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Musculoskeletal spine pain in adolescents: Epidemiology of non-specific neck and low back pain and risk factors
Journal of Orthopaedic Science xxx (xxxx) xxx
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Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original Article
Musculoskeletal spine pain in adolescents: Epidemiology of nonspecific neck and low back pain and risk factors Beatriz Minghelli* School of Health Jean Piaget Algarve, Piaget Institute Research in Education and Community Intervention (RECI), Portugal
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 July 2019 Received in revised form 5 September 2019 Accepted 15 October 2019 Available online xxx
Background: Neck pain (NP) and low back pain (LBP) have become a growing public health problem in adolescents that involve multiple factors, including modifiable factors, such as behavioral factors that include sedentary activities and adoption of inadequate postures. This study aimed to determine the prevalence of NP and LBP in adolescents and to investigate its association with sedentary activities and postures. Methods: The sample was comprised of 304 students, being 144 (47.4%) boys, aged between 10 and 17 years old (13.68 ± 2.02). The measurement instruments included a questionnaire, postural evaluation of some task and the transportation and weighing of the backpack. Results: The prevalence of NP and LBP were, respectively: in the lifetime: 51% and 65.1%; at the moment: 5.9% and 8.6%; and in a 12-month period: 39.8% and 47%. The older students (15e17 years old) had 3.03 times higher probability of developing LBP (95% CI (1.82e5.03; p 0.001) than the younger one (10e14 years), adolescents who used a mobile phone more than 10 h per week had 2.48 times higher probability of developing NP (95% CI: 1.29e4.75; p ¼ 0.006) than those who had used for a shorter period (until 10 h) and 2.39 more probability to developed the LBP (95% CI: 1.41e4.08; p ¼ 0.001). The students who sit with a spine in a wrong position had 3.24 more chances to have LBP (95% CI: 1.33e7.89; p ¼ 0.010). Conclusions: Data of this study showed a higher prevalence of NP and LBP in this sample and revealed that adolescents who used a mobile phone more than 10 h per week had more probability to develop both NP and LBP and older students and who sit with a spine in a wrong position had more chances to have LBP. © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Neck pain (NP) and low back pain (LBP) are symptoms experienced by individuals of all ages and have become a growing public health problem in adolescents [1,2] with prevalence estimates ranging from 21% to 42% [3] and 39% [4], respectively. Multiple factors, including nonmodifiable factors, such as gender, a previous history of NP and LBP and genetics, physiological, psychological and behavioral factors or a combination of these can be related to NP and LBP [5]. Currently, there has been an increase of sedentary activities associated with the use of electronic devices by adolescents that includes devices such as desktop and laptop computers, mobile
* Instituto Piaget, Escola Superior de Saúde Jean Piaget / Algarve, Enxerim, 8300025, Silves, Portugal. E-mail address: [email protected].
telephones, television and electronic game consoles [6e8]. Lack of physical activity, which implies less muscle flexibility and strength, associated with static posture and with insufficient recovery after local muscle fatigue because of static positions maintained for an extended period are factors that contribute to the development of NP and LBP. If these factors are associated with poor posture, the symptomatology may be aggravated. However, the data from studies are contradictory [9e15]. It is important to understand which factors are associated with these symptoms to avoid the chronicity of them. Besides that, the adolescents who experiencing NP and LBP in their teens have an increased risk of developing these symptoms in adult life [16,17]. Thus, the knowledge of musculoskeletal pain in adolescents is necessary not only because it impairs their health as a young person but predisposes them to the development of chronic pain in adulthood [18]. This study aimed to determine the prevalence of NP and LBP in adolescents and to investigate whether NP and LBP are associated with sedentary activities and postures.
