The relationship between the psychological stress of adolescents in school and the prevalence of chronic low back pain: a cross-sectional study in China

Low back pain (LBP) is a common musculoskeletal health problem. It is nonspecific and self-limiting, and a subset of patients develop chronic low back pain (CLBP), defined as symptoms persisting for longer than 3 months [1]. LBP imposes a great financial burden on healthcare systems in many countries and has become a leading cause of disability [2]. The number of individuals with LBP is likely to increase substantially over the coming decades [3]. Thus, special attention must be paid to LBP.

LBP occurs at all ages and has a significant impact on the quality of life of children and adolescents [4, 5]. In addition, psychological strain due to heavy social pressure is challenging for young people. Studies have shown that college students are presently suffering from psychological pressure related to future employment, their family, and their studies, and they have difficulty addressing interpersonal relationships. At this stage, students often encounter psychological problems such as depression, anxiety, and interpersonal sensitivity [6, 7]. However, a poor mental state is also a contributing factor to the development of and recovery from LBP [8, 9]. Kamper et al. noted that multidisciplinary biopsychosocial rehabilitation interventions are more effective than conventional care and physical therapy for reducing pain and disability in patients with CLBP, which also confirms the important relationship between psychological factors and LBP [10].

Although the psychological problems of adolescents and the factors that influence them have gradually become research focus, research into the influence of psychological factors on the prevalence of CLBP is still relatively insufficient. Previous related research has focused on high school students in China [11]. However, Chinese college students also represent a large group of adolescents who need considerable attention. Therefore, it is necessary to investigate the psychological status of college students and to analyze the impact of psychological factors on the prevalence of CLBP.

This study will investigate the psychological experiences of college students in China through extensive sample surveys and will analyze the relationship between students’ responses and the prevalence of CLBP to provide a reference for improving the health of college students in the future.

In this survey, a total of 10,000 questionnaires were delivered. We successfully retrieved 9453 (94.53%) and ultimately obtained 8664 valid questionnaires (86.64%). We excluded the unqualified and invalid questionnaires (i.e., those for which more than 15% of the answers did not reflect the participants’ intended response.

Among the 789 unqualified questionnaires, 410 were excluded because they were far from complete, and 53 were excluded due to a lack of response to key questions (Fig. 1). The analysis of the remaining 326 incomplete questionnaires showed that the prevalence rates of CLBP were not significantly different from those indicated by the 8664 completed questionnaires (26.58% vs. 26.62%).

Our previous study showed that there is a strong correlation between the prevalence of chronic pain and academic pressure among adolescents in Shanghai (China) [11]. This study expands the research population to the general population of China and uses learning pressure as an indirect indicator of the psychological state of college students. This is the first study to employ cross-sectional analysis to explore the associations between the self-reported mental health of Chinese adolescents and the prevalence of CLBP. According to the survey results, the prevalence of CLBP in college students in China was 26.62%, which may be lower than that in the local area but is still high [11, 14].

Student mental health problems are a growing concern in colleges in many countries [15, 16]. Students experience many pressures when beginning school. Increased independence, exposure to new social situations, the maintenance of academic responsibilities and increased access to alcohol or drugs place tremendous pressure on students. The results of our study show that the mental problems faced by college students today may greatly affect the prevalence of CLBP.

The distribution of CLBP by sex is consistent with that of previous studies [3]. The prevalence of CLBP was higher in female students than in male students. This finding may have several explanations. First, CLBP is related to physiological changes in the menstrual cycle, and the difference between chronic pain and menstrual pain is difficult to identify [17]. Second, a lack of muscle strength can lead to improper sitting postures, which are more likely to cause CLBP [18]. Third, primary dysmenorrhea is common in women, and women are more susceptible than men to adverse emotions and are more likely to experience pain. Therefore, the symptoms of CLBP are more likely to occur in women [19].

People with more physically demanding workloads at their jobs are more likely to suffer from LBP [20]. Agricultural students may experience more outdoor learning and a is relatively heavier burden on their lower back; consequently, these students have a higher prevalence of CLBP than others. Multivariate analysis indicated a significant correlation between year of study and chronic pain: with increasing grade levels, the prevalence of CLBP increased. Senior students often face great pressure, especially in terms of entrance examinations and academic research, which causes them to remain at their desks for long periods of time. Research has shown that sitting time is an independent risk factor for LBP, and a longer sitting time may explain the increased prevalence of CLBP in this group [21]. In addition, pressure can increase students’ susceptibility to physical changes and make them more likely to complain of pain.

A recent systematic review noted that the Patient Health Questionnaire-15 (PHQ-15) and the Symptom Checklist-90 (SCL-90) are the most suitable questionnaires for large-scale studies [22]. These questionnaires are relatively short and have good psychometric attributes. Despite some controversy, the SCL-90 is widely used to evaluate the mental health of Chinese people and is the most commonly used scale for evaluating the subjective symptoms of college students for research and practice [23]. For this study, we selected the 5 most representative dimensions of the SCL-90 and used them to measure the mental state of college students. The results showed that depression, anxiety, coercion, paranoia, and interpersonal sensitivity were risk factors for the onset of CLBP, which is consistent with findings of a previous study [24].

