Pain in the lumbar spine and/ or pelvic region; described as Lumbopelvic pain (LPP) has become a significant health concern for women in all societies [1-7]. The exact pathology behind the cause of LPP is still not known [1-7]. However, its increasing predominance among women is majorly due to its association with parturition since it involves alterations in lumbopelvic structures [3]. Similarly, abnormal stresses to the abdominal and pelvic structures also increase the risk of LPP. These observations are common in women with urinary incontinence, breathing disorders, etc [8, 9]. Hence, women are disproportionately vulnerable to LPP disorders [1-7].

The prognosis of LPP is poor among women, which severely deteriorates their psychological well-being [10-12]. Evidence suggests that in response to general stress, people either indulge in health-promoting or health-inhibiting habits [13]. When psychological stress coexists with LPP irrespective of what occurred first, it negatively influences lifestyle habits like lack of exercise, unhealthy diet, and subsequent weight gain. Health-inhibiting activities in turn mediate several lifestyle-related conditions that are widely recognized to interfere with the general and reproductive health of women [1, 14, 15]. One such common disorder prevailing among reproductive women is Polycystic Ovarian Syndrome (PCOS), which further escalates the risk of other health ailments like hypertension (HTN) and diabetes mellitus (DM type 2) [16-18].

Lack/low physical activity also involves a mechanism that accounts for endocrine alterations which again is a frequent observation among women experiencing LPP [18-20]. A common endocrine disorder among women is osteoporosis which severely accelerates the rate of lumbar vertebral disc degeneration once a woman attains menopause [21-23]. Low bone health, however, is prevalent among young premenopausal women as well [15]. Disrupted lifestyles owing to urbanization significantly disturb metabolic homeostasis giving rise to several health issues in women such as gastrointestinal diseases, delayed menarche, etc. where an alteration in the thyroid stimulating hormones(TSH) is most common [15, 24]. This is noteworthy since endocrine alterations are particularly associated with lumbar spine pathology in women, and routine exercises are frequent recommendations for good endocrine balance [16].

Physical activity is considered to be a protective factor in preventing LPP. The World Health Organization (WHO) has recommended at least 2.5 hours of moderate endurance activities for achieving significant health benefits for adults, even for those with chronic health conditions [25]. “Straighten up and move” was one such evidence-based program promoted by the WHO that aimed to create sensitization about the importance of daily exercises in the prevention of LPP and associated disabilities in economically deprived communities [26]. Conversely, functional disability secondary to LPP has socioeconomic consequences in terms of decreased productivity in work and increased treatment costs [27, 28].

It is known that only 25% of an individual’s health is determined by his/her genes and health-caring behaviors and the rest 75% is influenced by the environment, medical care, and social factors, and these factors are largely framed by the socioeconomic status of a person [29]. It is believed that populations with relatively low socioeconomic classes are vulnerable to physical illness since socioeconomic disparities come in the way of good healthcare services for poor families [30, 31]. India is a country where socioeconomic barriers to health don’t merely mean poor monetary status but also comprise caste(hierarchy in Indian society) [32], geographical region (rural/urban) [31], and even the unsupportive family [33, 34]. It has been noticed that under such circumstances, heath is never a priority of concern in women’s life [34]. Thus, the socioeconomically deprived Indian women are marginalized by structural as well as social barriers in seeking health care even if they recognize their illness. Whereas, the middle socioeconomic class Indian women weakly perceive their health and therefore don’t realize the need to seek health care [31]. They rather sought self-care and took over-the-counter pain medicines for LPP [31, 33, 35]. As a result, suffering from LPP continues to be elusive among women [31, 33, 35]. Surprisingly, in several communities, women are reluctant to engage in health screening initiatives owing to health illiteracy. Illiteracy or insufficient education doesn’t make them recognize the risks to their physical health [30, 31, 34, 36-41] and they end up adopting wrong lifestyle choices like reduced physical activities. Low physical activity, if maintained for a long time, eventually leads to musculoskeletal deconditioning and the development of LPP [39, 42-47]. A challenge in studying socioeconomic disparities in health and LPP is that the related components are often correlated with one another. We aimed to gather data on the direct linkage between socioeconomic status, general health, reproductive and exercise status, and LPP in Indian women. As a first step, the purpose of this study was to determine the frequency or percentage occurrence of these factors in women with LPP.

LPP is a predominant musculoskeletal condition that is strongly linked with women’s reproductive function [3, 14, 51, 52]. In our research sample, about 76.8% of participants reported LPP at the time of recruitment, implying a high prevalence rate in Indian women.

