key: cord-0798391-7twox40p authors: Grech, Stephan; Borg, Joseph N.; Cuschieri, Sarah title: Back pain: An aftermath of Covid‐19 pandemic? A Malta perspective date: 2021-06-06 journal: Musculoskeletal Care DOI: 10.1002/msc.1574 sha: 8a9b9265869873cf1a9af39646591f221b83e7f3 doc_id: 798391 cord_uid: 7twox40p BACKGROUND: Back pain is the commonest musculoskeletal complaint across the world. The Covid‐19 pandemic led to mitigating measures including remote working that enhanced a sedentary lifestyle. The aim of this study was to investigate whether back pain complaints have increased from pre‐Covid‐19 to during the Covid‐19 period among the adult population of Malta, while exploring the possible contributing factors. METHODS: An online survey was distributed through social media targeting the adult population of Malta. Questions on sociodemographic data, occurrence of back pain pre‐Covid‐19 and since the onset of Covid‐19 was gathered, along with changes in behavioural attitudes, daily routine and physical activity. Descriptive and multiple logistic regression analyses were performed. RESULTS: Out of the 388 responders, 30% experienced chronic back pain pre‐Covid‐19, 49% experienced back pain since Covid‐19, with the majority of the latter claiming that they never experienced back pain before Covid‐19. Significant changes were present in daily routine and physical activity (PA) patterns. Indeed, continuously sitting down (OR: 15.53; p ≤ 0.01), no PA (OR: 4.22; p ≤ <0.01), once a week PA (OR: 5.74; p ≤ <0.01), two to three times PA a week (OR: 2.58; p = 0.05) and four to five PA a week (OR: 3.46; p = 0.02) were associated with experiencing new onset back pain since the onset of Covid‐19, when adjusted for sex, age, education and employment status. CONCLUSION: The pandemic has changed population behaviour resulting in an enhanced back pain occurrence. This is anticipated to impact the individual’s disability adjusted life years as well as increase the burden on the economy and healthcare services. A designated multidisciplinary action plan is recommended to reduce back pain impact. Back pain, especially low back pain, is the commonest musculoskeletal complaint on a global level and is the leading cause of absenteeism from work (Driscoll et al., 2014; Hoy et al., 2012; Maher et al., 2017) . Additionally, it is responsible for a substantial healthcare and economic burden (Hartvigsen et al., 2018) . The small European county of Malta, with a total population of 442,413, is of no exception (National Statistics Office (NSO), 2020). In fact, it was reported that the commonest presenting complaint at primary healthcare was musculoskeletal (Cuschieri & Sammut, 2013) . Indeed, the point prevalence of low back pain at a population level in 2015 for Malta was 6.4%, with a disability-adjusted life years (DALYs) of 716 per 100,000 . In 2020, like the rest of the world, Malta reported the first Covid-19 case on the 7th of March and declared a public health emergency soon after (Cuschieri, 2020) . A number of mitigation measures were instituted, including shifting to remote working, social distancing, restrictions on number of people in gatherings and even lockdowns when it was medically appropriate (Cuschieri, 2020 (Patrick et al., 2014) . Furthermore, socio-demographic data and changes in behavioural attitudes (tobacco smoking, alcohol consumption) and weight changes were gathered. The last section of the survey was targeted towards those reporting having experienced new onset low back pain since the start of the Covid-19 pandemic. This section included the 'Oswestry low back pain disability questionnaire', which is a scoring tool to measure the individual's permanent functional disability due to low back pain (Fairbank & Pynsent, 2000) . The Oswestry low back pain disability questionnaire consists of 10 sections, each assessing the effect of low back pain on a different daily function. Each section scores between 0 (no disability) to 5 (very severe/disabling). The total score obtained is divided by 50 and multiplied by 100. The percentage is interpreted as follows: 0%-20% as minimal disability; 21%-40% as moderate disability; 41%-60% as severe disability; 61%-80% as crippled and 81%-100% as bed-bound or exaggerating of symptoms (Fairbank & Pynsent, 2000) . Only the significant associations will be reported. A p-value of ≤0.05 was considered as significant. A total of 388 participants responded, with a female predominance (74.48% CI95%: 69.91-78.57), although socio-demographically no significant differences were observed between males and females, as shown in Table 1 . Since the onset of Covid-19, 48% (CI95%: 42.92-52.91) reported a shift to remote working while 17% (CI95%: 13.40-20.95) reported to have started to follow a roster-based schedule, with days at the office and days working from home. Changes in behavioural attitudes (smoking and alcohol) were noted to be minimal. In fact, an increase in both