The Status of Anxiety, Physical Disability, Physical Activity and The Pain Intensity Among Young Adults with Non-Specific Low Back Pain (NSLBP) Based on Gender
DOI:
https://doi.org/10.37134/jsspj.vol14.2.4.2025Keywords:
Anxiety, Disability, Physical Activity, Pain Intensity, Non-specific Low Back Pain, Young Adults, GenderAbstract
Non-Specific Low Back Pain (NSLBP) is a leading cause of disability worldwide, particularly among young and middle-aged adults. It accounts for approximately 90% of all low back pain cases and is characterized by pain in the lower back without an identifiable cause. Therefore, this study aimed to examine the status of anxiety, physical disability, physical activity, and pain intensity among young adults with NSLBP in Kuantan, focusing on gender-based differences and interrelationships between these variables. Approximately 70 males and 130 females who aged from 18 to 30 years completed self-administered online questionnaires, comprising the Numerical Pain Rating Scale (NPRS), Generalized Anxiety Disorder Scale (GAD-7), Oswestry Disability Index (ODI), and International Physical Activity Questionnaire–Short Form (IPAQ-SF). An independent t-test revealed that female participants reported significantly higher anxiety (GAD-7: 10.82 ± 5.22 and 7.81 ± 5.03, respectively; p<0.001), greater physical disability (ODI: 6.69 ± 6.09 and 4.73 ± 5.95, respectively; p<0.05) and higher pain intensity (4.98 ± 2.20 and 3.83 ± 2.78, respectively; p<0.001) compared to male participants. In contrast, male participants in the intermediate activity group demonstrated significantly higher engagement in moderate and vigorous activities. The Pearson correlation analysis revealed a significant relationship between anxiety, pain intensity, and physical disability (r = 0.46 - 0.51, p<0.001), indicating that higher anxiety was associated with greater pain and functional limitations. Physical activity showed no significant correlation with anxiety, pain, and physical disability (r = - 0.05 to 0.09, p> 0.05). In conlcusio, female participants exhibited higher anxiety, pain, and disability, whereas males engaged more frequently in physical activity. These findings emphasize the importance of gender-sensitive approaches to NSLBP management that integrate both physical rehabilitation and psychological support.
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References
Ab Hamid Abas, A., Daud, A., Mohd Hairon, S., & Mohd Nazri Shafei, M. (2023). Prevalence and risk factors of low back pain in Malaysia: A scoping review. Malaysian Journal of Medical Sciences, 30(3), 32–41.
Abadi, F. H., Tiis, N. H. A. A., Zainuddin, F. F., Choeibuakaew, W., Elumalai, G., Sankaravel, M., & Motevalli, S. (2022). The impact of combination of core stabilization exercise and walking on pain perception and low-back pain disability. Pedagogy of Physical Culture and Sports, 26(5), 276-283.
Abd Rahman, N., Ariaratnam, S., Hashim, N. A., & Azhar, Z. I. (2024). Prevalence and factors associated with generalized anxiety disorder among patients with chronic pain: A single center cross sectional study in Malaysia. Plos one, 19(7), e0307992.
Abdulrahman, K. A. B., Al Askar, A. T. S., Alhamidi, A. K. A., Al Sharani, A. H. A., Alanazi, A. A. S., Alkatheeri, A. N. H., ... & Alharbi, A. J. (2024). Low back pain among college students in a public Saudi university: A cross-sectional study. Journal of Family Medicine and Primary Care, 13(9), 3798-3805.
Adlakha, D., & Parra, D. C. (2020). Mind the gap: Gender differences in walkability, transportation and physical activity in urban India. Journal of Transport & Health, 18, 100875.
Ahmad, N. A., Mohamad Kasim, N., Mahmud, N. A., Mohd Yusof, Y., Othman, S., Chan, Y. Y., ... & Aris, T. (2017). Prevalence and determinants of disability among adults in Malaysia: results from the National Health and Morbidity Survey (NHMS) 2015. BMC public health, 17(1), 756.
Alias, N., Lim, K. K., & Chan, Y. Y. (2022). Physical inactivity among adults in Malaysia by gender differences: Findings from the National Health & Morbidity Survey (NHMS) 2019. Poster Presentation at the 9th Asia Pacific Conference on Public Health. Institute for Public Health, Ministry of Health Malaysia.
Alif, S. M. A. A. M., & Isa, S. N. I. (2022). Work-related physical factors and low back pain among policemen in Kelantan: A cross-sectional study. Healthscope: The Official Research Book of Faculty of Health Sciences, UiTM, 5(1), 1-6.
Alireza, S., Rahimi, S., & Hosseini, F. (2024). Effects of dynamic neuromuscular stabilization on pain and disability in non-specific chronic low back pain. Journal of Bodywork and Movement Therapies, 34, 101–110.
Aljuraifani, R., Taylor, N. F., & Janse de Jonge, X. A. K. (2022). Occupational risk factors associated with low back pain among professional drivers: A systematic review and meta-analysis. BMC Musculoskeletal Disorders, 23(1), 318.
Alkasir, A. (2021). Telehealth for musculoskeletal rehabilitation & pain care: applying qualitative methods and the six-forces innovation framework to assess and address a prevalent US Healthcare need (Doctoral dissertation, Harvard University).
Alodhialah, A. M., Almutairi, A. A., & Almutairi, M. (2024, October). Assessing the association of pain intensity scales on quality of life in elderly patients with chronic pain: A nursing approach. In Healthcare (Vol. 12, No. 20, p. 2078). MDPI.
Alonso-Sal, A., Alonso-Perez, J. L., Sosa-Reina, M. D., García-Noblejas-Fernández, J. A., Balani-Balani, V. G., Rossettini, G., & Villafañe, J. H. (2024). Effectiveness of Physical Activity in the Management of Nonspecific Low Back Pain: A Systematic Review. Medicina, 60(12), 2065.
Alotaibi, M. A., Alhowimel, A. S., Alodaibi, F. A., Alimam, D., Alghadier, M., & Elnaggar, R. K. (2025). Fear-avoidance beliefs increase the perception of pain and disability in Saudi Arabian patients with chronic low back pain. Medicine (Baltimore), 104(30), e43510.
Alqhtani, R. S., Ahmed, H., Alshahrani, A., Alyami, A. M., Khan, A. R., & Khan, A. (2023). The Association of Psychological Variants with Back Pain, Muscle Endurance, and Functional Limitations in an Individual with Chronic Back Pain. Journal of Personalized Medicine, 13(12), 1671.
Alshehri, M. M., Alqhtani, A. M., Gharawi, S. H., Sharahily, R. A., Fathi, W. A., Alnamy, S. G., ... & Alenazi, A. M. (2023). Prevalence of lower back pain and its associations with lifestyle behaviors among college students in Saudi Arabia. BMC Musculoskeletal Disorders, 24(1), 646.
Alshehri, M. M., Alqhtani, A. M., Gharawi, S. H., Sharahily, R. A., Fathi, W. A., Alnamy, S. G., ... & Alenazi, A. M. (2023). Prevalence of lower back pain and its associations with lifestyle behaviors among college students in Saudi Arabia. BMC Musculoskeletal Disorders, 24(1), 646.
Anggiat, L. (2020). A brief review in non-specific low back pain: Evaluation and physiotherapy intervention. International Journal of Medical and Exercise Science, 6(3), 760-769.
Anuar, A., Hussin, N. Z. M. H., Maon, S. N., Hassan, N. M., Abdullah, M. Z., Mohd, I. H., & Sahudin, Z. (2021). Physical inactivity among university students. International Journal of Academic Research in Business and Social Sciences, 11(5), 356-366.
Apaydın, U. M. U. T., & Saraç, D. (2024). Assessment in Cerebral Palsy.
Apkarian, A. V. (2008). Pain perception in relation to emotional learning. Current Opinion in Neurobiology, 18(4), 464–468.
Apkarian, A. V. (2008). Pain perception in relation to emotional and sensory components. Brain Research Reviews, 60(1), 89–118.
Archibeck, E., Strigo, I., Scheffler, A., Torres-Espin, A., Khattab, K., Silvestros, P., ... & Bailey, J. (2025). Sex-based differences in biomechanical function for chronic low back pain and how it relates to pain experience. European Spine Journal, 1-10.
Asif, M., Habib, S., Anwar, S., Kausar, F., Gul, N., Fatima, K., ... & Aslam, I. (2024). Prevelanace of Non-Specific Low Back Pain with Compromised Endurance and Stability in Young Adult Females. Journal of Health and Rehabilitation Research, 4(1), 819-824.
Awad, M. Y. H., Warasna, H. J. M., Awad, B. Y. H., Shaaban, M. E., Ibrahim, T., Awad, I. Y. H., ... & Saad, R. J. (2025). Prevalence of lower back pain and its associations with lifestyle behaviors among university students in the West Bank, Palestine: a cross-sectional study. Annals of Medicine, 57(1), 2522974.
Ayushi, S., Mehta, S., & Patel, H. (2021). Association between sitting posture and non-specific low back pain among university students: A cross-sectional study. International Journal of Health Sciences and Research, 11(8), 112–118.
Azzam, A., Ibrahim, M., & Khalid, M. (2024). Manual therapy versus exercise in non-specific low back pain: Comparative outcomes on pain and function. Physiotherapy Research International, 29(2), e2009.