Among the studied gynecological covariates, PCOS and other menstrual issues (dysmenorrhea/ irregular or heavy menses) were found to have a strong association with LPP in the reproductive participants of our study. The mean age of attaining menopause in Indian women is 46.2 years, which is way less when compared to Western women [53]. About 24.8% of participants in our study were post-menopausal, among which 121 participants had LPP. This can be related to the literature stating that estrogen level deficits lead to the degeneration of lumbar intervertebral discs in post-menopausal women [22]. A notable observation in our study was that 4.2% of our participants reported undergoing a hysterectomy, among which 19 participants had LPP. This implies that hysterectomy is common among Indian women and is indeed a matter of concern for women’s health.

Disturbances in menstrual cycles have often been linked to over/under-active thyroid [54]. 33.3% of our study participants with LPP had hypo or hyperthyroidism. Further, UI, respiratory and gastrointestinal symptoms have been previously evaluated as risk factors for the development of LPP among women [9, 50]. The presence of premorbid health ailments predicts LPP with a predominantly higher risk among women [55]. We found several health issues in our study participants coexisting with LPP like diabetes, osteoporosis, hypertension, thyroid problems, UI, chronic cough, and chronic constipation. However, following multivariate regression analysis only UI (O.R.=3078.2) and chronic cough (O.R.=84.97) showed high odds for LPP. Compromised lumbopelvic control observed among patients with UI and respiratory issues could provide a physiological explanation for such associations [51, 56]. Hysterectomy has been significantly associated with UI in previous studies [8]. Since a substantial number of middle-aged women in our study had a hysterectomy, we can establish a possible link between UI, hysterectomy, and LPP. Further, a repetitive increase in intraabdominal pressure as observed during chronic cough, has been found to result in irreversible damage to the intervertebral disc in the long run. Moreover, the concurrent contraction of trunk flexors and extensors along with rapid forward trunk flexion during chronic coughing places an undue load on the lumbar spine structures, thereby increasing the risk of LPP [56-60]. Similarly, 81% of LPP participants in our study were suffering from chronic constipation. Straining during constipation too increases the intraabdominal pressure and can develop into LPP involving the same mechanism as that of chronic cough [56-58]. Therefore, it can be ascertained that any health condition that increases the intradiscal pressure will also augment the risk for LPP since the trunk musculature along with the respiratory diaphragm, transversus abdominis, and pelvic floor muscles provide mechanical stability to the lumbopelvic joints [9, 50, 59].

Even the transition to motherhood could be a risk to LPP as the physical strain directly sustained by the pelvic structures during parturition can alter lumbopelvic biomechanics; hence, often gives rise to certain LPP disorders [3, 56]. Parturition also disrupts the activity of pelvic floor muscles; hence LPP is a frequent symptom among women with urinary incontinence [50, 60]. The biomechanical consequences associated with parturition could also explain the high prevalence of LPP among parous participants (n=216) compared to nulliparous participants (n=168) in our study. Overall, 66.2% of participants in our study reported a history of LPP and could recall the number of times they experienced LPP in the past year. A previous history of LPP during the pregnancy phase was also strongly associated with current LPP in our study. History of LPP at the time of pregnancy is a strong risk for postpartum LPP that could persist for years [58, 10, 61]. Further, a previous history of LPP has also been found to be a risk factor for LPP during pregnancy for primiparous women as well [62, 63]. Another notable observation among the parous participants was concerning the mode of parturition in our study as well, where a history of c-section delivery (n=74) was strongly associated with current LPP. This can be justified as a consequence of muscle disruption that takes place during the surgical procedure, which can persist for years after the c-section delivery [64]. However, LPP was also evident among our participants who had previously undergone NVD (n=142). The percentage of LPP was high among participants who had ≥ 3 children of their own (52.8%). Possibly the number of times a woman goes through the process of parturition and subsequent changes in lumbopelvic musculoskeletal makes them vulnerable to LPP. We however did not assess the mode of each delivery among multiparous participants. Based on our study findings, it is evident that alteration in lumbopelvic stability can also be an indirect consequence of health ailments, subsequently leading to LPP. Further, the LPP risks differ from the reproductive status of women.

