In the work of manual handlers, improper load-lifting techniques can lead to debilitating musculoskeletal disorders, including chronic low back pain [1].

Repeated lifting of loads requiring moderate force can lead to adaptation or even strengthening of the involved tissues. However, lifting heavy loads with excessive frequency—without adequate rest and recovery—can result in fatigue and tissue deterioration. Beyond chronic low back pain, lifting heavy loads can cause disc disorders, various abdominal wall hernias, pelvic organ prolapse, and even osteoarthritis in weight-bearing joints [2].

Chronic low back pain associated with degenerative conditions of the lumbar spine significantly impairs individuals’ quality of life [3]. Due to the complex innervation of the spine and its surrounding structures, determining the specific cause of this low back pain can be challenging. Diagnosis is further complicated by the fact that radiological findings for these conditions do not necessarily correlate with the pain experienced by patients, often leading to inadequate symptom management [4][5]. Management is difficult because taking the patient’s history and performing a clinical examination are complex tasks, given the lack of a consensus or a formal “gold standard” approach [6]. Physical examination of the lumbar spine involves inspection and palpation. Additionally, active and passive tests of spinal range of motion may be performed [7].

Lumbar osteoarthritis (lumbar spondyloarthrosis) is one of the most common degenerative conditions. Its etiology stems from a multifactorial pathogenesis [4]. The clinical presentation of symptomatic lumbar osteoarthritis typically involves referred pain, morning stiffness, and restricted movement. Clinical examination helps rule out numerous causes of spinal pain, including neoplasms, disc herniation, and spinal stenosis. However, there are no validated orthopedic examination maneuvers capable of diagnosing lumbar osteoarthritis [8].

Intervertebral disc degeneration (discarthrosis) is defined as the wear and tear of the disc. Advanced stages lead to a loss of water content, reduced disc height, and segmental instability. Establishing a precise diagnosis for lumbar discarthrosis is difficult; treatment is controversial, and treatment failures are common [9][10].

Spondylolisthesis is characterized by the slippage of a vertebra relative to the one beneath it. Forward displacement is termed anterolisthesis; backward displacement, retrolisthesis; and lateral displacement, laterolisthesis. The clinical presentation varies widely, ranging from asymptomatic cases to those involving severe pain, neurological impairment, and functional disability [11]. Degenerative spondylolisthesis primarily affects the elderly, with a marked predilection for women [12].

Early diagnosis and appropriate management of these degenerative spinal conditions are essential. To establish a definitive diagnosis, clinicians can use computed tomography (CT), magnetic resonance imaging (MRI), and conventional radiography (CR) [11]. However, obtaining CT or MRI scans is time-consuming and costly, making them difficult to access in resource-poor settings. High-quality CR can facilitate definitive diagnosis—being inexpensive and easily accessible [13]—and improve patient management [14][15].

Several studies conducted in sub-Saharan Africa and the Democratic Republic of Congo have demonstrated a strong correlation between carrying loads on the head or back and the development of degenerative spinal lesions among certain women in rural and peri-urban areas [16]-[19].

A study conducted on the outskirts of Kisangani—examining the socio-anthropometric profile of women suffering from chronic low back pain in the Lubuya Bera sector [20]—revealed that these women had started carrying loads through Liyamba at a very early age and carried heavy loads of more than 50 kg, sometimes corresponding to double her body mass, at an almost daily rate on their backs using a type of basket known as a “Liyamba”, as illustrated in Figure 1.

Figure 1. (a) Woman carrying a basket of dried cassava chips (fufu); (b) carrying firewood; (c) carrying a basket of fresh maize cobs.

A hypothesis was proposed: this artisanal practice, which adhered to no relevant guidelines, could alter spinal alignment and lead to the early onset of degenerative lumbar lesions. Clinical examination and conventional radiography were essential for establishing a definitive diagnosis [20].