Baig, A. A. M., Ansari, B., Ahmed, S. I., Ishaque, F., & Farooqui, W. A. (2024). Association of demographics, lumbar active range of motion and disability in chronic low back: a baseline data analysis of a randomized controlled trial from Pakistan. BMC Musculoskeletal Disorders, 25(1), 489.
Bair, M. J., Krebs, E. E., & Poleshuck, E. L. (2021). Anxiety and depression in patients with chronic pain: Impact and implications for treatment. Current Psychiatry Reports, 23(2), 1–9.
Balagué, F., Mannion, A. F., Pellisé, F., & Cedraschi, C. (2012). Non-specific low back pain. The lancet, 379(9814), 482-491.
Balasubramanian, G. P., Simansalam, S., Paruchuri, S., Yi, L. L. Q., & Chui, J. H. (2024). Functional disability among the older adult population in Kedah, Malaysia. Clinical Epidemiology and Global Health, 29, 101673.
Barone Gibbs, B., Hergenroeder, A. L., Schuna, J. M., Davis, K. K., & Buman, M. P. (2018). Reducing sedentary behaviour to improve health in office workers: A randomized pilot study. Journal of Occupational and Environmental Medicine, 60(9), 777–782Chiarotto, A., Terwee, C. B., Ostelo, R. W. J. G., Boers, M., & Buchbinder, R. (2018). Core outcome domains for clinical trials in nonspecific low back pain. European Spine Journal, 27(6), 1231–1243.
Basri, N. F., Masuri, M. G., Danis, A., Isa, S. N. I., Abd Aziz, N. A., & Md Isa, K. A. (2021). Prevalence of low back pain with its associated risk factors among health science students. Healthscope: The Official Research Book of Faculty of Health Sciences, UiTM, 4(1), 51-59.
Batalha, A. P. D. B., Marcal, I. R., Main, E., & Ghisi, G. L. D. M. (2025). Barriers to physical activity in women from ethnic minority groups: a systematic review. BMC Women's Health, 25(1), 330.
Bauman, A., Bull, F. C., Chey, T., Craig, C. L., Ainsworth, B. E., & Sallis, J. F. (2022). The International Physical Activity Questionnaire: 20 years of development, research, and global application. Journal of Physical Activity and Health, 19(3), 217–229.
Beales, D. J., Smith, A. J., O’Sullivan, P. B., & Straker, L. M. (2022). Low back pain and gender differences in physical activity and sedentary behavior: A population-based study. BMC Musculoskeletal Disorders, 23(1), 318.
Bernatova, I., Smith, R., & Lee, C. (2024). Emotional modulation of sensory and affective pain dimensions: An electroencephalography study. Neuroscience & Biobehavioral Reviews, 150, 105–115.
Bosse, A., Mavromatis, J., & Schütz, C. (2021). Pain catastrophizing and vigilance in chronic musculoskeletal pain: A predictive relationship. European Journal of Pain, 25(4), 761–772.
Boutevillain, L., Dupeyron, A., Rouch, C., Richard, E., Coudeyre, E., & Cottencin, O. (2020). Fear-avoidance beliefs and physical activity in chronic low back pain: Mediating role of anxiety and catastrophizing. Pain Medicine, 21(6), 1143–1151.
Briggs, A.M., Sumi, Y. & Banerjee, A. The World Health Organization guideline for non-surgical management of chronic primary low back pain in adults: implications for equitable care and strengthening health systems globally. glob health res policy 10, 26 (2025).
Brinjikji, W., Diehn, F. E., & Carr, C. M. (2022). Spinal anatomy and biomechanics: Implications for back pain. American Journal of Neuroradiology, 43(2), 221–230.
Brisbine, B. R., et al. (2025). How do fluctuations in endogenous sex hormones affect pain sensitivity? Frontiers in Pain Research.
Burrows, N. J., Barry, B. K., Sturnieks, D. L., Booth, J., & Jones, M. D. (2020). The relationship between daily physical activity and pain in individuals with knee osteoarthritis. Pain Medicine, 21(10), 2481-2495.
Burtscher, J., Millet, G. Y., Burtscher, M., et al. (2024). Dose-response relationship of moderate-intensity physical activity and cardiovascular risk: An analysis from Austria. BMC Public Health, 24, 2843.
Butevillain, L., Dupeyron, A., Rouch, C., Richard, E., Coudeyre, E., & Cottencin, O. (2020). Fear-avoidance beliefs and physical activity in chronic low back pain: Mediating role of anxiety and catastrophizing. Pain Medicine, 21(6), 1143–1151.
Caneiro, J. P., O’Sullivan, P. B., Roos, E. M., & Linton, S. J. (2023). The complexity of pain and disability: Integrating psychological, social, and behavioral factors in musculoskeletal pain management. Pain Reports, 8(1), e1057.
Casares, M. Á., Martínez, M. E., & López, J. F. (2024). Validation of the Generalized Anxiety Disorder Assessment (GAD-7) in primary-care settings. Journal of Affective Disorders, 340, 125–134.
Casas S, A. S., Patiño S, M. S., & Camargo L, D. M. (2016). Association between the sitting posture and back pain in college students. Revista de la Universidad Industrial de Santander. Salud, 48(4), 446-454.
Chaichan, K., & Pensri, P. (2023). Physical and psychological factors associated with non-specific low back pain among female cleaners in academic settings. Journal of Health Science and Alternative Medicine, 5(3), 35–43.
Chen, Y., Liu, J., & Zhang, L. (2021). Reliability and validity of the Chinese version of the International Physical Activity Questionnaire–Short Form among university students. BMC Public Health, 21(1), 1194.
Chen, Y., Xu, S., & Liu, X. (2021). Sedentary behavior, posture, and low back pain among university students: A cross-sectional study. Frontiers in Public Health, 9, 687846.
Chen, Z. (2024). Voluntary Postural Control in People with Low Back Pain (Doctoral dissertation, Swinburne).
Cheng, Y., Yu, Y., Wang, Y., Fan, A., Yang, H., Wang, H., & Tang, L. (2023). Effects of lumbar-pelvic training combined with electroacupuncture on chronic nonspecific low back pain. Medicine, 102(29), e34407.
Chong, C. Y., Tan, C. X., Tsai, M. C., Tan, S. S., Hariyono, H., & Tan, S. T. (2024). Gender differences in dietary intake and physical activity among university students: a post-COVID-19 pandemic study. Nutrition & Food Science, 54(7), 1190-1201.
Choudhury, M., Alam, S., & Rahman, H. (2024). Psychological distress and disability in chronic low back pain: A mediational model. Pain Management Nursing, 25(1), 37–45.
Christie, A., Smith, B., & Jones, C. (2021). Emotional distress is associated with greater pain intensity and disability among adults with low back pain: A cross-sectional study. Pain Reports, 6(1), Article e885.
Cieza, A., Causey, K., Kamenov, K., Hanson, S. W., Chatterji, S., & Vos, T. (2021). Global estimates of the need for rehabilitation based on the Global Burden of Disease Study 2019: A systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396(10267), 2006–2017.
Citko, A., Górski, J., & Marcinowicz, L. (2018). Sedentary lifestyle and nonspecific low back pain in medical personnel in North-East Poland. BioMed Research International, 2018, Article ID 1965807.
Clael, S., Campos, L. F., Correia, K. L., de Lucena, J. M. S., Gentil, P., Durigan, J. L., ... & Martins, W. R. (2021). Exercise interventions can improve muscle strength, endurance, and electrical activity of lumbar extensors in individuals with non-specific low back pain: a systematic review with meta-analysis. Scientific Reports, 11(1), 16842.
Cleveland Clinic. (2023). Generalized anxiety disorder (GAD): Symptoms & treatment. https://my.clevelandclinic.org/health/diseases/23940-generalized-anxiety-disorder-gad
Comerford, J. A. (2023). Core stabilization exercises for managing non-specific low back pain in adults: A narrative review of their efficacy alone or with multidisciplinary approaches. Chiropractic Journal of Australia (Online), 50(1), 29-51.
Cornellia, M., & Achim, K. (2023). The role of physical functioning and rehabilitation strategies in managing non-specific low back pain: A systematic review. Journal of Musculoskeletal Science and Practice, 58, 102613.
Costa, L. O. P., Maher, C. G., McAuley, J. H., Hancock, M. J., Smeets, R. J., & Ferreira, P. H. (2021). Prognosis for patients with chronic low back pain: The role of pain intensity and disability. European Spine Journal, 30(6), 1455–1466.
Crawford, J., Lin, C. C., & Ferreira, G. E. (2024). Prevalence and determinants of non-specific low back pain in young adults: A global systematic review and meta-analysis. Musculoskeletal Science and Practice, 72, 102835.
Cruz, E. B., Canhão, H., Fernandes, R., Caeiro, C., Branco, J. C., Rodrigues, A. M., et al. (2020). Prognostic indicators for poor outcomes in low back pain patients consulted in primary care. PLoS ONE, 15(3), e0229265.
Daniel, F., Lim, J., & Wong, S. (2019). Validation of the International Physical Activity Questionnaire (IPAQ) for assessing physical activity among Malaysian adults. Malaysian Journal of Public Health Medicine, 19(1), 45–52.
