In the captain’s chair: a cross-sectional study on back pain among commercial airline pilots in Saudi Arabia

Abstract

Background

Musculoskeletal disorders, including back pain, pose a significant challenge to workforce health, particularly in professions characterized by prolonged periods of sedentary activities. This challenge is notably relevant in commercial airline piloting due to unique ergonomic issues. Despite extensive research on back pain in various occupational settings, an understanding of the specific factors contributing to back pain among commercial airline pilots in Saudi Arabia is still lacking.

Methods

This cross-sectional survey aimed to investigate the prevalence of back pain among Saudi Arabian commercial airline pilots. A structured questionnaire, developed through literature review and expert consultation, covered demographic information, occupational details, and back pain history. The survey was administered online to active pilots recruited through the Saudi Airlines Medical Services, with data collection spanning six weeks.

Results

Among 310 predominantly male participants (99.0%), a significant prevalence of back pain was identified, with 71.3% reporting lower back pain in the last 12 months. Factors associated with a decreased likelihood of low back pain included comfortable seat conditions (odds ratio [OR]: 0.3; 95% confidence interval [CI]: 0.2–0.7), a senior officer position (OR: 0.5, 95% CI: 0.3–0.8), and regular exercise (OR: 0.6, 95% CI: 0.3–1.0). Higher flying hours in the past year were associated with an increased prevalence of back pain (OR: 2.2, 95% CI: 1.2–4.1). The multivariable analysis revealed that a comfortable seat was the single independent factor most significantly associated with back pain (OR: 0.3; 95% CI: 0.1–0.7).

Conclusions

This study highlights a notable prevalence of back pain among Saudi Arabian commercial airline pilots, underscoring the need for targeted interventions. The critical role of seat comfort emphasizes the importance of ergonomic considerations. Findings contribute to the global discourse on pilot health, emphasizing the necessity for ongoing evaluation and potential revisions to existing guidelines.

Clinical trial number

Not applicable.

Background

Musculoskeletal disorders represent a significant global health challenge, exerting a notable impact on individual well-being and workforce productivity across various occupational settings [1]. This issue is particularly pertinent in professions characterized by prolonged periods of sedentary activities and ergonomic challenges [2]. Commercial airline pilots, as a distinctive occupational group within the aviation profession, face extended periods of sitting, exposure to high gravitational forces during flight, and irregular work schedules [3,4,5].

Extensive research has been conducted on the prevalence of back pain across diverse occupational settings [1]. This research consistently underscores the substantial impact of back pain on workforce productivity and individual welfare [6, 7]. While existing literature within the aviation context explores physiological and psychological stressors associated with flying—such as prolonged sitting, vibration, and gravitational forces—a comprehensive understanding of the specific factors contributing to back pain among commercial airline pilots remains notably limited [8,9,10,11].

Extended periods of sitting can significantly strain and fatigue the lower back muscles. Poor posture often exacerbates these issues by promoting misalignment of the spine and increasing stress on the lumbar region. The sustained pressure on the lumbar discs and facet joints during prolonged sitting may accelerate disc degeneration and irritate the facet joints, contributing to chronic back pain [12, 13]. Additionally, prolonged sitting typically leads to increased muscle stiffness and reduced flexibility in the lower back, further compounding discomfort and susceptibility to pain [14].

While extensive research has explored back pain prevalence across various occupations, specific studies on commercial airline pilots in Saudi Arabia are limited. Insights can be drawn from related fields with prolonged sitting, such as radiology, where a study in Saudi Arabia found a high prevalence of musculoskeletal symptoms, including lower back pain, attributed to extended computer use and poor ergonomic conditions [15].

A noteworthy contribution to the epidemiology of back pain among pilots comes from a study conducted among German commercial airline pilots, revealing unexpectedly high prevalence rates. In this study, 82.7% of pilots reported experiencing chronic low back pain, with an association between the number of flying hours and the prevalence of acute low back pain [16]. Additionally, a study in Colombia revealed a 71.1% prevalence of lower back pain among pilots. Factors associated with the occurrence of back pain included occupational exposure to physical load, work time, and mental workload [17, 18]. Despite these findings, the context of Saudi Arabian aviation is underexplored, and there may be unique factors influencing the prevalence of back pain among pilots in this region. For instance, the nature of flight routes and crew management may differ from those in other regions. These variables underscore the need for region-specific research to better understand the risk factors for back pain in this demographic.

The aviation industry in Saudi Arabia has experienced substantial growth in recent decades, resulting in an increased number of pilots contributing to the expansion of commercial airline services. Despite this growth, our understanding of the prevalence and determinants of back pain among Saudi Arabian pilots remains limited. Therefore, this study aims to examine the factors contributing to back pain in this specific occupational group. By doing so, we aim to enhance the existing knowledge base, ultimately informing targeted interventions and preventive measures that can mitigate the impact of musculoskeletal disorders on the health and well-being of Saudi Arabian commercial airline pilots.