Previous research had analyzed specific aspects of lifting or manual handling in various international and African settings—covering psychosocial, ergonomic, clinical, radiological, and therapeutic factors, as well as risk factors for chronic low back pain [21]-[23]—without addressing the clinical and paraclinical aspects of carrying heavy loads on the back in resource-limited settings like the one in this study.

Furthermore, there was a significant lack of awareness regarding proper techniques for carrying loads on the back and a lack of scientific evidence concerning the adverse effects on the lumbar spine in this resource-poor environment, where women typically sought hospital care only in cases of advanced lesions or confirmed complications [22].

The objective of this research was to determine the clinical and radiological status of women suffering from chronic low back pain in the peri-urban area of Kisangani who carried heavy loads on their backs (a practice known as “Liyamba”), in order to assess the health issues they faced.

The mean age of women with chronic low back pain was 42.1 ± 6.0 years; the most significant clinical characteristics observed were sudden onset, constant pain, severe pain, and a duration of morning pain/stiffness exceeding 30 minutes. Any work requiring physical exertion was a factor that aggravated the pain, while medication intake was a significantly more effective pain-relief factor than other care alternatives. Other joints significantly affected were the knee and the hip (Table 1, Table 2).

Table 3 below shows that the anteroposterior view of the back revealed exclusively scoliotic features, whereas the lateral view predominantly showed lumbar hyperlordosis. Left and right lateral bending and rotation were severely restricted.

Table 4 shows that normal radiological findings differed significantly between cases and controls, with several characteristic lesions; the most frequent were simple disc degeneration, multilevel disc degeneration, simple lumbar osteoarthritis, and multilevel lumbar osteoarthritis. The most common sites for degenerative vertebral lesions were L4-L5, L5-S1, and L3-S1.

Table 5 shows that abortion, prolapse, Caesarean section, and Multilevel discarthrosis were factors associated with chronic low back pain (p < 0.05).

Table 6 shows that factors mentioned above were not associated with chronic low back pain.

Table 1. Medical complaints associated with low back pain.

*T-student; **Chi carré de Pearson.

Table 2. Gynecological, obstetric, and surgical data. Certain co-morbidities—such as inguinal hernia, pelvic organ prolapse, or a history of Caesarean section, miscarriage, or infant death (occurring more than three times)—were associated with chronic low back pain (p < 0.05).

*Pearson’s chi-squared test.

Table 3. Physical and radiological data (diagnosis).

*Pearson’s chi-square; **Fisher’s test.

Table 4. Radiological diagnosis.

*Fisher’s test.

Table 5. Bivariate analysis of factors associated with chronic low back pain.

Table 6. Multivariate analysis of factors associated with chronic low back pain.

This study aimed to determine the clinical and radiological status of women suffering from chronic low back pain in the peri-urban area of Kisangani, specifically those who carried heavy loads on their backs.

The medical complaints and physical signs observed in this study aligned with the clinical definition of chronic low back pain found in the literature, demonstrating persistent discomfort and an impaired quality of life for the affected women [36][37].

The results of this study showed that the prevalence of pelvic organ prolapse and inguinal hernia was significantly higher among women with chronic low back pain (94% and 91%, respectively) compared to the control group (6% and 9%; p < 0.001). Many authors have reported similar findings [38][39]. They posited that, in addition to commonly cited risk factors, such as advanced age, early childbearing, grand multiparity, vaginal delivery, short interpregnancy intervals, assisted delivery (e.g., vacuum extraction), high birth weight, high body mass index, and levator ani muscle malformations, repetitive heavy lifting during the peripartum period contributes to the increased incidence of pelvic organ prolapse and abdominal wall hernia in developing countries. This is attributed to the influence of relaxin, which causes the body’s musculo-ligamentous structures to loosen and stretch. Other authors have noted that carrying heavy loads on the head or back—as seen in this context—causes increased intra-abdominal pressure and raises overall biomechanical tension on the musculoskeletal tissues supporting the muscles and ligaments that anchor the pelvic organs; this places additional strain on weakened pelvic floor tissues, thereby accelerating the development of prolapse and the protrusion of viscera through weak points in the abdominal wall [29][40][41]. In this study, prolapse occurred in women of reproductive age. Tinelli [42] noted a high rate of pelvic organ prolapse in older, postmenopausal women and in those with high parity, attributed to ligamentous laxity resulting from senescence. However, he observed that certain postural alterations—specifically excessive lumbar curvature caused by poor lifting technique—could shift the vaginal axis toward a more vertical orientation in younger women, thereby facilitating uterine descent.

