Abstract
Low Back Pain (LBP) and obesity have emerged among the very common health problems particularly in patients who are attending health care at primary levels in the United Arab Emirates. As such, the causal connection between obesity and LBP have for the past few years have piqued the interest of many researchers. It is noteworthy, though, that there is still a wide range of controversy concerning the association between the two, in addition to the presence of various conflicting observations. A significant challenge in the process of trying to ascertain the primary cause and the implication of LBP in association with obesity is the nature of the condition. Fundamentally, LBP is a condition that cannot be easily determined. This is mainly attributed to the fact that it is heterogeneous, comes in many dimensions in nature, and very little information is known concerning the etiology of the disease. This research proposes a clinically-driven collaborative research effort to investigate the spinal biomechanics of obesity and LBP in the UAE, a country where both obesity and LBP are more than double the global averages.
The proposed study will investigate the spinal biomechanics of obesity and LBP in the UAE and come up with new strategy to determine whether the BMI of the patient is the cause of LBP or not. A musculoskeletal simulation model will be developed to identify the volume of mechanical load that can affect the spine thus the low back pain. Moreover, this research will study 3 different hypotheses for reasons leading to increase mechanical load on the musculoskeletal system.
This research was supported by the Government of Abu Dhabi to help fulfill the
vision of the late President Sheikh Zayed Bin Sultan Al Nahyan for sustainable
development and empowerment of the UAE and humankind.
Acknowledgments
Not ready yet.
Contents
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Correlation between Obesity and Low Back Pain. 11
- Problem Definition, Significance, and Magnitude. 12
- Local challenge and relevance. 15
- Motivation and contribution. 17
2.1. Obesity and Low Back Pain. 20
2.2. Literatures review in UAE.. 32
1.2. Musculoskeletal Modeling and Simulation. 37
1.2.2. AnyBody Modeling System.. 40
4.1. Results in both posture. 43
4.1.1. Results in normal stand posture: 43
4.1.2. Results in Forward Flexion posture: 49
4.2. Analysis and discussion. 55
A Model Data (Input / Output) 58
List of Tables
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List of Figures
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The term obesity can be defined as the excess accumulation and storage of fat in the human body. This definition creates a separation in context of the body weight, which is a measure of the general mass, from obesity, which is based on the approximation of the amount of fat present in the body. The main tool currently used worldwide for estimating overweight and obesity is the body mass index or BMI. Defined as the ratio of the weight of an individual (kg) divided by the square of their height (m2), a BMI ratio of >25 indicates overweight, while that of >30 defines obesity. Obesity is a global public health challenge of severe proportions. Increasing at an alarming rate, worldwide, obesity has more than doubled in the last two decades, with more than 2.1 billion people (30% of the world’s population) overweight and obese. According to new research by the McKinsey Global Institute (MGI), a devastating $2.1 trillion or 2.8 percent of global GDP is currently spent on obesity annually, but less than 1% on prevention. Today, obesity comprises the 5th leading risk factor for mortality in the world (around 3.4 million annual deaths), as it significantly increases the risk for developing numerous chronic diseases including coronary heart disease (by over 50%), ischemic stroke (by 44%), type 2 diabetes (by 23%), as well as many cancers (up to 41%). The problem is expected to worsen, where almost half of the world’s adult population is expected to be overweight or obese by 2030 . The global trend of sustained growth in obesity prevalence indicates that the current measures in the prevention, treatment, and management of the condition are largely ineffective.
World Health Organization (WHO) 2014 data reveals that the UAE currently ranks fifth in the world in obesity, at a prevalence rate of 36% (33% males and 39% females). In other words, three in every ten Emirati males and almost 4 out of every 10 females are obese, with an economic burden amounting to $6 billion/year in associated disease cost. If we also include the percentage of overweight individuals, based on the most recent Global Burden of Disease report, more than 60% of men and 66% of women in the UAE are currently overweight or obese (average of 63% or more than double the global average of 30%). Furthermore, while the UAE slightly fares better than the US in adult obesity prevalence (US current rate is 38%), UAE children are 1.8 times more obese than American children, indicating a dangerous future trend and prognosis as well as ineffective prediction tools and preventive/intervention strategies, particularly considering the very young median age of the population (30.3 yrs.) (Badawood et al 2017).
With an immense prevalence rate of 70-80%, low back pain (LBP) is considered the single leading cause of disability throughout the world, plaguing the lives of millions of individuals and imposing huge health and socioeconomic challenges, worldwide. Although various factors have been associated with LBP prevalence, the causative and underlying mechanisms, key information for prevention and clinical management, remain largely elusive. The primary aspects that are used to predict LBP include physical stress, for example, lifting, driving, and frequent movements which involve the back. Some of the psychosocial aspects related to the problem comprise of high-perceived workload and also the time pressure. Other personal behavior, such as smoking, drinking and a sedentary lifestyle have also been associated with LBP. The visible attributes of the weight of the human body and also cases related to being obese are not easily comprehended.
Correlation between Obesity and Low Back Pain
Over the past few decades many studies found a positive correlation between weight and LBP. Despite the evidence that body weight has been associated with LBP, the causal link remains not well established. Most existing studies in literature conclude that body weight should be considered a possible weak risk indicator, but there is insufficient data to assess if it is a true cause of LBP. Longitudinal studies suggest overweight/obesity is a risk factor for low back pain, and the co-occurrence of pain and overweight/obesity negatively affects quality of life. The mechanism of relationship is unknown but is hypothesized to include mechanical and metabolic abnormalities, possibly secondary to lifestyle choices. Several studies demonstrate that treatments for obesity reduce pain secondary to weight loss. Researchers agree that it is important to focus on expanding knowledge about mechanisms of the relationship between LBP and obesity, testing explanatory models addressing their co-occurrence, towards improved and more effective therapeutic and rehabilitation modalities.
It is instrumental to note that the widely increased aspects of mechanical based requirements are often deemed as the main cause of Low Back Pain. Body metabolism based disorders, in addition, may also play a detrimental role. According to research, the postulated kind of obesity, mixed with other co-morbidities such as diabetes type II, heart disease and hypertension, may initiate pathophysiological alterations the musculoskeletal system (vertebral bone, discs, ligaments and tendons) , hereby adding to the additional mechanical load attributed to obesity .
Cross-sectional studies show support for a relationship between obesity and LBP. Similarly, longitudinal studies suggest overweight/obesity early in life may be a risk factor for developing LBP, and some evidence supports a dose-response relationship between BMI and pain. While research to date has explored possible relationships between weight and low back pain, future research needs to further clarify the relationships through specific examination of mechanisms and pathways, such as musculoskeletal models.
The issue of being overweight is fundamentally a routine livelihood element which deemed as the primary element which causes the Low Back Pain. There is various theoretical hypothesis which is connected between obesity and Low Back Pain.it has been subjected to the postulation that too much weight of the human body that fundamentally have dissenting implication on the human back which is instigated by excessively oversize of the body.
It is instrumental to note that the widely increased aspects of mechanical based requirements from the issue of obesity have instrumentally been deemed as the main cause of Low Back Pain. In essence, it is apparent that the body metabolism based disorders, in essence, may have a lot of detrimental. According to research, the postulated kind of obesity, mixed with other co-morbidities of the cases of diabetes and also the issue of hypertension may have pathophysiology alterations of the illness of ligaments and body tendons based on the process of growing old which in turn impacts on LBP.