Daud, A., Hairon, S. M., & Shafei, M. N. (2023). Prevalence and risk factors of low back pain in Malaysia: A scoping review. The Malaysian Journal of Medical Sciences: MJMS, 30(3), 32.
Daud, A., Mohamad, N., & Ismail, N. (2023). Physical activity levels and low back pain among young adults in Malaysia: A cross-sectional review. Malaysian Journal of Public Health Medicine, 23(2), 15–26.
Daud, M. N., Abdullah, R., & Rahman, M. H. (2023). Gender and mental health as key risk factors for low back pain in Malaysia: A scoping review. Malaysian Journal of Public Health Medicine, 23(1), 45–56.
De Sire, A., Ammendolia, A., Gimigliano, A., Tiberi, R., Cisari, C., & Invernizzi, M. (2021, July). Spinal orthoses prescription for vertebral fragility fractures by italian physical and rehabilitation medicine physicians: The SPIN-VER survey. In Healthcare (Vol. 9, No. 7, p. 892). MDPI.
Delgado, P., García, R., & Suárez, L. (2023). Effects of endurance and strengthening exercise on pain and disability in chronic low back pain: A systematic review. BMC Musculoskeletal Disorders, 24(1), 112–125.
Deng, W., Sun, H., & Zhang, Y. (2020). Comparison of self-reported and accelerometer-measured physical activity in adults using the IPAQ-SF. International Journal of Environmental Research and Public Health, 17(12), 4390.
Deng, W., Wang, X., & Ma, Y. (2019). Reliability and validity of the International Physical Activity Questionnaire in Chinese populations: A systematic review. Journal of Physical Activity and Health, 16(7), 611–618.
Deros, B. M., Isa, N. S. M., Daruis, D. D. I., Ismail, A. R., & Parasuraman, R. (2011). Prevalence of Back Pain among Taxi Drivers in Klang Valley. Malaysian Journal of Ergonomics (MJEr), 1, 85-90.
Diyana, M. A., Karmegam, K., Shamsul, B. M. T., Irniza, R., Vivien, H., Sivasankar, S., ... & Kulanthayan, K. C. M. (2019). Risk factors analysis: Work-related musculoskeletal disorders among male traffic policemen using high-powered motorcycles. International Journal of Industrial Ergonomics, 74, 102863.
Donoso, B., Castellote-Caballero, Y., Villegas-Fuentes, A., Tsiarleston, G., Gil-Gutiérrez, Y. M., Fernández-Álvarez, J. E., ... & Segura-Jiménez, V. (2024). Effects of a multidimensional approach based on exercise and mindfulness on pain, disability, quality of life, mental health, and gait parameters in patients with non-specific chronic low back pain: the BACKFIT randomized controlled trial.
Dudeney, J., et al. (2024). Anxiety and depression in youth with chronic pain: A meta-analysis. JAMA Pediatrics, 178(4), 345–354.
Dwyer, J. J., Staley, K. M., & Donnelly, J. E. (2024). Barriers and facilitators to exercise participation among women with chronic musculoskeletal pain. Journal of Physical Activity and Health, 21(2), 115–127.
Elkin, J., Rachwani, J., & Murphy, S. (2020). Validity and reliability of the International Physical Activity Questionnaire–Short Form among university students. International Journal of Environmental Research and Public Health, 17(21), 8044.
Falla, D., Jull, G., Hodges, P. W., & Hodges, P. W. (2021). Gender differences in the neuromuscular control of the spine and implications for low back pain. Journal of Orthopaedic & Sports Physical Therapy, 51(5), 247–256.
Fater, D. C., Norris, C., & Wilkins, K. (2024). Adolescent back pain and risk of chronic low back pain in adulthood: A longitudinal cohort study. Spine Journal, 24(1), 22–31.
Fillingim, R. B., Loeser, J. D., Baron, R., & Edwards, R. R. (2023). Gender, sex, and pain: A contemporary review of biological and psychosocial mechanisms. Pain, 164(2), 217–229.
Florian, S., Reininghaus, A., & Tesarz, J. (2022). Psychological and social characteristics in patients with low back pain: A systematic review and meta-analysis. Pain Practice, 22(7), 653–668.
Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., & Gross, D. P. (2022). Prevention and treatment of low back pain: Evidence, challenges, and promising directions. The Lancet, 400(10356), 1902–1915.
Francescato Torres, S., Brandt de Macedo, A. C., Dias Antunes, M., Merllin Batista de Souza, I., Dimitre Rodrigo Pereira Santos, F., de Sousa do Espírito Santo, A., ... & Pasqual Marques, A. (2019). Effects of electroacupuncture frequencies on chronic low back pain in older adults: triple-blind, 12-months protocol for a randomized controlled trial. Trials, 20(1), 762.
García-Moreno, J. M., Calvo-Muñoz, I., Gómez-Conesa, A., & López-López, J. A. (2024). Assessment of the effects of physiotherapy on back care and prevention of non-specific low back pain in children and adolescents: A systematic review and meta-analysis. Healthcare, 12(10), 1036.
George, S. Z., Fritz, J. M., & Childs, J. D. (2023). Physical activity and outcomes in low back pain: A review of recent evidence. Spine Journal, 23(2), 147–156.
Ghasemi, F., Beversdorf, D. Q., & Herman, K. C. (2024). Stress and stress responses: A narrative literature review from physiological mechanisms to intervention approaches. Journal of Pacific Rim Psychology, 18, 18344909241289222.
Golovacheva, V. A., Tabeeva, G. R., & Golovacheva, A. A. (2023). Non-specific low back pain: principles and algorithms for successful management of patients in real clinical practice. Neurology, Neuropsychiatry, Psychosomatics, 15(3), 85-94.
Gonçalves, A., Coelho, A., & Pinto, R. (2022). Gender differences in anxiety and pain sensitivity among adults with musculoskeletal pain. European Journal of Pain, 26(9), 1952–1964.
Grace, J., & Ahmed, S. (2020). Physical activity and low back pain in young adults with cerebral palsy: A cross-sectional study using the IPAQ-SF. Disability and Rehabilitation, 42(14), 1985–1993.
Grace, P. M., Finn, D. P., & Cahill, C. M. (2020). Physical activity and musculoskeletal pain in young adults with cerebral palsy. Frontiers in Human Neuroscience, 14, 580.
Grisworld, S. R., Gargano, F., & Learman, K. (2019). Dry needling versus non-thrust manipulation for nonspecific low back pain. Journal of Manual & Manipulative Therapy, 27(1), 45–54.
Hadiqa, A., Khalid, M., & Imran, M. (2021). Effects of static exercise versus Swiss ball training on postpartum low back pain. Pakistan Journal of Rehabilitation, 10(1), 22–30.
Hong, S. K., & Shin, D. C. (2020). Relationship between pain intensity, disability, and depression among office workers with chronic low back pain. Journal of Physical Therapy Science, 32(7), 457–462.
Hallegraeff, J. M., Kan, R., van Trijffel, E., & Reneman, M. F. (2020). State anxiety improves prediction of pain and pain-related disability after 12 weeks in patients with acute low back pain: a cohort study. Journal of Physiotherapy, 66(1), 39–44.
Hallegraeff, J. M., Kan, R., van Trijffel, E., & Reneman, M. F. (2020). State anxiety improves prediction of pain and pain-related disability after 12 weeks in patients with acute low back pain: a cohort study. Journal of physiotherapy, 66(1), 39-44.
Hanel, J., Owen, P. J., Held, S., Tagliaferri, S. D., Miller, C. T., Donath, L., & Belavy, D. L. (2020). Effects of exercise training on fear-avoidance in pain and pain-free populations: systematic review and meta-analysis. Sports Medicine, 50(12), 2193-2207.
Hartvigsen, J., Hancock, M. J., & Maher, C. G. (2022). What low back pain is and why we need to pay attention. Nature Reviews Rheumatology, 18(5), 253–262.
Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Hoy, D., & Buchbinder, R. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356–2367.
Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Hoy, D., & Woolf, A. D. (2022). What low back pain is and why we need to pay attention. The Lancet Rheumatology, 4(5), e349–e356.
Hazelton, C. (2022). Trunk muscle function is not associated with low back pain in young people whilst muscle morphology is associated with back strength in young adult males: Results from cross-sectional and prospective analyses.
Heidari, A., Amiri, M., & Jafarzadeh, H. (2024). The impact of emotional distress on disability progression in patients with non-specific low back pain. International Journal of Orthopaedic and Sports Medicine, 8(1), 45–53.
Heidari, A., Amiri, M., & Jafarzadeh, H. (2024). The impact of emotional distress on disability progression in patients with non-specific low back pain. International Journal of Orthopaedic and Sports Medicine, 8(1), 45–53.
Helou, K., El Helou, N., Mahfouz, M., Mahfoud, Z., Salameh, P., & Mattar, E. (2018). Validity and reliability of an Arabic version of the International Physical Activity Questionnaire in Lebanon. Journal of Physical Activity and Health, 15(1), 24–30.
Herman, P. M., Qureshi, N., Arick, S. D., Edelen, M. O., Hays, R. D., Rodriguez, A., ... & Coulter, I. D. (2023). Definitions of chronic low back pain from a scoping review, and analyses of narratives and self-reported health of adults with low back pain. The journal of pain, 24(3), 403-412.