https://doi.org/10.1016/j.jos.2019.10.008 0949-2658/© 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Minghelli B, Musculoskeletal spine pain in adolescents: Epidemiology of non-specific neck and low back pain and risk factors, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.008
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2. Methods An epidemiological and cross-sectional study was conducted to gather data on musculoskeletal spine pain in adolescents. This research has been approved by the IRB of the authors’ affiliated institutions and by School Direction. Written informed consent was obtained from all parents or guardians of the students. 2.1. Population The population included students from the 5th and 7th-grades of the public elementary school E.B. 2,3 Dr Garcia Domingues in Silves city, and 8th and 10th-grades of the public schools E.B. 2,3 D. nio Martinho Castelo Branco, elementary school, and Poeta Anto ~o city, south of Portugal. All Aleixo, high school, both in Portima schools are located in the south of Portugal. Silves is a city with about 6300 inhabitants and it is the seat of a municipality with an area of 680.06 km2 and 37,126 inhabitants. ~o has about 40,000 inhabitants, seat of a municipality with Portima an area of 182.06 km2 and 55,614 inhabitants; the city center is situated about 2 km from the sea and is an important center for fishing and tourism. The sample selection process was done taking into account the logistic questions of the schedules of the schools that participated in this study. Inclusion criteria involved cumulatively students of both sexes, until 17 years old, whose sponsor of education authorised study participation, and who were present on the days of the evaluations. 2.2. Measurement instrument The measurement instruments were applied in a single session by the investigator and included a questionnaire, postural evaluation of sitting posture and mobile phone use and the transportation and weighing of the backpack.
without flexion in the front plane and/or with a lateral deviation in the sagittal plane. Next, the student was asked to write a text message using his/her mobile phone. Postures analysis were considered correct if the student kept the spine in an extension position. For logistic reasons, the evaluation of the use of the mobile phone was only realized to the students of the 8th and 10th-grades. The evaluator requested that each task be performed; no demonstration was provided. Each student performed the test individually. 2.2.3. Backpack evaluation The student was asked about which was the most frequent way of transporting his/her backpack. After that, the backpack and student were weighed using a SECA 780 digital scale with a capacity of 150 kg and a precision of 100 g. A backpack was classified as having excessive weight if it was more than 10% of the individual's body weight [21]. 2.3. Data analysis First, descriptive statistical data were obtained regarding all the variables in the study through measures of central tendency and dispersion. Subsequently, the influence of the included variables on the presence of NP and LBP was assessed using binary logistic regressions, based on the Enter method; crude odds ratios (OR) and respective confidence intervals (CI) were also calculated. A final multivariate model was developed, using the Forward Likelihood Method, and its validity, quality of fitting and predictive capacity were assessed by Omnibus and the Nagelkerke correlation coefficient. In all inferential analysis, statistical significance was set at 0.05. Statistical analysis was performed with Statistical Package for Social Sciences (SPSS), version 24.0. 3. Results
2.2.1. Neck and Low back pain questionnaire The questionnaire was applied in the form of a structured interview, which could clarify doubts that emerged without interfering with their opinions or producing biased answers. The questionnaire included questions about the biological characteristics of the students (gender and the student's age), hours of sedentary habits practice, practice of sports with a frequency of at least 2 times a week, and about the occurrence of NP and LBP in different periods: at the moment of application of the questionnaire, lifetime prevalence (throughout all life), in the last 6 months and in the last 12 months. Students who presented NP and LBP within the last 12 months were asked to continue and fill out the questionnaire answering if he/she has sought a health professional because of the pain, and if so, should indicate which, and if there was any treatment and if so, what kind of treatment was applied. The students who reported LBP were asked if their parents had back pain. LBP was characterized by the presence of symptoms in the lumbar region (lower part of the spine), between the costal margin and the inferior gluteal folds, including pain, muscle tension or stiffness [19]. Neck pain was defined as neck pain felt in the cervical and upper trapezius region [20]. This definition was presented in the questionnaire. Besides that, the evaluator showed the student where to report the pain. 2.2.2. Postural habits evaluation To evaluate the seated posture during the writing task, the student was asked to sit in a chair and write some data. The standard posture considered was sitting with the spine extended
The sample was comprised of 304 students, being 144 (47.4%) boys and 160 (52.6%) girls, aged between 10 and 17 years old (13.68 ± 2.02). Fifty (16.4%) were enrolled in the 5th-grade, 46 (15.1%) in 7th-grade, 105 (34.5%) in the 8th-grade, and 103 (33.9%) in the 10th-grade. One hundred eighty-six (61.2%) students referred that who practiced some kind of sport at least twice a week. Table 1 shows the hours per week of sedentary habits. The values of the prevalence of NP and LBP are presented in Table 2. One hundred forty-nine (49%) adolescents referred that his/her father reported LBP in a period of his life, 114 (37.5%) said they never felt, and 41 (13.5%) said they did not know if their father complained of back pain. One hundred seventy (55.9%) said that his/her mother already complained of back pain, 99 (32.6%) said the mother never felt LBP, and 35 (11.5%) did not know. Only the students who referred NP and/or LBP were asked if they sought health care professionals and/or had some kind of treatment for pain. Thus, the following percentages takes into account the total number of students presenting both NP and LBP or presenting only one of the symptoms, totaling 190 students. Fortyeight (25.3%) adolescents of 190 (100%) had sought out a health professional because of the NP and/or LBP. Of those (n ¼ 48; 100%), 18 (37.5%) went to the doctor, 21 (43.8%) sought a physiotherapist, 5 (10.4%) had osteopaths, and 4 (8.3%) other professionals. LBP was the main cause of demand for health services (32; 66.7%), NP was responsible by 18.8% (n ¼ 9) and 7 (14.6%) individuals sought a health professional because of both pains.