World Health Organization statistics show that that low back pain (LBP) is the leading cause of disability in the world, interfering with an individual’s quality of life and as well as the quantity and quality of work performance. In industrialized countries, LBP has been cited as the second most frequent chronic condition that warrants visiting a doctor, the fifth most common reason for hospitalization, and the third most frequent cause for invasive spinal surgeries. The worldwide lifetime prevalence of low back pain is reported to be as high as 84%, and the prevalence of chronic low back pain is about 27%, with 11–15% of the population being disabled.
“Mechanical” low back pain, for which the underlying pathology remains elusive, by definition, excludes pain resulting from neoplasia, fracture or inflammatory arthropathy, as well as referred pain (anatomical sites outside the spine). Most epidemiological studies of mechanical LBP are based on reported symptoms, rather than quantitative objective diagnostic criteria. Although various risk factors have been established for mechanical LBP, including physical activities and psychosocial aspects, its pathogenesis is mostly unclear and its etiology is non-homogeneous.
With immense prevalence rates, both obesity (33%) and low back pain (LBP) (70-80%) are considered among the fastest rising 21st century epidemics, plaguing the lives of millions of individuals and imposing huge health and socioeconomic challenges worldwide. Although obesity has been associated with LBP prevalence, its causative role and underlying mechanisms, key data for prevention and clinical management, remain largely elusive. This is in part due to limitations in the measures used to define and assess obesity for a particular population, as well as the lack of noninvasive diagnostic tools that shed better light on the etiology of LBP. Spinal clinicians often struggle on two levels:
- from a diagnostic perspective, in terms of the decision to use expensive imaging (MRI and CT scans) that are often incapable of revealing the impact of the excessive mechanical loads associated with overweight; and
- From a treatment/clinical management perspective, in terms of prescribing adequate personalized therapeutic and rehabilitative modalities.
Regardless whether obesity is the instigator or otherwise the primary contributor to lower back pain, it is generally agreed that increased body weight disturbs the normal loading biomechanics of the spine. For example, when an individual is overweight/obese, the added weight within the midsection gradually shifts to the pelvic region forward and leads to curving the spine excessively inward deviating from the normal spinal curvature. This condition is known as hyperlordosis or the swayback. It is a situation which exerts added pressure on the muscles of the back which are then compelled to bear increased weight (Melissas,Volakakis, &Hadjipavlou, 2003). Another example is abdominal obesity where the added waist circumference has been shown to increase the moment arm and hence generated moments at the vertebrae. In general. The spine is designed to carry the body's weight and distribute the loads appropriately, whether encountered during rest or activity. When excess weight is carried, the spine is forced to assimilate the burden, which may lead to structural compromise and damage (eg, injury, degeneration). One region of the spine that is most vulnerable to the effects of obesity is the low back—the lumbar spine.
A significance challenge in the process of trying to ascertain the primary cause and the implication of LBP in association with obesity is the nature of the condition. Fundamentally, LBP is the kind of condition that cannot be easily determined. A particular examination, instead of general context of LBP may be critical in helping out the connection between LBP and obesity. Within a demographic-oriented setting of individuals, the presence of higher related BMI and waist-Hip ratio measures were connected to high-intensity low back pain, (Gasibat et al 2017). Regardless, there is still no substance to prove that back pain is closely associated with the existence of lean tissue mass. In addition, the relationship between the rates of metabolic obesity and back pain has not been established.
The causal connection between obesity and LBP have for the past few years piqued the interest of many researchers. It is noteworthy, though, that there is still a wide range of controversy concerning the association between the two, in addition, t the presence of various conflicting observations. For instance in spondylosis, there is a decline in body engagement as well as disc herniation. The research which attempts to show a positive connection between the two aspects indicates that increased BMI is associated with osteophytes; which are mainly in thoracic and lumbar spines. Osteophytes is an expression denoting to bone spurs, which take a shape on the spine through a long period of time. Figure 2.1you can see the different between the normal spine and Osteoarthritic spine.
A research was carried out in the nationals of the United Arab Emirate, which are between the age of 25 and also 65 years who went to visit the PHC centers, regardless of the kind of their complaints, apart from the very ill and also other related complaints apart from the people who apologize from taking part in the process. Based on the presence of high level of illiterate nurses who are qualified through their Arabic language on the questionnaires that were handed to the people and also on face to face interviews. A sampling design was developed through the employment of administrative divisions that were present in Al-Ain city. In the quest to secure a comprehensive sample of the study based population, the planning was made in such a way that it the location size was put into consideration (Rodriguez et al 2017).
In context, the low based socioeconomic status in UAE is closely related to the emergence of LBP. As a matter of fact, education is one of the critical indicators which shows the socio-economic status mainly because it is not likely to be affected by chronic illnesses which affect people at adulthood. Various studies across the UAE investigated the connection that exists between education and Low Back Pain. According to the research carried out, there is explicit close connection between education and Low Back Pain. In the contemporary research, it is visible to note that the contemporary study reveals that the majority of the male and the female with Low Back Pain were mainly illiterate. It is important to note that obesity itself may be instigated by LBP as a result of poor lifestyle behavior and lack of good education. In the population of the Arabian community, lack of germane aspect of body exercise or lack of lifestyle habits within the female population may be the primary factors which leads to the presence of increased cases of LBP among the people (De la Garza-Ramos et al 2015).
Moreover, as a matter of fact, trunk and also a severe loss of muscle mass and obesity gradually progresses as the people grow older but the implication of muscle loss in essence on severe low back pain has not been subjected to close examination and also assessment. In UAE, the prevalence of the issue of LBP was primarily found to be higher in the females as compared to the male. The females and also the housewives in essence are perceived to spend a lot of their time and work simply around the house (Zhang, et al 2018). This may compel them to sit or bend for a longer duration of time or to end up lifting objects which are heavy. The amount of work, in general, may be doubled in the event that they are compelled to work at some kind of professional tasks types. This can elucidate the presence of high based prevalence among the women who stay at home and also attempts to explain the presence of the same in the female population.
The existing facts and information do not encourage offering patients advice that weight reduction is primarily crucial. Especially, in terms of minimizing of the amount of pain in the low back. However, this does not disapprove of the advantages of losing weight, particularly concerning co-morbidities. Based on the suggestions presented by various scholars, the reduction of body mass may be mitigated the pain of the back which can instigate the problems to the victim and also lead to the total reduction of their adherence for any form of exercise regimen (Budhrani-Shani et al 2016). The obese people mainly in UAE primarily limited kind of exercise capacity and endeavoring to lose weight through personal exercise may, in the long run, prove to be rather hard and stressful, which is more disadvantage to the patient in general.
Overall, it has been found that the cases of obesity are predominant among the female than the male in the UAE. Probably the reason in some of this cases is that, previously in UAE society, women do not go out from their homes unless necessary, and when they do, they must be accompanied by at least one man, so it was so difficult and not flexible for them to practice physical activities different than household Chores. Also, lack of proper education and increase in poverty levels are the primary factors which contribute to the presence of many people with this particular condition (Vismara et al 2010). It is essential that patients ought to attempt to keep and slowly improve their fitness levels by endeavoring to shun gaining excessive body mass (Prince, 2015). In a society which is perceived as being perfect, this could be a moderate or otherwise vigorous physical activity for around half an hour on weekly basis. This is fundamentally a good approach through the process of having a better pattern and also a recommended kind of program of minimal-significance when it comes to training to be fit.