Hernandez-Lucas, P., Leirós-Rodríguez, R., Lopez-Barreiro, J., & García-Soidán, J. L. (2024). Prevention of non-specific back pain through exercise and education: A systematic review and meta-analysis.
HESHAM, A. E., MOUSTAFA, S. H., HESHAM, M. H., & AHMED, M. K. (2024). Effect of Preoperative Modic Changes on the Outcome of Patients with Lumbar Degenerative Disc Disease Following Posterior Spinal Fusion or Laminectomy. The Medical Journal of Cairo University, 92(03), 65-70.
Hesham, N., Farouk, R., & Williamson, E. (2024). Physical activity and chronic low back pain: A review of exercise adherence and outcomes. Healthcare, 12(2), 217.
Ho, E. K. Y., et al. (2022). Psychological interventions for chronic, non-specific low back pain: A systematic review and meta-analysis. BMJ, 376, e067718.
Hodačová, L., Pilbauerová, N., Čermáková, E., Machač, S., Schmidt, J., Hodač, J., & Kapitán, M. (2022). The prevalence and development of neck and lower back pain and associated factors in dentistry students—a long-term prospective study. International Journal of Environmental Research and Public Health, 19(14), 8539.
Hong, J. H., & Shin, H. S. (2020). Depression and disability among patients with non-specific low back pain: Mediating roles of pain catastrophizing and self-efficacy. Journal of Clinical Medicine, 9(11), 3422.
Hong, S., & Shin, D. (2020). Relationship between pain intensity, disability, and depression in office workers with chronic low back pain. Journal of Exercise Rehabilitation, 16(2), 152–158.
Hong, S., Palermo, T., & Murray, C. (2024). Psychosocial Risk and Resilience Factors Associated with Pain in Young Adults. The Journal of Pain, 25(4), 62.
Hoos, T., Espana-Romero, V., & Andersen, L. B. (2022). Assessment of recall bias in the IPAQ-SF among office workers and sedentary adults. European Journal of Sport Science, 22(7), 1054–1063.
Horváth, J., Seres, I., Paragh, G., Fülöp, P., & Jenei, Z. (2024). Effect of low- and moderate-intensity aerobic training on body composition, cardiorespiratory functions, biochemical risk factors and adipokines in morbid obesity. Nutrients, 16(23), 4251.
Hoy, D., Blyth, F., March, L., & Buchbinder, R. (2023). Low back pain in young adults: An emerging public health challenge. Global Spine Journal, 13(1), 87–98.
Hoy, D., March, L., & Blyth, F. (2021). Epidemiology of low back pain and its global impact. Best Practice & Research Clinical Rheumatology, 35(3), 101682.
Hu, Y., Li, Z., Zhang, J., & Wang, L. (2022). Anxiety symptoms and associated factors among chronic low back pain patients: A cross-sectional study. Frontiers in Public Health, 10, 878865.
Hušáková, M., Levitová, A., Domluvilová, D., Dad’ová, K., & Pavelka, K. (2022). Depression and anxiety in individuals with axial spondyloarthritis and nonspecific low back pain who are interested in non-pharmacological therapy options: Cross-sectional study. Medicine, 101(39), e30866.
Ikeda, N., Tsuboi, S., & Tanaka, E. (2021). Socioeconomic inequalities in chronic low back pain among older adults in Japan: A cross-sectional study. BMC Musculoskeletal Disorders, 22(1), 98.
Islam, M. S., Ferdous, Z., & Potenza, M. N. (2020). Panic and generalized anxiety during the COVID-19 pandemic among Bangladeshi people: An online pilot survey early in the outbreak. Journal of Affective Disorders, 276, 30–37.
Islam, M. S., Rahman, M. M., & Hossain, M. D. (2024). Prevalence and severity of chronic non-specific low back pain among adults in Bangladesh. Journal of Back and Musculoskeletal Rehabilitation, 37(1), 45-52.
Ismail, A. R., Tamrin, S. B. M., & Hashim, Z. (2015). The association between whole-body vibration and low back pain among taxi drivers in Malaysia: A cross-sectional study. International Journal of Occupational Safety and Ergonomics, 21(1), 19–25.
Izadi, M., et al. (2024). Sex differences in the determination of prescribed load–velocity relationships. Frontiers in Physiology, 15, Article 1293044.
Izham Zain, N., Aidil Anuar, M., & Ahmad Hakim, N. (2021). Gender and age-related differences in the prevalence of non-specific low back pain among adults in Malaysia. Malaysian Journal of Public Health Medicine, 21(3), 67–74.
Izham, N. A. (2021). Gender differences in anatomical and functional characteristics associated with non-specific low back pain among adults: A review. Malaysian Journal of Public Health Medicine, 21(2), 142–149.
Jiang, Y., Wang, Y., Wang, R., Zhang, X., & Wang, X. (2022). Differences in pain, disability, and psychological function in low back pain patients with and without anxiety. Frontiers in Physiology, 13, Article 906461.
Johannes, C. B., LeResche, L., Birnbaum, H. G., & Foley, K. A. (2023). Epidemiology of chronic pain by gender and age: Patterns, trends, and health implications. Pain Reports, 8(2), e1053.
Jongprasitkul, N., Konchalard, K., & Sinthoppong, K. (2023). Prevalence of low back pain and associated factors among motorcycle taxi drivers in Sriracha. Chulalongkorn Medical Journal, 67(2), 180-188.
Jordan, K., & David, L. (2021). The relationship between physical activity and non-specific low back pain: An updated evidence-based review. BMC Musculoskeletal Disorders, 22(1), 841.
Jordan, M., & David, C. (2021). The role of physical activity in the prevention and management of non-specific low back pain: A systematic review. Pain Practice, 21(5), 569–582.
Kahere, M., & Ginindza, T. (2021). The prevalence and risk factors of chronic low back pain among adults in KwaZulu-Natal, South Africa: an observational cross-sectional hospital-based study. BMC musculoskeletal disorders, 22(1), 955.
Kanas, M., Almeida, C., & Silva, J. (2018). Effect of supervised versus unsupervised home-based exercise therapy in chronic low back pain. Physiotherapy Research International, 23(4), e1734.
Kanas, M., Santos, M., & Pereira, M. (2018). Effects of supervised and unsupervised home-based exercise therapy for chronic low back pain. Journal of Bodywork and Movement Therapies, 22(4), 1028–1035.
Kappelides, P. (2024). Barriers and enablers of women carers from culturally and linguistically diverse communities participating in physical activities. Frontiers in Sports and Active Living, 6, 1444025.
Karayannis, N. V., Jull, G. A., & Hodges, P. W. (2021). Psychological distress and altered pain processing in chronic musculoskeletal disorders. Pain Reports, 6(2), e930.
Karimi, R., Prego-Domínguez, J., & Takkouche, B. (2023). Factors contributing to the link between physical well-being and chronic pain in young people from Galicia, Northwest Spain. Journal of Clinical Medicine, 12(13), 4228.
Kendal Huepper, T. (2022). Evaluating low back pain outcome measures: A review of the Oswestry Disability Index and Roland-Morris Disability Questionnaire. Journal of Spine Research, 45(3), 201–209.
Kevin, C. (2021). College students' COVID-19 vaccine hesitancy. Synnott, CK (2021) College Students' COVID-19 Vaccine Hesitancy. The Journal of Higher Education Management, 36(2), 152-159.
Khadour, F. A., Khadour, Y. A., Alhatem, W., Albarroush, D., & Dao, X. (2024). Risk factors Associated with Pain Severity in Syrian patients with non-specific low back Pain. BMC Musculoskeletal Disorders, 25(1), 687.
Khan, M. A., Lee, J., & Seo, Y. (2024). Anxiety and pain perception in musculoskeletal disorders: A cross-sectional analysis. Journal of Pain Research, 17, 305–316.
Khan, S., et al. (2024). Prevalence of Lower Back Pain (LBP) and Its Associated Risk and Disability Among Medical Students. Healthcare, 13(13), 1490.
Kikuchi, R., Tashiro, Y., & Nakamura, M. (2019). Risk factors for non-specific low back pain in children and adolescents: A cross-sectional study. BMC Musculoskeletal Disorders, 20, 583.
Kishner, S., Moradian, M., Morello, J. K., & Gest, T. R. (2017). Lumbar spine anatomy. Pristup, 20, 2020.
Knezevic, N. N., Candido, K. D., Vlaeyen, J. W. S., Van Zundert, J., & Cohen, S. P. (2021). Low back pain and psychological factors: A review of recent literature. Pain Practice, 21(8), 848–863.
Koppenaal, T., van der Heiden, J., Kloek, C. J., Arensman, R. M., Ostelo, R. W., Veenhof, C., & Pisters, M. F. (2023). Characteristics and health outcomes associated with activation for self-management in patients with non-specific low back pain: A cross-sectional study. Musculoskeletal Science and Practice, 67, 102830.
Kritzer, T. D., Lang, C. J., Holmes, M. W., & Cudlip, A. C. (2024). Sex differences in strength at the shoulder: a systematic review. PeerJ, 12, e16968.Kuner, R., & Flor, H. (2021). Structural plasticity and reorganization in chronic pain. Nature Reviews Neuroscience, 22(10), 619–638.