This study showed that the rate of spontaneous abortion was significantly higher among women with chronic low back pain (59%) compared to controls (41%, p < 0.001). Spontaneous abortion is documented as the most common pregnancy complication, occurring in approximately 10% to 15% of all confirmed and suspected pregnancies worldwide. Pregnancy loss can result from direct trauma, as well as stress and emotional distress stemming from physical, emotional, and sexual abuse [43]. Furthermore, recurrent spontaneous abortion can be caused by chromosomal or genetic abnormalities, anatomical anomalies (congenital and acquired), autoimmune diseases, pre-thrombotic states, endocrine factors, infections, and environmental or psychological factors [44].

In the context of this study in the Lubuya Bera community—an impoverished rural area—the need to transport food and non-food items for daily consumption, combined with sometimes difficult water supply conditions, compelled women to carry heavy loads even during vulnerable periods of their lives, such as early pregnancy. Given the challenges of diagnosing early pregnancy (first trimester) in an isolated rural setting, we concur with Alberman [45] that the true prevalence of recurrent miscarriage in the Lubuya Bera community might be higher than reported. Carrying and lifting loads during these times posed an increased risk of miscarriage due to reduced load-bearing capacity associated with ligamentous laxity. According to MacDonald [46], while carrying heavy loads could trigger an isolated miscarriage—through reduced uterine blood flow or physical stress capable of inducing preterm contractions—it was not identified as the primary cause of recurrent pregnancy loss. He estimated that high-intensity physical activity in women with a history of miscarriage could increase the risk of very early pregnancy loss. Similarly, Juhl [47], supported by Meierhofer [23], reached the same conclusion: frequent heavy lifting during pregnancy was identified as a potential risk factor for spontaneous miscarriage, particularly when accompanied by prolonged standing. Standing for more than two hours a day also increased the likelihood of preterm birth. However, these authors noted that evidence linking specific load-carrying practices—such as carrying loads on the head or back—to recurrent miscarriage had not yet been established.

This research showed that a history of Caesarean section was significantly more common among women with chronic low back pain (82%) compared to the control group (18%; p < 0.001). A link between Caesarean delivery and low back pain was noted; approximately 70% of women who underwent a Caesarean section reported back and lower back pain during their recovery [48]. Several indications for elective or emergency Caesarean sections were identified, notably fetal distress, fetopelvic disproportion, malpresentation, pre-eclampsia, uterine rupture, umbilical cord prolapse, and antepartum hemorrhage.

In the context of this study, where pregnant women continued to carry heavy loads on their backs, this physical strain—causing increased intra-abdominal pressure—could lead to changes in pelvic alignment. The documented risk was pelvic organ prolapse, which in turn contributed to fetal malpresentation [48].

According to Wilson [49], although no statistical correlation links the mode of delivery to the immediate onset of lower back pain, several factors specific to Caesarean sections could promote or aggravate existing lower back pain. For instance, Caesarean scars could create adhesions between internal tissues (fascia, muscles, organs). These scars tissues disrupted mobility and the distribution of physical loads, potentially resulting in persistent lower back pain.