This kind of findings does lead to the possibility that despite the biomechanical elements which are connected to the spinal loading are connected to the back pain. It is the primary issue that majority of the people in UAE suffer from and the issues of high level of illiteracy and also poor education aggravates the matter further (Dario et al 2017). As noted for the research, it is common knowledge that being obese and having LBP are typical health- related issues mainly in people suffering from this condition who visit medical institutions United Arab Emirates. Despite the fact that some research established a weak connection that exists between LBP and being obese, it is worthwhile to mention that there is insufficient amount of evidence to clearly find the direct based causal relationship between the two aspects. This may be as a result of the quality of research work used to draft the general quality of the research work, the sampling process, data variations in collecting and also measuring the same. It is apparent that the scope of experiencing LBP and being obese are the primary determinants of disability and ill health of the patients (Smuck et al 2014).
A connection between the two could possibly be noted since the prevalence of such conditions does share a lot of covariates: which comprises of low based occupational status, the type of sedentary livelihood and also the scope of psychological distress. According to research, there is a notable connection between the body mass and also the LBP, despite the fact that there is no substantive causal connection. This as such shows that perhaps there the aspect of obesity, in essence, does lead to the presence of elements of LBP. (Ewald, Hurwitz, &Kizhakkeveettil, 2016). Therefore, it is essential that in the future, studies will be required to focus on confirming or otherwise refuting any kind of potential relationship which exists between the two typical issues.
Chapter 2
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2. Literature Review
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The pathological increase in body weight adversely affects the condition of bones, joints, ligamentous apparatus and the performance of their functions. This influence is due to several factors. In the foreground - increased body weight leads to increased mechanical load on the musculoskeletal system. The main impact is taken by the spine, more precisely - its lumbosacral department, which accounts for the lion's share of the body weight load. Because of the increased load, the intervertebral discs suffer. This part of bones consist of cartilaginous tissue, which are responsible of shock absorbers; also it consist of pads which reduce the force of external influences on the spine during movement. Moreover it protect the bone tissue of the vertebrae from deterioration (Ibrahimikacuri et al., 2015). However they often prematurely wear out, this kind of cases called osteochondrosis; and one of the reasons for this pathological process is obesity. The increased mechanical pressure on the spine due to obesity, leads to a decrease in the elasticity of the intervertebral discs, which lead to reduction discs thickness, correspondingly, minimize the height of the intervertebral spaces. In addition, the disc which has affected by the previous conditions and lost its elasticity, it is more likely to experience a lumbar herniated disc. These factors cause the infringement of the sensory and motor roots of the spinal nerves between the vertebrae. As a result, the lumbosacral radiculitis is formed, and the external symptoms of it are pain and limitation of movements in the lumbar area (Ibrahimikacuri et al., 2015). With the passage of time, sensitive and motor disorders spread to the lower limbs. The muscles of the shins and thighs are subjected to atrophy. The finale of the pathological changes - is cauda equina syndrome. It is a figurative name for a bundle of nerve fibers passing through the spinal canal. Displacement of vertebrae and disc herniation with osteochondrosis lead to infringement of the cauda equina in the spinal canal. Which cause intense pain in the lower back, in the groin and the lower extremities. Thus, obviously obesity is undoubtedly the most risk factor associated with low back pain, as overweight leads to overloads of all joints and backs especially. Besides, extra pounds contribute to the fact that these people become lazier to do physical activities, which increases pain.
The effect of obesity on the course of osteochondrosis is poorly understood. Although there is evidence of a relationship between obesity and the progression of degenerative-dystrophic changes in the spine, caused by biomechanical and systemic metabolic factors. Under the pain syndrome in the lower back (LBP) is understood the pain localized between the XII pair of ribs and the gluteal folds. Recently, the opinion was formed that the LBP is a multidisciplinary problem in which neurological, rheumatological, traumatological and orthopedic aspects are intertwined. LBP most often develops between the ages of 20 and 50, with the most severe pain observed at the age of 50-64 years. In the age of 20 to 64 years, 24% of men and 32% of women suffer from back pain (Ibrahimikacuri et al., 2015). Anxiety is caused by the fact that 12-26% of children and adolescents also complain of back pain. Among women, according to different authors, the prevalence of BNS reaches 19-67% of the total population; with a peak, pain is at the age of 35-45 years (Harms, Peers, Chase, 2010; Breen, Carr, Langworthy et al., 2011).
Overweight often causes back pain, because the back muscles exposed to more stress, in this case people with higher weight are more at risk of painful sensations in the lumbar region. Doctors are sure: overweight signals about violations in the endocrine system, and two dozen extra fatty deposits can adversely affect the functioning of the cardiovascular system and the health of the back. A high body mass index causes a significant risk of degeneration of the intervertebral discs in the lumbar region. Scientists at the University of Hong Kong have studied how weight affects the spine (Samartzis et al., 2012). The study involved 2,599 patients aged 21 years and above. 73% of participants suffered from degeneration of intervertebral discs. 36% of them were overweight, and 9% - obesity. Participants were examined with the help of MRI, and the researchers traced the direct relationship between the number of extra pounds and the degree of degeneration, as well as the narrowing of disk space.
Back pain is a consequence of uprightness, as the greatest burden is placed on the lumbar spine. Also, the detrimental effect on the spine has the presence of hypodynamia, along with malnutrition, stress, and obesity. For most people, pain in the lumbar region is a fairly common phenomenon, which gradually becomes a part of everyday life of a person. Back pain may appear and disappear suddenly and not appear anymore (Ibrahimikacuri et al., 2015). Low Back Pain (LBP) is a widespread phenomenon in modern society. Injuries, infections, diseases of the abdominal cavity organs, inflammatory processes, psychological factors and sedentary lifestyle; all these new things on the community, are great affects and strong reasons leading to LBP. The results of the study show that, overweight and obesity play a significant role in that too. Moreover, the results of a cross-sectional study of scientists from the University of Hong Kong, Pokfulam, involving 2,599 volunteers from South Korea (mean age 41.9 years) indicate a reliable relationship between the presence, severity and prevalence of degenerative changes in the intervertebral disc and overweight in adults (Samartzis et al., 2012). In this study, degenerative changes in the intervertebral discs were present in 1890 (72.7%) participants. The body mass index (BMI) was significantly higher in comparison with persons without changes (23.3 and 21.7 kg / m2, respectively, p <0.001). It should be emphasized that for the Mongoloid race, a BMI above 23 kg / m2 is considered excess, and obesity is diagnosed with a BMI above 25 kg / m2. The study used radiographic and clinical data. The study also included the measurements of body height and body weight, magnetic resonance imaging of the lumbar spine, a risk ratio (RR) and a 95% confidence interval (CI) were calculated (Samartzis et al., 2012). A significant increase in the degree of degenerative changes in the intervertebral discs (p <0.001), their severe damage (p <0.001), the extreme degree of changes with the narrowing of the joint gap (p <0.001) was accompanied by excessive body weight and obesity. In the corrected multidimensional logistic regression model, there was a positive linear trend (r (2) = 0.99) between BMI and the presence of degenerative changes in intervertebral discs with an overweight (RR 1.30, 95% CI 1.03-1.62) and obesity (RR 1.79, 95% CI 1.17-2.74) (Samartzis et al., 2012). The final stage of degenerative changes of the intervertebral discs with narrowing of the lumen was expressed in people with excessive body weight (adjusted RR 1.72, 95% CI 1.23-2.41) compared to those with normal body weight (Samartzis et al., 2012).