Kuswanto, D., Radiansyah, R. S., Eljatin, D. S., Haykal, M. N., Karimah, R., Indriani, R. D., ... & Wirayuda, A. A. B. (2025). Prognostic Scoring Model for the Transition From Acute to Chronic Non-specific Low Back Pain in Primary Health Care Units in Indonesia. Journal of Preventive Medicine and Public Health, 58(4), 422.
Kwon, M. A., Shim, W. S., Kim, M. H., Gwak, M. S., Hahm, T. S., Kim, G. S., Park, J. H., & Kim, J. (2006). A correlation between low back pain and associated factors: A study involving 772 patients. Korean Journal of Anesthesiology, 50(1), 74–80.
Landen, S., et al. (2023). Physiological and molecular sex differences in human skeletal muscle. The Journal of Physiology.
Lavelle, G., Killeen, T., & Doran, M. (2019). Evaluation of the International Physical Activity Questionnaire–Short Form (IPAQ-SF) in adults. Journal of Physical Activity and Health, 16(5), 412–418.
Lavelle, G., O’Sullivan, K., & Smith, A. (2019). Test–retest reliability and concurrent validity of the IPAQ-SF compared to accelerometry in adults with chronic conditions. BMC Sports Science, Medicine and Rehabilitation, 11(1), 28.
Le Shi, L., Lu, Z. A., Que, J. Y., Huang, X. L., Liu, L., Ran, M. S., Gong, Y. M., Yuan, K., Yan, W., Sun, Y. K., Shi, J., Bao, Y. P., & Lu, L. (2020). Prevalence of and risk factors associated with mental health symptoms among the general population in China during the COVID-19 pandemic: A cross-sectional study. JAMA Network Open, 3(7), e2014053.
Le, J., Thomas, N., & Gurvich, C. (2020). Cognition, the menstrual cycle, and premenstrual disorders: A review. Brain Sciences, 10(4), Article 198.
Le, L. H. L., et al. (2024). Sex differences in pain catastrophizing and its relation to chronic pain. Journal of Pain Research.
Lee, J., Kim, E., & Park, S. (2022). Gender differences in anxiety and functional outcomes among patients with chronic low back pain. Frontiers in Psychology, 13, 872.
Lee, K. X., Quek, K. F., & Ramadas, A. (2024). Factors associated with the health-related quality of life of Malaysian young adults post-pandemic. Nursing Reports, 14(2), 1158-1169.
Lee, S. H., & Liang, H. W. (2023). Discriminative changes in sitting and standing postural steadiness in patients with chronic low back pain. IEEE Transactions on Neural Systems and Rehabilitation Engineering, 31, 3752-3759.
Lee, S., & Lim, J. (2021). Fear-avoidance beliefs as predictors of disability in women with chronic low back pain. Musculoskeletal Science and Practice, 56, 102450.
Leistner, C., & Menke, A. (2020). Hypothalamic–pituitary–adrenal axis and stress. Handbook of clinical neurology, 175, 55-64.
Lenze, E. J., Munin, M. C., Dew, M. A., Rogers, J. C., Seligman, K., Mulsant, B. H., & Reynolds, C. F. (2001). Adverse effects of depression and cognitive impairment on rehabilitation outcome in the elderly. American Journal of Geriatric Psychiatry, 9(2), 175–180.
Levi, D., Shinar, D., & Kalichman, L. (2021). Autonomy in exercise therapy and its effect on adherence and outcomes in non-specific chronic low back pain. Healthcare, 9(6), 702.
Levi, M., Sharon, R., & Becker, N. (2021). Exercise therapy autonomy and adherence in nonspecific chronic low back pain. Journal of Back and Musculoskeletal Rehabilitation, 34(5), 901–909.
Li, Q., Luan, J., Lin, Y., Kong, M., Guo, X., & Zhao, J. (2024). The effects of psychological distress after surgery in patients undergoing lumbar spinal fusion. BMC Musculoskeletal Disorders, 25, 289.
Li, X., Yang, C., & Wu, J. (2022). Anxiety, pain perception, and functional disability in chronic low back pain patients. Journal of Pain Research, 15, 1567–1579.
Li, Y. H., Li, N., Liu, Z. X., Du, S., Shuai, Y., Yang, R., ... & Li, W. (2025). The effectiveness of artificial intelligence health education accurately linking system on self-management in non-specific lower back pain patients. Frontiers in Public Health, 13, 1630329.
Li, Z., Wang, M., & Zhang, H. (2023). The mediating role of anxiety and depression in chronic low back pain: A systematic review. Pain Practice, 23(1), 33–44.
Lin, F., Zhang, J., & Gao, W. (2023). Neural mechanisms of anxiety-induced pain amplification: A neuroimaging perspective. Frontiers in Behavioral Neuroscience, 17, 115839.
Linton, L., Barr, M., & Valentin, S. (2022). Prehabilitation for recreational runners: Motivators, influencers, and barriers to injury prevention strategies for running-related injury. Journal of sport rehabilitation, 31(5), 544-553.
Linton, S. J., & Shaw, W. S. (2019). Impact of psychological factors in the experience of pain. Physical Therapy, 99(5), 413–421.
López-Torres, O., Nieto-Acevedo, R., Guadalupe-Grau, A., & Elías, V. E. F. (2025). Sex Differences in Bench Press Strength and Power: A Velocity-Based Analysis Adjusted for Body Composition. Journal of Functional Morphology and Kinesiology, 10(3), 284.
Louw, Q. A., Morris, L. D., Crous, L. C., & Ferreira, M. L. (2023). Risk factors for the development of non-specific low back pain in young adults: A systematic review. Musculoskeletal Science and Practice, 64, 102783.
Lu, J., Wang, J., & Zhang, L. (2023). The effect of housework, psychosocial stress, and residential environment on musculoskeletal disorders in women. International Journal of Environmental Research and Public Health, 20(15), 9301.
Lu, Y. M., Chen, C. H., & Lue, Y. J. (2022). A cross-sectional study of disability and quality of life in patients with low back pain: Focus on sex and gender. Journal of Back and Musculoskeletal Rehabilitation, 35(1), 177-184.
Lucky, T. T., Ahmad, N., & Lee, C. K. (2018). Prevalence and risk factors of low back pain among undergraduate students: A cross-sectional study. International Journal of Public Health and Clinical Sciences, 5(2), 100–110.
Maher, C. G., Ferreira, G. E., & Lin, C. C. (2023). Global trends in low back pain burden: Implications for prevention and management. Nature Reviews Rheumatology, 19(7), 393–405.
Maher, C. G., Underwood, M., & Buchbinder, R. (2023). Non-specific low back pain. The Lancet, 401(10377), 1046–1059.
Maizatul, N. Z., Saat, N. Z. M., Hanawi, S. A., Janet, B. M., Lishantini, P., Tatiana, S., & Tan, E. W. (2022). The association between low back pain and quality of life among health sciences students.
Majeedkutty, N. A., & Jabbar, M. A. (2022). Prevalence and Correlates of Low Back Pain among University Students during Covid 19 Home Conf inement: A Cross sectional Study. Malaysian Journal of Ergonomics (MJEr), 4, 20-35.
Majeedkutty, N. A., & Jabbar, M. A. (2024). Prevalence and correlates of low back pain among university students during COVID-19 home confinement: A cross-sectional study. Malaysian Journal of Ergonomics, 4(1), 20-35.
Marijančić, V., et al. (2024). Gender differences in the relationship between physical activity and spinal posture among students. Biomechanics Journal, 9(4), 189.
Marijančić, V., Jerković, M., & Knežević, O. M. (2024). Gender differences in trunk muscle endurance and postural alignment among young adults. Journal of Musculoskeletal Research, 27(1), 15–26.
Marijančić, V., Peharec, S., Starčević-Klasan, G., & Grubić Kezele, T. (2024). Gender differences in the relationship between physical activity, postural characteristics and non-specific low back pain in young adults. Journal of Functional Morphology and Kinesiology, 9(4), 189.
Mayo Clinic. (n.d.). Back pain — Symptoms & causes. Mayo Clinic. Retrieved October 8, 2025, from https://www.mayoclinic.org/diseases-conditions/back-pain/symptoms-causes/syc-20369906
McCracken, L. M., Scott, W., & Vowles, K. E. (2022). Pain-related anxiety, avoidance, and acceptance: Their roles in chronic pain adjustment. Pain, 163(5), 910–918.
MedlinePlus. (n.d.). Low back pain — acute. U.S. National Library of Medicine. Retrieved October 8, 2025, from https://medlineplus.gov/ency/article/007425.htm
Melody, T., Buchbinder, R., Ferreira, M. L., & Maher, C. G. (2024). Global, regional, and national burden of low back pain, 1990–2020: A systematic analysis for the Global Burden of Disease Study 2020. The Lancet Rheumatology, 6(2), e89–e102.
Merino-Soto, C., Angulo-Ramos, M., Rovira-Millán, L. V., & Rosario-Hernández, E. (2023). Psychometric properties of the generalized anxiety disorder-7 (GAD-7) in a sample of workers. Frontiers in psychiatry, 14, 999242.