Additionally, Gialdini C et al. [50] estimated that the incision of abdominal muscles and tissues temporarily reduced spinal support by weakening the abdominal wall, thereby placing greater strain on the back muscles to compensate. Furthermore, these authors noted that—while often transient—pain at the epidural or spinal anesthesia injection site was frequently reported by patients as a source of lower back discomfort. Finally, postoperative and postpartum factors—such as postural changes—played a role; following a Caesarean section, abdominal pain often led women to adopt a stooped posture to protect the incision. This misalignment created muscle tension in the lower back. Caring for the baby—specifically carrying, breastfeeding, or lifting the infant from the crib—placed strain on a back already made vulnerable by pregnancy hormones that loosen ligaments [51]. However, Bettaieb H et al. [52] demonstrated that the occurrence of lower back pain during the postpartum period did not depend on the circumstances of the pregnancy or delivery; nevertheless, its impact on women’s quality of life appeared to be significant.

The results of the present study showed that the proportions of grade I and II degenerative anterolisthesis (Figure 2(a)) were significantly higher among patients with chronic low back pain (60% and 67%) compared to controls (40% and 37%; p < 0.001). A study conducted by Akkawi [35] demonstrated that the prevalence of degenerative spondylolisthesis was strongly age-dependent—common in individuals over 50 due to ligamentous hyperlaxity—and sex-dependent, with a female-to-male ratio of 6:1 attributed to hormonal influences. In a context comparable to the present study regarding women carrying heavy loads on their backs, Knapik et al. [53] demonstrated that when an individual walked while carrying a load in this manner, forward trunk inclination generated repetitive microtrauma to the vertebrae and other perivertebral structures with every step, causing constant mechanical stress. Even in women under the age of 50, excessive mechanical stress at each level of the lumbar spine can lead to intervertebral disc degeneration—characterized by loss of disc height—and laxity of the annulus fibrosus and facet joints. Wang et al. [54] estimated that this degeneration altered the wear patterns and deformation of the vertebral joints. The articular surface gradually shifted toward a sagittal and horizontal orientation, and its capacity to resist anterior shear forces diminished, resulting in vertebral segmental instability and progressive degenerative spondylolisthesis. For these authors, disc degeneration and degenerative spondylolisthesis reinforce each other, creating a vicious circle [54].

Figure 2.Radiographic images of women with chronic low back pain: (a) anterolisthesis at L5-S1 in a 38-year-old woman; (b) multilevel lumbar osteoarthritis (L2-L4) with right-convex scoliosis in a 41-year-old woman.

The results of the present study showed that the proportions of simple disc degeneration (discarthrosis), multilevel disc degeneration, simple lumbar osteoarthritis, and multilevel lumbar osteoarthritis (Figure 2(b)) were significantly higher among patients with chronic low back pain (78%, 75%, 79%, and 75%, respectively) compared to the control group (22%, 25%, 21%, and 25%; p < 0.001). These findings were consistent with those obtained by Goode et al. [21], who noted that radiographic images frequently obtained during initial consultations for incident chronic low back pain revealed spinal osteoarthritis.

In their study, Farshad et al. [55] found a high incidence of spondylophytes in the general population. They observed that their formation began as early as age 20. By age 40, small spondylophytes were present in the majority of the population, and by age 80, severe forms were present in almost all patients [55]. In the context of this study, where young women carried heavy loads on their backs, this activity regularly caused strain and mechanical stress on the spine. Ramirez et al. [56] noted that repetitive stress on spinal tissues—particularly under high spinal loads—was associated with a high risk of fatigue failure in vertebral tissues. Such fatigue of the lumbar paraspinal musculature was linked to impaired postural control and an increased risk of workplace injury. According to Chaib [57], activity-related lumbar injuries generally did not occur immediately following a traumatic event but rather developed once ligaments began to slacken after prolonged stretching. The body would respond by adopting alternative measures to maintain spinal stability. Muscle spasms could develop along the spine, triggered by a ligamentomuscular reflex in which stretched ligaments reacted rapidly by signaling overlying muscles to contract, thereby preventing spinal destabilization. This author also noted that the body responded to joint instability by inducing a low-grade inflammatory state, which potentiated degenerative changes—such as spondylophyte formation—that could help reduce the force per unit area acting on the joints.