The goal of another prospective study conducted in a population of Norwegians aged 30-69 years (8,733 men and 10,149 women without chronic LBP and 2,669 men and 3,899 women with its presence at the initial stage of the study) was to determine the effect of overweight and obesity on the increased probability of occurrence of chronic LBP during the 11-year period (Heuch et al., 2012). At the end of the study, a survey of patients from both groups showed a chronic pain syndrome, which was defined as pain that persisted continuously for three months over the past year. As a result, a positive relationship was found between BMI and the risk of LBP among people without it at the beginning of the study (Heuch et al., 2012). After adjustment for age, education, place and type of work, physical activity, smoking, blood pressure and serum lipids, the RR for a BMI ≥30 kg / m2 compared with a BMI <25 kg / m2 was 1.34 (95% CI 1.08-1.67) for men and 1.22 (95% CI 1.03-1.46) for women. A significant positive relationship is established between BMI and repeated LBP in women (Heuch et al., 2012). Thus, elevated BMI is associated with the development of chronic LBP, both in patients with and without it at the beginning of the study (Heuch et al., 2012). However, it remains unclear whether the initial presence of low back pain affects the increase in BMI in the future. After all, it is believed that the pain syndrome limits the motor activity, which, in turn, is one of the risk factors for the development of obesity.
Excess weight affects the back condition in the most negative way. The spine and sacroiliac joints bear the full weight of the body and maintain a normal posture. Excess weight leads to chronic pain in the low back (Allardyce, 2012). Many full people feel good and do not complain about health. However, this does not mean that everything is in order in their bodies: when the disease will make itself felt, it is difficult to say, but it must be remembered that every extra kilogram will sooner or later appear in the form of acute pain. That is why every six months it is necessary to conduct a spine examination and be sure to follow the rules for preserving its health (Allardyce, 2012). Any load on the back and lower limbs lead to uneven stretching of the pelvic muscles, as a result of which the pelvis changes its axis, which is bad for the spine.
There were a lot of investigations conducted to prove that lowering in body weight reduces the low back pain of the patients. The nowadays medicine has lots of ways how to reduce the body weight. One of such methods is the method of reducing the volume of the stomach. Recent investigation has shown that people who are overweight who have undergone an operation to resect the stomach (reducing the volume of the stomach) to reduce the amount of food consumed, eventually get rid of not only excess weight, but also from pain in the lower back (Phend, 2008). The scientists from the University of Southern California in the US has come to such conclusions, after studying the consequences of surgery for gastrectomy in 38 patients who were obese and had pain in the lower back. Six months after the operation, back pain decreased in the subjects by 44%. During this time, 30 women and eight men who took part in the study lost an average of 38 kg (Jones, 2015). "The study suggests that a significant weight loss, which is a consequence of surgery for gastrectomy, leads to a significant reduction in pain in the lower back if it worried the patient before the operation. Since our study has produced encouraging results, larger clinical trials are needed that will prove the effectiveness of such operations for the treatment of back pain, "says Dr. Paul Khoueir. (Phend, 2008) Currently, in the US, to undergo a gastric resection for medical reasons, the patient should have a body mass index (BMI) of 40 or 35 (measured in pounds and inches) with the presence of obesity-related diseases such as diabetes, heart disease, hypertension, as well as sleep apnea (respiratory arrest) (Jones, 2015). It is known that obese people have an increased risk of developing arthritis of the knee and hip joint, although there is no information about the effect of excess weight on the lumbar spine. And although overweight people with back pain are often advised to lose weight, the relationship between these two phenomena remains unproven.
According to Miller et al (2017), pain in lower body parts is in most cases associated with many issues, the most recent but common one is associated with is overweight and obesity. On their research to determine effects of weights, Miller et al. (2017), argue that obese individuals experience different types of pain. Furthermore, they argue that that the pain depends entirely on the gender of the individual. It is worthwhile to highlight that; their research focused on both genders whereby it indicated that the obese females feel more pain as compared to their male counterparts. In this case, as per the research, the pain is associated with the societal with the body structure that female has. Of importance, a lot of fact in their body as well as a structure to allow for reproduction is a major contributor (Miller et al., 2017). Another argument that these researchers pose it the report that overweight and average weight women have more of the same view as obese male.
Most of the studies show the direct dependence between the obesity or overweight and the lower back pain. Rahman Shiri et al. (2010) in their meta-analysis have shown that both overweight and obesity increase the risk of low back pain. “Overweight and obesity have the strongest association with seeking care for low back pain and chronic low back pain.” (Shiri et al., 2010). They also proved that the female patients suffer from the lower back pain more frequently than male patients. This conclusion was obtained in the mentioned above investigation of Heuch et al. (2012) and Miller et al. (2017). “Our findings suggest that the association between overweight or obesity and the prevalence of low back pain is stronger for women than for men.” (Shiri et al., 2010) The variations connected with gender in the connection of overweight or obesity with LBP could be due to hormone-related obesity and correlated differences in pain sensibility. In male patients, high BMI may indicate upper muscle mass; in the female patients, it can show the amount of adipose tissue (Shiri et al., 2010). The current study suggested that obesity or overweight are the potentially changeable risk factor for low back pain. Thus, the reduction of the BMI can reduce the overload on the spine and especially on the lower back. Although, well-conducted prospective investigations, including intervention studies, are required to confirm all these findings. *
The low back pain is also associated with the structure and state of the bones. The state of hip bones also determines the presence or absence of the LBP. Another negative consequence of obesity is osteoporosis (Allardyce, 2012). By this term is meant a decrease in bone density. Previously, it was believed that weight gain automatically leads to an increase in strength and densification of bones. This compensatory mechanism is supposedly designed to increase the stability of the musculoskeletal system to an increased load. But recently it has been established that in fact, everything is not so, and the density of bones does not increase, but, on the contrary, decreases (Allardyce, 2012). Partly this is due to a deficiency of vitamins A, E, D and minerals - calcium, magnesium, zinc, the balance of which is disturbed in obesity. But there is another reason - hormonal. Obesity is accompanied by a change in the ratio of hormones of the pancreas, adrenal glands, pituitary gland, thyroid gland. Hormonal imbalance leads to a disruption of the digestion of minerals by bone tissue. The fat cells (adipocytes) themselves are also hormone-producing (Allardyce, 2012). They are isolated biologically active substances, among them - cytokines, adiponectin, and others activate osteoclasts. The action of these cells is aimed at washing away minerals from the bones, and the destruction of collagen, a protein that provides bone strength. Moreover, collagen is beneficial for the health condition of joints. Intervertebral discs are not an exception to the rule. Thus, obesity affects the state of lower back causing its pain. Clinically, osteoporosis is manifested by fragility and pathological brittle bones. Patients suffering from osteoporosis, a small enough impact (push, fall in place) to get a fracture. Sometimes fractures arise spontaneously - so-called spontaneous fractures (Allardyce, 2012). In addition, osteoporosis serves as an additional factor in the development of osteochondrosis, arthrosis, the curvature of the spine. All these changes in the musculoskeletal system are inherently irreversible. However, weight loss slows their progression and facilitates flow.
Hashimoto et al. (2017) argue that the amount of fat in one’s body is relative to the amount of back pain they are likely to experience. This is according to their research among a Japanese population. In this case, the parameter that is used is the mass and height index (BMI) and also the percentage of fat in the body. Obese individuals have a high BMI and even a relatively high quantity of body fat. The two parameters are low for average weight individuals, and they do increase with an increase in weight. In a study conducted it was realized that individuals with a high BMI experience intense pain in the lower parts of the body. It was also realized that individuals with a high-fat percentage experience intense pain. In this way, it was found out that the two parameters: BMI and Fat percentage are directly related to the amount of pain that is experienced by a patient (Hashimoto et al., 2017). If patients want to reduce their pain, they should keep the two parameters as low as possible.