Merino-Soto, C., Angulo-Ramos, R., Rovira-Millán, D., & Rosario-Hernández, L. (2023). Psychometric properties of the Generalized Anxiety Disorder-7 (GAD-7) in a working population. Frontiers in Psychology, 14, 10083254.
Merino-Soto, C., et al. (2023). Psychometric properties of the Generalized Anxiety Disorder-7 (GAD-7) in occupational and clinical samples: A systematic review. Frontiers in Psychiatry, 14, 999242.
Michel Kanas, M., Pereira, M., & Silva, R. (2018). Functional capacity and quality of life in chronic low back pain after supervised exercise. European Journal of Physiotherapy, 20(4), 206–213.
Mikkonen, J., Valkeinen, H., Kankaanpää, M., & Arokoski, J. (2022). Fear-avoidance beliefs and movement behaviour in patients with chronic low back pain. BMC Musculoskeletal Disorders, 23, Article 234.
Min, Y., Zhang, Y., & Zhao, J. (2020). Reliability and responsiveness of disability and pain assessment tools in lumbar disc herniation patients. Journal of Orthopaedic Surgery and Research, 15(1), 112.
Mishra, A. K., Patel, D., & Sahoo, S. (2023). A comprehensive review of generalized anxiety disorder: Epidemiology, burden, and treatment needs. International Journal of Psychiatry and Mental Health, 11(2), 1–18.
Mohamad Saufi, M. F., & Zamri, E. N. (2023). Psychological distress and low back pain severity among academic staff in Malaysia: A cross-sectional study. Malaysian Journal of Health Research, 29(2), 44–53.
Mohamad, F., Dahlan, R., Ismail, I. Z., Kadir, H., Kamaruddin, K. N., Shibraumalisi, N. A., ... & Shamsuddin, N. H. (2024). Self-system and mental health status among Malaysian youth attending higher educational institutions: A nationwide cross-sectional study. Malaysian Family Physician: the Official Journal of the Academy of Family Physicians of Malaysia, 19, 12.
Moix, J., Kovacs, F. M., Martín, A., Plana, M. N., & Royuela, A. (2011). Catastrophizing, state anxiety, anger, and depressive symptoms do not correlate with disability when variations of trait anxiety are taken into account. a study of chronic low back pain patients treated in Spanish pain units [NCT00360802]. Pain Medicine, 12(7), 1008-1017.
Morelhão, P. K., Franco, M. R., Oliveira, C. B., Hisamatsu, T. M., Ferreira, P. H., Costa, L. O., ... & Pinto, R. Z. (2018). Physical activity and disability measures in chronic non-specific low back pain: a study of responsiveness. Clinical Rehabilitation, 32(12), 1684-1695.
Moreno, E., Muñoz-Navarro, R., & Medrano, L. A. (2020). The Generalized Anxiety Disorder-7 Scale in primary care: A psychometric analysis. BMC Psychiatry, 20(1), 480.
Morrison, C., Mellins, C. A., Synder, C., Shea, E., Kluisza, L., Robbins, R., ... & Mufson, L. (2024). Optimizing generalized anxiety disorder screening in young adults perinatally affected by HIV: A psychometric analysis. Journal of Mood & Anxiety Disorders, 7, 100066.
Muhammad Waseem, A., Hossein, K., & Syed Amir, G. (2017). Effectiveness of core stabilization exercises and routine exercise therapy in management of pain in chronic nonspecific low back pain: a randomized controlled clinical trial.
Munir, S. (2022). Generalized anxiety disorder. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870/
Munir, S., Takov, V., & Coletti, V. A. (2021). Generalized anxiety disorder (nursing).
Munusamy, S., Ramasamy, S., & Sukir, N. I. (2024). A systematic review on mental health and its associated factors among educators in Malaysia. BMC Public Health, 24(1), 2634.
Mutubuki, E. N., et al. (2019). The longitudinal relationship between pain intensity, disability, and health-related quality of life in patients with chronic low back pain. Clinical Journal of Pain, 35(10), 869–878.
National Institute of Mental Health (NIMH). (2024). Generalized anxiety disorder (GAD) — Statistics. https://www.nimh.nih.gov/health/statistics/generalized-anxiety-disorder
Nieto, J. (2024). Sex differences in muscular strength and rehabilitation outcomes in chronic low back pain patients. Musculoskeletal Science and Practice, 69, 102900.
Norzebah Hamidon, N., Sulaiman, N., & Lee, K. H. (2022). Prevalence and associated factors of low back pain among university students in Malaysia. Malaysian Journal of Medicine and Health Sciences, 18(2), 47–54.
O’Sullivan, P. (2016). Unraveling the complexity of low back pain. Journal of Orthopaedic & Sports Physical Therapy, 46(6), 419–430.
Okolo, C. A. (2024). Cultural variability in pain perception: A review of cross-cultural factors. International Journal of Social Research and Applications.
Oliveira, C. B., Maher, C. G., Pinto, R. Z., & Lin, C. W. C. (2020). Clinical relevance and responsiveness of pain intensity scales in low back pain: A systematic review. Pain Medicine, 21(6), 1161–1172.
Oliveira, C. B., Maher, C. G., Pinto, R. Z., Traeger, A. C., Lin, C. W. C., Chenot, J. F., & Ferreira, M. L. (2022). Clinical practice guidelines for the management of non-specific low back pain in primary care: An updated systematic review. European Spine Journal, 31(4), 889–904.
Özsoy, G., & İlçin, N. (2021). The impact of non-specific low back pain on postural control, balance, fall, mobility and physical activity in elderly individuals: a comparative study. Türk Fizyoterapi ve Rehabilitasyon Dergisi, 32(1), 67-73.
Paganini, G. A., Summers, K. M., Ten Brinke, L., & Lloyd, E. P. (2023). Women exaggerate, men downplay: Gendered endorsement of emotional dramatization stereotypes contributes to gender bias in pain expectations. Journal of Experimental Social Psychology, 109, 104520.
Pak, R., Alilou, M. M., Roudsari, A. B., & Yousefpour, F. (2024). Experiential avoidance as a factor in generalized psychological vulnerability: in the relationship between chronic pain and pain anxiety with pain disability. Pain Management Nursing, 25(3), e256-e264.
Park, J., Lee, C., & Han, S. (2022). The influence of anxiety on pain persistence in patients with chronic low back pain. Spine Journal, 22(3), 451–460.
Park, S., Kim, E., & Lee, H. (2021). The role of anxiety and depression in pain perception among patients with chronic low back pain. Frontiers in Psychology, 12, 689.
Patwardhan, V., et al. (2024). Global burden and sex-differences in low back pain and associated mental health disorders: A systematic analysis. Lancet Public Health, 9(3), 210–223.
Peter, K. A., Rüesch, P., & Meier, L. (2020). The impact of home working on low back pain intensity and ergonomic behavior during the COVID-19 pandemic: A cross-sectional study among adults aged 35–49 years. International Journal of Environmental Research and Public Health, 17(24), 9184.
Pheh, K. S., Tan, C. S., Lee, K. W., Tay, K. W., Ong, H. T., & Yap, S. F. (2023). Factorial structure, reliability, and construct validity of the Generalized Anxiety Disorder 7-item (GAD-7): Evidence from Malaysia. Plos one, 18(5), e0285435.
Porwal, S., Rizvi, M. R., Sharma, A., Ahmad, F., Alshahrani, M. S., Raizah, A., ... & Ahmad, I. (2023, July). Enhancing functional ability in chronic nonspecific lower back pain: the impact of EMG-guided trunk stabilization exercises. In Healthcare (Vol. 11, No. 15, p. 2153). MDPI.
Presto, P., Mazzitelli, M., Junell, R., Griffin, Z., & Neugebauer, V. (2022). Sex differences in pain along the neuraxis. Neuropharmacology, 210, Article 109030.
Presto, P., Sehar, U., Kopel, J., & Reddy, P. H. (2024). Mechanisms of pain in aging and age-related conditions: focus on caregivers. Ageing Research Reviews, 102249.
Purushothaman, V. K., Thua Ke, H., Subbarayalu, A. V., Marimuthu, P. R., Vasanthi, R. K., & Kayarohanam, S. (2025). Analysing low back pain among university students in Malaysia: A public health perspective on disability and influencing factors. National Journal of Community Medicine, 16(1), 35–41. (Used ODI among Malaysian students; identified predictors)
Qaseem, A., Wilt, T. J., & McLean, R. M. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical guideline. Annals of Internal Medicine, 166(7), 514–530.
Rajapakshe, W. (2024). Addressing Academic Stress: Implications for Female Students in Saudi Arabia. In Utilizing Case Studies in Business Education (pp. 101-119). IGI Global.
Rajeev, P., Sharma, D., & Patel, R. (2024). Relationship between pain intensity and functional limitation in chronic low back pain: A biomechanical analysis. Clinical Biomechanics, 110, 106226.
Rathleff, M. S., Jensen, M. B., & Andersen, T. E. (2022). Responsiveness and minimal important change of the numerical pain rating scale in musculoskeletal pain. European Journal of Pain, 26(1), 55–65.
Rišová, K., & Póczošová, V. (2023). Gender differences in unsafety perception and precautionary behaviour among adolescents: Case study of a small peripheral town in Slovakia. Moravian Geographical Reports, 31(2), 95-105.
