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Economic burden of low back pain on patients seen at the outpatient physiotherapy clinics of secondary and tertiary health institutions in Ibadan.


Low back pain (LBP) is the most common musculoskeletal problem that brings patients to the hospital. (1) It is usually accompanied by painful limitation of movement, often influenced by physical activities and postures and may also be associated with referred pain. (2) In the United States, LBP has reached epidemic proportions and represents a significant threat to the public health of its citizens. (3)

The recurrence of the condition is common. The lifetime prevalence is over 70% in industrialized countries, with peak prevalence between ages 35 and 55. (4) In Nigeria, the prevalence of LBP among hospital workers was reported to be 46%, with the highest prevalence (69%) recorded amongst nursing staff, followed by secretaries/administrative staff (55%) and cleaners/aids (47%). Heavy physical work (45%), poor posture (20%) and prolonged standing or sitting (20%) were the most frequent activities associated with LBP amongst these workers. (5) Some studies have found the prevalence of LBP to be stable over several years. (4,6,7) In Germany, the prevalence of LBP was found to be stable over a decade. (6) The high number of patients with recurrent pain makes it difficult to distinguish between prevalence of acute and chronic LBP.

The economic burden of a disease is the sum of all costs associated with that condition which would not otherwise be incurred if that disease did not exist. (8) However, given the many categories of costs that must be considered (direct, indirect and intangible), it could be challenging to fully estimate the economic burden of an illness as data is often not available. intangible costs are rarely included when estimating the economic burden of an illness because of the general societal uneasiness about placing a monetary value on these aspects of a disease. (8)

LBP is a costly condition to the society in terms of work absenteeism, health care utilization, and disability benefits. Previous estimates of the total annual cost of LBP in the United States have ranged from $20-$50billion. (10) According to Shekelle et al., (9) the direct and indirect costs of low back pain, are estimated at $60 billion annually in the United States.

A closer evaluation of the economic burden of LBP reveals that it is the commonest reason for activity limitations in individuals under the age of 45, (11) the second most common complaint heard in physician's offices, (12) the third leading cause for surgery, and the fifth most common cause for hospitalization. (13) Hemmila (14) found that about one-third of the direct costs (health care utilization) of LBP was spent on complementary therapies and that sick leaves accounted for 55 % of the total cost.

LBP is the most expensive benign condition in industrialized countries and it is the number one cause of disability that affects people less than 45 years. For those older than 45 years, it is the third leading cause of disability. (15) It results in significant restrictions on activities of daily living and participation, such as inability to work. (10) Furthermore, the economic and societal impact of LBP appears to be huge. Individuals with LBP incur millions of dollars in medical expenditure each year in the United States. (10) This economic burden is of particular concern in developing countries where there are already limitations in health care delivery and funds are directed towards epidemics such as human immunodeficiency virus/Acquired Immune Deficiency syndrome. (16)


The study protocol was approved by the University of Ibadan/ University College Hospital (UI/UCH) joint Institutional Review Committee. Participants for this study were all consenting patients with mechanical LBP who were receiving physiotherapy on an outpatient basis from Ring Road State Hospital, and University College Hospital, both in Ibadan. They were individuals who were not on a health insurance scheme at the time of the study.

The rationale and procedure of the study was explained to each participant and his/her informed consent was obtained. The Roland Morris LBP Disability Questionnaire was used to assess how LBP affected the participants' ability to manage in everyday life in terms of physical disability. The questionnaire is composed of twenty-four items (17) and has proven evidence of psychometric properties of construct validity (r = 0.89), and test-retest reliability (r = 0.80). (12) It is scored by simply summing up the items circled on the questionnaire by the participant. It has a minimum score of 0 and a maximum score of 24. A self-developed questionnaire (Economic Burden of LBP questionnaire with component questions/items adapted from information obtained from literature on the socioeconomic impact of LBP) was used to assess the economic burden of LBP for this study. The questionnaire has 43 items and is divided into three sections; Section A has 13 items on socio-demographic information of participants; Section B has 14 items on the direct costs of care; Section C has 16 items on the indirect costs of care. This self-developed questionnaire was assessed for content validity by an expert panel committee consisting of five physiotherapists knowledgeable in the design and development of questionnaires. The instrument was then pretested on 15 patients with low back pain. The patients had a clear understanding of all the items in the self-developed questionnaire.


