067 Seating Modification, Back Posture

Seating modification, back posture
and change in lower back pain

amongst occupational car drivers
with chronic lower back pain
Dr Kelly-Ann Bowles
Prof Jenny Keating
Dr Lisa OBrien
Mr Rob Laird
Dr Andrew Ronchi
Ms Sarah Tinitali
Prof Terry Haines
January 2016
Research report # 067-0116-R01
Further information
For further information on this report, please email info@iscrr.com.au
Related documents (at the time of writing)

Title and author
Reference number
N/A
N/A
This research report was prepared by

Dr Kelly-Ann Bowles and Prof Terry Haines,
Department of Physiotherapy, Monash University,
Allied Health Research Unit, Monash Health
Disclaimer
ISCRR is a joint initiative of WorkSafe Victoria, the Transport Accident Commission and Monash University. The
accuracy of the content of this publication is the responsibility of the authors. The opinions, findings, conclusions
and recommendations expressed in this publication are those of the authors and not necessarily those of TAC or
ISCRR.
This publication may not involve an exhaustive analysis of all existing evidence. Therefore it may not provide
comprehensive answers to the research question(s) is addresses. The information in this publication was current
at time of completion. It may not be current at time of publication due to emerging evidence.
Table of Contents
Executive Summary----------------------------------------------------------------------------------- 3
Purpose --------------------------------------------------------------------------------------------------- 4
Rationale -------------------------------------------------------------------------------------------------- 4
Key research questions ----------------------------------------------------------------------------- 5
Methods --------------------------------------------------------------------------------------------------- 5
Research/review Findings -------------------------------------------------------------------------- 7
Discussion, conclusions and implications --------------------------------------------------- 9
Potential impact, use of the research/review and recommendations ------------- 11
References --------------------------------------------------------------------------------------------- 11
Appendices -------------------------------------------------------------------------------------------- 13
Appendix A: Systematic Review Manuscript-------------------------------------------- 13
Appendix B: Methodology Manuscript ---------------------------------------------------- 32
ii
Executive Summary
Background
Low back pain has been described as the major cause of disability worldwide (1). In Australia,
approximately 10% of the population experience substantial disability from low back pain in any sixmonth period (2). Low back pain also contributes to considerable economic strain. In the most recent
Australian economic burden study, the estimated cost of low back pain in a one year period was
AU$9.17 billion (2). AU$8.15 billion of this burden of disease was driven by loss of earnings and
productivity costs, where people were not able to engage in their usual occupations (2).
The notion that poor sitting posture is a risk factor for low back pain is reported widely in the literature
(3-5). There is a substantial evidence base that has examined postures adopted in static sitting and
relationships with low back pain (6-9). Comparatively less work however, has been undertaken on more
dynamic sitting behaviour that may be required as part of occupational activities, such as driving an
automobile.
This project measured pelvic, trunk and lumbar flexion/extension and pelvic, trunk and lumbar lateral
flexion through real time lumbar motion monitoring. Eleven occupational drivers with reported low back
pain were recruited for the study and were monitored whilst driving their standard vehicle with the
standard car seat and then a modified car seat (either replacement of the standard car seat with a
modified car seat or the placement of a lumbar support roll in the standard car seat).
Main findings
1. Our systematic review identified that a relationship between low back pain and postures
assumed while driving may exist, but further research using more robust and reproducible
measurement approaches needs to be undertaken to confirm this.
2. Our reliability study found that driving posture data is best represented by mean lumbar
flexion, collected at any time within a work shift, but not within the first five minutes of any
drive.
3. Our intervention study found that car seat modifications can lead to significant changes to pelvic
flexion during driving. The effect that this change in posture then has on resultant pain requires
further investigation.
Implications
With a large number of Australians driving as a part of their occupation the mechanisms by which back
pain may be reduced through car seat modification needs to be identified. Establishing interventions
that may allow low back posture to be modified may reduce the risk of developing back pain for nonsufferers and may allow those with back pain to work more comfortably. This research has established
that modifications to a standard car seat can significantly change pelvic flexion angles, with further
research required to see the follow on effect to resultant pain. These modifications may be as simple
as inserting an off the shelf lumbar support role for some sufferers. The beneficiaries of this work may
include drivers of all workplace vehicles including taxi drivers, couriers and health clinicians visiting
patients in their own home.
3
ISCRR Research report 067-0116-R01
Purpose
The purpose of this pilot research was to determine if modifications to a standard car seat can affect
real-time lumbar spine posture in occupational drivers with reported back pain. Additionally this
research will provide data for sample size estimates for a larger study, determine a reliable methodology
for future research in the area and provide foundation information to assess the relationship between
lumbar posture during driving and resultant low back pain.
Rationale
Lower back pain is a leading cause of disease burden in Australia. Direct health care costs of lower
back pain are in excess of $1 billion annually, though these are dwarfed by indirect costs (primarily time
off work due to back pain) which are estimated to be eight times as large (2). Associations between
driving automobiles for extended periods or driving as an occupation and development of lower back
pain have been established since the 1970s (10, 11). Despite this evidence, there is still uncertainty as
to how prolonged driving causes lower back pain.
How might driving cause lower back pain?
Theories regarding whole body vibration, and extreme or sustained postures have been posited. Such
physiological stressors could potentially contribute to lumber disc degeneration or straining of other
soft-tissues in the lumbar spine. A recent review found that there is insufficient evidence to form a
conclusion on whether whole-body vibration, postural stressors or other factors, specific or not specific
to driving, are common causes of low back problems in drivers (11). Whole body vibration has also
been argued to be a waning factor in absolute contribution to lower back pain due to engineering
improvements and reductions in vibration in recent automobile models (12).
Some theories to explain how occupational driving can lead to lower back pain can be extrapolated
from non-driving related sitting. A review of the mechanisms of lower back pain in sitting has found that
sitting is unlikely to pose a threat to non-degenerate discs through the mechanism of raised intra-discal
pressure (13). Thus greater focus is arguably warranted on understanding mechanisms that may strain
other soft tissues in the lumbar spine, such as holding sustained postures at extremes of range of
motion during driving. A survey of n=202 Australian airline pilots about seating found that inability to
adjust the amount of lumbar and thigh area support were key concerns related to their seating options
(14), which is consistent with the premise that sustained postures may contribute to discomfort and pain.
Can lumbar spine postures in sitting be modified?
Adults have difficulty moving into an ideal sitting posture with lumbar lordosis (extension) and thoracic
kyphosis (flexion) (15), and are likely to require specialised seating to maintain such postures for
extended periods. Modified seating has been shown to change lumbar spine position and the
distribution of sitting pressures in laboratory conditions (16). However, it is unknown whether seating
modifications in vehicles change lumbar spine postures when people are driving in real life.
Can modified seating reduce driving-related lower back pain?
At present, there are no randomised controlled trials of seating modifications interventions to reduce
driving-related lower back pain and the burden it imposes on society. This study examined the extended,
real-time lumbar spine posture of n=11 people with back pain who drive their vehicle for more than 2
hours per day as a part of their occupation. Three participants had their usual car seat replaced with a
modified car seat, and eight participants placed a lumbar support in their car during a second day of
driving. This will be the first study to provide real time, insitu measurement of lumbar spine
posture while driving.
4
Key research questions

