, Greif G (1990) Ruckenschmerzen in Han-
nover. Aktuelle Rheumatologie 15:3237
269
Rollman GB, Lautenbacher S (2001) Sex dierences in musculo-
skeletal pain. Clin J Pain 17:2024
Santos-Eggimann B, Wietlisbach V, Rickenbach M, Paccaud F,
Gutzwiller F (2000) One-year prevalence of low back pain in
two Swiss regions: estimates from the population participating
in the 19921993 MONICA project. Spine 25:24732479
Schiltenwolf M, Neubauer E (2002) Entwicklung eines Kurz-
fragebogens zur Fruherkennung des Chronizierungsrisikos bei
akuten Ruckenschmerzen. Department of Orthopaedic Sur-
gery, University of Heidelberg, Heidelberg
Schneider S (2002) Lebensstil und Mortalitat. Welche Faktoren
bedingen ein langes Leben? Westdeutscher Verlag, Wiesbaden
Schneider S (2003) Schichtzugehorigkeit und Mortalitat in der
BRD: Empirische Uberprufung theoretischer Er-
klarungsansatze. Sozialer Fortschritt 52:6473
Schroeder E, Pottho P, Reis U, Klamert A (1998) Data evaluation
in the German health survey. Gesundheitswesen 60:104107
Stevenson JM, Weber CL, Smith JT, Dumas GA, Albert WJ (2001)
A longitudinal study of the development of low back pain in an
industrial population. Spine 26:13701377
Taimela S, Diederich C, Hubsch M, Heinricy M (2000) The role of
physical exercise and inactivity in pain recurrence and absen-
teeism from work after active outpatient rehabilitation for
recurrent or chronic low back pain: a follow-up study. Spine
25:18091816
Thefeld W, Stolzenberg H, Bellach BM (1999) The Federal health
survey: response, composition of participants and non-re-
sponder analysis. Gesundheitswesen 61:S57S61
Thorbjornsson CB, Alfredsson L, Fredriksson K, Michelsen H,
Punnett L, Vingard E, et al (2000) Physical and psychosocial
factors related to low back pain during a 24-year period. A
nested casecontrol analysis. Spine 25:369374
Trampisch H, Windeler J, Ehle B, Lange S (2000) Medizinische
Statistik. Springer, Berlin Heidelberg New York
van Poppel MN, Koes BW, Deville W, Smid T, Bouter LM (1998)
Risk factors for back pain incidence in industry: a prospective
study. Pain 77:8186
Vezyroglou G, Mitropoulos A, Antoniadis C (1996) A metabolic
syndrome in diuse idiopathic skeletal hyperostosis. A con-
trolled study. J Rheumatol 23:672676
Vingard E, Nachemson A (2000) Work-related inuences on neck
and low back pain. In: Nachemson AL, Jonsson E (eds) Neck
and back pain: the scientic evidence of causes, diagnosis, and
treatment. Lippincott Williams & Wilkins, Philadelphia, pp 97
126
Vingard E, Alfredsson L, Hagberg M, Kilbom A, Theorell T,
Waldenstrom M, et al (2000) To what extent do current and
past physical and psychosocial occupational factors explain
care-seeking for low back pain in a working population?
Results from the Musculoskeletal Intervention CenterNor-
rtalje Study. Spine 25:493500
Vuori IM (2001) Doseresponse of physical activity and low back
pain, osteoarthritis, and osteoporosis. Med Sci Sports Exerc
33:S551S586
Waddell G (1998) The back pain revolution. Churchill Livingstone,
Edinburgh
Waddell G, Waddell H (2000) A review of social inuences on neck
and back pain and disability. In: Nachemson AL, Jonsson E
(eds) Neck and back pain: the scientic evidence of causes,
diagnosis, and treatment. Lippincott Williams & Wilkins,
Philadelphia, pp 1356
Winkler J, Stolzenberg H (1999) Social class index in the Federal
health survey. Gesundheitswesen 61:178183
Winkler G, Filipiak B, Hense HW, Schwertner B (1998) External
quality control in the German health survey 1997/98: concept
and initial experiences. Gesundheitswesen 60:108112
Yip YB, Ho SC, Chan SG (2001) Socio-psychological stressors as
risk factors for low back pain in Chinese middle-aged women.
J Adv Nurs 36:409416