In this study, excess load placed on the back muscles could lead to abnormal joint movements and result in injuries, changes in joint alignment, and the worsening of arthritis, as demonstrated by Lindsey et al. [4]. This arthritis was advanced due to the deterioration of the viscoelastic properties of synovial fluid—specifically hyaluronic acid, which acts as a lubricant and shock absorber for the spine. In addition to the decline in synovial fluid, leukotrienes and prostaglandins caused inflammation in the facet joints. This inflammation attracted neutrophils and macrophages, leading to vasodilation and venous congestion within the joint. The recurrent nature of the injury sensitized pain receptors (nociceptors) over time. Furthermore, insufficient blood supply contributed to the pathogenesis of intervertebral disc degeneration, demonstrating that osteoarthritis is a disorder directly linked to overuse and wear and tear [58][59].

The results of this study showed that, in addition to lower back pain, the other joints significantly affected were the knee and the hip; among patients with chronic low back pain, the prevalence was 84% for the knee and 82% for the hip, compared to 16% and 18% in the control group (p < 0.001). The correlation between hip pain and low back pain appears to be primarily biomechanical and postural in nature. The hip and the lumbar spine are closely linked by the joint chain connecting the femur, the pelvis, and the vertebral column [21]. In the context of this study, where the patients with low back pain were required to carry heavy loads on their backs, this created an overload on the back and weight-bearing joints, leading to simultaneous wear in both joints—a condition known in English-speaking literature as “hip-spine syndrome”.

According to Kechagias [60], when a hip became painful or stiff—due to hip osteoarthritis, for instance—the body would naturally alter its movement patterns to minimize pain. This could create spinal imbalance. Pain often resulted in a limp. To compensate for the hip’s limited mobility, the back was subjected to asymmetrical or uncomfortable loads, potentially leading to long-term lower back pain. Furthermore, the patient might adopt an abnormal posture, giving rise to the various forms of scoliosis observed in this study (Figure 2(b)). Loss of hip flexibility forced the pelvis to tilt, often increasing lumbar hyperlordosis or creating compensatory muscle tension. Chang CC et al. [61], discussing “Hip-Spine Syndrome”, described the strong interaction between these two regions (hip and lumbar spine), considering the joints interdependent. The hip is connected to the pelvis, which in turn is directly linked to the lumbar spine; any restriction in hip mobility disrupted the overall balance of the pelvis and, by extension, the spine. They described the concept of movement limitation: if the hip could no longer perform normal rotation or extension, the lumbosacral junction would “absorb” the body’s rotational movements, accelerating wear on the discs or vertebral joints. However, Kouyoumdjian [62] observed that the psoas muscle acts as a direct bridge between the lumbar vertebrae and the femur; inflammation or tension—caused by hip osteoarthritis, for example—could radiate directly to the lower back. He also noted that muscle imbalance or gluteal muscle insufficiency placed an excessive load on the erector spinae muscles, thereby promoting lower back pain. Thus, Oshima et al. [63] observed that any change in alignment resulting from pathological or degenerative alterations in the knee, hip, or spine could lead to compensatory changes at other sites—along with the progression of deformities—in order to maintain postural balance [64].