Research objectives are to:
i) investigate the association between sitting posture and low back pain while driving an automobile via
a systematic review of the literature;
ii) determine a reliable and repeatable methodology for assessing real time lumbar spine posture for
occupational drivers; and
iii) determine if modifications to a standard car seat result in a change in lumbar spine posture and
resultant back pain for occupational drivers with reported back pain.
Methods
Research question one was addressed via a systematic review that has been submitted for publication
in Applied Ergonomics. The submitted manuscript can be found in Appendix A.
Research question two was addressed by a methodology study that is in draft format for peer reviewed
publication, with submission planned once the systematic review has been accepted for publication.
This methodology manuscript can be found in Appendix B and will be submitted to Spine.
For research question three the following methods were used to complete a prospective cohort study:
Population: Occupational drivers who had reported back pain were recruited via IdealSeat Company,
Mordialloc, Victoria, Australia and from community advertising.
Sample size: As this was a pilot study a convenience sample was used based on available referrals
from the car seat company, with eight community participants also recruited.
Exclusion criteria: People who did not report low back pain or discomfort when driving their vehicle;
those with insidious or serious pathologies of the lumbar spine, or conditions of the spinal cord; pregnant
women; those who participate in large amounts of manual labour or heavy lifting as part of their job;
and those who have an allergy to tape or glue. In addition, people who drove non-standard occupational
vehicles during their work shift (e.g. bus, truck or train) were excluded due to the presence of
confounding factors that have the potential to affect driving posture.
Intervention: Driving posture when participants either had a modified seat placed in their vehicle, or
placed a lumbar support roll into their standard car seat.
Comparator: Driving position using a standard car seat.
Outcomes: Lumbar spine posture during driving including lumbar, trunk and pelvis flexion/extension
and lumbar, trunk and pelvis lateral flexion. Average pain at the end of the driving day (Visual analogue
scale).
Analysis: The analysis methodology from the second publication was followed in this study. Pelvic,
trunk and lumbar flexion/extension and pelvic, trunk and lumbar lateral flexion were determined from
the mean flexion data. Data from a drive was exported to Microsoft Excel, with time of entry into the
vehicle was identified by a large increase and then decrease in lumbar flexion. The first five minutes
and thirty seconds of the drive were ignored due to shown decreased repeatability for flexion data for
this time period. The mean flexion data for each outcome over the subsequent five minutes of the drive
were then calculated. Paired t-test analysis was completed using SPSS for all flexion and pain variables.
Findings were deemed significant if p<0.05.
Measurement of lumbar posture using the ViMove system (dorsiVi, Melbourne, Victoria,
Australia): The ViMove system is a wireless inertial 3-D measurement system allowing real time
measurement of spinal movement and electromyography of the erector spinae muscle group.
Participants who had the modified car seat fitted into their vehicle were met at the IdealSeat company,
and community participants were met at their place of work. All participants were fitted with the sensors
by a trained biomechanist as displayed in Figure 1. Initial baseline live assessments were then
completed on all participants to assess the individuals lumbar posture and function. Participants were
then given the Recording and Feedback Device (RFD) to carry during their day (needs to be within 10
metres of participant for monitoring). At the end of the day the system was returned to the researcher
for analysis. Participants who placed the lumbar support roll into their vehicle, completed two days of
5
driving assessment in random order, with those who has the modified seat recording driving posture in
both conditions on the same day. Figure 2 illustrates the printout of the monitoring session for one
participant. Pelvic and trunk measures are each taken from their own motion sensor, with lumbar
measures derived from both motion sensor measures.
Figure 1: A) Sensor placement for ViMove system with the large sensors measuring motion
and the smaller sensors measuring electromyography and B) Recording and Feedback Device
(RFD) carried by the participant during monitoring session (compared in size to mobile
phone).
6
Figure 2: Monitoring session printout for one participant including driving sessions with the
blue circles.
Measurement of pain at the end of the driving day: A 0 to 10 visual analogue scale was used to
assess participant pain at the end of the driving day (Figure 3). Participant who inserted the lumbar roll
into their standard car seat reported pain data for both the intervention and control conditions.
Figure 3: Visual analogue scale question used at the end of the driving day.
Research/review Findings
The systematic review found that a majority (six of the seven) of included papers reported a relationship
between driving posture and low back pain, but that these findings are based on studies with
considerable methodological flaws that cannot be reproduced. This field of research is clearly still in its
infancy given the low number of studies conducted (7 papers were derived from 5 studies) and
questionable methods used to collect data, particularly related to posture. A relationship between low
back pain and postures assumed while driving may exist, but further research using more robust and
reproducible measurement approaches needs to be undertaken to confirm this. The review also
suggested that future research is required to enhance our understanding of whether postures assumed
while driving contribute to low back pain. Importantly, as tools are now available that are capable of
measuring outcomes such as sitting posture in real time during activities such as driving (17, 18), further
research assessing lumbar flexion measures during driving are required.
This second paper for this project provides a methodology for the classification and analysis of realtime lumbar flexion data during driving. Based on the results, it is recommended that driving posture
data be represented by mean lumbar flexion, collected at any time within a work shift, but not within the
first five minutes of any drive. Peak lumbar flexion showed weaker test-retest reliability in comparison
to mean lumbar flexion, but did demonstrate at least acceptable levels of test-retest reliability.
Measuring the standard deviation of lumbar flexion showed poor test-retest reliability and the use of
this outcome cannot be recommended at this time.
For the prospective cohort study, 11 participants completed a driving session in a standard car seat
and with a fitted modified car seat or the use of a lumbar support roll. Three participants were male
and eight were female, with participants working in occupations such as sales representative, public
servants and health professionals who visited patients at home. The mean age of the participants was
39.5 years with a range from 24 to 53 years. The mean time of back pain onset was roughly 8 years
and participants reported an mean pain intensity score of 42 (0 -100 scale using QVAS; (19)) at baseline.
The addition of the lumbar support roll to the participants car seat resulted in a significant increase in
pelvic extension (p=0.037) by approximately six degrees. Figure 4 illustrates the mean pelvic flexion
angle for each participant during driving in both seating conditions. Although no other measure resulted
in a significant change, the trunk sensor for one participant did cease collecting data during the trial,
resulting in no trunk and an incorrectly derived lumbar measure for that condition (excluded from
analysis). This did result in a sample size of seven participants for the lumbar and trunk outcomes.
Therefore although lumbar flexion was reduced by a similar amount to the pelvic flexion measures, this
finding was not significantly (p=0.170) possibly due to the smaller sample size and the slightly greater
variance within the data. No significant change was seen in the lateral flexion measures as a result on
modifying the car seat.
7
FLEXION ANGLE (O)
Mean pelvic flexion for

different conditions
0
-5
-10
-15
-20
-25
-30
-35
-40
-45
-50
Normal
LumbarRoll
Figure 4: Mean pelvic flexion for all participants with the lumbar support roll, in both seating
conditions.
The insertion of the lumbar roll resulted in a non-significant (p=0.351) decrease of one visual analogue
scale point in average pain when compared to the standard car seat. Figure 5 illustrates the average
reported pain for each participant in each car seat condition. One participant did comment a priori that
an increase in lumbar extension was know to increase her pain. All but this participant reported a
preference to the lumbar support roll condition post driving. This participant is represented by the
orange line in Figures 4 and 5 and recorded the greatest change in pelvic flexion/extension, and the
largest increase in pain with the additional of the lumbar roll. As the researchers identified that back
pain is not uniform in its triggers and this participant could been deemed as an outlier for this cohort,
pain data was then analysed without this participant. From this analysis, the reduction in pain was not
significant (p=0.078) but did suggest a trend toward the positive effect of the insertion of the lumbar roll
on back pain. It should be noted that the position of the pelvic sensor could possibly affect pain
measures in the lumbar support roll condition, with three participants noting the sensor did dig in more
with the lumbar support roll in place.
8
Average pain for different

conditions
10
9
8
PAIN (VAS)
7
6
5
4
3
2
1
0
LumbarRoll
Normal
Figure 5: Average pain for all participants with the lumbar support roll, in both seating
conditions.
As the participant sample available for the modified car seat group was limited, no significant results
were found between the seat conditions for this group. Two participants had near identical mean pelvic
measures for both conditions, with the non-significant (p=0.192) increase in pelvic extension for this
group approximately four degrees. As both conditions were completed on the one driving day, pain
data for this cohort was not available for each driving condition.
This research does demonstrate that car seat modifications can lead to significant changes to pelvic
flexion during driving. The effect that this change in posture then has on resultant pain requires further
investigation.
Discussion, conclusions and implications

To our knowledge this is the first study to provide real time, insitu measurement of lumbar spine posture
while driving. This research has established that although a relationship between low back pain and
postures assumed while driving may yet exist, but further research using more robust and reproducible
measurement approaches need to be undertaken to confirm this finding. A methodology study did find
that real time measurement of lumbar posture represented by mean flexion angles, is highly repeatable
and reliable, and using these methods, this research did shown that modifications to a standard car
seat with the insertion of a lumbar support roll, can significant modify pelvic flexion during driving.
Prior to this research the effect of an intervention on sustained flexed postures and low back pain for
occupational drivers was unknown (Figure 6A). Although some research had discussed the effect of
posture on back pain while driving (20-22), these papers did not measure exact lumbar angles and
investigated changes in posture whilst driving, rather than assessing sustained flexion angles. This
pilot study has provided foundation research outcomes in understanding the effect of seating
modifications on mean pelvic lumbar flexion during driving. We have established that modification to a
car seat can lead to significant changes in pelvic flexion (Figure 6B). In addition, there is a current trend
9
suggesting that the modification to the car seat could reduce low back pain. Future research is now
required to further establish the effect of car seat modification on low back pain and to further investigate
the link between changes in mean pelvic flexion and low back pain.
B
Figure 6: Flow chart diagram illustrating the knowledge regardin the relationship between car
seat modification and low back posture and resultant pain prior to (A) and post (B) this research
project.
The limitations of this study were:

The small sample size of this pilot research may have affected the statistical finding and
therefore further research with a larger sample is require to confirm these preliminary results;
Average low back pain measures were not collected for each seat condition for the modified car
seat group, therefore the effect of the modified car seat on low back pain can not be reported;
The ViMove system includes a low back pelvic sensor that was reported did dig in more to the
participants back when the lumbar support roll was in place. This may have affected the
average low back pain measures for this condition.
10
Potential impact, use of the research/review and

recommendations
With a large number of Australians driving as a part of their occupation the mechanisms by which back
pain may be reduced through car seat modification needs to be identified. Establishing interventions
that may allow low back posture to be modified may reduce the risk of developing back pain for nonsufferers and may allow those with back pain to work more comfortably. This research has established
that modifications to a standard car seat can significantly change pelvic flexion angles, with further
research required to confidently establish the follow on effect to resultant pain. The modification to the
car seat may be as simple as inserting an off the shelf lumbar support roll, however different back
issues may require different interventions to relieve back pain while driving. The beneficiaries of this
work may include drivers of all workplace vehicles including taxi drivers, couriers and health clinicians
visiting patients in their own home.
References
1.
Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain:
estimates from the global burden of disease 2010 study. Annuls of the Rheumatic Diseases [Internet]. 2014;
73(6):[968-74 pp.].
2.
Walker BF, Muller R, Grant WD. Low back pain in Australian adults: the economic burden. Asia Pac J
Public Health. 2003;15(2):79-87.
3.
Manek NJ, MacGregor AJ. Epidemiology of back disorders: prevalence, risk factors, and prognosis.
Curr Opin Rheumatol. 2005;17(2):134-40.
4.
Neumann WP, Wells RP, Norman RW, Kerr MS, Frank J, Shannon HS. Trunk posture: reliability,
accuracy, and risk estimates for low back pain from a video based assessment method. Int J Ind Ergonom.
2001;28(6):355-65.
5.
Yilmaz E, Dedeli O. Effect of physical and psychosocial factors on occupational low back pain. Health
Science Journal. 2012;6(4):598-609.
6.
Claus AP, Hides JA, Moseley GL, Hodges PW. Is 'ideal' sitting posture real?: Measurement of spinal
curves in four sitting postures. Manual Therapy. 2009;14(4):404-8.
7.
Williams MM, Hawley JA, McKenzie RA, van Wijmen PM. A comparison of the effects of two sitting
postures on back and referred pain. Spine. 1991;16(10):1185-91.
8.
Dankaerts W, O'Sullivan P, Burnett A, Straker L. Differences in sitting postures are associated with
nonspecific chronic low back pain disorders when patients are subclassified. Spine [Internet]. 2006; 31(6):[698704 pp.].
9.
Park RJ, Tsao H, Claus AP, Cresswell AG, Hodges PW. Recruitment of Discrete Regions of the Psoas
Major and Quadratus Lumborum Muscles Is Changed in Specific Sitting Postures in Individuals With Recurrent
Low Back Pain. Journal of Orthopaedic and Sports Physical Therapy. 2013;43(11):833-40.
10.
Kelsey JL, Githens PB, O'Conner T, Weil U, Calogero JA, Holford TR, et al. Acute prolapsed lumbar
intervertebral disc. An epidemiologic study with special reference to driving automobiles and cigarette smoking.
Spine. 1984;9(6):608.
11.
Gallais L, Griffin MJ. Low back pain in car drivers: A review of studies published 1975 to 2005. Journal
of sound and vibration. 2006;298(3):499-513.
12.
Lings S, Leboeuf-Yde C. Whole-body vibration and low back pain: A systematic, critical review of the
epidemiological literature 19921999. International archives of occupational and environmental health.
2000;73(5):290-7.
13.
Claus A, Hides J, Moseley GL, Hodges P. Sitting versus standing: Does the intradiscal pressure cause
disc degeneration or low back pain? Journal of Electromyography and Kinesiology. 2008;18(4):550-8.
14.
Lusted M, Healey S, Mandryk J. Evaluation of the seating of Qantas flight deck crew. Applied
Ergonomics. 1994;25(5):275-82.
15.
Claus AP, Hides JA, Moseley GL, Hodges PW. Is idealsitting posture real?: Measurement of spinal
curves in four sitting postures. Manual Therapy. 2009;14(4):404-8.
16.
Makhsous M, Lin F, Hendrix RW, Hepler M, Zhang LQ. Sitting with adjustable ischial and back
supports: biomechanical changes. Spine. 2003;28(11):1113.
11
17.
Charry E, Umer M, Taylor S. Design and validation of an ambulatory inertial system for 3-D
measurements of low back movements. The Meeting of Intelligent Sensors, Sensor Networks and Information
Processing (ISSNIP); 2011 Dec. 6-9; Adelaide, South Australia2011. p. 58-63.
18.
Ronchi AJ, Lech M, Taylor NF, Cosic I. Reliability study of the new back strain monitor based on clinical
trials. the meeting of the 30th Annual Institute of Electrical and Electronics Engineers International Engineering
in Medicine & Biology Society (IEEE EMBS) Conference; Vancouver, British Columbia, Canada2008.
19.
Von Korff M, Deyo RA, Cherkin D, Barlow W. Back pain in primary care: outcomes at 1 year. Spine.
1993;18(7):855-62.
20.
Tamrin SBM, Yokoyama K, Jalaludin J, Aziz NA, Jemoin N, Nordin R, et al. The association between
risk factors and low back pain among commercial vehicle drivers in peninsular Malaysia: a preliminary result.
Industrial health. 2007;45(2):268-78.
21.
Okunribido OO, Magnusson M, Pope MH. Low back pain in drivers: The relative role of whole-body
vibration, posture and manual materials handling. Journal of Sound and Vibration. 2006;298(3):540-55.
22.
Sakakibara T, Kasai Y, Uchida A. Effects of driving on low back pain. Occupational medicine.
2006;56(7):494-6.
12
Appendices
Appendix A: Systematic Review Manuscript
Poor posture causes low back pain