Forty participants completed the two questionnaires which were self-administered. Descriptive statistics of mean, standard deviation and percentages were used to summarize the data obtained. Inferential statistics of independent t-test were used to compare the economic cost of LBP between male and female patients. A chi square method was used to test the association between economic cost of care and the physical disability of the patients with LBP. Level of significance was set at 0.05.


A total of forty individuals with LBP receiving physiotherapy in secondary and tertiary health institutions in Ibadan participated in this cross-sectional study. The majority (62.5%) of the participants were male. The age group of participants ranged from 30 to 80 years. A large percentage (87.5%) of the participants were forty and above (table 1). Respondents with primary education accounted for the highest (50%) number of respondents. The majority (97.5%) of the participants were married. Traders accounted for the greatest percentage (42.5%) of workers involved in this study. Almost half (47.5%) of the respondents reported that the duration of onset of low back pain was less than a year, while 10.0% reported a duration of more than 5 years.

The estimated annual economic cost was averaged at 139,156.25 [+ or -] 77,091.16 naira with direct costs (114,661.25 [+ or -] 74,230.53 naira) accounting for 82.4% (table 4). About 60.10% of the direct costs was attributed to physiotherapy (68,875.20 [+ or -] 53,988.52 naira) followed by the cost of physician's visit (27009.00 [+ or -] 13314.95 naira). The cost of medications was the least (2796.33 [+ or -] 903.70 naira) (table 2). The estimated average annual indirect cost was 24,495.00 [+ or -] 16,837.13 naira. The estimated average annual cost of transportation of respondents was 17,772.00 [+ or -] 13,526.12 naira. Only 27.5% of the respondents were accompanied to the hospital for their treatment. The estimated average cost of transportation of accompanying persons was 12938.18 [+ or -] 9331.78 naira per year. Only three respondents had paid helpers whose average cost was estimated at 34,000 [+ or -] 19,287.30 naira annually. The average annual cost of meals outside the home was 9738.46 [+ or -] 4850.69 naira annually (table 3). Two-fifths of the participants reported that they did not spend money on meals outside the home. The average loss of work hours per hospital visit was estimated at 10.25 [+ or -] 6.75 hours per month.

The mean direct cost of care for the male respondents was 109,594.80 [+ or =] 54,340.00 naira while that of the females was 123,105.33 [+ or =] 49,210.54 naira. The mean indirect cost of care for the male respondents was 24,902.40 [+ or =] 975.00 naira while that of the females was 23,816.00 [+ or =] 908.12 naira. There was no significant difference (p = 0.60) in the overall economic burden of low back pain between male and female participants in this study (table 5).

There was a significant association ([chi square] = 37.87; p = 0.04) between respondents' disability scores and the economic costs of LBP (table 6).


The economic burden of a disease is the summary of all costs associated with that condition. This means that the burden of a disease cannot be obtained if that condition does not occur in the first place. The economic burden of a disease can further be divided into various categories, these categories include direct cost, indirect cost and intangible cost. However, in this study, the direct and indirect costs of care were summed up as the economic burden. The average annual economic cost of care obtained in this study is enormous relative to the earning capacity of an average Nigerian. It appears there is no comparable published data on the economic burden of low back pain in the Nigerian environment hence comparison can only be made with studies from other parts of the world. Individuals with LBP incur millions of dollars in medical expenditure each year in the United States. (10) The findings of Williams et al. (18) that indirect costs contribute 85 % of the total costs of LBP does not support the findings of the present study. In this study, indirect cost contributed 26%. This could be explained by the fact that the majority of the participants bore all the expenses of the direct and indirect costs unlike what obtains in developed countries where healthcare is borne mainly by the government and insurance companies. This study did not include participants whose expenses are borne by health insurance companies.