On the spine and joints, a huge load falls every day, which, with excess weight, increases even more. Excess body weight leads to the development of many diseases, including changes in the articular apparatus - arthrosis and arthritis, and spine, provoking the development of osteochondrosis and intervertebral hernias (Allardyce, 2012). Thus, excess weight is not just harmful to the spine - it is he who directly causes many of its diseases. Excess weight is a predisposing factor for the development of all known pathologies of the musculoskeletal system, the most important part of which is the spine. Also, excess weight affects many other body systems, primarily cardiovascular and is a risk factor for the development of many other diseases, such as atherosclerosis, hypertension, diabetes (Allardyce, 2012). Excess weight is formed when we eat much more calories (as energy units) than burn them during physical work. And our body begins to spend its internal reserves - when we spend more energy, but less gets inside. Thus, it is possible to lose weight by increasing physical activity and reducing the number of calories and following the rules of nutrition (Allardyce, 2012). But very often a person suffering from these or other diseases of the musculoskeletal system, sometimes can not afford to exercise intensively because of the limitation of mobility. In this case, proper nutrition is often the only way to reduce weight.
A longitudinal and cross-sectional study provided by Frilander et al. (2015) paid their attention to the low back disorders connected with obesity in the male patients only. As it was proven before, the low back pain is associated mostly with female gender because of the body constitution and hormone consistency of the organs. This study decided to investigate men aged 30–50 years (n=1385) who participated in a national health examination survey (Frilander et al., 2015). Body mass index was measured at baseline and follow-up, and waist margin at follow-up. Weight at the ages of 20, 30, 40 and 50 years was determined, when relevant. Several measures of weight were used to calculate age-standardized average body mass index (BMI) across the life course (Frilander et al., 2015). The clinically established result measures included chronic low back syndrome and sciatica. (Frilander et al., 2015) “Baseline BMI (20 years) predicted radiating LBP in adulthood, with the prevalence ratio (PR) being 1.26 (95% CI 1.08 to 1.46) for one SD (3.0 kg/m2) increase in BMI. Life course BMI was associated with radiating LBP (PR=1.23; 95% CI 1.03 to 1.48 per 1 unit increment in Z score, corresponding to 2.9 kg/m2). The development of obesity during follow-up increased the risk of radiating LBP (PR=1.91, 95% CI 1.03 to 3.53). Both general and abdominal obesity (defined as the waist-to-height ratio) were associated with radiating LBP (OR=1.64, 95% CI 1.02 to 2.65 and 1.44, 95% CI 1.02 to 2.04). No associations were seen for non-specific LBP.” (Frilander et al., 2015). Conclusions indicate that in case of overweight or obesity in early adulthood, as well as during life, the risk of radiation, but not nonspecific LBP among men, increases. Taking into account the current global epidemic of obesity, special attention should be paid to preventive measures, starting with youth, and measures should be taken to prevent further weight gain during life (Frilander et al., 2015). Although, there are some gaps in the research. Most of the respondents were former servicemen. That is why it is difficult to indicate whether the low back pain was caused by the gained weight or because of the excessive physical activity experienced during the military service (Frilander et al., 2015). They could get protrusion and hernia earlier when they had normal body mass index. Some of the weight-related measures were self-reported by the respondents. That is why it is difficult to know exactly whether their evidence was with or without any biases which could affect the observed associations. Moreover, military records did not pay attention to the abdominal adiposity at baseline. Thus, it is impossible to provide the associations of abdominal obesity during the life.
For some researchers, the interdependence between the obesity and overweight still remains unproven nowadays. That is why they need to conduct more and more additional researches. Thus, Ting-Ting et al. (2016) in the journal Clinical Spine Surgery provided a meta-analysis in order to update the current knowledge about the association between overweight, obesity, and low back pain (LBP) risk (Ting-Ting et al., 2016). The authors argue that despite there were lots of studies conducted during the past several decades, “available data from studies on the association between obesity and LBP remains debatable.” (Ting-Ting et al., 2016). The scientists searched through the PubMed and EMBASE databases to find the previous investigations related to the topic of obesity and low back pain correlation. Also, the subgroup and sensitivity analyses were conducted to test the possible candidate-effect factors. The “subgroup analysis proved that increased body mass index was associated with an increased incidence of LBP in both men (overweight: pooled OR=1.16, 95% CI, 1.04–1.31; obesity: pooled OR=1.36, 95% CI, 1.15–1.61) and women (overweight: pooled OR=1.24, 95% CI, 1.04–1.50; obesity: pooled OR=1.40, 95% CI, 1.08–1.82).” (Ting-Ting et al., 2016) Moreover, there was no evidence of publication bias. (Ting-Ting et al., 2016) Thus, the findings of the study proved that overweight and obesity are the risk factors for the lower back pain among both men and women. Thus the advantages of the research were that the targeted population was taken despite the gender. In such a way, the authors did not declare any conflicts of interests.
The lower back pain is often associated with the presence of hernias or protrusions. It is no secret that sometimes-extra pounds do not go to good health. This rule applies to some diseases (cardiovascular, digestive organs, etc.), but in the case of a hernia becomes particularly important (Obesity and Back Pain Treatment, 2016). The fact is that overweight is the cause of spinal congestion. Even if a person does not suffer from an intervertebral hernia, excess kilograms are a classic provoking factor (Obesity and Back Pain Treatment, 2016). In some cases, alone or in combination with others, it can lead to the development of pathology in the lower back and other departments. It is all the more important to control weight when a hernia has already arisen. Problems of weight loss excite many people, especially women. Usually, this is due to the desire to stay in good physical shape and look attractive. However, with an intervertebral hernia, weight loss is not only aesthetic value. Doctors recommend adhering to a diet and performing exercises for slimming with a herniated spine (Obesity and Back Pain Treatment, 2016). This will not allow the development of the disease and even help to recover.
In observation of the research conducted by Bener et al. (2003), low back pain (LP) is a common problem that is reported by patients that attend primary health care in the United Arab Emirates. The researchers at the same time found a close link between obesity and back pain in these number of patients who are mostly aged between 25 to 65 years. The region at the same time is highly comprised of obese individuals who have adopted poor feeding and eating habits at the same time. Males, as considered to females in the research, reported a higher complain of back pain and are the population that is more obese than the females. In another research conducted to determine the epidemiology of low back pain in the United Arab Emirates, (Bener et al., 2004), the researchers also identified that the lifestyle of the people in the region of United Arab Emirates is comprised of many risk factors. Lifting heavy weights, long-standing hours and smoking were the major factors that affected men than women. On the same note, men experienced low back pain concerns more than the female counterparts. However, it was also identified that those individuals that engaged in constant exercises were less associated with lower back pain. Feeding habits and other lifestyles and the prevalence was higher in women than men.
Chou et al. (2016) explain that obesity and lower back pain are a major public problem not only in the United Arab Emirates but in the entire globe. Since other studies on the same issue have not covered the relationship between low back pain and men, this research was determined to identify this problem. It was identified that older men reported high low back pain incidences than younger men in the study. At the same time, obese individuals reported the same problems and fat men versus thin men did not show any difference. The conclusion, therefore, was that men of a heavyweight than were obese at the same time were considered to experience back pain this linking obese and back pain and no link between heavyweight and back pain. Dafeeah et al. (2014) carried a research to determine the link between low back pain and lifestyle of the individuals in the region. The research identified that low back pain is prevalent among all genders and it is more prevalent in the older people than in the young individuals. Some of the major factors that the researchers in the study by Dafeeah et al. (2014) were weakness in the legs, smoking and prolonged standing hours of the individuals. Despite this, there was a global problem as defined in the above-named research relating to back pain among the old and those that adopted the bad lifestyle.