Methods

Study design

This cross-sectional survey aims to explore the prevalence of back pain among pilots in Saudi Arabia and identify any associated demographic and occupational factors.

Study participants

Participants were recruited through Saudi Airlines Medical Services, which distributed the questionnaire link to all pilots on their records after the necessary approvals were obtained. This approach ensured outreach to the entire population of pilots employed by the airline. However, the exact number of pilots who received the questionnaire could not be determined, precluding calculation of the response rate.

Survey administration

The questionnaire was administered online to ensure convenience and accessibility for the participants. The survey link was disseminated through various social media platforms, making it easily accessible to a diverse range of active pilots in Saudi Arabia. This mode of administration was chosen to accommodate the busy schedules of pilots and to leverage the reach of online platforms. The survey was designed to be completed within a reasonable time frame, with an estimated completion time of 7 min. Data collection spanned a period of 6 weeks, from August 1, 2023 to September 12, 2023.

Questionnaire development

A structured questionnaire, developed through an extensive literature review and consultation with aviation and musculoskeletal experts, comprised three comprehensive sections: demographic and professional characteristics, occupational information, and back pain history. The questionnaire was circulated in English, which is the primary working language for the participants involved in this study.

To ensure the validity and reliability of the questionnaire used in this study, a rigorous validation process was undertaken. Initially, a comprehensive review of existing literature and similar instruments was conducted to identify key domains and questions relevant to back pain among pilots [16, 17, 19, 20]. The draft questionnaire was then evaluated by a panel of experts in occupational health and ergonomics, who provided feedback on content relevance, clarity, and comprehensiveness. Based on their input, the questionnaire was revised to address any identified issues. Following these revisions, the questionnaire was piloted with a group of 12 commercial pilots to assess its clarity, relevance, and feasibility before it was distributed to the larger sample. The participants who piloted the questionnaire were not involved in completing the survey after the piloting phase to maintain the integrity of the data collection process. The feedback from the pilot test was used to make final adjustments before the full-scale administration.

Content of questionnaire

Exposure variables

The demographic and health information section covered age (< 30 years, 30–39 years, 40–49 years, ≥ 50 years), gender (male or female), marital status (single, married, or divorced), weight (in kg), height (in cm), smoking status (smoker/non-smoker), presence of chronic diseases, and regular exercise (defined as at least 3 times/week).

The occupational information included positions (captain or senior officer), experience years, total flying hours (< 3,000, 3,000–5,000, 5,000–10,000, > 10,000), flying hours in the past year (< 500, 500–700, > 700), rest period between flights (< 1 h, 1–4 h, 4–24 h, > 24 h), and flight routes. Flight routes were intricately categorized into distinct regions: domestic, Middle East, European, Subcontinent India, Far East, and North American flights. Subsequently, these flight routes were further classified into three overarching categories based on duration: flights lasting less than 6 h, flights ranging from 6 to 12 h, and flights exceeding 12 h.

Seat comfort was evaluated using a 5-point Likert scale, where participants were asked to rate their perceived comfort level with options ranging from “very uncomfortable” to “very comfortable”. Participants were also asked whether they were required to remain seated and refrain from leaving their seats during flights.

Outcome variables

The Nordic Musculoskeletal Questionnaire assessed back pain through inquiries regarding whether participants experienced any pain in the upper or lower back in the last 12 months, the last 7 days, or if they were hindered from normal activities due to back pain in the last 12 months. Additional questions covered the duration of pain (1–7 days, 8–30 days, > 30 days), whether participants sought healthcare professional assistance within the last 12 months for back pain, routine screening for back pain during annual checkups, and a history of back pain injury. The study regarded the presence of back pain in the last 12 months as the primary outcome.

Statistical analysis

After checking for completeness and consistency, the data were analyzed using IBM SPSS for Windows, version 26 (IBM Corp., Armonk, NY, USA). All variables were categorical variables and were presented as percentages and frequency distributions. The comparisons between variables were conducted using chi-squared or Fisher’s exact tests. A multivariable analysis was performed to identify independent factors associated with experiencing back pain in the last 12 months. Candidate variables for the multivariable analysis were selected based on bivariate analyses. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using the full model fit, and the results were reported in comparison to the designated reference group. The significance level for the statistical analyses was defined as α = 0.05.

Ethical considerations

The study obtained approval from the Ethics Committee of King Abdulaziz University. Informed consent was obtained, emphasizing voluntary participation and ensuring confidentiality. Stringent data privacy and security measures were implemented to uphold ethical standards.