Please cite this article as: Minghelli B, Musculoskeletal spine pain in adolescents: Epidemiology of non-specific neck and low back pain and risk factors, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.008
B. Minghelli / Journal of Orthopaedic Science xxx (xxxx) xxx
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Table 1 Hours per week of sedentary habits. Sedentary habits (hours per week)
Not use
up to 5 h
6e10 h
11e15 h
16 h
Watching television Mobile phones use Console/computer games
44 (14.5%) 13 (4.3%) 132 (43.4%)
137 (45.1%) 33 (10.9%) 96 (31.6%)
70 (23%) 49 (16.1%) 31 (10.2%)
38 (12.5%) 75 (24.7%) 29 (9.5%)
15 (4.9%) 134 (44.1%) 16 (5.3%)
Table 2 Prevalence values of NP and LBP. Spine musculoskeletal pain
Prevalence values Lifetime
At the moment
6-month period
12-month period
Low back pain Neck pain
198 (65.1%) 155 (51%)
26 (8.6%) 18 (5.9%)
119 (39.1%) 104 (34.2%)
143 (47%) 121 (39.8%)
One hundred eight (56.8%) of 190 (100%) students underwent some type of treatment. Of these (n ¼ 108; 100%), 48 (44.4%) took medication, 23 (21.3%) did physiotherapy, 14 (13%) rested, 5 (4.6%) stop their activities, and 18 (16.7%) had another type of treatments. Fifty-three (49.1%) students underwent some type of treatment because of LBP, 31 (28.7%) because of neck pain and 24 (22.2%) because of both. Regarding the practical postural evaluation, 270 (88.8%) adolescents sat in an inadequate form (with spine flexion in the front plane and/or with a lateral deviation in the sagittal plane). One hundred ninety-seven of 206 students (95.6%) used the mobile phone in the wrong way, with flexion of the spine, mainly of the cervical region. Ninety-one (29.9%) students reported carrying the backpack with one handle, and 98 (32.2%) presented excess of weight in his/ her backpack. Table 3 shows the values of backpack weight distributed by school grades.
Table 4 shows the relationship between the occurrence of NP and LBP over the last 12-month period and sex, age group, sedentary habits, physical activity practice, and postural habits, obtained by application of the binary logistic regression model. The final model was considered mathematically valid (Omnibus, HosmereLemeshow and Nagelkerke: p ¼ 0.005, p < 0.001 and R2 ¼ 0.50). It was found that older students (15e17 years old) had a 3.03 times higher probability of developing LBP (95% CI (1.82e5.03; p 0.001) than the younger one (10e14 years old). Additionally, adolescents who used a mobile phone more than 10 h per week had a 2.48 times higher probability of developing NP (95% CI: 1.29e4.75; p ¼ 0.006) than those who had used for a shorter period (until 10 h) and the same was observed regarding LBP with a 2.39 more probability to developed this symptom in lower back (95% CI: 1.41e4.08; p ¼ 0.001). The students who sit with a spine in a wrong position had 3.24 more chances to have LBP (95% CI: 1.33e7.89; p ¼ 0.010).