while driving; evidence-based position
or dogma?
A systematic review of the association between sitting posture
and low back pain while driving an automobile
Sarah Tinitalia, Jennifer L Keatinga, Kelly-Ann Bowles a,b, Terry Haines a,b
aMonash
University Peninsula Campus, McMahons Road, Frankston, Victoria, Australia
3199
b Allied
Health Research Unit, Kingston Centre, 400 Warrigal Road, Cheltenham,
Victoria, Australia 3192
sarah.tinitali@gmail.com
jenny.keating@monash.edu
kelly-ann.bowles@monash.edu
terrence.haines@monash.edu
Corresponding Author:
Kelly-Ann Bowles
Allied Health Research Unit, Kingston Centre, 400 Warrigal Road, Cheltenham,
13
Ph: +61 425 261 585
This paper can be in black and white print
Abstract
Several authors have claimed a relationship between poor posture and low back pain
while driving. The strength of these claims however, is yet to have been subjected to
critical analysis and review. We undertook a systematic review and critical appraisal
of the evidence examining this relationship. Six of the seven articles identified an
association between these variables, yet none of these studies used a validated and
reliable means for measuring driving posture. Only one study used a measure of back
pain that has previously been subjected to validation, though this tool was translated
into a different language without report of the translation procedure. These and other
limitations bring the strength of the relationship between posture and low back pain
while driving into question. Future research in this field needs to employ validated and
reliable methods for measuring posture (preferably in real-time) and pain to advance
our understanding of this relationship.
Keywords
Low back pain
Driving
Posture
14
Introduction
Low back pain has been described as the major cause of disability worldwide (1). In
Australia, approximately 10% of the population experience substantial disability from
low back pain in any six-month period (2). Low back pain also contributes to
considerable economic strain. In the most recent Australian economic burden study,
the estimated cost of low back pain in a one year period was AU$9.17 billion (2).
AU$8.15 billion of this burden of disease was driven by loss of earnings and productivity
costs, where people were not able to engage in their usual occupations (2).
There are many occupations that require extended periods of sitting. The notion that
poor sitting posture is a risk factor for low back pain is reported widely in the literature
(3-5). The ability to engage in these occupations may therefore be impaired by low
back pain attributable to poor sitting postures. There is a substantial evidence base
that has examined postures adopted in static sitting and relationships with low back
pain (6-9). Comparatively less work however, has been undertaken on more dynamic
sitting behaviour that may be required as part of occupational activities, such as
driving an automobile.
The link between poor sitting posture and low back pain during driving may have been
first postulated by Troup (10), though they provided no direct evidence of this link. A
later review by Lyons (11) discussed a potential mechanism; that low back pain may
be caused by adoption of awkward driving postures due to the poor ergonomic
design of vehicles. However, Lyons (11) referenced data from only one empirical study
by Krause et al. (12) who reported an increased risk of back or neck pain for drivers
who experienced ergonomic problems, such as difficulty seeing out of the vehicle or
problems with operating vehicle controls. Krause et al. (12) did not directly measure
driving posture beyond self-report, and their findings should therefore be treated with
caution.
15
More recently, a review by Lis et al. (13) considered the association between
occupational sitting and low back pain while assuming awkward postures and/or
while exposed to whole-body vibration. The review considered a range of driving
populations, including drivers of buses, tractors, cranes, helicopters, and rubbish
collection trucks. Four eligible papers reported a moderate positive association
between low back pain and sitting in a vehicle (average OR=2.1). The conditions
experienced by the drivers in this review are likely to differ considerably across
participant occupations, particularly in regards to the movements of the spine and
upper limbs when operating various vehicle functions. The trunk and upper limb
movements required of a helicopter pilot or garbage truck driver are likely to differ to
those required of a bus or truck driver. Trunk movements in automobile drivers are also
likely to differ when an individual is driving on an uneven surface, or at a high speed,
in comparison to a standard public road. It is therefore difficult to make individual
findings regarding pain experienced while operating specific vehicles based on a
review of such a heterogenous group of vehicles.
Given the limitations of these previous reviews, and the publication of more recent
empirical studies, a systematic review was undertaken to synthesise and critically
appraise the available evidence in this field. An understanding of this relationship is
needed to guide the appropriate development of future strategies to minimise the
burden of low back pain associated with driving.
Review Aim
The aim of this review was to synthesise and appraise the evidence examining the
association between sitting posture during occupational driving and low back pain,
and to identify factors that may mediate such an association.
Material and Methods

Searching
Searching was performed by the lead author. The complete holdings of five databases
(AMED, CINAHL Plus, Cochrane Central Register of Controlled Trials, Cochrane
16
Database of Systematic Reviews, and Ovid MEDLINE) were searched up to February

2015. Search results were pooled in bibliographic management software, duplicates
were removed, and ineligible papers were deleted based on title, abstract, and full
text. Reference lists of relevant reports were then screened for additional papers not
found in the primary search. Author and citation checks were performed for all first
authors of eligible papers. Figure 1 presents the search terms, truncations and Boolean
operators used. A sample search is available from the first author on request.
Figure 1: Search Terms

1. Sit$ OR Seat$ OR Driv$
2. Posture$ OR Position$ OR Angle$ OR Pose$
3. Low$ back OR Low-back OR Low$ spin$ OR Low-spin$ OR Low$ vertebra$ OR
Low-vertebra$ OR Lower-back OR Lower-spin$ OR Lower-vertebra$ OR Lumbar
OR Lumbar-back OR Lumbar-spin$ OR Lumbar-vertebra$ OR Lx
4. Automobile$ OR Vehicle$ OR Car$ OR Taxi$ OR Bus$ OR Van$ OR Truck$ OR
Lorr$ OR Transport$
5. 1 AND 2 AND 3 AND 4
Eligibility criteria
Papers were included in the review if they reported data on the relationship between
sitting posture while driving a car, bus, truck or van and pain in the lumbar spine region;
measured driving posture and low back pain; and were reported in English. To minimise
confounding factors, papers were excluded if they included people with spine
anomalies; genetic conditions associated with the spine; insidious or serious
pathologies of the lumbar spine (e.g. cancer, inflammatory diseases, fracture);
conditions or injuries involving the spinal cord; or pregnant women. Studies that
considered sitting posture in a rally car or other forms of occupational automobiles
were also excluded, due to factors associated with each vehicle type: differing driving
surfaces in comparison to a standard public road (e.g. tractors); differing forces acting
through the body of the driver (e.g. rally cars, due to their extreme speed); and the
differing requirements of the tasks being performed by the driver (e.g. forklifts,
helicopters).
Planned Quality Assessment

17
A modified Reliability Quality Assessment Tool by Pretorius and Keating (14) was
adapted to assess the presence of bias in included studies. Each report was assessed
against the criteria of inception cohort, method of assessment, subject blinding,
assessor blinding and analysis methods. Modifications made to the tool included the
addition of the subject blinding criteria, separation of the inception cohort criteria into
two items (random sampling, and comparison of sample and source populations), and
removal of the attrition criteria and items specific to the study by Pretorius and Keating
(14). The modified tool can be viewed in Table 1. A critical analysis was also planned
to further consider sources of bias, including methods by which low back pain and
driving posture were measured, and methods by which these measurements were
analysed.
Table 1: Modified Reliability Quality Assessment Tool

