Coexistence of Biopsychosocial Factors With Lumbopelvic Pain in Indian Women: A Systematic Review

In general, women appear to report lumbopelvic pain (LPP) more frequently. In addition to the biomechanical risks, this systematic review aimed to identify the add-on biopsychosocial implications of LPP among women in the Indian community. PubMed, ScienceDirect, Web of Science, PEDro, and Google Scholar were searched twice from inception to a final systematic literature search in December 2022. All studies addressing Indian women with LPP were selected. Studies on non-musculoskeletal LPP were excluded. Qualities of non-experimental and experimental research articles were assessed through the Critical Appraisal Skills Programme (CASP) checklist and Cochrane risk of bias criteria for Effective Practice and Organization of Care reviewsrespectively. Data synthesis was narrative as the selected studies differed substantially. Habitual squatting, kneeling, and continuous sitting were identified as ergonomic risks to LPP. Menopause, cesarean, and multiple deliveries influence the onset of LPP among women. There is a severe deficit in data about the musculoskeletal implications of LPP. There are insufficient data present to summarize the biopsychosocial risks of LPP. Even the exact anatomical sites of LPP were not described in most articles. Due to the severe scarcity of data, there is an alarming need to explore the musculoskeletal as well as psychosocial consequences of LPP in Indian women. Among rural women, LPP was common in those working as laborers; which are physically robust jobs with respect to strength and anthropometrics of women. Domestic chores in India involve a lot of manual work; placing unequal loads on the lumbar spine, eventually resulting in LPP. Therefore ergonomic strategies for women should be designed to meet the needs and demands of their respective occupations as well as domestic chores.


Introduction And Background
Owing to musculoskeletal lumbopelvic pain (LPP), women face significant rehabilitative, social, and financial inferences throughout the world [1,2]. The likelihood of developing chronicity of LPP also appears to be high among women [1,3,4]. Hence, LPP in women is a crucial musculoskeletal concern for healthcare professionals. Even the World Health Organization (WHO) has stressed the importance of spine care in everyday activities [5]. However, rural India is still unaware of non-pharmacological treatments for musculoskeletal LPP [6]. The plight of women is worse in such Indian communities, as they are barely allowed to access essential health screenings [7]. When instead, women are in dire need of musculoskeletal screenings [8,9]. Globally, women are frequent visitors for the rehabilitation of LPP [4]. However, in some Indian communities, misogyny is an obstacle for women in seeking healthcare [10]. It won't be surprising if Indian women are coping with unattended LPP disabilities.
Disability secondary to LPP impedes workplace performance and consequently inflicts substantial costs to health and quality of life. To minimize these costs, several industries came up with various innovative strategies in order to prevent LPP in workplaces. Ergonomic and general spine care interventions are quite popular in the prevention of occupation-based injuries to the musculoskeletal system in the west [11]. These strategies could help the rising number of Indian women in the agriculture field; however, ergonomic-based equipment designed for ease of manual workforce may not match with anthropometrics and physical strength of women [12]. Further, physical ergonomic-based interventions alone are not effective in preventing LPP [13] compared to participatory ergonomic strategies [14]. Hence, LPP takes a toll on the work and social life of afflicted women [15]. To develop an efficient ergonomic-based program for the prevention of LPP; one must be updated on the risks contributing to LPP [11].
The reduced work productivity on account of LPP also expedites the psychological well-being of women already bearing LPP. As per the definition by the International Association for the Study of Pain, pain is an 'unpleasant sensory and emotional experience' that is associated with actual impairment [15]. Thus, LPP is partially an emotional experience, which somehow is associated with the psychological well-being of an individual. Unfortunately, women have high odds of psychological distress in response to various social, familial, work, and health issues that indirectly influence LPP. Women with LPP have self-reported the worsening of symptoms when burdened with a domestic workload.
Having a thorough understating of the possible risks of LPP in women will add insights to women-specific rehabilitation. Hence, the purpose of this review was to consolidate studies addressing Indian women experiencing LPP to gather information in terms of parameters like the clinical presentation and risk factors of lumbopelvic pain.

Review Methodology
This systematic review was in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Review protocol registered at PROSPERO: CRD42021227044 on January 23,2020).

Ethical Considerations
This review is in accordance with research ethical standards and doesn't involve animal and human subjects.

Search Strategy
PubMed, ScienceDirect, Web of Science, PEDro, and Google Scholar were searched from inception up to August 2022 followed by an updated search on December 2, 2022. Boolean operators "AND" and "OR" were combined with keywords 'lumbago', 'low back pain', 'lumbar pain', 'pelvic pain', 'chronic pelvic pain', 'pelvic girdle pain', 'lumbopelvic pain', 'India', and women' ( Table 1). A literature search was not restricted to any particular language; however, all studies were found in the English language, and translations were not required. Searched citations retrieved from the databases were merged and duplicates were removed. Full texts of articles were scrutinized by two authors for final inclusion in the review.

Search strategy
Free-text search words (as well as MESH terms) Lower back pain, pelvic pain, Lumbago, Backache, India, women with required AND or OR Boolean operators in the searches. Science direct chronic low back pain AND India AND women; Title, abstract, keywords: chronic low back pain. lower back pain AND India AND women; Title, abstract, keywords: lower back pain AND women. backache AND India AND women. lumbar pain AND India AND women; lumbar pain AND women. pelvic pain AND India AND women. lumbago AND India AND women; lumbago. pelvic girdle pain AND India AND women. lumbopelvic pain AND India AND women.
Cochrane library chronic pelvic pain in Title Abstract Keyword AND "India" in Keyword AND women in Keyword lower back pain in Title Abstract Keyword AND "India" in Keyword AND women in Keyword lumbar pain in Title Abstract Keyword AND "India" in Keyword AND women in Keyword lumbopelvic pain in Keyword AND "India" in Keyword AND women in Keyword.