Table 3 Values of backpack weight for grades groups. School grades
Backpack weight Mean ± standard deviation (kg)
Minimum e Maximum (kg)
Excess of weight
5th grade 7th grade 8th grade 10th grade
5.29 ± 1.33 5.52 ± 1.26 4.61 ± 1.28 3.0 ± 1.09
2.2e8 2.1e7.7 1.3e9.5 0.8e5.8
39 (78%) 27 (58.7%) 26 (24.8%) 6 (5.8%)
Table 4 Relationship between the event the presence of spine musculoskeletal pain and variables about non-modifiable and modifiable risk factors. Spine musculoskeletal pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain a
Variables a
Gender (boys) girls a
Age group (10e14 years) 15e17 years Watching television (per week) (>10 h)a until 10 h Mobile phones use (per week) (until 10 h)a > 10 h Console games (per week) (>10 h)a until 10 h Physical activity practice (yes)a no Physical activity practice (no)a yes Posture with the use of mobile phones (incorrect)a correct Sitting posture (spine evaluated) (correct)a incorrect Backpack weight (adequate)a excess Backpack weight (excess)a adequate
OddsRatiocrude (CI 95%); p-value
Multivariable (CI 95%); p-value
1.42 1.29 1.25 3.38 1.01 1.09 1.79 2.38 1.11 1.13 1.12 1.03 2.58 3.92 1.00 0.57
e e e 3.03 e e 2.48 2.39 e e e e e 3.24 e e
(0.89e2.25); 0.139 (0.82e2.02); 0.276 (0.78e2.01); 0.353 (2.07e5.51); 0.001 (0.55e1.85); 0.976 (0.60e1.98); 0.778 (1.07e2.99); 0.027 (1.44e3.96); 0.001 (0.58e2.12); 0.764 (0.59e2.14); 0.706 (0.70e1.79); 0.625 (0.65e1.63); 0.905 (0.63e10.62); 0.189 (1.65e9.29); 0.002 (0.61e1.63); 0.999 (0.35e0.94); 0.026
(1.82e5.03); 0.001
(1.29e4.75); 0.006 (1.41e4.08); 0.001
(1.33e7.89); 0.010
Reference class.
Please cite this article as: Minghelli B, Musculoskeletal spine pain in adolescents: Epidemiology of non-specific neck and low back pain and risk factors, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.008
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B. Minghelli / Journal of Orthopaedic Science xxx (xxxx) xxx
4. Discussion This study revealed a high prevalence of NP and LBP in the sample analyzed of students living in south of Portugal. Similar data were obtained in Minghelli et al. study [12] who also evaluated students of South region of Portugal, with ages between 10 and 16 years old (n ¼ 966), and verified a prevalence of LBP in 12-month period in 47.2% of the adolescents; it is noteworthy that the data collection was 7 years ago (between 2011 and 2012) and the results values stays the same (47%) in other adolescents analyzed in this study (2019). Data of lifetime prevalence of LBP showed a slight increase in values between these studies from 62.1% from the old study [12] to 65.1% in this recent study. Akbar et al. [22] revealed a lifetime prevalence of 70.3% in 950 adolescents in Kuwait, aged 14e19 years old. Regarding the prevalence of LBP in 6-month period, our data (39.1%) were close those verified in Shan et al. study [15] that analyzed 3600 adolescents in Shanghai, aged between 15 and 19 years old, and showed a prevalence of 33.1%. Akbar et al. [22] revealed higher values in the same period (49.1%). Relatively to NP in 6-month period, our data (34.2%) is higher than obtained in Myrtveit et al. study [9] that evaluated 8900 Norwegian students and revealed a prevalence of 20%; but in this cited study the age of the sample varied between 17 and 19 years old differing from the analyzed age of our study. Silva et al. [6] also presented a lower value than our study (18.5%), in the same period analyzed, in 961 Brazilian adolescents, aged 14e19 years. Shan et al. [15] study showed a higher prevalence in this same period (40.8%). Considering the study of Shan et al. [15], it was observed that symptoms of NP already start to have a higher percentage than the LBP (40.8% versus 33.1%). The same was observed in Joergensen et al. study [23] that evaluated a lifetime prevalence of spinal pain among 46,726 Danish adolescentes, aged 11 to 14-year-olds and revealed 31.9% of NP and 14.1% of LBP. Manayesh et al. [2] revealed results of NP in 14.2% and LBP in 6.9% (previous 12 months) in 723 Ethiopian adolescentes with mean age of 11.5 years (SD 2.7 years). Comparing the results of all prevalence periods analyzed in our study, we can see that the percentage of LBP presence is higher than NP, but the percentages differ by only 5 to 14 percentage points. Our lifetime prevalence of NP (51%) were similar to those obtained in Straker et al. study [24] who evaluated 1597 adolescents with a mean age of 14.1 years and obtained a lifetime prevalence of neck/shoulder pain of 47%. Static postures held for long periods and wrongly may also be factors that may contribute to the development of NP and LBP. This study verified that the adoption of incorrect posture for sitting can increase a probability to develop LBP (p ¼ 0.002). Minghelli et al. [12] revealed