Criteria
Yes =
1
No =
0
1. Inception cohort
All those eligible for admission into the study were invited to participate.
Scoring: Yes, if the report states that consecutive, or randomly selected,
eligible participants were invited to participate in the study.
2. Inception cohort
All participants in the study were a representation of the source
population.
Scoring: Yes or no. Yes if the report describes the participants and they are
a representative of the group of interest e.g. the participants involved in a
study of bus drivers represent the bus driver population.
3. Method of assessment
The methods used to measure driving posture and low back pain were
described in enough detail to enable replication.
Scoring: Yes or no. Yes if the method is explained to a degree that
replication is possible.
4. Subject blinding
During the observation or measurement of posture, participants were
unaware of the outcome being assessed.
Scoring: Yes or no. Yes, if participants were not aware that the relationship
between sitting posture and pain was being assessed.
18
5. Blind Assessor
Drivers posture, and their pain, were assessed by independent assessors or
if not, it was probable that one measurement did not bias the
measurement of the other.
Scoring: Yes or no. Yes if the paper states that there was blinding of the
assessor or a method of posture and pain measurement was used that
minimised the possibility of bias.
6. Analysis
Data were reported that enabled a view of the relationship between pain
and driving posture.
Scoring: Yes or no. Non exhaustive examples of such data could be raw
scores for each participant on both measures, correlations between pain
and posture measures, mean scores (and variability estimates) on one
parameter for subjects grouped on the other parameter (e.g. posture in
high versus low pain subjects), change in pain with changes in posture.
TOTAL SCORE
Planned Data Extraction and Synthesis

Data extracted from eligible papers included study design, participant characteristics,
methods used to assess driving posture and low back pain, data analysis methods,
and the reported statistical or textual description of the association between driving
posture and low back pain. Any evidence provided as to the validity or reliability of
assessment and analysis methods was also extracted. Where data collection
techniques and reporting methods were sufficiently comparable, a meta-analysis was
planned. In the event this was not possible, a narrative, critical synthesis approach was
planned.
Results
Search yield and search results
A total of 485 articles were identified by the search strategy. There were 41 duplicates,
which were then deleted. A further 387 articles were excluded based on title and
abstract, and the remaining 57 articles were read in full. 50 articles were excluded
following full text review, with the remaining seven publications included (15-21). Figure
19
2 presents a PRISMA flow chart describing the search and screening results as per
Moher et al. (22).
Figure 2: Flow of studies into the review
461 articles identified through searching
(AMED = 30, CINAHL Plus = 3, Cochrane
Central Register of Controlled
24 additional articles identified through other

sources
Trials = 36, Cochrane Database of

Systematic Reviews = 108, Ovid MEDLINE
= 284)
Total search yield: 485
444 articles after duplicates

removed
444 articles screened
387 articles excluded

(333 by title, 54 by abstract)
57 full-text articles assessed for

eligibility
50 full-text articles excluded:
17 did not measure driving

posture in an eligible vehicle
7 articles eligible for
qualitative synthesis and
quantitative synthesis
21 did not measure driving

posture or low back pain
7 did not report data on how

driving posture affects LBP
20
Quality Assessment
Quality assessment using the modified Reliability Quality Assessment Tool revealed that
all except one study (19) failed to provide sufficient detail in the method to allow for
replication of the low back pain and/or driving posture assessment approach. None
of the studies reported any degree of blinding of the participant or researcher of what
posture assessment results were when capturing pain data or vice versa. This may be
important as a patient or researcher could potentially (consciously or unconsciously)
influence the response to a later question based on the response to the former.
Characteristics of included studies

The populations in the eligible studies were occupational drivers, including bus drivers,
taxi drivers, police officers, and drivers of trucks and vans. Two of the papers by
Okunribido et al. (16, 17) presented data for the same study population. A further
paper published by the same lead author is likely to include bus drivers from the same
sample, as population characteristics were identical. These papers were handled as
three separate studies, as they reported different relationships between driving posture
and low back pain. Four of the included papers utilised a cross-sectional survey design
(15-17, 19), and three papers used both a cross-sectional survey and an observational
component (18, 20, 21).
The average mean participant age across the included studies was 42.4 years. Sample
sizes varied, ranging from 61 (18) to 1242 (15). Participants were predominantly male
due to the eligibility criteria of individual studies (21), or the presence of few females in
the source population (15-19). Table 2 presents sample characteristics and design of
included studies.
21
Table 2: Study Design and Population Characteristics

Head
Author
(Year)
Study Design
Driver
Type
Sample
size at
start of
study
Sample
size at
end of
study
Mean (SD)
Age (years)
Gender
Ratio
(M:F)
Mean (SD)
BMI (kg/m2)
Mean (SD)
driving
distance per
day (km)
Mean (SD)
driving time
per day
(hours)
Mean (SD)
days of
driving
each
month
Mean (SD)
length of time in
current
profession
(years)
Bovenzi
(2006)
Cross-sectional
survey/
Observational
Bus
171
43.6 (6.6)
1:0
26.6 (3.2)
6.0 (0.8)
16.1 (8.5)
Chen
(2005)
Cross-sectional
survey
Taxi
1355
1242
44.5 (8.7)
1193:49
9.8 (2.8)
26.2 (2.6)
11.4 (7.8)
Okunribid
o (2006)
Cross-sectional
survey
Police
Police: 75
Police: 58
Police: 34.5 (5.9)
Police: 26.0 (2.7)
Police: 12.9 (7.24)
Truck/
Van
Truck/ Van:
110
Truck/ Van:
64
Truck/Van: 46.9
(11.0)
Few
women,
data
pooled
Bus
Bus: 80
Bus: 61
Taxi
Taxi: 90
80
Truck/Van: 27.7
(4.5)
Truck/van: 10.5
(8.6)
Bus: 47.6 (10.4)
Bus: 28.3 (4.4)
Bus: 16.1 (11.7)
Taxi: 30
Taxi: 49.3 (8.3)
Taxi: 28.3 (4.8)
Taxi: 11.1 (8.7)
61
LBP: 48.1 (9.7)
Okunribid
o (2007)
Cross-sectional
survey/
Observational
Bus
Okunribid
o (2008)
Cross-sectional
survey
Police
Police: 75
Police: 58
Police: 34.5 (5.9)
Truck/
Van
Truck/Van:
110
Truck/ Van:
64
Truck/Van: 46.9
(11.0)
Bus
Bus: 80
Bus: 61
Taxi
Taxi: 90
-
19:1
No LBP: 46.8 (11.5)
Sakakibar
a (2006)
Cross-sectional
survey
Car
Tamrin
(2007)
Cross-sectional
survey/
Observational
Bus
LBP: 28.5 (4.0)

No LBP: 28.1 (4.9)
Few
women,
data
pooled
Police: 26.0 (2.7)
LBP: 7.5 (1.4)
No LBP: 7.6
(1.8)
-
LBP: 14.3 (7.8)

No LBP: 17.9 (12.2)
Police: 12.9 (7.2)
Truck/Van: 27.7
(4.5)
Truck/van: 10.5
(8.6)
Bus: 47.6 (10.4)
Bus: 28.3 (4.4)
Bus: 16.1 (11.7)
Taxi: 30
Taxi: 49.3 (8.3)
Taxi: 28.3 (4.8)
Taxi: 11.1 (8.7)
551
LBP: 37 (8.5)
530:21
No LBP: 35.8 (8.7)

-
760
43 (8.64)
LBP: 111 (54)
LBP: 3.8 (1.8)
No LBP: 115
(104)
No LBP: 3.5
(1.8)
10.5 (0.1)
LBP: 14.2 (8.8)

No LBP: 12.8 (8.7)
22
Posture Measurement
Tamrin and colleagues (20) measured posture through direct observation by filming
participants with a video camera while driving. This video footage was then rated by
an unspecified number of raters to count the number of times that various movements
(bending forward, leaning, sitting straight, twisting) were performed. The participants
in the study by Okunribido et al. (18) were observed by an unspecified assessor while
driving. The assessor noted the posture configuration (torso against backrest, torso
straight, torso bent, torso twisted, and/or torso bent and twisted simultaneously)
assumed by the driver at one-minute intervals (p. 30). The inter-rater reliability of these
observation approaches were not specified.
There was no measurement of the
magnitude of movement in each direction nor the length of time spent in each
movement. Bovenzi et al. (21) performed direct observation by taking video and still
photography footage of participants during a workshift, but did not provide detail on
the methods with which these data were interpreted. Bovenzi et al. (21) and
Okunribido et al. (18) also assessed driving posture with a self-assessed questionnaire,
in addition to direct observation.
The self-assessed questionnaire method of posture measurement was utilised by six

papers (15-19, 21). One paper asked participants to select a posture that they usually
adopted while driving from a polychotomous list (straight, slightly slouched, or
slouched) (19). Participants were unable to specify a combination of these postures
or relative time spent in each posture, indicating an underlying assumption that drivers
adopt only one posture. Five of the questionnaires asked participants to rate the
frequency with which specific driving postures were adopted (15-18, 21). None of
these papers reported data demonstrating the reliability or validity of their
measurement approach. Okunribido et al. (16-18) reported the use of a previously
validated questionnaire developed by Pope et al. (23), however the reference
provided was only for a draft questionnaire that has not since undergone further
investigation of its psychometric properties. Only one study reported the wording of
the question that was used to elicit posture assessment data (19). The issues of
reproducibility, reliability and validity for self-reported measures of posture can be
questioned as Okunribido et al. (18) found discrepancies between self-report and
23
direct observation approaches. They found participants reported that torso against
backrest was assumed more commonly than torso straight, but that observation
found the reverse to be true.
Low Back Pain Measurement

All seven papers measured low back pain using a self-assessed questionnaire.
Sakakibara et al. (19) developed a questionnaire, while the other authors used or
modified
previously
formed
questionnaires
(15-18,
20,
21).
The
surveillance
questionnaire used to measure driving posture by Okunribido et al. (16-18) was also
used to measure low back pain (see Section 3.3.2). Bovenzi et al. (21) reported the use
of a modified Nordic Questionnaire yet referenced the standardised version, and did
not provide information on the specific modifications made. Chen et al. (15) based a
questionnaire on items from the Nordic Questionnaire and the Job Contents
Questionnaire in combination with other items, but did not report the final item set.
Tamrin et al. (20) used the Standardised Nordic Questionnaire translated into Malay
language, however, it is unclear if the best practice crosscheck, as specified by
Kuorinka et al. (24) was performed following translation. Sakakibara et al. (19)
developed a questionnaire with items that measured the presence, severity, duration
and previous history of low back pain, and the effect of driving on low back pain.
Unlike the other six articles, Sakakibara et al. reported the questionnaire items (19).
The validity of low back pain measurement approaches employed by the included
studies is unknown. This is due to modifications made to previously formed
questionnaires, the use of questionnaires lacking validation information, and the
formation of new questionnaires. Reliability information was also not provided for the
measurement approaches within these articles.
The association of driving posture and low back pain