Mirtz & Greene, (2005) explained in their research that obesity is one of the highest causal factors of low back pain. Although there have been debates all along over this issue, the research, therefore, was aimed at identifying the link between the two variables. The conclusion of the research at the same time stated that there was a close link between obesity and back pain due to many factors that were identified. The body mass index is the major identified challenge in the obese individuals. In this case, an obese individual has a higher BMI, which means that the weight is more than the body can support. In this case, they must strain the body more so the back borne which is central in balancing the body weight. Therefore, indicates that high BMI results to the low capability of the body to handle the weight, which leads to low back pain. There are instances that back pain persists and becomes chronic in same individuals. This is accelerated by the risk factors, which in most of the times the individuals are not aware of. Some of these risk factors are smoking, low socio-economic background, lack of physical exercises, and bad posture (Lionel, 2014).
The researchers also identified that there are no such efforts by the medical institutions and other relevant stakeholders in managing the issue since it was identified. Identifying the problem and not providing a solution to it have surrounded most of the research.
Faghri & Momeni, (2014) carried out a research on how to solve the problem of back pain and obesity at the same time. From the research, it was identified that adopting a healthy lifestyle will solve all the problems that these individuals experience. A healthy lifestyle, therefore, means that eating the right portions of food each time, maintaining a life full of exercising and not involving in strenuous activities that might cause damage to the body skeletal formation. Physical activities are among the best suggestions that were put across by Faghri & Momeni, (2014) a solution to obesity and other lifestyle-related diseases. Workplace ethics and observation of the health standards also play a role in this case in that individuals need to adopt good sitting postures among other issues related to their well being physical. (Sumchai, 2015) also identified that exercising helps solve the problem of weak muscles, healthy body in terms of physique among others. Extensive exercises and strenuous activities also cause low back pain when not handled correctly. These individuals adopting a healthy life and managing to lose the same weight thus lowering the cases of low back pain can avoid obesity at the same time. Individuals that are younger in age are required to engage themselves in extensive physical activities and at the same time, not engage in activities that strain their muscles nor their back. Lifting heavy weights is one of the issues that face the young generation and the old in that they at times do not understand the limits they have to get to (Gasibat et al., 2017).
Low back pain patients exhibit some symptoms that complicate their health at the same time. Anxiety is one of them is anxiety which affects their daily activities. There are general body weaknesses, depression instances and somatization as indicated in the research by (Verjee et al., 2013). The psychological distress, therefore, forms the largest effect of this kind of patients in their entire life. Further, leading a life of not being unable to deliver on their abilities and capabilities at the same time. Much money is spent in treating such pains and effects that come with back pain and obesity. Thus, with the best systems in place like the observation of the lifestyle that is healthy and engaging in physical activities at the same time will be of benefit to the entire population in the UAE. Further research, however, must be conducted regarding the ways in which this challenge can be managed and how the population can engage in healthy lifestyles at the same time.
As it can be seen, there are lots of investigations related to the problem of connection between obesity and lower back pain. All the researches have proven that overweight leads to the lower back pain. The obesity cannot be the direct cause of the pain, but it can be the reason for the other factors which lead to pain. Obesity causes the hormonal deterioration, the absorption of the useful minerals and vitamins by the body’s tissues. The lack of organic substances provokes the weakness of the muscular cord around the spine, which leads to the appearance of protrusions and hernias. The excess weight only aggravates the size of the protrusions and hernias. The larger they are - the stronger pain a person will suffer. The main limitation of almost all the studies is that it is impossible to take into account all the factors of the person’s lifestyle previously and at the moment. The back pain could appear before the person gains weight. In such a way it would be necessary to search the other side of the problem. The presence of protrusions and hernias can provoke the obesity because it severely influences the nervous system of the body. Thus, it is not good to take into account the present state of the body. The etiology of the disease should be investigated from the very beginning. This factor is the largest gap, which is observed in the mentioned investigations. Moreover, when the authors rely on the oral evidence of the respondents.
All research in the UAE about obesity and low back pain is very limited and has followed the previous research path. No new methods and modern techniques have been used to look at the relationship between LBP and obesity. In this research, we are going to use a modern simulation technique to simulate mechanical load on the spine and how it affected by different loads, taking into account other factors such as age, health status, job type and etc. In any case, the current literature review and research can prove that excessive weight and obesity are one of the most significant leading factors to the lower back pain and illnesses associated with this issue.
Chapter 3
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1.1. Research challengers
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Just like in any other developing countries, transitional and dynamic social factors in UAE impede reliable epidemiology findings that are comparable to those found in developed nations. For instance, studies indicate that the condition of LBP is usually manifested at old age because the obesity scourge began later in developing nations (Shiri et al., 2008). Similarly, there is little data and research available for developing countries in regard to association of obesity and LBP, which poses challenges for comparative analysis. On this note, data that can act as benchmark for new research is limited. If the studies exist, it lacks multi-national perspective and it does not take in to account social, economic and perhaps nutritional conditions that each country undergoes during each stage in their development journey. These limitations indicate a significant research gap on relationship between LBP and obesity especially for comparative studies in developed and developing nations. Likewise, it has been observed that there are inconsistent findings on the correlation between obesity and LBP. While some studies hold that the relationships exist, others nullify it (Koyanagi et al., 2015) Lack of consistent findings in relation to this hypothesis further complicates the reliability and accuracy of new studies, as it is in this case.
1.2. Musculoskeletal Modeling and Simulation
This study focused on the Musculoskeletal Modeling and Simulation, which was used to measure body movement and forecast the possible outcomes of interventions on individual walking activity. Musculoskeletal Model is invasive instrument that is used to assess tension in muscles and measure forces generated when joints are in contact. These are conditions that are developed when human body is in motion, but unlike other cases such as muscle action, which are measured by noninvasive models, they require invasive measurements, and the musculoskeletal model is the appropriate tool. Establishing a correlation between muscle activity and human motion as well as knowing the usual movements of the body requires an empirical understanding. Nonetheless, it has been found that experimental observations, like gait examinations cannot lead to reliable understanding of complex neuromuscular activity that regulate human movement, thus, computerized simulations are necessary for finding the correlation of such complex matter. The simulations are meant to provide knowledge on muscle activity and kinematics of the joints, therefore, provide information on cases of pathological problems (Pandy & Berme, 1988).
Musculoskeletal model simulations are beneficial in many ways. These simulations provide understanding to clinical investigations for informed medical responses. It is a tool that incorporates and links divergent biomechanical data thus leading to reliable interpretations (Talaty, n.d). With Musculoskeletal Modeling simulations, it is possible to regulate and control the observed subject and conditions of the study, which is vital for assessing effects when changes are introduced. In this manner, researchers make specific systematic alterations and observe and identify vital elements of performance (Pandy, 2001). This perspective is supported by Komura,Shinagawa, and Kunii (2000), who claim that Musculoskeletal Modeling and simulations provides for formation and retargeting of body motions. As hinted above, establishing and understanding causal relationship in human motion is usually difficult because of presence of many possible interdependent causes. Strength of muscles, muscle action and orientation of human body are some of the factors that influence such performance. For example, muscle length can sometimes be attributed to shift in body direction or posture, which also impacts body’s ability to generate force. But, this condition can also result from multiple causes including pathological changes and injury. Capturing and examining such conditions, which happen simultaneously can be greatly challenging. As such, invasive procedures are needed to measure such variables; and Musculoskeletal Modeling and simulation is the suitable tool. With Musculoskeletal Modeling, it is easy to predict the impact of variables. According to Talaty (n.d), it allows the researcher to have control of the study. Parameters that are usually difficult to estimate can be measured with this tool. Complex associations evident in human motion can be untangled. Unlike other research models, Musculoskeletal Modeling and simulations is remotely vulnerable to ethical restrictions.