LPP that commences during parturition sometimes progresses to chronicity for as long as twelve years, severely deteriorating the psychological well-being among women [10-12]. We included general psychological stress as part of health status in our study. A shorter duration like one month, has been considered to be enough for assessing general psychological stress levels [65]. Hence, we asked our participants about how often they felt stressed in the past month as we did not intend to assess any specific cause of psychological distress. A direct link between psychological stress and musculoskeletal pain disorders is not established in the literature [66, 67]. However, hindrances in work and social life due to LPP succumbs an individual to poor psychological health [66]. Women have recognized stressful environments like a load of domestic responsibilities to be worsening their pre-existing LPP symptoms [68]. Physiologically, how people emotionally perceive chronic musculoskeletal pains relies on their psychological health status and varies between individuals. The intrinsic neuromodulatory system in the brain is activated by emotion (positive/negative), attention as well as the perception of pain. Hence, pain perception can alter the activity of descending pain and afferent pathways. This possibly explains why chronic musculoskeletal pain leads to psychological distress and vice versa [69, 70].

Poor psychological well-being can engender poor lifestyle habits like sedentarism [1, 65]. The consequences of continuous sitting/standing for occupational demands have been explored in several studies; however, the impact of habitual physical activities on LPP is not well documented [71]. Hence, we identified the duration of regular exercises in our study where about 61% (n=305) of participants reported that exercise was not part of their daily routine, not even 150 minutes/week, which is the WHO recommendation. However, on multivariate logistic regression, we also found high odds (OR=360.15) of LPP for participants who were not at all involved in exercises in their everyday routine. The WHO has long emphasized maintaining the strength and flexibility of the spine by implementing exercises in daily routines [26]. Therefore, exercises have a crucial role even in LPP rehabilitation as well [72, 73]. Still, women are less likely involved in exercise habits possibly because they are less enthusiastic about exercise [74, 75]. Being aware of the benefits of exercising is one such significant measure to prevent LPP among women. Hence, we strongly recommend that healthcare stakeholders take the initiative by developing public health policies focusing on women’s health and sensitizing them about the role of regular exercise in preventing LPP.

Contrastingly, in terms of socioeconomic disparities, we also found that 30% of LPP participants in the upper SES indulged in more than 2.5 hours of weekly exercises. We did not assess the type of exercises among our study participants. Since we recruited participants from the general population, there is a high possibility that these participants were involved in vigorous exercises and/or unguided exercises which could have resulted in LPP. Unawareness about non-pharmacological measures for musculoskeletal LPP like physiotherapy has been observed in rural Indian communities, where the majority of the population is socioeconomically deprived [76]. Though the current study took place in an urban Indian city, most of the study participants reporting LPP belonged to upper-lower SES (n=106). Hence, the impact of LPP is huge from an individual as well as a socio-economic perspective [2]. Unawareness could be thought of as one of the possible reasons for the high prevalence of LPP among participants from lower SES because, unlike rural areas, urban populations have access to healthcare facilities. Further, adapting self-help strategies is a common practice among Indian women to cope with LPP, where the underprivileged opt for home measures while the privileged women self-medicate [31, 33]. Menstrual issues like dysmenorrhea/ irregular or heavy menses were prevalent among our LPP participants in both upper and lower SES. We can’t associate SES with these menstrual issues since it was common in both socioeconomic strata. The only thing common among our participants was the urban environment. Since these menstrual issues could result from metabolic disturbances, which are known to be influenced by poor lifestyle habits like decreased physical activity, psychological stress, and improper dietary habits [15, 20]. Another possible reason could be the occupations commonly observed among the population with low SES as a majority of them are involved in physically strenuous jobs that increase the risk of injury in the lumbopelvic complex [30, 77-79]. However, LPP risk is about 25% higher among women compared to male workers for a similar amount of exposure to strenuous physical tasks [48] as ergonomically the strength and anthropometrics of women are not the same as for male workers [80].

UI, chronic cough, PCOS, dysmenorrhea/irregular and/or heavy menses, general psychological stress, and noninvolvement in exercises were identified to be highly associated with LPP among Indian women. Noteworthily, many lifestyle-related conditions were found to be strongly associated with LPP, like hypo/hyperthyroidism and chronic constipation. Hence, there is an alarming need for sensitization among women about inculcating health-promoting lifestyle habits like exercise and a good diet. Since a poor lifestyle is not only a risk for LPP but several health ailments interrelated to women’s reproductive status. Formative information has been provided through the current study findings, which can be used to plan empirical strategies to engage women in LPP rehabilitation. It is also evident from the study findings that women presenting with LPP should be screened for health and reproductive status. Further, the amalgamation of this study data strengthens the association between socioeconomic class and health influences of women with LPP and suggests significant inferences for healthcare practice and research. A healthcare professional needs to be aware of the potential general health-related risks beyond the musculoskeletal origin, to reduce LPP suffering among women.