Five of the seven papers reported an association between low back pain and driving
with the back in a bent or twisted posture (15-17, 20, 21). This posture was associated
24
with current low back pain (16) and history of low back pain in the past 12 months (15,
17, 20, 21). Driving with the back bent and twisted simultaneously was also associated
with history of low back pain in the past 12 months (17).
Okunribido et al. also reported an association between driving with the torso against
the backrest and both current low back pain (16) and history of low back pain in the
past 12 months (17). Tamrin et al. (20) reported an association between torso straight
and a lower risk of low back pain. In contrast to the findings of these six papers,
Sakakibara et al. (19) found no significant difference between the driving postures of
participants with or without low back pain (p=0.67).
Studies by Bovenzi et al. (21) and Okunribido et al. (16-18) also examined the
relationship between a summative score incorporating posture (+/- other factors) and
low back pain. Bovenzi et al. (21) calculated a self-developed physical load index
for each participant based on their exposure to awkward postures and heavy
physical work. Observational and questionnaire data were used to determine
exposures. Awkward posture exposure was calculated through consideration of each
posture and how long participants assumed each posture during a shift (never, less
than 1-hour, 1-2-hours). Exposure to heavy physical work was determined by rating the
frequency with which physical activities were performed (not at all, 1-10 times, more
than 10 times). The average physical workload index for the sample was then divided
into quartiles to represent grades of physical load (mild, moderate, hard and very
hard). A very hard physical load index was associated with an increased risk of low
back pain disability (OR 2.57, 95% CI 1.25-5.26) and history of low back pain within the
previous 12 months (OR 2.25, 95% CI 1.39-3.64) (21). However, the physical workload
index incorporated both driving and non-driving work postures, as well as non-driving
activities. The relationship between the physical workload index and low back pain is
therefore not a representation of the relationship between driving posture and low
back pain.
Okunribido et al. (16-18) calculated a personal posture score for each participant by
assigning severity points to specific postures and frequencies of occurrence. Driving
25
with the torso against the backrest was deemed the least severe posture, with the
greatest severity assigned to driving with the back bent and twisted simultaneously.
The severity point of a posture assumed by an individual was multiplied by the
frequency of occurrence point. The addition of all point totals determined a posture
score for the individual (16-18). Drivers of police cars and taxi drivers had low posture
scores, while truck, van and bus drivers had medium posture scores. Medium posture
scores were associated with current low back pain (OR 1.288, 95% CI 0.5982.777) (16).
In the 2007 paper by Okunribido et al., however, drivers with low back pain were
associated with a lower posture score compared to the drivers with no pain.
Okunribido et al. (16) reported that the posture score was yet to be validated.
Discussion
This review has found that a majority (six of the seven) of included papers reported a
relationship between driving posture and low back pain, but that these findings are
based on studies with considerable methodological flaws that cannot be reproduced.
This field of research is clearly still in its infancy given the low number of studies
conducted (7 papers were derived from 5 studies) and questionable methods used to
collect data, particularly related to posture. A relationship between low back pain and
postures assumed while driving may yet exist, but further research using more robust
and reproducible measurement approaches needs to be undertaken to confirm this.
Our conclusion of uncertainty of the presence of a relationship contrasts to that of the

review by Lis et al (13). Lis et al. (13) concluded that there was an association between
the low back pain and awkward driving postures, such as sitting forward, or driving
with the trunk flexed, bent and twisted (p. 289). However, their conclusion was driven
by four studies (25-28) that were excluded from our review as they were not amongst
standard road vehicles. Further, Lis et al (13) did not undertake any critical appraisal
of the measurement approaches used to capture posture or pain data, and did not
use such an appraisal to influence their conclusions as we have done.
26
A criticism raised earlier regarding previous reviews in terms of heterogeneity of the

included participant populations, could also be raised of this review. We excluded
studies amongst helicopter pilots, cranes, and other vehicles that are not
conventionally used for road-based transportation. This means that we did include
studies amongst drivers of cars, vans, buses, and trucks. It is possible that the nature of
relationship between low back pain and posture between these vehicle types may be
different. However, subdividing to this extent would have resulted in a very limited
number of papers being included. Furthermore, these studies did not report findings in
a consistent manner sufficient to allow statistical pooling.
This review led to identification of four studies (29-32) that included potentially relevant
data from mixed populations (including those that would have been included and
excluded from our review) but did not present this data in a disaggregated way. These
studies were excluded from our review. We may have had sufficient data of higher
quality to make a conclusion in favour of a relationship between low back pain and
posture while driving, had the disaggregated data been available.
Future research is required to enhance our understanding of whether postures

assumed while driving contribute to low back pain.
Importantly, tools are available
that are capable of measuring an outcome such as sitting posture in real time that
could be used for this purpose (33, 34). These tools have been investigated for validity
and reliability (34), and have already started to be used for clinical applications (35).
In addition, cross-sectional studies used to date provide no temporal sequencing that
may help satisfy this Bradford Hill criteria of causality (36). For this, prospective studies
that demonstrate first, the adoption of particular postures, followed by the
development of low back pain are required. These studies would provide strong
justification for intervention studies that could be used to demonstrate whether
changing postures assumed while driving can be useful for reducing the burden of low
back pain.
Conclusions
27
The aim of this review was to synthesise and appraise the evidence examining the
association between sitting posture during occupational driving and low back pain,
and to identify factors that may mediate such an association. The relationship
between these outcomes remains open to challenge, due the use of measurement
methods that lacked validity and reliability. A true understanding of this relationship
cannot be known until further studies using validated, reliable and real-time methods
for posture measurement are performed.
Acknowledgements
This systematic review was completed as part of an Honours degree, without a funding
source. The review is an advisory paper for a study funded by the Institute for Safety,
Compensation and Recovery Research (ISCRR). Although this paper was written
independently from the study, the authors would like to acknowledge the support
provided by ISCRR.
28
References
1.
Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back
pain: estimates from the global burden of disease 2010 study. Annuls of the Rheumatic Diseases
[Internet]. 2014; 73(6):[968-74 pp.].
2.
Walker BF, Muller R, Grant WD. Low back pain in Australian adults: the economic burden.
Asia Pac J Public Health. 2003;15(2):79-87.
3.
Manek NJ, MacGregor AJ. Epidemiology of back disorders: prevalence, risk factors, and
prognosis. Curr Opin Rheumatol. 2005;17(2):134-40.
4.
Neumann WP, Wells RP, Norman RW, Kerr MS, Frank J, Shannon HS. Trunk posture:
reliability, accuracy, and risk estimates for low back pain from a video based assessment method. Int
J Ind Ergonom. 2001;28(6):355-65.
5.
Yilmaz E, Dedeli O. Effect of physical and psychosocial factors on occupational low back
pain. Health Science Journal. 2012;6(4):598-609.
6.
Claus AP, Hides JA, Moseley GL, Hodges PW. Is 'ideal' sitting posture real?: Measurement of
spinal curves in four sitting postures. Manual Therapy. 2009;14(4):404-8.
7.
Williams MM, Hawley JA, McKenzie RA, van Wijmen PM. A comparison of the effects of two
sitting postures on back and referred pain. Spine. 1991;16(10):1185-91.
8.
Dankaerts W, O'Sullivan P, Burnett A, Straker L. Differences in sitting postures are
associated with nonspecific chronic low back pain disorders when patients are subclassified. Spine
[Internet]. 2006; 31(6):[698-704 pp.].
9.
Park RJ, Tsao H, Claus AP, Cresswell AG, Hodges PW. Recruitment of Discrete Regions of
the Psoas Major and Quadratus Lumborum Muscles Is Changed in Specific Sitting Postures in
Individuals With Recurrent Low Back Pain. Journal of Orthopaedic and Sports Physical Therapy.
2013;43(11):833-40.
10.
Troup JD. Driver's back pain and its prevention: A review of the postural, vibratory and
muscular factors, together with the problem of transmitted road-shock. Appl Ergon. 1978;9(4):207-14.
11.
Lyons J. Factors contributing to low back pain among professional drivers: a review of current
literature and possible ergonomic controls. Work. 2002;19(1):95-102.
12.
Krause N, Ragland DR, Greiner BA, Fisher JM, Holman BL, Selvin S. Physical workload and
ergonomic factors associated with prevalence of back and neck pain in urban transit operators. Spine.
1997;22(18):2117-26.
13.
Lis AM, Black KM, Korn H, Nordin M. Association between sitting and occupational LBP. Eur
Spine J. 2007;16(2):283-98.
14.
Pretorius A, Keating JL. Validity of real time ultrasound for measuring skeletal muscle size.
Phys Ther Rev. 2008;13(6):415-26.
15.
Chen JC, Chang WR, Chang W, Christiani D. Occupational factors associated with low back
pain in urban taxi drivers. Occ Med (Oxford). 2005;55(7):535-40.
16.
Okunribido OO, Magnusson M, Pope MH. Low back pain in drivers: The relative role of
whole-body vibration, posture and manual materials handling. J Sound Vib. 2006;298(3):540-55.
17.
Okunribido OO, Magnusson M, Pope MH. The role of whole body vibration, posture and
manual materials handling as risk factors for low back pain in occupational drivers. Ergonomics.
2008;51(3):308-29.
18.
Okunribido OO, Shimbles SJ, Magnusson M, Pope M. City bus driving and low back pain: a
study of the exposures to posture demands, manual materials handling and whole-body vibration.
Appl Ergon. 2007;38(1):29-38.
19.
Sakakibara T, Kasai Y, Uchida A. Effects of driving on low back pain. J Occup Med (Oxford).
2006;56(7):494-6.
20.
Tamrin SBM, Yokoyama K, Jalaludin J, Aziz NA, Jemoin N, Nordin R, et al. The association
between risk factors and low back pain among commercial vehicle drivers in Peninsular Malaysia: a
preliminary result. Ind Health. 2007;45(2):268-78.
21.
Bovenzi M, Rui F, Negro C, D'Agostin F, Angotzi G, Bianchi S, et al. An epidemiological study
of low back pain in professional drivers. J Sound Vib. 2006;298(3):514-39.
22.
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred Reporting Items for Systematic Reviews
and Meta-Analyses: The PRISMA Statement. Ann Intern Med. 2009;151(4):264-9.
23.
Pope M, Magnusson M, Lundstrom R, Hulshof C, Verbeek J, Bovenzi M. Guidelines for
whole-body vibration health surveillance. J Sound Vib. 2002;253(1):131-67.
24.
Kuorinka I, Jonsson B, Kilbom A, Vinterberg H, Biering-Sorensen F, Andersson G, et al.
Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl Ergon.
1987;18(3):233-7.
29
25.
Bridger RS, Groom MR, Jones H, Pethybridge RJ, Pullinger N. Task and postural factors are
related to pack pain in helicopter pilots. Aviat Space Environ Med. 2002;73(8):805-11.
26.
Massaccesi M, Pagnottaa A, Soccettia A, Masalib M, Masieroc C, Grecoa F. Investigation of
work-related disorders in truck drivers using RULA method. Appl Ergon [Internet]. 2003; 34(4):[303-7
pp.].
27.
Bovenzi M, Zadini A. Self-reported low back symptoms in urban bus drivers exposed to
whole-body vibration. Spine. 1992;17(9):1048-59.
28.
Bovenzi M, Betta A. Low-back disorders in agricultural tractor drivers exposed to whole body
vibration and postural stress. Appl Ergon. 1994;25(4):231-41.
29.
Bovenzi M. A longitudinal study of low back pain and daily vibration exposure in professional
drivers. Ind Health [Internet]. 2010; 48(5):[584-95 pp.]. Available from:
https://www.jstage.jst.go.jp/article/indhealth/48/5/48_MSWBVI-02/_article.
30.
Okunribido OO, Magnusson M, Pope MH. Delivery drivers and low-back pain: A study of the
exposures to posture demands, manual materials handling and whole-body vibration. Int J Ind
Ergonom. 2006;36(3):265-73.
31.
Damkot DK, Pope MH, Lord J, Frymoyer JW. The relationship between work history, work
environment and low-back pain in men. Spine. 1984;9(4):395-9.
32.
Liira JP, Shannon HS, Haines TA. Long-term back problems and physical work exposures in
the 1990 Ontario Health Survey. American Journal of Public Health. 1996;86(3):382-7.
33.
measurements of low back movements. The Meeting of Intelligent Sensors, Sensor Networks and
Information Processing (ISSNIP); 2011 Dec. 6-9; Adelaide, South Australia2011. p. 58-63.
34.
Ronchi AJ, Lech M, Taylor NF, Cosic I. Reliability study of the new back strain monitor based
on clinical trials. the meeting of the 30th Annual Institute of Electrical and Electronics Engineers
International Engineering in Medicine & Biology Society (IEEE EMBS) Conference; Vancouver, British
Columbia, Canada2008.
35.
Kent P, Laird R, Haines TP. The effect of changing movement and posture using motionsensor biofeedback, versus guidelines-based care, on the clinical outcomes of people with sub-acute
or chronic low back pain-a multicentre, cluster-randomised, placebo-controlled, pilot trial. BMC
Musculoskelet Disord. 2015;16(131):1-19.
36.
Hill AB. The environment and disease; Association or causation? Proceedings of the Royal
Society of Medicine [Internet]. 1965; 58(295-300). Available from:
http://www.ncbi.nlm.nih.gov/pubmed/14283879?dopt=Abstract&holding=f1000,f1000m,isrctn.
30
Appendix
Results of Assessment by Modified Reliability Quality Assessment Tool
The articles were assessed for the presence of bias using a modified Reliability
Quality Assessment Tool. The tool is presented in Section 2.3 (Table 1). Table 3
presents the results for each article.
Head
Year
Author
Criteria
Criteria
Criteria
Criteria
Criteria
Criteria
QA
Score
(Yes/N
(Yes/N
(Yes/N
(Yes/N
(Yes/N
(Yes/N
o)
o)
o)
o)
o)
o)
Bovenzi
2006
Yes
No
No
No
No
Yes
2/6
Chen
2005
Yes
Yes
No
No
No
Yes
3/6
Okunribid
2006
No
No
No
Not
Not
Yes
1/6
Stated
Stated
No
Not
No
1/6
Yes
1/6
o
Okunribid
2007
No
Yes
No
Stated
o
Okunribid
2008
No
o
Sakakibar
Not
No
Stated
Not
Not
Stated
Stated
2006
Yes
No
Yes
No
No
Yes
3/6
2006
No
No
No
No
No
Yes
1/6
a
Tamrin
31
Appendix B: Methodology Manuscript
Lumbar flexion during driving:

Establishing a methodology for
characterising real-time posture
data collected by innovative
technology
Sarah Tinitali, BPhysio(Hons)a, Terry Haines PhDa,b, Kelly-Ann Bowles PhDa,b
aDepartment
of Physiotherapy, School of Primary Health Care, Faculty of Nursing,
Medicine and Health Sciences, Monash University Peninsula Campus, McMahons

Road, Frankston, Victoria, Australia 3199,
bAllied
Health Research Unit, Kingston Centre, 400 Warrigal Road, Cheltenham,
Corresponding Author:
Kelly-Ann Bowles
Allied Health Research Unit, Kingston Centre, 400 Warrigal Road, Cheltenham,
Ph: +61 425 261 585
Conflicts of Interest and Source of Funding: Data analysed by this study were collected
in an observational pilot trial funded by the Institute for Safety, Compensation, and
32
Recovery Research (ISCRR), which represents WorkSafe, the Transport Accident

Commission and Monash University. The authors analysed the results of this research
independently of the funding bodies and no funder had any influence on how these
data were presented or conclusions reached.
33
Keywords:
Driving
Car
Sitting
Posture
Lumbar
Low back
Lumbar flexion
Real-time
Test-retest reliability measures
Analysis
Low back pain
Occupation
Work
Level of Evidence:
Level 3
34
Structured Abstract:
Study Design: Test-retest reliability study nested within a prospective cohort study.
Objective: To determine a methodology for the analysis of real-time occupational
driving posture data in the low back pain population.
Summary of Background Data: Occupational driving and poor posture have been
reported to be associated with low back pain. The association of working in a flexed
posture and low back pain has also been discussed. The link between driving posture
and low back pain is yet to be defined due to the lack of studies in the field using
validated and reliable driving posture measurement tools. Reliable and validated realtime measurement tools are now available, yet reliable methods of analysis of these
data are yet to be established.
Methods: 10 occupational drivers completed a typical work shift while fitted with an
inertial motion sensor system (ViMove). Real-time lumbar flexion data were extracted,
with comparison of the test-retest reliability of mean lumbar flexion, peak lumbar
flexion, and standard deviation of lumbar flexion analysed at different times across a
work shift, and in different sections within a drive.
Results: Mean lumbar flexion was highly repeatable over numerous drives in one day.
Analysis of mean lumbar flexion within sections of drives revealed increased testretest reliability if the first five minutes of driving data were excluded. Peak lumbar
flexion had acceptable test-retest reliability over numerous drives in one day, while
standard deviation of lumbar flexion was not a repeatable measure.
Conclusions: Mean lumbar flexion was a reliable outcome for characterising driving
posture in occupational drivers with low back pain. Peak lumbar flexion may be used
35
if appropriate to the individual study aim. The use of standard deviation of lumbar
flexion as a posture outcome is not recommended.
Key Points:
1. Measures of mean lumbar flexion were highly repeatable across a work shift
2. The reliability of mean lumbar flexion within a drive was improved when the first
five minutes of driving data were excluded
3. Peak lumbar flexion has acceptable reliability over multiple drives, yet was not as
reliable as mean lumbar flexion
4. Standard deviation of lumbar flexion as a representation of movement either side
of a sustained posture was not a reliable measure of posture, and was therefore
not recommended for future analyses of driving posture
36
Mini Abstract/Prcis
A reliable method of driving posture analysis using high quality measurement tools is
yet to be established. This study determined that mean lumbar flexion collected from
five minutes after the commencement of a drive provides the most repeatable outcome
of posture analysis.
37
Introduction
Low back pain is the major contributor to worldwide disability. The 2010 Global Burden
of Disease Study reported it to be responsible for the greatest years lost due to
disability (YLD) compared to any other condition.(1) The burden of low back pain is
increasing. Between 1990 and 2010, disability-adjusted life years (DALYs) caused by
low back pain increased from 58.2 million (95% CI 39.9 78.1 million) to 83 million
(95% CI 56.6 111.9 million).(1) In 2010, an estimated 21.7 million DALYs caused by
low back pain were as a result of ergonomic factors associated with occupation.(2)
The interplay of occupational risk factors such as heavy lifting, repetitive movements,
and non-neutral body postures have been reported to be responsible for 37% of
worldwide low back pain.(3) A study on upright working posture reported an
association between low back pain and lumbar flexion, with extreme flexion associated
with increased risk of low back pain.(4) Unlike lumbar flexion, the relationship between
low back pain and working in a position of lumbar rotation was only apparent after
additional analyses.(4)
Studies measuring sitting posture and its relationship with low back pain are reported
in the literature.(5-8) Extended time spent driving an automobile has also been linked
to low back pain,(9) with papers listing factors present during driving such as wholebody vibration and awkward postures as risk factors for the condition.(10) Current
research typically measures driving posture with cross-sectional questionnaires or
external observation, however studies have shown these measurement methods are
flawed.(11, 12) The association between driving posture and low back pain currently
38
remains unknown, due to the use of posture measurement techniques with unknown
validity and reliability.(12-18)
Innovative tools are now available that are capable of measuring driving posture in
real-time in a validated and reliable way.(19, 20) A current major limitation in any study
measuring driving posture, however, is the lack of established methodology for the
analysis of collected data. Studies of kinematic analysis typically compare the testretest reliability of mean or peak values.(21) Current research has indicated that
lumbar flexion of greater than 60 for more than 5% of a work shift can be associated
with the development of low back pain,(4) and that end range positions may put
structures of the lower back at risk of injury.(22) Studies have also reported the
negative effect that sustained postures can have on the lumbar spine.(23) These
posture outcomes could be used to characterise driving posture, but which outcome
is the more reliable? The effects of time on driving posture over a work shift and
whether a driver takes time to settle into a driving posture after beginning a drive must
also be determined for future analyses.
In order to progress the field of low back pain and its risk factors, methods to measure,
report and classify driving posture data in this pain population are essential. The aim
of this study was to determine a methodology for the analysis of real-time posture data
in occupational drivers with low back pain.
39
Materials and Methods