Emotions such as depression and anxiety can lead to a decrease in patients’ pain thresholds; this reduces their tolerance of pain and increases their sensitivity [25], which subsequently increases the prevalence of self-assessed CLBP. In addition, more negative emotions often indicate fewer positive emotions. As negative mood states may be associated with the release of peripheral inflammatory cytokines that cause feelings of pain, positive mood states can activate the endogenous opioid system to release oxytocin to relieve the effects of pain [26, 27]. A more positive momentary mood is associated with reduced momentary pain and fewer restrictions [28]. In addition, CLBP can lead to psychological problems, such as depression and anxiety, which contribute to a vicious cycle and aggravate CLBP among many students [25, 29].

Unhealthy mental states, which may be due to poor campus life experiences, learning stress and adverse interpersonal relationships, may also be associated with CLBP.

An unsatisfying campus life tends to increase the risk of CLBP. Fujii et al. used the Somatic Symptom Scale-8 (SSS-8) and the EuroQol Five-Dimension (EQ-5D) questionnaire to analyze the association between the burden of physical symptoms and health-related quality of life in Japanese adults with CLBP (n = 3100), and they found that poor quality of life may aggravate somatic pain in patients with CLBP [30]. The results showed that among college students, those with bad personal habits, such as alcoholism and smoking, had a higher risk of illness than others, which is consistent with the findings of previous research [31]. Insomnia is not uncommon among college students [32]; decreased sleep quality affects academic performance [33], and significant correlations were found between sleep quality and obsessive–compulsive symptoms, somatization, depression, anxiety and overall symptoms [34]. We found that students with insomnia had a higher incidence of CLBP, which mirrored the findings of previous research [35]. However, LBP in turn promotes insomnia [36]. Poor emotional experiences are also associated with LBP, which indicates why dissatisfaction with one’s school and major may lead to greater sensitivity to pain [37].

The results of the study showed that excessive learning pressure is a risk factor for a high incidence of CLBP in college students. High expectations from parents, the fast pace of life, the feeling that others are working harder, the fear of not being able to achieve one’s goals, and the intense class competition create excessive pressure on college students. The Chinese education system emphasizes the importance of academic achievement. The mainstream ideology of the general public is to pursue good grades and obtain a good job. This ideology may burden Chinese adolescents with high levels of mental pressure.

Excessive learning pressure can lead to heavy schoolbags and sedentary, overweight students who engage in less exercise [38]. College students may develop chest kyphosis and tilting of the spine when they are sedentary, which may cause back injury [39]. Currently, college students’ schoolbags tend to be too heavy, which puts excessive pressure on the lower back [40]. In addition, excessive learning pressure indirectly reduces students’ exercise time, which in turn leads to back muscle fatigue [41]. All of these factors contribute to the occurrence of CLBP.

The results of the study show that interpersonal problems are also a risk factor for CLBP. Some college students have a bad relationship with classmates and parents or feel that their emotional life is unsatisfying. To some extent, all of these situations cause certain psychological and social problems, which affects the prevalence of LBP.

There are some limitations to our study. First, the SCL-90 mainly measures a person’s psychological state and neglects his or her ability to adjust during certain situations. In addition, people with strong psychological adjustment ability, will soon adjust their mental state to an appropriate level, even if they encounter discomfort. However, a person with poor psychological adjustment skills who is in a good position may present a better psychological state than a person with high psychological adjustment ability who is not in a good position. In practice, this means that someone with a high SCL-90 score may not be mentally disabled, while someone with a low SCL-90 score may be. Second, a cross-sectional study cannot establish causal relationships. Third, the reliability and validity were relatively low because there was no scale in the self-assessment questionnaire that measured levels of pain. LBP is nonspecific and is difficult to identify. Therefore, prior to the launch of the formal survey, we provided full illustrations and explanations of LBP to ensure the standardization of the questionnaire, and we found that differences in the severity of pain among different individuals were not significant and that cases of severe pain were rare. Fourth, students with chronic pain were more willing to complete the survey, and students with low moods were more likely to avoid the survey. In addition, the psychological state of depressed students was susceptible to implied influence. Fifth, although the data sample was large, results are always affected by bias and cannot always represent the true situation. Finally, the criteria, standards and methods applied to pain and chronic pain vary, and it is difficult to conduct studies that are more convincing than previous studies. Thus, the problem of bias exists to a certain extent.

To minimize the bias, we conducted a presurvey. Through communication with the participants, the questions were revised to be more objective and correct. A professional psychological consultant conferred with the survey participants to help them address their emotional problems.

Overall, there is a high incidence of mental problems and CLBP in Chinese college students, and the association between these factors is strong.

Currently, Chinese college students face serious psychological problems, which are closely related to the high prevalence of CLBP. In addition, as indirect indicators of mental health, poor quality of campus life, excessive learning pressure and unsatisfying interpersonal relationships contribute to CLBP.

As a result, we recommend that further cohort studies explore the intrinsic link between self-reported psychological problems and CLBP, and we call for the dedication of more attention and care to the mental health of college students.