Ristic, B., Carletto, A., Fracassi, E., Cristofalo, D., Rossini, M., Maggioni, L., ... & Tosato, S. (2025). Gender differences in psychological features and determinates of quality of life in axial spondyloarthritis and psoriatic arthritis: a cross-sectional study. BMC psychology, 13(1), 619.
Robinault, L., Niazi, I. K., Kumari, N., Amjad, I., Menard, V., & Haavik, H. (2023). Non-specific low back pain: an inductive exploratory analysis through factor analysis and deep learning for better clustering. Brain Sciences, 13(6), 946.
Romero-Morales, C., Villafañe, J. H., Jácome-López, R., Tullio, M., Strelczuk, A., Miñambres-Martín, D., Lara-Cabrero, J. L., & Jiménez-Sáiz, S. L. (2024). Gender Differences in Core Muscle Morphology of Elite Alpine Skiers: Insights from Ultrasonography. Sensors, 24(13), 4073.
Šagát, P., Bartík, P., Bartík, P., Prieto González, P., Tohănean, D. I., Knjaz, D., … (2020). Impact of COVID-19 quarantine on low back pain intensity, prevalence, and associated risk factors among adult citizens residing in Riyadh (Saudi Arabia): A cross-sectional study. International Journal of Environmental Research and Public Health, 17(19), 7302.
Sahi, R. S., Eisenberger, N. I., & Silvers, J. A. (2023). Peer facilitation of emotion regulation in adolescence. Developmental Cognitive Neuroscience, 62, 101262.
Salas-González, J., Heredia-Rizo, A. M., Fricke-Comellas, H., Chimenti, R. L., & Casuso-Holgado, M. J. (2025). Patterns of pain perception in individuals with anxiety or depressive disorders: A systematic review and meta-analysis of experimental pain research. The journal of pain, 105530.
Saragiotto, B. T., Maher, C. G., & Ferreira, M. L. (2023). The lumbopelvic region and low back pain: Understanding mechanical and neuromuscular factors. Musculoskeletal Science and Practice, 65, 102705.
Saulicz, M., Saulicz, A., Myśliwiec, A., Knapik, A., Rottermund, J., & Saulicz, E. (2023). Effect of nordic walking training on physical fitness and Self-Assessment of health of people with chronic Non-Specific lower back pain. International Journal of Environmental Research and Public Health, 20(9), 5720.
Schumacher, M. E., Chen, L., & Spence, J. C. (2024). Low-to-moderate intensity physical activity and its role in managing musculoskeletal disorders. International Journal of Behavioral Medicine, 31(3), 412–424.
Seighali, N., Abdollahi, A., Shafiee, A., & Maghsoudi, M. R. (2024). The global prevalence of depression, anxiety, and sleep disorder among patients coping with post–COVID-19 syndrome: A systematic review and meta-analysis. BMC Psychiatry, 24, 105.
Serra, M. V. G. B., Scalon, J. D., Tonello, M. G. M., & Quemelo, P. R. V. (2020). Musculoskeletal disorders, stress perception and physical activity in police officers. Fisioterapia e Pesquisa, 27(1), 22-27.
Shahab, M., & Abood, M. (2023). Postural stability impairments in individuals with non-specific low back pain: A comparative study. Journal of Musculoskeletal & Neuronal Interactions, 23(4), 465-472.
Shao, Y., Lin, H., & Zhang, Y. (2021). Predictors of functional disability in chronic non-specific low back pain. BMC Musculoskeletal Disorders, 22(1), 987.
Shen, Z., Wang, X., & Xiong, H. (2023). Sex differences in chronic pain-induced mental disorders: A review of neurobiological mechanisms. Frontiers in Molecular Neuroscience, 16, Article 1102808.
Shi, L., Lu, Z., Que, J., Huang, X., Liu, L., Ran, M., Gong, Y., Sun, Y., Yan, W., Yan, K., Shi, J., Bao, Y., Lu, L. (2020). Prevalence of and risk factors associated with mental health symptoms among the general population in China during the coronavirus disease 2019 pandemic. JAMA Network Open, 3(7), e2014053.
Shilabant Sen Sribastav, S., et al. (2017). Prevalence and associated risk factors of low back pain among different occupational groups in Malaysia: A cross-sectional study. Malaysian Orthopaedic Journal, 11(2), 20–25.
Shiri, R., Coggon, D., & Viikari-Juntura, E. (2021). Physical activity and low back pain: A complex and dynamic relationship. European Spine Journal, 30(12), 3564–3574.
Shiri, R., Falah-Hassani, K., & Lallukka, T. (2022). Obesity, smoking, and physical inactivity as risk factors for low back pain: A systematic review and meta-analysis. Pain, 163(5), 857–869.
Shiri, R., Karppinen, J., Leino-Arjas, P., Solovieva, S., & Viikari-Juntura, E. (2018). Physical activity and low back pain: A systematic review of recent literature. European Spine Journal, 27(3), 278–291.
Shokri, P., Zahmatyar, M., Falah Tafti, M., Fathy, M., Rezaei Tolzali, M., Ghaffari Jolfayi, A., ... & Safiri, S. (2023). Non‐spinal low back pain: Global epidemiology, trends, and risk factors. Health Science Reports, 6(9), e1533.
Shraim, M., Hooftman, W. E., & Burdorf, A. (2022). Socioeconomic position and non-specific low back pain: A systematic review and meta-analysis. European Spine Journal, 31(4), 874–888.
Singh, S., Shahi, P., Asada, T., Kaidi, A., Subramanian, T., Zhao, E., ... & Iyer, S. (2023). Poor muscle health and low preoperative ODI are independent predictors for slower achievement of MCID after minimally invasive decompression. The Spine Journal, 23(8), 1152-1160.
Sipaviciene, S., & Kliziene, I. (2020). Effects of different exercise programs on low back pain and disability among sedentary workers. Clinical Biomechanics, 75, 105–112.
SoungKyun Hong, S., & Shin, D. C. (2020). Relationship between pain, disability, and depression in office workers with chronic low back pain. International Journal of Environmental Research and Public Health, 17(21), 7995.
Spoonemore Jr, S. L., McConnell, R. C., Owen, W. E., Young, J. L., Clewley, D. J., & Rhon, D. I. (2023). The influence of pain-related comorbidities on pain intensity and pain-related psychological distress in patients presenting with musculoskeletal pain. Brazilian Journal of Physical Therapy, 27(4), 100532.
StatPearls. (2023). Anxiety. In NCBI Bookshelf. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470361/
Steffens, D., Maher, C. G., & Ferreira, M. L. (2023). Risk factors and prognosis of non-specific low back pain: Recent insights and evidence updates. Pain Practice, 23(4), 412–425.
Sulaiman, H. M., & Zafar, S. (2023). A Review on Effects of Exercises Therapy for Office Workers with Chronic No Specific Low Back Pain. Clinical Medicine And Health Research Journal, 3(6), 663-670.
Sun, J., Liang, K., Chi, X., & Chen, S. (2021). Psychometric properties of the GAD-7 in a large sample of Chinese adolescents. Healthcare, 9(12), 1709.
Suri, P., Boyko, E. J., Goldberg, J., Forsberg, C. W., & Jarvik, J. G. (2021). The association between sex and low back pain in adults: Results from a longitudinal cohort study. Spine, 46(18), 1234–1242.
Suri, P., Rainville, J., & Katz, J. N. (2011). Pain flares in acute low back pain and association with disability outcomes. Pain, 152(2), 250–256.
Suri, P., Rainville, J., & Katz, J. N. (2011). Pain flares in acute low back pain: Patterns and outcomes. Pain, 152(8), 1743–1749.
Suri, P., Rainville, J., & Katz, J. N. (2011). The influence of pain flares on disability outcomes in acute low back pain. Spine, 36(19), 1609–1615.
Syed, W., Samarkandi, O., Alanazi, A. A., Alotaibi, N., & Al-Rawi, M. B. A. (2024). Assessment of myocardial infarctions knowledge, attitudes and beliefs among adults living in Riyadh Saudi Arabia–insights from cross-sectional study. Scientific Reports, 14(1), 31457.
Teh, C. H., Tan, W. S., & Lee, S. L. (2022). Gender differences in the impact of low back pain on daily activities among university students in Malaysia. Journal of Musculoskeletal Research, 25(2), 123-130.
Tompra, N., Zduńczyk, B., & Sklempe Kokic, I. (2023). Physical functioning and pain-related disability in adults with chronic low back pain: A systematic review. Journal of Back and Musculoskeletal Rehabilitation, 36(1), 101–112.
Toussaint, A., Huesing, P., Gumz, A., Wingenfeld, K., Haerter, M., Schramm, E., & Loewe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of affective disorders, 265, 395-401.
Treede, R. D. (2018). The role of emotional and cognitive factors in pain perception. Pain Reports, 3(2), e665.