Ethics approval was obtained from the Monash University Human Research Ethics
Committee (Approval No. CF13/3300 2013001717). All participants gave informed
consent. A test-retest reliability study nested within a prospective cohort study was
performed that analysed control group data collected from an observational pilot trail.
Ten occupational drivers were recruited by an expression of interest email sent to all
staff at Monash University and Monash Health, Victoria, Australia. Participants
registered their interest, and were included if they met all eligibility criteria.
Eligible participants included adults with self-reported low back pain who spend at
least two-hours of accumulated time driving a car on standard public roads for their
occupation. Participants excluded from the study were people who did not report low
back pain or discomfort when driving their vehicle; those with insidious or serious
pathologies of the lumbar spine, or conditions of the spinal cord; pregnant women;
those who participate in large amounts of manual labour or heavy lifting as part of their
job; and those who have an allergy to tape or glue. In addition, people who drove nonstandard occupational vehicles during their work shift (e.g. bus, truck or train) were
excluded due to the presence of confounding factors that have the potential to affect
driving posture. Participants received reimbursement for their time and a report of their
individual results at the end of the study.
Data were collected using the ViMove (dorsaVi, Melbourne, Australia), a wireless
inertial 3-D measurement system. This system has demonstrated good agreement
when validated against high quality motion sensor measurement tools such as the NDI
40
Optotrak (0.9 [95% CI = 1.8] root mean square error),(20) and has excellent
reliability in measurement of lumbar flexion (inter-tester reliability ICC 0.95, intra-tester
reliability ICC 0.99).(19) The ViMove has demonstrated superior reliability in
measurement of lumbar flexion compared to other tools.(19) The system includes
small sensors that are adhered to the lower back (Figure 1), and has a collection
frequency of 20Hz.(20) A detailed description of the ViMove and its application has
been described elsewhere.(24)
Figure 1: ViMove System (Kent et al., 2015)

The ViMove was fitted to each participant by a biomechanist trained in the operation
of the system. Lumbar spine motion was measured while participants completed a
driving work shift. It was expected that participants would enter and exit their vehicle
multiple times during the shift, as they performed occupational-specific tasks. Data
from multiple drives for each participant were therefore collected.
41
At the end of the shift, real-time data were extracted from the ViMove feedback device
to the ViMove LIVE software where it was plotted in graphical format (Figure 2). Entry
into and exit out of the vehicle were determined by a peak flexion and then extension
immediately prior to and post a section of sitting in the presence of vibration. Entry and
exit points for each drive were determined by two independent assessors. Data
present from 30 seconds after entering a vehicle until 30 seconds prior to exiting a
vehicle were nominated as driving data.
Figure 2: ViMove LIVE Software graphical representation
42
Three drives of at least 15 minutes in duration were randomly selected for each
participant and exported into an Excel v14.5.5 spreadsheet (Microsoft Corp;
Washington, USA). Three outcomes were calculated for further analysis: 1) mean
lumbar flexion; 2) peak lumbar flexion; and 3) standard deviation of lumbar flexion
(indication of deviation from sustained posture). Outcomes were calculated for multiple
intervals and sections for each of the participant drives, and summarised in a table
(Table 1) in preparation for entry into analysis software.
Table 1: Sample table for driving data for one participant drive
Interval
Section
A) 30-sec
B) 1-min
C) 5-mins
1) 0-5-mins
2) 0-10-mins
3) 10-15-mins
1
Total Drive
2
3
1 = Mean lumbar flexion, 2 = Peak lumbar flexion, 3 = Standard deviation of lumbar flexion
43
Data Analysis
All statistics were completed using SPSS Inc. v23.0 (IBM Corp; Armonk, NY). A twoway random intraclass correlation (ICC[2,1]) with absolute agreement was calculated
to determine the reliability of each outcome. Analyses were performed between three
drives over a work shift, sections of drives, and intervals of drives. Intraclass
correlation (ICC[2,1]) coefficient scores less than 0.69 were deemed poor, 0.70-0.89
acceptable, and greater than 0.90 excellent test-retest reliability.
Results
All drivers except one were employed in the health industry and drove standard
vehicles on metropolitan bitumen roads during their work shift. The mean age of
participants was 36.5 years, and 9 of the participants were female.
Analysis of mean lumbar flexion across multiple drives within a work shift revealed
excellent test-retest reliability (ICC[2,1]=0.95 [95% CI 0.84-0.99]). Peak lumbar flexion
had acceptable test-retest reliability (ICC[2,1]=0.76 (0.91 [95% CI 0.35-0.94]),
whereas the test-retest reliability of the standard deviation of lumbar flexion across
multiple drives was poor (ICC[2,1]=-0.07 [95% CI -2.68-0.73]). Due to this poor testretest reliability, no further analyses were performed for this outcome.
Analyses for sections within a drive were then completed, with analysis of Sections 13 (0-15-minutes of driving) demonstrating acceptable test-retest reliability of mean
lumbar flexion (ICC[2,1]=0.77 [95% CI 0.31-0.94]) and excellent test-retest reliability
44
of peak lumbar flexion (ICC[2,1]=0.91 [95% CI 0.74-0.98]). After visual inspection of

mean lumbar data (Figure 3), it appeared that data within Section 1 (0-5 minutes of a
drive) were highly variable compared to data within Sections 2-3 (5-15 minutes of a
drive). Analysis of mean lumbar flexion was then repeated with Section 1 excluded,
resulting in an ICC[2,1] coefficient of 0.96 (95% CI 0.82-0.99).
Figure 3: Mean lumbar flexion within sections of a drive

Further analyses were then performed for intervals within a drive. The test-retest
reliability of mean lumbar flexion for intervals A, B and C were allexcellent (Table 2).
Analysis of peak lumbar flexion during driving intervals revealed excellent test-retest
reliability within Interval B (one minute of driving), and an acceptable test-retest
reliability within Interval A (30 seconds of driving). Results of all analyses are
presented in Table 2.
A power analysis for this study demonstrated that having 10 subjects provides 80%
power to detect a correlation coefficient of 0.71.(25)
45
Table 2: Results of intraclass correlation analyses on posture outcomes

during different times within and over drives
Mean Lumbar Flexion
(95% CI Interval)
Peak Lumbar Flexion

(95% CI Interval)
SD of Lumbar Flexion
(95% CI Interval)
Over 3 Drives
0.95 (0.84-0.99)
0.76 (0.35-0.94)
-0.07 (-2.68-0.73)
Sections 1-3
0.77 (0.31-0.94)
0.91 (0.74-0.98)
Section 2-3
0.96 (0.82-0.99)
0.44 (-1.54-0.86)
Interval A
0.96 (0.82-0.99)
0.83 (0.34-0.96)
Interval B
0.94 (0.76-0.98)
0.95 (0.80-0.99)
Interval C
0.96 (0.82-0.99)
0.45 (-1.27-0.86)
SD = Standard Deviation.
46
Discussion
This is the first study published in the scientific literature to establish a methodology
for analysing real-time driving posture data. The results of this study have shown that
a number of the outcome measures had excellent or acceptable test-retest reliability,
indicating that this method is a reliable method for future analyses of lumbar flexion
while driving.
Mean lumbar flexion was the most repeatable driving posture outcome, with excellent
test-retest reliability across multiple drives during a work shift, and within sections of a
drive if the first 5 minutes of driving data are excluded. When determining the amount
of data to analyse, the excellent test-retest reliability within Interval A indicates that
analysis of 30 seconds of driving posture data is sufficient when characterising driving
posture with mean lumbar flexion.
Previous research has demonstrated the importance of investigating lumbar flexion

while driving.(13-17) Although Tamrin et al.(17) suggested having a straight back
resulted in a lower risk of low back pain, direct measurement of the degree of lumbar
flexion was not performed in their research. This cross-sectional/observational study
videoed participants while they completed a driving shift, with no numerical
measurement of lumbar flexion collected. Previous research has shown that external
observational can only detect large magnitudes of positional change, even when
expert measurement is performed.(11) Measurement tools that are capable of
capturing minimal changes in position are therefore needed when measuring an
47
outcome such as driving posture. Using the methods presented by this paper, claims
made by researchers such as Tamrin et al.(17) can be studied, using direct numerical
measurement of lumbar flexion with increased accuracy.
Peak lumbar flexion had acceptable test-retest reliability across multiple drives in a
work shift. Analysis of one minute of posture data revealed excellent peak lumbar
flexion test-retest reliability compared to analyses of intervals of different durations.
The reduced quality of test-retest reliability of peak lumbar flexion in comparison to
mean lumbar flexion was expected. Peak lumbar flexion, as the name suggests,
represents a once-off extreme movement towards end of range. Analysis showed,
however, that the use of peak values had acceptable test-retest reliability, and could
be used by researchers if appropriate to the individual research aim.
Previous investigations of lumbar spine posture and its association with pain while
driving have not sought to directly measure lumbar spine posture.(12-18) In vitro
studies have reported prolapse of the intervertebral disc to occur when simulation of
the spinal column lifting an object while in flexion beyond their range of movement
(hyperflexion) is performed.(22) That is, individuals with reduced lumbar range of
movement as the result of a stiff spinal column may be at risk of disc prolapse when
they move into lumbar flexion that exceeds their normal range of movement.(22)
Although this research did show that the degree of lumbar flexion that corresponds to
the failure point of anatomical components of the spine varies, this research did
measure flexion angles. The findings of our research have shown that peak lumbar
flexion, possibly nearing dangerous levels for some individuals, can be accurately
48
measured and reliably analysed.
Poor test-retest reliability was present when examining the outcome of standard
deviation of lumbar flexion. This outcome was examined as previous researchers have
hypothesized that holding a sustained posture for extended periods may cause lower
back pain.(23) This would have been indicated by having a lower standard deviation
in lumbar spine motion measures. However, the lower test-retest reliability of this
measure would suggest that at this stage, this outcome is not appropriate for
comparative analyses.
No research to date conducted during occupational driving in a low back pain