The ratio of direct costs to indirect costs of care obtained from this study (3:1) supports previous findings that direct cost often contributes largely to the economic costs of disease. (8,9,10) From a Finnish study reported in 2002, almost one third of the direct back pain costs in health care utilization was spent on complementary therapies and sick leaves which accounted for 55% of the total costs. (14) Physiotherapy visits were a major contributor to the direct cost of care in this study followed by physician visits. This is similar to the findings in Lafuma et al., (19) where physical therapy contributed the most (41.6%) to the direct cost of care followed by physicians' fees (23.9%).

Indirect costs or productivity losses are the labour earnings that are forgone as a result of an adverse health outcome. The decreased productivity can be a result of illness, death, side effects, or time spent receiving treatment. Indirect costs include lost earnings and productivity of both patients and the family members who take care of them. For some diseases which result in premature death, the indirect cost is the loss in potential wages and benefits. In this study, indirect cost of care included the cost of transportation to keep appointments, cost of transportation of the accompanied person, cost of meals outside the house, and the cost of paid help. The estimate of indirect cost obtained from this study could be limited by the fact that only a minority of the participants expended cost on meals for accompanied persons, paid help and had meals outside the house. The small sample size of participants in this study is identified as a limitation of this study. More studies are recommended to explore the economic costs of LBP on a larger population.

A closer evaluation of the economic burden of LBP reveals that it is the most common reason for activity limitation in individuals under the age of 45. (11) LBP is the most expensive benign condition in industrialized countries and it is the number one cause of disability that affects people less than 45 years and for those older than 45 years, it is the third leading cause of disability. (15) It results in significant restriction on activities of daily living and on participation, such as inability to work. (10) In this study, many of the participants had high scores on the Rolland Morris Back Pain Disability Questionnaire; this can be explained from findings of previous studies where LBP has been identified as one of the leading causes of disability. There was a significant association though between disability and economic burden of LBP based on the results of this study. This finding is similar to that of Becker et al., (20) where a significant association was found between disability and economic cost of LBP.


(1.) Omokhodion FO, Sanya AO. Risk factors for low back pain in office workers. Journal of Occupational Medicine 2003; 53:287-289.

(2.) Kovacs FM, Abria V, Povo F, Heinbaun DG. Local and Remote Sustained Trigger Therapy for exacerbation of Chronic Back Pain. Spine 1997; 22(7) 788-797.

(3.) Deyo RA. Low back pain. A primary care challenge. Spine 1996; 21(24): 2826-2832.

(4.) Van Tulder, Becker A, Bekkering et al. European guidelines for the management of acute nonspecific low back pain in primary care. European Spine Journal 2006; 15(2): S169-S191.

(5.) Omokhodion FO, Umar US, Ogunnowo BE. Low Back Pain in a Nigerian University Journal of Occupational Medicine 2000; 53: 287-289.

(6.) Huppe A, Muller K, Raspe H. Is the occurrence of back pain in Germany decreasing? European Journal of the Public Health 2007; 17(3): 318-322.

(7.) Ihleback C, Eriksen. Are the myths of low back pain alive in general Norwegian Population? Scand J Public Health 2003; 31: 395-398.

(8.) Dagenais S et al. A systematic review of low back pain cost of illness studies in the United States and internationally Spine 2008; 8:8-20.

(9.) Shekelle PG, Coulter I, Hurwitz EL, Genovese B, Adams AH, Mior SA, Brook RH. Congruence between decisions to initiate chiropractic spinal manipulation for low back pain and appropriateness criteria in North America. Ann Intern Med. 1998; 129: 9-17.

(10.) Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. Journal of Rheumatic Diseases 2006; 88(2): 21-40.

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(12.) Deyo RA. Low back pain, a primary care challenge. Spine 1996; 21(24): 2826-2832.

(13.) Krishnaney AA, Park J, Benzel EC. Surgical management of neck and low back pain Clinical Neurology 2007; 25(2): 507-521.

(14.) Hemmila H. Quality of life and cost of care of back pain patients in Finnish general practice. Spine 2002; 27(6): 647-653.

(15.) Gatchel RJ, Plantin PB, Mayer TG. The dominant role of psychosocial risk factors in the development of chronic low back pain disability. Spine 1995; 20: 2702-2709.

(16.) Walker BF, Muller R, Grant WD. Low back pain in Australian adults. Health provider utilization and care seeking. J Manipulative Physiol Ther 2004; 27: 327-35.