Software for Interactive Musculoskeletal Modeling was applied as a tool for analyzing and modeling musculoskeletal structures of the participants. According to MAC (2016), this tool, particularly enables the understanding of force generated by joints at different body posture. In this way, the muscle movements and moments that develop at a particular body posture are established. Software for Interactive Musculoskeletal Modeling has different features. First, it has the capacity to import information and provide a real time analysis in 3D system. These activities happen concurrently when information is being recorded (Taga, 1995). Moreover, Software for Interactive Musculoskeletal Modeling has gait presentation tool. This tool records and presents information on different levels of motions. These reports are presented in statistical tools such as mean, standard deviation and graphical data. With these tools, one can easily establish gait movements. This feature is supported by scripting tool, which is helpful for creating active simulations and developing plots as well as reports. There are significant benefits that accompany the Software for Interactive Musculoskeletal Modeling. First, it leads to enhanced understanding of captured motion, which is aided by intuitive tendencies of kinematics and gait activities. Because many processes can be simulated at the same time, Software for Interactive Musculoskeletal Modeling usually results in enhanced surgical effects. Comprehensive presentations of gait activity are promoted through graphical reports. Biomechanics studies usually employ computerized models to develop musculoskeletal schemes and simulate body movements like running and walking. Software for Interactive Musculoskeletal Modeling is an instrumental tool for achieving this objective.
In particular, Anybody Modeling System was applied in this study. In other words, this is was the chosen form of musculoskeletal system. According to Rasmussen, Damsgaard and Christensen (2000), Musculoskeletal Models are categorized in to two: forward and dynamic systems, inverse and dynamic systems. For forward systems, they predict motions that accompany certain muscular activity. Inverse systems perform the vice versa, which is they measure muscle activity resulting from certain motion. Anybody modeling system is an example of inverse and dynamics tools of musculoskeletal model, and it performs four significant purposes. Rasmussen, Damsgaard and Christensen (2000) indicates that with Anybody Modeling system, it is possible to develop a model right from scratch and manipulate it to any shape that fit and serve divergent purposes. It also provides for exchange of models and fosters corporation when creating models. It also enhances numerical competence thus leading to maximization of designs for use in less costly computers. Crowninshield (1978) asserts that anybody Modeling systems is a tool that leads to optimal measurement and estimation of muscle forces.
1.3. Study cases
Meanwhile, for the purpose of this study, a constant height of =1.75 m will be used to measure and calculate the BMI of various participants. Moreover, the study will be based on three cases:
- Case A: Normal weight, where IBM is < 25
- Case B: Overweight, where IBM is > 25 and < 30
- Case C: Obesity, where IBM is > 30
In all these cases, two forms of postures are examined: standing and flexion forward, as you can see if figure below :
Participants that fall in different three cases were examined to measure the Proximo-Distal force and Antero-Posterior force. These measurements were done on both postures and captured in Anybody Modeling system.
1.4. Different Hypotheses
In this project, there are three Hypotheses were been studding:
- Hypothesis 1:
There is a positive relationship between BMI and low back pain. Whenever BMI become higher, the higher risk of exposure of lower back pain. This relationship is based on the fact that, more load on the spine will causes damages on the vertebrae which will lead to low back pain.
- Hypothesis 2:
- When the fat around the waist increase, spinal load increase (not finish yet)
- Hypothesis 3:
- Comparing between all cases in both posture (Standing and flexion extension) (not finish yet)
4.0 Results and Analysis
In this part the results from planned model are provided. The following section include of the basic case results from the current experiment. Moreover, its include analysis of results from different perspectives. By entering data as discussed above in AnyBody Modeling System, I select the measurements of proximo-distal and antero-posterior for both posture. Proximo-distal force refer to the vertical force, and antero-posterior force refer to the horizontal force as showing in the figure 4.1. I choose those measurements because they refer to the 4 main direction.
4.1. Model Basic input/ output data
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Tables above show that, in the posture of normal stand, the maximum proximo-distal force was on L5 for all 3 cases, while the minimum force was on L3. On the other hand, for the second posture which is forward flexion; the maximum proximo-distal force was on L1, while the minimum force was on L4. Changing amount of force through different postures have a huge effects on mechanism load on the spine. Based on the tables above, it is evident that that posture is a major contributor to the rising cases of back pain. The body is normally developed in a manner that encourages movement. However, due to the increased modernization and the growth of technology, individuals in UAE similar to the rest of the world are living an inactive lifestyle dissimilar to the situation in the past 50 years as showed by the tables. In that in addition, to adopting an inactive posture that pressures the body to operate within a hyper tension the back is forced to remain in the posture for the longest period for instance in the office while operating a computer and in the car. In fact when one gains weight rather intensely, the situation is worsened. |
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4.2. Results in both posture
4.2.1. Results in normal stand posture:
Using (tables 4.1-4.4 and figures 4.2-4.9), a comparison was made between the forces on lumbar vertebrae in forward flexion posture. And the results showing below:
- The ratio of increased the force between a vertebra and the vertebra which follow by, is relatively constant. Where the increase between the lumbar vertebrae in the normal weight is 23.75%; in overweight it is 29.25%, and in obese people it is 47%.
- We can note that, the difference in force between normal and overweight is increasing slightly, on the other hand, the different between normal and obese is increasing sharply. This result supports the theory which said that, the higher BMI, lead to higher risk of LBP; and that is because, force in obesity case is greater than the force in normal case in about 23%, which is considering aa a high rate. The greater the force on the vertebrae, the more likely to hurt the spine.
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Figure 4.3: Increase in force between L1 and L2, in normal stand posture |
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Figure 4.4: Proximo-Distal Force (N) on L2 and L3, in normal stand posture |
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Figure 4.5: Increase in force between L2 and L3, in normal stand posture |
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Figure 4.6: Proximo-Distal Force (N) on L3 and L4, in normal stand posture |
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Figure 4.7: Increase in force between L3 and L4 in normal stand |
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Figure 4.8: Proximo-Distal Force (N) on L4 and L5, in normal stand posture 2 |
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Figure 4.9: Increase in force between L4 and L5 in normal stand Without a doubt, the illustration of the charts and tables of the comparative analysis amid normal, overweight and obese clearly illustrates a major difference amid the three as well as the underlying factors. Normal weight can best be described as a balance in BMI or Body mass index. This means that the height and weight must be within the provided structure. However one can have the normal weight but still be categorized as obese if the fat contained in the body are excess that what the body requires. This situation is regarded as normal weight obesity which implies that an individual has the similar and severe health threats as an obese person. On the other hand, obesity refers to having intense fats amounts in the body which rejects the widely acknowledged perception of obesity as weighing much. BMI cannot be used to determine whether an individual is obese given that it does not determine the amount of fats but normally communicates if the weight is within the proper range. Based on the figures it is evident that the populace of overweight and obese people in UAE is on the rise. In that normal weight is only owned by 24 percent of the populace followed by overweight with 29 percent and obese 47 percent. Overweight and obesity are the major contributor of the increasing cases of low back pain issues because such situations hinders an individual’s movement. In that those that are restrained by weight find it hard to engage in physical exercises such as movement and active participation in activities. In turn they opt for easier and digitized strategies such as the use of cars which leads to back pain. In addition the population of those with normal weight and exercises the right posture is decreasing relatively in the country. |
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4.2.2. Results in Forward Flexion posture:
Using (Tables 4.5-4.8 and Figures 4.10-4.17); a comparison was made between the forces on lumbar vertebrae in forward flexion posture. And the results showing below:
- The ratio of increased the force between a vertebra and the vertebra which follow by, is relatively constant. Where the increase between the lumbar vertebrae in the normal weight is 21.5%; in overweight it is 28.25%, and in obese people it is 50%.