Results

Demographic and health habits

The study included 310 pilots, predominantly male (307, 99.0%). Age distribution indicated that 93 pilots (30.0%) were below 30 years, 108 (34.8%) fell between 30 and 39 years, 61 (19.7%) were aged 40–49, and 48 (15.5%) were 50 years or older. Marital status varied, with 118 (38.1%) being single, and 185 (59.7%) married.

Concerning health data, body mass index categories revealed that 123 (39.7%) were overweight, and 53 (17.1%) were classified as obese. The majority reported no chronic diseases (291, 93.9%). Smoking was prevalent among 194 (62.6%), while 158 (51.0%) engaged in regular exercise. Sleep duration varied, with 19 (6.1%) reporting less than 5 h, 259 (83.5%) reporting 5–8 h per night, and 32 (10.3%) reporting more than 8 h (Table 1).

Table 1 Participant characteristics and Occupational Information (N = 310)

Occupational information

The study population comprised both Captains (141, 45.5%) and Senior Officers (169, 54.5%). Experience levels varied, with 179 (57.7%) having 0–10 years, 43 (13.9%) having 11–15 years, and 88 (28.4%) having over 15 years of experience. Flying hours totaled less than 3,000 for 148 (47.7%) of pilots, while 49 (15.8%) reported flying between 3,000 and 5,000 h, 62 (20.0%) reported flying between 5,000 and 10,000 h, and 51 (16.5%) reported flying more than 10,000 h.

In the past year, 96 (31.0%) reported flying less than 500 h, 116 (37.4%) reported flying between 500 and 700 h, and 98 (31.6%) reported flying more than 700 h. The majority experienced flight routes of less than 6 h (203, 65.5%). Overall, 152 (49.0%) reported unrestricted seat movement. Turbulence was reported as never experienced by 1 (0.3%), sometimes experienced by 248 (80.0%), and usually experienced by 61 (19.7%) participants (Table 1).

Back pain history

A substantial majority of participants, comprising 221 individuals (71.3%), reported experiencing lower back trouble in the last 12 months. Additionally, a significant proportion of 145 participants (46.8%) also reported upper back trouble. The impact of back pain on daily activities was notable, with 64 participants (20.6%) reporting being prevented from normal activities during the same period. A considerable number sought medical attention for their back pain, as 87 participants (28.1%) had consulted a physician in the last 12 months. Over the last 7 days, 135 participants (43.5%) experienced back trouble.

The duration of back pain varied, with 162 participants (52.3%) reporting 1–7 days, 59 participants (19.0%) reporting 8–30 days, and 89 participants (28.7%) reporting more than 30 days in the last 12 months. Surprisingly, a large majority of participants, totaling 254 (81.9%), had not been screened for back pain during their annual routine checkup. Additionally, a small portion reported a history of having hurt their back in an accident, as reported by 16 participants (5.2%) (Table 2).

Table 2 Back pain history among participants (N = 310)

Bivariable associations of low back pain

Table 3 explores the association of low back pain with demographic and occupational factors among the surveyed pilots. The prevalence of low back pain in the last 12 months was significantly higher among those who reported uncomfortable seat comfort (82.5%) compared to those with neutral (74.2%) or comfortable (62.2%) seat comfort (P = 0.01). A significant association was also found between the position and low back pain, with Captains (78.7%) experiencing higher rates than Senior Officers (65.1%) (P = 0.01). Similarly, a significant association was observed between regular exercise and low back pain, with non-exercisers (77.0%) reporting higher prevalence compared to those engaging in regular exercise (65.8%) (P = 0.03). The number of flying hours in the past year also showed a significant association with low back pain (P = 0.03), where pilots with 500–700 h (74.1%) and those with over 700 h (77.6%) reported higher prevalence compared to those with fewer than 500 h (61.5%). Additionally, the experience level of 11–15 years showed a near significant association with low back pain (83.7%) compared to those with 0–10 years (66.5%) or over 15 years (75.0%) (P = 0.05).

Table 3 Association of Low Back Pain with demographic and occupational factors

Multivariable analysis of factors associated with low back pain

Table 4 presents the results of the multivariable logistic analysis examining factors associated with low back pain in the last 12 months among the surveyed pilots. Notably, seat comfort emerged as a single independent significant factor, with pilots reporting comfortable seat conditions having a significantly lower odds ratio for low back pain (OR = 0.3, P = 0.01) compared to those who reported having uncomfortable seats. The position of senior officer showed a lower odds ratio for low back pain compared to captains (OR = 0.5, P = 0.11). In the age group category, pilots aged 40–49 years and those aged 50 years or older did not demonstrate a significant association with low back pain compared to those below 30 years (P = 0.94 and P = 0.80, respectively). Similarly, marital status did not show a significant association with low back pain, with married and divorced individuals having odds ratios of 1.2 (P = 0.70) and 1.3 (P = 0.77), respectively. Among health habits, smokers had a higher likelihood of experiencing low back pain (OR = 1.5, P = 0.14), although this did not reach statistical significance. Engaging in regular exercise did not show a significant association with low back pain (OR = 0.7, P = 0.26). Sleep duration of more than 8 h demonstrated a higher odds ratio for low back pain (OR = 3.4, P = 0.08), although it did not reach statistical significance.