(17.) Rolland M, Morris R. A study of the natural history of back pain: part 1 development of a reliable and sensitive measure of disability in low back pain. Spine 1983; 8: 141-145.

(18.) William JH, Money JK, Kristina SB. Implications for physical activity in the population with low back pain. American Journal of Lifestyle and Medicine 2009; 3(1): 63-70.

(19.) Lafuma A, Fagnani F, Vautravers P. Management and cost of care for low back pain in primary care settings in France. Pharmaco Economics 1998;14(3): 313-22.

(20.) Becker A, Held H, Redelli M. Low back pain in primary care, loss of care and prediction of future health care utilization. Spine 2010; 35(18): 1714-1720.





Department of Physiotherapy, College of Medicine, University of Ibadan, Ibadan.

Correspondence: Adesola C. Odole, Department of Physiotherapy, College of Medicine, University of Ibadan, Ibadan * Email
Table 1. Socio-demographic characteristics of participants

Characteristics No %

 Male 25 62.5
 Female 15 37.5

Age group (years)
 30-40 5 12.5
 40-50 13 32.5
 50-60 11 27.5
 60-70 9 22.5
 70 and above 2 5

Marital Status
 Married 39 97.5
 Single 0 0
 Widowed 1 2.5
 Cohabiting 0 0

 Banking 5 12.5
 Trading 17 42.5
 Teaching 3 7.5
 Security 2 5
 Farming 2 5
 Driving 2 5
 Estate management 1 2.5
 Business 4 10
 Civil service 2 5
 Engineering 2 5

Level of Education
 University 5 12.5
 Post secondary 4 10
 Secondary 3 7.5
 Technical 2 5
 Teacher Grade II 3 7.5

 Primary 20 50
 Incomplete Secondary 1 2.5

 No Formal Education 2 5

Table 2. Direct cost of care of low back pain

 Annual cost (naira)

Sex n % Mean SD %

Physician's Visit
Male 25 62.5 29169.6 13254.25
Female 15 37.5 23408 13057.05
Total 40 100 27009 13314.95 23.56

Physiotherapy Visit
M 25 62.5 75426 68875.2
F 15 37.5 86344 62650.55
Total 40 100 68875.2 53988.52 63

Diagnostic Test
M 25 62.5 3782 1521.85
F 15 37.5 2893.33 787.6
Total 40 100 3448.75 1355.64 3

Topical Creams/Gels/Sprays
M 2 50 7488 2661.5
F 15 37.5 7160 2627.62
Total 40 100 7365 2649.2 6.4

Supportive Devices
M 2 50 3500 0
F 2 50 3750 353.55
Total 4 100 3625 250 3.12

M 0 0 0 0
F 15 100 2796.33 903.7
Total 15 2796.33 903.7 0.92

Overall 114661.25 74230.53 100

Table 3. Indirect cost of care of low back pain

 Annual cost (naira)

 n Mean SD
Respondent 40 17772 13526.12
Accompanying person 11 12938.18 9331.78
Meals Outside Home 13 9738.46 4850.69
Paid Helps 3 34000 19287.3
Total 24495 16837.13
Hours lost per 10.25 6.75
 hospital visit

Table 4. Economic costs of low back pain

Costs (Naira) Mean SD %

Direct 114661.25 74230.53 82.4
Indirect 24495 16837.13 17.6
Total 139156.25 77091.16 100

Table 5. Comparison between economic costs of male and
female patients with low back pain

Economic Burden Male Female p value

Direct costs 109594.8 123105.33 0.549
Indirect costs 24902.4 23816 0.862
Overall costs 134497.2 146921.33 0.598

Table 6. Association between Respondents'
Disability Scores and Economic Burden of Care

Economic costs Disability value p value

Indirect costs 24.48 0.02 *
Direct costs 23.07 0.05 *
Overall costs 37.87 0.04 *

* Significant at p < 0.05
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Article Details
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Author:Odole, Adesola C.; Akinpelu, Aderonke A.; Adekanla, Babatunde A.; Obisanya, Olatunji B.
Publication:Journal of the Nigeria Society of Physiotherapy
Geographic Code:0DEVE
Date:Jun 1, 2011
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