tobacco smoking (6.96% CI95%: 4.79-9.97) and alcohol consumption (6.44% CI95%: 4.37-9.37) was reported by the minority of the participants. Conversely this was not the case for physical activity patterns, where a significant difference was present between pre-Covid-19 and since Covid-19 activity, as shown in Figure 1 ( Indeed, it has been reported that prolonged periods of sitting down results in low lumbar muscles activation with transmission of load to passive structures (intervertebral discs and ligaments) with a consequential low back pain (Mörl & Bradl, 2013) . This is supported by the highly significant relationship established in our study between continuously sitting down and back pain. This lifestyle change may be the leading contributor for the enhanced back pain complaints since the onset of Covid-19. Another potential reason is the lack of ergonomic office furniture available at home, which also can contribute to back pain (Gerding et al., 2021 ). The sedentary lifestyle and self-isolation linked with Covid-19 has been reported to be linked with increased weight gain and the risk of developing obesity (Bakaloudi et al., 2021; Cuschieri & Grech, 2020) . In fact, a proportion of our study participants complaining of back pain reported to have increased in body weight. Increase in body mass index has been proven to be a risk factor for low back pain (Muthuri et al., 2020) , which further supports our findings. The literature on the effect of leisure physical activity on back pain is controversial, with some claiming a risk reduction for back pain, whilst others reported moderate risk for back pain (Heneweer et al., 2011; Shiri & Falah-Hassani, 2017) . This study strongly links the relationship between lack or low levels of physical activity with back pain and brings forward the recommendation that physical activity should be encouraged even if confined to the home. Such activity will have a dual positive outcome, not only on decreasing potential back pain but also in helping to maintain a stable body weight while preventing associated conditions including obesity and diabetes. Although it is still early days into the pandemic to assess the permanent disability attributed due to Covid-19 induced back pain, up till a year into the pandemic it appears that low back pain has not yet contributed to high disability effect, according to the Oswestry Disability Index. However, further follow-up research is merited to evaluate the extent of this condition over longer periods of time. This observational survey was distributed through social media platforms targeting the adult residents of Malta. This kind of methodology limits participation to those registered to the various social media platforms used (Facebook and Linkedln) and is subject to personal preference and intuition to participate. Furthermore, the survey is susceptible to self-reporting and recall bias. Since the survey was available on social media and anonymous data was gathered, individuals from anywhere across the world could participate and not picked up by the researchers. The survey was tested among the authors and their colleagues. These responses were not considered for the actual study. However, the survey was not pilot tested through social media due to the anticipation of a low response rate when the actual survey was launched. It is clear that since the onset of Covid-19, back pain occurrences have increased among the Malta population, especially new onset back pain. During pre-Covid-19, back pain was contributing to a large proportion of DALYs in Malta, indeed it ranked as the second leading cause of disease and disability Institute for Health Metrics and Evaluation (IHME), 2019). Therefore, the enhanced back pain occurrence since Covid-19 is anticipated to lead to a higher disability and population burden on the healthcare systems. This brings forward the recommendation that a back pain clinic at primary healthcare level should be set up, currently not available in Malta yet previously proposed (Cuschieri et al., 2014) , to provide a multidisciplinary management care to these individuals. Impact of the first COVID-19 lockdown on body weight: A combined systematic review and a meta-analysis COVID-19 panic, solidarity and equity-the Malta exemplary experience Obesity population at risk of COVID-19 complications Outcome of low back pain patients referred to orthopeadic outpatient clinic A study of general practice consultations at Mosta Health Centre, Malta. The Journal of the Malta College of Family Doctors Measuring disability-adjusted life years (DALYs) due to low back pain in Malta. 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Systematic review and meta-analysis of 36 prospective cohort studies Back pain: An aftermath of Covid-19 pandemic? A Malta perspective All authors contributed to the writing and reviewing of the article. GRECH ET AL. Data is available upon request. https://orcid.org/0000-0003-2012-9234