Table 4 Factors Associated with Low Back Pain (last 12 Months) - multivariable analysis

Discussion

In this study, our aim was to investigate the prevalence of back pain among commercial airline pilots in Saudi Arabia and identify associated demographic and occupational factors. Our findings reveal a notable prevalence of back pain, with 71.3% of participants reporting such issues in the last 12 months. This underscores the significance of musculoskeletal health concerns within this occupational group, necessitating a comprehensive exploration of contributing factors and potential interventions.

Comparing our results with previous studies conducted among commercial airline pilots globally, our findings align with the heightened prevalence of back pain reported in studies conducted in Germany and Colombia. The unexpectedly high prevalence rates of chronic low back pain in German pilots (82.7%) and Colombian pilots (71.1%) underscore the global nature of this issue [16, 17]. Our study adds a crucial dimension by focusing specifically on Saudi Arabian pilots, a population that has not been previously studied in this context.

Our study identified several factors associated with back pain among Saudi Arabian pilots. One noteworthy finding is the strong association between seat comfort and the prevalence of low back pain. The study found that seat comfort was the single independent factor associated with back pain. Pilots reporting uncomfortable seat conditions exhibited a significantly higher likelihood of experiencing back pain. Prolonged periods of sitting, often in less-than-ideal ergonomic conditions, expose pilots to increased pressure on the lumbar spine [21,22,23]. Discomfort arising from poor seat design or inadequate lumbar support can lead to musculoskeletal strain, contributing significantly to the reported prevalence of back pain.

The multifaceted nature of factors contributing to back pain among pilots is evident in our results. The position held within the airline, with Captains experiencing higher rates of back pain compared to Senior Officers, suggests a potential link between hierarchical roles and occupational stress [24]. Captains, in leadership roles with distinct duties and potential stressors, may encounter unique challenges that contribute to a higher prevalence of back pain. Understanding the specific demands placed on captains, both in terms of physical requirements and the stress associated with leadership responsibilities, is crucial for tailoring interventions to address their distinct needs. The association between back pain and flying hours emphasizes the occupational exposure endured by pilots. Extended periods of flight, especially those lasting more than 12 h, subject pilots to sustained sitting, gravitational forces, and limited movement—all of which are recognized risk factors for musculoskeletal issues [21,22,23].

Although our study did not find a statistically significant protective effect of regular exercise against low back pain among pilots, existing literature supports the notion that exercise can be beneficial in preventing back pain. A systematic review and meta-analysis by Shiri et al. demonstrated that exercise alone reduces the risk of low back pain by approximately 33% [25]. The review highlighted that exercise programs, particularly those combining strengthening with either stretching or aerobic exercises, can effectively lower the incidence of back pain and associated disability.

Our findings warrant consideration in the context of international guidelines and standards for pilot health. While our study did not directly assess adherence to specific guidelines, the observed associations emphasize the need for ongoing evaluation and potential revisions to existing recommendations. Integrating ergonomic enhancements in seat design and encouraging regular breaks during flights may be crucial in addressing the high prevalence of back pain. Future research should focus on conducting similar studies within occupational clinics specific to each airline. Such targeted investigations would provide more granular insights into the prevalence and risk factors associated with back pain among pilots. By analyzing data collected from these specialized settings, researchers could identify airline-specific practices and environmental conditions that contribute to back pain.

Despite the valuable insights gained from our study, several limitations should be acknowledged. The cross-sectional design limits our ability to establish causation, and the reliance on self-reported data introduces the potential for recall bias. Additionally, the sample, though diverse, may not be fully representative of all Saudi Arabian pilots. Another potential limitation is volunteer bias, as participants who chose to respond to the survey may have different characteristics or experiences compared to those who did not volunteer, potentially affecting the generalizability of the findings.

Our study has direct implications for the aviation industry in Saudi Arabia. Addressing the identified factors, particularly focusing on seat comfort and flight hours, may contribute to the development of targeted interventions and policies aimed at reducing the prevalence of back pain among pilots. Moreover, our findings highlight the need for regular health assessments and ergonomic evaluations to ensure the well-being of this crucial occupational group.

Conclusions

In conclusion, this study illuminates the prevalence and determinants of back pain among commercial airline pilots in Saudi Arabia. Our findings reveal a significant prevalence of back pain, emphasizing the urgent need for targeted interventions to address musculoskeletal health in this occupational group. Seat comfort emerges as a pivotal factor, underscoring the importance of ergonomic considerations in mitigating back pain. The study contributes to the global discourse on pilot health, aligning with prior research on commercial airline pilots worldwide.