- We can note that, the difference in force between normal and overweight is increasing slightly, on the other hand, the different between normal and obese is increasing sharply. This result supports the theory which said that, the higher BMI, lead to higher risk of LBP; and that is because, force in obesity case is greater than the force in normal case in about 28.5%, which is considering aa a high rate. The greater the force on the vertebrae, the more likely to hurt the spine.
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Figure 4.10: Proximo-Distal Force (N) on L1 and L2, in Forward Flexion posture
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Figure 4.11: Increase in force between L1 and L2, in Forward Flexion posture |
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Figure 4.12: Proximo-Distal Force (N) on L2 and L3, in Forward Flexion posture |
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Figure 4.13: Increase in force between L2 and L3, in Forward Flexion posture |
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Figure 4.14: Proximo-Distal Force (N) on L3 and L4, in Forward Flexion posture |
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Figure 4.15: Increase in force between L3 and L4 in Forward Flexion posture |
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Figure 4.16: Proximo-Distal Force (N) on L4 and L5, in Forward Flexion posture |
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Figure 4.17: Increase in force between L4 and L5 in Forward Flexion posture L4 and L4 appears to be the most essential parts with respect to posture and spinal development. The muscles are responsible for movement or coordination and posture. If they contract then a tough and opposing external pressure is created and the movement of the spine, body and pelvis. In addition, it is the functioning of the muscles that offers a desirable approach for boosting the stiffness of the muscles which is usually a common thing during physical activities. Most of the functional activities usually need the contribution of these muscles in a general context. This normally leads to stabilized movement and so on. Based on the analysis it is evident that external force is usually higher among the obese and overweight individuals than those with normal weight. In that for instance pressure accounts to 50 percent and 29 percent among obese and overweight persons in respective. On the other hand the pressure only accounts for 21 percent among individuals with normal weight. The increase in pressure between L4 and L5 normally leads to a forward posture due to the spinal strain that forces one to adopt the stand. On the other hand, it was established that the forward Flexion pressure increased with 2.37, 3.837 and 6.56 respectively among, normal, overweight and obese people. This is makes it apparent that the risk of pressure increases rises twice between an overweight and obese individual. It clearly illustrates that the different between the two is evident. While an overweight person will be referred to as obese, obesity magnifies the risk further. This does not however imply that an overweight person is safe since the difference of pressure increase is more than 1.5 which is high. The higher the pressure the higher the threat of the prevalence and dominance of LBP. Because the rate is high among the obese people this clearly illustrates that obesity is a major contributor to low back pain.
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4.3. Analysis and discussion
However, the measurements of the two postures do not vary significantly for this group of participants. Nonetheless, there is striking difference in relation to the second and third cases. Overweight case, where IBM is >25 and <30, reported great increase in force in both postures, indicating increased spinal motion. While the third case recorded the highest levels of force intensity. In regard to specific posture positions, the difference remained constant, which indicates that high force is associated with standing posture relative to flexion extension posture. From these observations, it is apparent that force intensifies with increase in IBM. Further, it changes depending on posture applied.
We can conclude that different postures can also affect LBP. For people who work in that kind of job where it allows them to flex and have a continuous movement, they are less risk of LBP. On the other hand, people who have to stand for long hours, they are more susceptible to LBP, because the force is centered on L4 and L5 of lumber; as indicated by the results in this study. Additional to that, people whose work forces them to continually bend forward are suffering of pain in L1, as the concentration of force is on it. So for the normal people if the force are keeping effects the spine for long time can cause LBP, add to that the extra weight; logically the pain will increase and the situation will become worse. These findings indicate that there is correlation between increase in IBM and increase in spinal load.
These results are synonymous with the findings of other previous studies. In their study of the association of BMI and spinal pain, Baker and Giles (1999) observed that LBP increased with BMI levels. The participants of their study who were obese reported LBP condition. Leboef et al (1999) performed the same survey in Denmark and they established that there is positive link between LBP and BMI. However, the researchers indicate that the intensity of LBP depends on the duration of the condition with high levels being recorded on chronic cases of LBP. In similar study, Fanuee et al (2002) concluded that LBP prevalence and chronic cases of LBP are more pronounced on obese people. Mirtz and Greene (2005) examined the relationships between BMI and LBP. Using a comparative observation on different BMI measurements, they concluded that the risk of LBP was minimal at BMI <30. Moderate risk was associated with BMI > 30, and higher risk is linked to BMI>40. The results demonstrated that the responses of L4 nad L5 with regard to distinct postures leads to the exxagerated forces.
Chapter 5
5.0: Conclusion and Recommendations
In summing up, pain in the lower parts of the body has a real connection with obesity. If many people take measures aiming at reducing their weight, they will reduce the back pain a great deal. Such practices as regular exercise will help one reduce the back pain. MRI is a special parameter that can be depended on determining the existence of pain; it also helps us understand Modic changes. This can help in determinng the prevalence of the pain as well as determining the most appropriate medical and physical measure that is to be adopted to reduce the issue. Based on the analyisis above , it is evident athat LBP is highly prevalent among in close measures among both genders but higher among older persons. In addition, having weaker legs or bones that affects an individuals posture in addition to smoking and increated rates of standing and stting holds a substnatial effects with regard to LBP. This study supports the fact that LBP is currently an essentla clinical, socila and economic challenge in UAE and it representes a major health issue across the globe. The fact that obesity and overweight issues are the major contributors of the issue best illustrtaes the health urgency of the issue. It is claer that despite the fact that obesity is high in the country which accounts to 50 percent of the population with those with normal weight only representing 21 percent, this has become a major health problem in general. As long as the spread of obesity continues in the country, it means that the issue of LBP will still be high which is a threat to public health.
Recommendations
Low Back Pain (LBP) is a severe clinical and social economic issue in UAE, which is one of the most mutual source of disability and close to every individual particularly the agining ons suffers from the illness. Close to every individual suffers once during their life but adequate treatment is however, not so common. Obesity is a major contributor to the rise of LBP in the country. Obesity refers to being overweight as well as having high rates of fats in the body more than the body necesitates in general. It is thus, proposed that in order to address the LBP issue obesity must first be solved. It means that if individual focuses on reducing their weight, it is evident that the risks must be lowered. Being overweight hinders individuals from actively getting involved in physical activities. This means that awareness should be created among the public to allows them understand the issue of obesity and its association to LBP. It is evident that it is the absence of knowledge that contributes to obesity. Lifestyle chnage is also needed. The chnage entails getting actaively involved in physical activities and proper dieting in order to ensure that weight gain does not get an opportunity for obesity and weight gain. Lifestyle chnage will not only lower the risk of obesity and that of LBP and this will eliminate the health and socio-economic issue.
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