Characteristics of LPP
Selection criteria of studies: Source [16] Participants: Studies on Indian women with musculoskeletal pain in the lumbopelvic region irrespective of the chronicity of pain.
Studies selected: Studies addressing Indian women with LPP as the primary problem.
Studies excluded: Studies associating LPP with pregnant population; non-musculoskeletal origin; allopathy and complementary medicine; reviews and case studies.
Study design: All studies available that address Indian women, including peer and non-peer-reviewed gray literature and accepted manuscripts.

Outcome Measures
Lumbopelvic pain whether in the form of lumbar pain, pelvic pain, or a combination of the two.

Data Extraction
The recommendation of Chapter 7 of the Cochrane handbook [17] was followed for data extraction. A template was designed and pre-tested to obtain data relevant to this review. Disputes were resolved by authors through discussions. The following data were acquired: author details and publication year, title, study objective, research design, sample size, and characteristics, LPP description, LPP parameters assessed, outcome measure, and result.

Assessment of Risk of Bias
Qualities of non-experimental and experimental research articles were assessed through the Critical Appraisal Skills Programme (CASP) checklist and Cochrane risk of bias criteria for Effective Practice and Organization of Care reviews, respectively. Judgment for domains in CASP was assigned as Yes, Can't tell, and No, where scores of 8-10, 5-7, and ≤4 meant high, moderate, and low-quality studies, respectively. Judgment of domains for Cochrane risk of bias criteria for effective practice and organization of care reviews were: high-risk studies, low-risk studies, and unclear (?), i.e. not specified in the article.

Data Synthesis
Data synthesis was narrative, as huge variations were observed between studies and were not appropriate for meta-analysis.

Results
Overall, 169 LPP studies were retrieved from many databases (PubMed: 35; Pedro: 1, Science Direct: 124, Web of Science: 2, Google Scholar: 7). After removing the duplicate research articles, 124 study titles, as well as abstracts, were then screened. Full-text eligibility was assessed for 48 studies, which resulted in 21 articles (14 non-experimental and 7 experimental) for the review (Figure 1).

Description of Pain Within the Lumbopelvic Region
The commonest term was 'Low back pain' (LBP). The majority of studies did not outline a well-defined pain location within the lumbopelvic region ( Table 4).
Socioeconomic: Married women, marrying after 30 years of age, illiteracy, and low family income [20].

Discussion
Overall, 21 studies were included in this review, where 14 were non-experimental and seven were experimental studies. According to the findings of this review, the prevalence of LPP is high among Indian women. Therefore, there is a need to conduct women-oriented research addressing LPP.

Risk Factors
It is suggested that LPP in women commonly coexists with gynecological, urologic, gastrointestinal, psychological, and musculoskeletal pathologies [36][37][38][39][40]. LPP risks specific to female reproductive function have been identified in this review [19,20,25,28]. Osteoporosis is the most common metabolic disorder that is known to accelerate degeneration in the lumbar spine discs. However, endocrinological pathology has been uninvestigated for LPP [41]. This clearly shows the severity of data deficiency on LPP in Indian women.
This review also observed ergonomic factors contributing to LPP, which were long hours of continuous sitting among urban working women [19,30]. While among rural women, LPP was common in those working as laborers, which are physically robust jobs with respect to strength and anthropometrics of women [22]. Further, certain jobs that are quite easy for men might be difficult for women's anthropometrics, which needs women-specific ergonomic designs [12]. LPP was also reported by rural housewives who were not involved in any kind of physical activity except household chores [20,21]. In most Indian societies, women are the sole bearers of household chores, which involve sweeping the floors and washing utensils and clothes manually [20]. Bending of the trunk, squatting, and kneeling are associated with these household activities. Spending a substantial amount of time in such postures on an everyday basis can alter the biomechanical symmetry between innominate bones, reduce motor control of adjacent muscles, and/or cause trauma to lumbopelvic structures, which eventually leads to LPP [42,43]. Hence, there is a dire need to sensitize the deleterious effect of such habitual postures adopted by these women.
With a huge emphasis on the psychological aspect of LPP in recent literature [44], only work-related psychological risks were observed in the present review. It is noteworthy that these psychological risks were majorly reported by women working in physically exhausting jobs like chicken embroidery and laborers [22,27]. Occupations with extensive physical demands are known to affect the psychosocial life of LPPafflicted individuals [45].
For the anthropometrics, high BMI was noted as the risk for LPP in this review [19,23,24,30], consistent with the literature [46,47]. Contrarily, two studies in this review showed no association between BMI and LPP [20,26]. However, there were only a few obese women (n=17) in one study [20], and the mean BMI was 20.8 in the other study [26]. The BMI-related data in this review is not sufficient to support its association with LPP.
An attempt was made to reduce the possibility of publication bias by conducting a comprehensive search for relevant articles. Moreover, the risk of bias was assessed for both experimental and non-experimental studies through appropriate tools.

Limitations
Only articles in the English language were included, which could have potentially missed important information about LPP in non-English language sources.

Conclusions
The prevalence of LPP is high in Indian women. There is a severe deficiency in data on LPP, demonstrating an alarming need for research studies on the musculoskeletal as well as biopsychosocial consequences of LPP in Indian women. Further, ergonomic advice for women with LPP should be planned considering the needs and demands of their respective occupations as well as domestic chores since working women might spend a substantial amount of time at their workplace, but they too have a responsibility of household chores. During the risk of bias assessment, it was found that the overall quality of most of the studies was poor irrespective of the study designs. Though it was not the objective of this systematic review, it is a distinct finding, as it indicates a lacuna in data availability for LPP among women.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.