U.S. Preventive Services Task Force (USPSTF). (2023). Recommendation: Anxiety disorders in adults — Screening. https://www.uspreventiveservicestaskforce.org/recommendation/anxiety-adults-screening
Uçar, İ., Karartı, C., Cüce, İ., Veziroğlu, E., Özüdoğru, A., Koçak, F. A., & Dadalı, Y. (2021). The relationship between muscle size, obesity, body fat ratio, pain and disability in individuals with and without nonspecific low back pain. Clinical Anatomy, 34(8), 1201-1207.
van Hooff, M. L., Vriezekolk, J. E., Kroeze, R. J., O’Dowd, J. K., van Limbeek, J., & Spruit, M. (2021). Targeting self-efficacy more important than dysfunctional behavioral cognitions in patients with longstanding chronic low back pain; a longitudinal study. BMC musculoskeletal disorders, 22(1), 824.
van Koppen, B., Zandwijk, P., van Mameren, H., & de Bie, R. (2022). Patient adherence to physical activity advice (PAPA) in patients with low back pain: Study protocol for a multicentre randomized controlled trial. Physiotherapy Research International, 27(4), e1969.
Vancleef, L. M. G., Lauwerier, E., & Crombez, G. (2020). Catastrophizing and pain: An integrated framework for understanding chronic pain outcomes. European Journal of Pain, 24(3), 458–468.
Vega-Retuerta, N., Sánchez-Parente, S., & Segura-Jiménez, V. (2025). Effectiveness of multidisciplinary approaches including exercise to treat non-specific chronic low back pain: A systematic review and meta-analysis across multiple regions. Preventive Medicine, 108381.
Vega-Retuerta, N., Sánchez-Parente, S., & Segura-Jiménez, V. (2025). Effectiveness of multidisciplinary approaches including exercise to treat non-specific chronic low back pain: A systematic review and meta-analysis across multiple regions. Preventive Medicine, 108381.
Vetterlein, A., Reuter, M., von Häfen, L., Dressler, S., & Plieger, T. (2024). The influence of sex and gender, gender ontological beliefs, and sexism on pain sensitivity judgments: implications for health care settings and beyond. Gender Issues, 41(3), 15.
Viderman, D., Kalikanov, S., Myrkhiyeva, Z., Alisherov, S., Dossov, M., Seitenov, S., & Abdildin, Y. (2025). Impact of Exercise Therapy on Outcomes in Patients with Low Back Pain: An Umbrella Review of Systematic Reviews. Journal of Clinical Medicine, 14(17), 5942.
Villarreal-Zegarra, D., Paredes-Angeles, R., Mayo-Puchoc, N., Arenas-Minaya, E., Huarcaya-Victoria, J., & Copez-Lonzoy, A. (2024). Psychometric properties of the GAD-7 (General Anxiety Disorder-7): a cross-sectional study of the Peruvian general population. BMC psychology, 12(1), 183.
Villarreal-Zegarra, D., Paz-Jimenez, J., & Perales, A. (2024). Psychometric properties of the GAD-7 in the Peruvian population. BMC Psychology, 12(1), 1688.
Villarreal-Zegarra, D., Ruiz, M. E., & Gonzales, R. (2024). Psychometric properties of the GAD-7: A systematic assessment. Journal of Affective Disorders Reports, 9, 100410.
Waller, R., Smith, A. J., O'Sullivan, P. B., Slater, H., Sterling, M., & Straker, L. M. (2020). The association of early life stressors with pain sensitivity and pain experience at 22 years. Pain, 161(1), 220-229.
Wang, L. Y., Fu, T. S., Tsia, M. C., & Hung, C. I. (2023). The associations of depression, anxiety, and insomnia at baseline with disability at a five-year follow-up point among outpatients with chronic low back pain: a prospective cohort study. BMC musculoskeletal disorders, 24(1), 565.
Wasiak, R., Kim, J., & Pransky, G. (2020). Functional impairment in low back pain: A review of measurement tools. Journal of Occupational Rehabilitation, 30(4), 631–645.
Williams, K. L., & Johnson, D. P. (2024). Assessment of pain intensity and disability using VAS and ODI among young adults with sedentary behaviour–related low back pain. Journal of Musculoskeletal Pain and Rehabilitation, 36(2), 85–92.
Williamson, E. (2021). The self-management paradox: Physical activity and adherence in chronic low back pain. Physiotherapy Theory and Practice, 37(8), 928–939.
Williamson, E. J., McDonald, H. I., Bhaskaran, K., Walker, A. J., Bacon, S., Davy, S., ... & Kuper, H. (2021). Risks of covid-19 hospital admission and death for people with learning disability: population based cohort study using the OpenSAFELY platform. bmj, 374.
Williamson, S. (2021). Changing behaviour: Role of theories and techniques in increasing physical activity in non-specific low back pain patients (Doctoral dissertation, London South Bank University).
Wirth B, Schweinhardt P. Personalized assessment and management of non-specific low back pain. Eur J Pain. 2024 Feb;28(2):181-198. doi: 10.1002/ejp.2190. Epub 2023 Oct 24. PMID: 37874300.
Wong, S. S., Wong, C. C., Ng, K. W., Bostanudin, M. F., Tan, S. F. (2023). Depression, anxiety, and stress among university students in Selangor, Malaysia during COVID-19 pandemics and their associated factors. PLOS ONE, 18(1), e0280680.
World Health Organization. (2020). WHO guidelines on physical activity and sedentary behaviour for children and adolescents aged 5-17 years: Summary of the evidence. International Journal of Behavioral Nutrition and Physical Activity, 17, Article 141.
World Health Organization. (2023, June). Low back pain fact sheet. https://www.who.int/news-room/fact-sheets/detail/low-back-pain
Wu, A., March, L., Zheng, X., Huang, J., Wang, X., Zhao, J., & Blyth, F. M. (2020). Global low back pain prevalence and years lived with disability: A systematic review and meta-analysis. Annals of the Rheumatic Diseases, 79(3), 367–374.
Xiao, H., Shu, W., Li, M., Li, Z., Tao, F., Wu, X., Yu, Y., Meng, H., & Verma, S. (2020). Social distancing, screen time, and anxiety among medical students during the COVID-19 pandemic in China. Frontiers in Psychiatry, 11, 566222.
Xie, M., Huang, Y., Cai, W., Zhang, B., Huang, H., Li, Q., Qin, P., & Han, J. (2024). Neurobiological underpinnings of hyperarousal in depression: A comprehensive review. Brain Sciences, 14(1), Article 50.
Yao, M., Chen, S., & Zhang, H. (2020). Reliability and validity of back pain outcome measures among patients with lumbar disc herniation. BMC Musculoskeletal Disorders, 21(1), 854.
Yao, M., Zhang, Y., & Li, J. (2020). Reliability and validity of back pain outcome measures in lumbar disc herniation. BMC Musculoskeletal Disorders, 21(1), 420.
Yigman, Z. A., Cankurtaran, D., & Umay, E. (2023). Physical Activity in Workers with Low Back Pain is Associated with Paraspinal Muscle Mass. Muscles, Ligaments & Tendons Journal (MLTJ), 13(3).
Yilmaz, G., & Kaldirimci, M. (2023). Gender-based differences in physical disability and pain perception among chronic low back pain patients. Pain Practice, 23(2), 148–157.
Young, J. J., Kongsted, A., Hartvigsen, J., Ammendolia, C., & Jensen, R. K. (2023). Similar improvements in patient-reported outcomes for non-specific low back pain patients with and without lumbar spinal stenosis symptoms following a structured education and exercise therapy program. BMC Musculoskeletal Disorders, 24(1), 839.
Yusoff, I. S. Md, Sabri, M. F., & Mohd Tamrin, S. B. (2024). Older Malaysian Taxi Drivers: Working environment in the new norm from ergonomic perspective. International Journal of Academic Research in Business & Social Sciences, 11(12).
Zahari, Z., Justine, M., & Ishak, N. A. (2019). Reliability and validity of the Malay version of the Oswestry Disability Questionnaire among low back pain patients. Healthscope: The Official Research Book of Faculty of Health Sciences, UiTM, 2, 1-10.
Zahra, N. A. I., Sheha, E. A. A. E., & Elsayed, H. A. (2020). Low back pain, disability and quality of life among health care workers. International Journal of Pharmaceutical Research and Allied Sciences, 9(2-2020), 34-44.
Zang, W., & Yan, J. (2024). Exercise interventions for nonspecific low back pain: a bibliometric analysis of global research from 2018 to 2023. Frontiers in Medicine, 11, 1390920.
Zhang, S., et al. (2024). Factors affecting functional disability in patients with non-specific low back pain: A cross-sectional analysis. BMC Musculoskeletal Disorders, 25, Article 210.
Zhang, Y., Chen, Q., & Liu, X. (2023). Gender differences in anxiety and pain sensitivity among adults with musculoskeletal pain. Journal of Psychosomatic Research, 168, 111025.
Zhou, F., Wu, J., & Wang, L. (2022). The effect of anxiety and depression on physical disability in low back pain: A longitudinal study. Pain Medicine, 23(7), 1279–1288.
Zhou, Q., Liu, X., & Wu, Y. (2022). Neural mechanisms linking emotional distress and chronic pain: Evidence from neuroimaging studies. Frontiers in Human Neuroscience, 16, 846932.
Zhou, T., Salman, D., & McGregor, A. H. (2024). Recent clinical practice guidelines for the management of low back pain: a global comparison. BMC musculoskeletal disorders, 25(1), 344.
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