This study showed that the most common sites for degenerative spinal lesions were L4-L5, L5-S1, and L3-S1. These results were consistent with those obtained by Musa [65], who noted that the segment most frequently affected by degenerative spondylolisthesis was L4-L5, while high-grade listhesis was more common at the L5-S1 level. These degenerative lesions predominantly occurred between L3 and S1 due to the anatomical configuration and mechanical stresses unique to these levels. These vertebrae formed a transition zone and were subjected to significant stress. According to Koslosky E et al. [66], the L5 vertebra possesses a distinctive anatomy. It is the final mobile vertebra of the spine. Its body is wedge-shaped—taller anteriorly than posteriorly—a feature that determines the lumbosacral angle. Its transverse processes are short and stout, and its inferior articular processes are oriented differently to interlock perfectly with the sacrum, creating a natural locking mechanism. This unique anatomy predisposed the area to very specific and intense mechanical stresses [65]. According to Lin et al. [67], the lumbosacral junction (L5-S1) served as the connecting point between the mobile section of the spine (the lumbar region) and the fixed section (the sacrum). The L5 vertebra bore almost the entire weight of the upper body. The L5-S1 junction formed an inclined angle, with the sacral plateau (S1) naturally tilted forward. Gravity exerted a constant shear force, pushing the L5 vertebra to slide along this “slope”. In the context of this study, the women of Lubuya Bera carried heavy loads on their backs, thereby overloading the upper part of their spines. For Goode [21], the L4-L5-S1 region acted as the back’s primary pivot point, combining maximum load-bearing with significant flexion mobility; this heavily stressed anatomical junction absorbed the full weight of the upper body, transferring the weight of the torso to the legs.

A bivariate analysis in this study—related to the radioclinical status of women who carry heavy loads on their backs by Liyamba—revealed that four variables were significantly associated with chronic low back pain.

A history of Caesarean section was associated with an odds ratio (OR) of 4.97. This meant that a Caesarean section performed on a woman in the peri-urban area of Kisangani increased the risk of developing chronic low back pain more than fourfold. This highlights the need to regulate the indications for and performance of Caesarean sections in resource-limited settings.

In this study, multilevel disc degeneration had an odds ratio of 4, degenerative anterolisthesis 3.13, and lumbar osteoarthritis 2.63; this indicates that these radioclinical diagnoses increased the risk of developing chronic low back pain fourfold, more than threefold, and more than twofold, respectively. These degenerative conditions were primarily diagnosed via conventional radiography in young women of childbearing age who were exposed to strenuous physical demands—specifically carrying heavy loads on their backs, sometimes using a traditional basket known as a “Liyamba”.

However, a multivariate analysis revealed that, overall, the factors mentioned above were not associated with low back pain. This meant that, within the scope of this study, these factors—found in both those with and without low back pain—could not on their own account for the patients’ chronic low back pain, given the potential involvement of various other factors and confounders.

This study clinically demonstrated that the female patient from Lubuya Bera, who suffered from chronic low back pain, exhibited all the characteristics of low back pain accompanied by hip and knee pain. Her medical history included a Caesarean section and recurrent spontaneous abortions, with comorbidities of pelvic organ prolapse and inguinal hernia. Conventional radiography revealed several degenerative conditions, the most frequent being anterolisthesis, simple disc degeneration, multilevel disc degeneration, simple lumbar osteoarthritis, and multilevel lumbar osteoarthritis, primarily affecting the L3 to S1 levels.

Most of the clinical data collected for this study relied on self-reported health complaints and were subject to potential reporting bias. The failure to record neurological signs meant that radiating pain could not be characterized. A lack of sufficient financial resources prevented the performance of spinal CT scans—which were available in Kisangani—as well as the production of knee and hip radiographs. The small sample size may limit the generalizability of the findings. Therapeutic aspects and clinical management were not addressed in this study.

It has been shown that carrying loads on the back or head among women with chronic low back pain leads to degenerative lumbar spine conditions and disorders associated with increased intra-abdominal pressure.The impact on these women’s quality of life appeared to be significant.

Clinical assessment revealed that women with chronic low back pain in Lubuya Bera lived with constant, intense lower back pain and prolonged morning stiffness, accompanied by hip and knee pain.Conventional radiography enabled the diagnosis of degenerative spinal conditions.

Conduct further studies on the holistic management of these women with chronic low back pain, with the aim of improving their quality of life. Investigate the neurological impact by performing CT scans or even MRI scans in any suspected cases.

First author: conception, data collection, redaction; Second et third authors: data statistics analysis; Fourth et the latest: conception et text correction.