population has clearly indicated the timing of their driving posture analysis. Although
some researchers briefly describe their data collection, no research indicated if a
settling time was allowed, or if driving posture data collected early or late in a work
shift differed from each other. Some researchers have suggested that time spent
driving may be associated with low back pain,(16, 18) yet no study has investigated
the effect of fatigue during a driving work shift on lumbar flexion. Our results have
shown that for our cohort, test-retest reliability of mean lumbar flexion between multiple
drives across a day was excellent, suggesting that mean lumbar flexion remains
consistent throughout a driving work shift.
This study has its limitations. The use of only lumbar flexion movement is unlikely to
be sufficient to characterise driving posture. Driving activities such as performing a
head-check when changing lanes, are likely to incorporate a component of lumbar
49
rotation. Lumbar rotation has been reported to be associated with low back pain, albeit
not as clearly as lumbar flexion.(4) The ViMove system was selected for the
measurement of driving posture due to its excellent validity and reliability in the
measurement of lumbar flexion.(19, 20) At the time of data collection, the ViMove was
not capable of measuring lumbar rotation. Improvements in technology have enabled
the system to now be capable of measuring this movement (software v5.9.10336.0).
Further studies that establish a methodology for the analysis of lumbar rotation during
occupational driving would be beneficial to this field of research.
The method of excluding 30 seconds of data either side of driving data to account for
postures assumed as a participant enters and exits a vehicle has not been validated.
This method was utilised to minimize analysis on non-driving postures. It is possible,
however, that participants began driving within this 30 second period, or spent longer
than 30 seconds sitting with the motor running before exiting the vehicle.
The use of a small sample (n=10) may be considered to be a limitation in this research.
Smaller samples generally have wider confidence intervals surrounding their reliability
coefficients. Our analyses identified significant ICC values for several of the outcomes
examined, indicating that the sample size was sufficient to achieve the aim of this
study.
This paper provides a methodology for the classification and analysis of real-time
lumbar flexion data during driving. Based on the results, we recommend that driving
posture data be represented by mean lumbar flexion, collected at any time within a
50
work shift, but not within the first five minutes of any drive. Peak lumbar flexion showed
weaker test-retest reliability in comparison to mean lumbar flexion, but did
demonstrate at least acceptable levels of test-retest reliability. Measuring the standard
deviation of lumbar flexion showed poor test-retest reliability and the use of this
outcome cannot be recommended at this time.
As the reliability of these measures has now been illustrated, future studies can be
completed that consider the relationship of lumbar flexion angle while driving and low
back pain, or comparative studies investigating the effects of interventions on lumbar
flexion while people with low back pain are driving. This methodology may be
transferable to analysis of driving posture in populations without low back pain, and
sitting posture in non-driving occupations. Further studies are required using the data
collection and analysis methods described by this study, before the reliability of this
methodology in other populations can be established.
51
References
1.
Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back
pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(6):968-74.
2.
Driscoll T, Jacklyn G, Orchard J, Passmore E, Vos T, Freedman G, et al. The global burden
of occupationally related low back pain: estimates from the Global Burden of Disease 2010 study. Ann
Rheum Dis. 2014;73(6):975-81.
3.
Punnett L, Pruss-utun A, Nelson DI, Fingerhut MA, Leigh J, Tak S, et al. Estimating the global
burden of low back pain attributable to combined occupational exposures. Am J Ind Med.
2005;48(6):459-69.
4.
Hoogendoorn WE, Bongers PM, De Vet HC, Douwes M, Koes BW, Miedema MC, et al.
Flexion and rotation of the trunk and lifting at work are risk factors for low back pain: results of a
prospective cohort study. Spine. 2000;25(23):3087-92.
5.
Park RJ, Tsao H, Claus AP, Cresswell AG, Hodges PW. Recruitment of Discrete Regions of
the Psoas Major and Quadratus Lumborum Muscles Is Changed in Specific Sitting Postures in
Individuals With Recurrent Low Back Pain. J Orthop Sports Phys Ther. 2013;43(11):833-40.
6.
Claus AP, Hides JA, Moseley GL, Hodges PW. Is 'ideal' sitting posture real?: Measurement of
spinal curves in four sitting postures. Man Ther. 2009;14(4):404-8.
7.
Williams MM, Hawley JA, McKenzie RA, van Wijmen PM. A comparison of the effects of two
sitting postures on back and referred pain. Spine. 1991;16(10):1185-91.
8.
Dankaerts W, O'Sullivan P, Burnett A, Straker L. Differences in sitting postures are
associated with nonspecific chronic low back pain disorders when patients are subclassified. Spine.
2006;31(6):698-704.
9.
Kelsey JL. An epidemiological study of the relationship between occupations and acute
herniated lumbar intervertebral discs. Int J Epidemiol. 1975;4(3):197-205.
10.
Lis AM, Black KM, Korn H, Nordin M. Association between sitting and occupational LBP. Eur
Spine J. 2007;16(2):283-98.
11.
Passier LN, Nasciemento MP, Gesch JM, Haines TP. Physiotherapist observation of head
and neck alignment. Physiother Theory Pract 2010;26(6):416-23.
12.
Okunribido OO, Shimbles SJ, Magnusson M, Pope M. City bus driving and low back pain: a
study of the exposures to posture demands, manual materials handling and whole-body vibration.
Appl Ergon. 2007;38(1):29-38.
13.
Bovenzi M, Rui F, Negro C, D'Agostin F, Angotzi G, Bianchi S, et al. An epidemiological study
of low back pain in professional drivers. J Sound Vib. 2006;298(3):514-39.
14.
Okunribido OO, Magnusson M, Pope MH. Low back pain in drivers: The relative role of
whole-body vibration, posture and manual materials handling. J Sound Vib. 2006;298(3):540-55.
15.
Okunribido OO, Magnusson M, Pope MH. The role of whole body vibration, posture and
manual materials handling as risk factors for low back pain in occupational drivers. Ergonomics.
2008;51(3):308-29.
16.
Chen JC, Chang WR, Chang W, Christiani D. Occupational factors associated with low back
pain in urban taxi drivers. Occup Med (Oxf). 2005;55(7):535-40.
17.
Tamrin SB, Yokoyama K, Jalaludin J, Aziz NA, Jemoin N, Nordin R, et al. The association
between risk factors and low back pain among commercial vehicle drivers in peninsular Malaysia: a
preliminary result. Ind Health. 2007;45(2):268-78.
18.
Sakakibara T, Kasai Y, Uchida A. Effects of driving on low back pain. Occup Med (Oxf).
2006;56(7):494-6.
19.
Ronchi AJ, Lech M, Taylor NF, Cosic I, editors. A reliability study of the new Back Strain
Monitor based on clinical trials. Conference Proceedings of the Institute of Electrical and Electronics
Engineers Engineering in Medicine and Biology Society; 2008; Vancouver, British Columbia, Canada:
Insitute of Electrical and Electronics Engineers.
20.
measurements of low back movements. . The meeting of Intelligent Sensors, Sensor Networks and
Information Processing (ISSNIP); Adelaide, South Australia2011.
21.
Lange GW, Hintermeister RA, Schlegel T, Dillman CJ, Steadman JR. Electromyographic and
kinematic analysis of graded treadmill walking and the implications for knee rehabilitation J Orthop
Sports Phys Ther. 1996;23(5):294-301.
22.
Adams MA, Hutton WC. Prolapsed intervertebral disc. A hyperflexion injury. Spine.
1982;7(3):184-91.
52
23.
Little JS, Khalsa PS. Human lumbar spine creep during cyclic and static flexion: creep rate,
biomechanics, and facet joint capsule strain. 33. 2005;3(391-401).
24.
Kent P, Laird R, Haines TP. The effect of changing movement and posture using motionsensor biofeedback, versus guidelines-based care, on the clinical outcomes of people with sub-acute
or chronic low back pain-a multicentre, cluster-randomised, placebo-controlled, pilot trial. BMC
Musculoskelet Disord. 2015;16(131):1-19.
25.
Portney LG, Watkins MP. Foundations of Clinical Research: Pearson New International
Edition: Applications to Practice. Harlow, Essex: Pearson Education Limited; 2014.
53
www.iscrr.com.au

067 Seating Modification, Back Posture

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

067 Seating Modification, Back Posture

Transféré par

Droits d'auteur :

Formats disponibles

Seating modification, back posture

and change in lower back pain

Related documents (at the time of writing)

This research report was prepared by

Key research questions

FLEXION ANGLE (O)

Mean pelvic flexion for

Average pain for different

Discussion, conclusions and implications

The limitations of this study were:

Potential impact, use of the research/review and

Poor posture causes low back pain

University Peninsula Campus, McMahons Road, Frankston, Victoria, Australia

Health Research Unit, Kingston Centre, 400 Warrigal Road, Cheltenham,

Victoria, Australia 3192

Ph: +61 425 261 585

This paper can be in black and white print

Material and Methods

Database of Systematic Reviews, and Ovid MEDLINE) were searched up to February

Figure 1: Search Terms

Planned Quality Assessment

Table 1: Modified Reliability Quality Assessment Tool

Planned Data Extraction and Synthesis

24 additional articles identified through other

Trials = 36, Cochrane Database of

Total search yield: 485

444 articles after duplicates

444 articles screened

387 articles excluded

57 full-text articles assessed for

50 full-text articles excluded:

17 did not measure driving

21 did not measure driving

7 did not report data on how

Characteristics of included studies

Table 2: Study Design and Population Characteristics

Police: 34.5 (5.9)

Police: 26.0 (2.7)

Police: 12.9 (7.24)

Bus: 47.6 (10.4)

Bus: 28.3 (4.4)

Bus: 16.1 (11.7)

Taxi: 49.3 (8.3)

Taxi: 28.3 (4.8)

Taxi: 11.1 (8.7)

LBP: 48.1 (9.7)

Police: 34.5 (5.9)

No LBP: 46.8 (11.5)

LBP: 28.5 (4.0)

Police: 26.0 (2.7)

LBP: 7.5 (1.4)

LBP: 14.3 (7.8)

Police: 12.9 (7.2)

Bus: 47.6 (10.4)

Bus: 28.3 (4.4)

Bus: 16.1 (11.7)

Taxi: 49.3 (8.3)

Taxi: 28.3 (4.8)

Taxi: 11.1 (8.7)

No LBP: 35.8 (8.7)

LBP: 111 (54)

LBP: 3.8 (1.8)

LBP: 14.2 (8.8)