that students who sit with the spine incorrectly positioned presented 2.49 greater probability of having LBP (95% CI 1.91e3.2; p 0.001), as well as students adopted improper positions for watching televison or playing games have 2.01 greater chances (95% CI 1.55e2.61; p 0.001). Grimmer and Williams [25] found associations between recent LBP and the amount of time spent in seated posture. Regarding the mobile phone use, the data of this study did not present a statistical significance between NP and the wrong posture for use the phone (with flexion of cervical) but showed significant association with the time of use, revealing that adolescents who use more than 10 h per week may be an increased risk of developing both NP and LBP. Similar results were obtained by Shan et al. [15] who period of mobile phone use longer than 2 h per day were related to a significant increase in the prevalence of NP and LBP (p < 0.05) and by Silva et al. [26] who revealed that the use of mobile phones for 5 h or more was significantly associated with increased odds of pain in the last 7-days for the LBP (OR ¼ 3.20; p < 0.05).
Several studies showed a relationship with mobile phone use associated with flexion of cervical posture to view the display, however, the association between neck flexion during mobile phone use and neck disability has not been scientifically confirmed to date. Namwongsa et al. study [7] verified that flexed neck posture was associated with neck disorders (OR ¼ 2.44; CI ¼ 1.21e4.90). This study also verified that older students have more chances to developed NP and LBP, data similar to other studies [1,12,15,27]. Older adolescents may be more exposed to physical and environmental aggression because of their increasing range of activity in terms of frequency and intensity than the younger one. Besides that, older adolescents tend to show a greater propensity for pain because of their uncertainties in conceptualizing a multitude of bodily sensations associated with puberty [28]. Other variable that revealed statistically significant association with LBP was the backpack weight which revealed an unexpected result in which students carrying the properly weighted backpack were most likely to have LBP. Several studies did not find an association between the excess of weight on backpack and the LBP [11,29]. This result can be explained by the fact that the time each student carries the school bag has not been evaluated. That is, students who had adequate weight in the backpack could carry it for long periods leading to the occurrence of pain. Akbar et al. [22] suggested that the perceived heaviness of school bag is far more important than the actual bag weight. This study showed some limitations including the self-reported questionnaire, the memory bias, the evaluation of posture in just a moment (may not be the posture that corresponds to that adopted most of the time), not being analyzed over a day and the backpack weighing was not done on more days to calculate the week average. However, these limitations are difficult to overcome because of logistical school issues and children's privacy and parental consent so that children could be observed on homework. Future studies that evaluated the frequencies and durations of exposure of mobile and screens devices are suggested. 5. Conclusions Data of this study showed a higher prevalence of NP and LBP in the analyzed sample and revealed that adolescents who used a mobile phone more than 10 h per week had more probability to develop both NP and LBP and older students and who sit with a spine in a wrong position had more chances to have LBP. This increased prevalence of NP and LBP in adolescents implies an increase in medication use, consultations with health professionals, overloading the health system, increase of school absenteeism and physical inactivity, leading to greater use of electronic devices. Since many of these variables are risk factors that can be modifiable through an intervention, educational sessions need to be implemented in schools. Theoretical-practical sessions to teaching the best posture to be adopted during sitting position at school (which implies a static posture maintained for long periods), stretching exercises to be implemented after being in a long posture, alternating positions, explanations about the spinal anatomy for better understanding of our body, as well as the consequences of a posture maintained for a long period. Mobile phone use can be reduced by encouraging sports activities and performing breaks after long periods of use. Study design Epidemiological and cross-sectional.
Please cite this article as: Minghelli B, Musculoskeletal spine pain in adolescents: Epidemiology of non-specific neck and low back pain and risk factors, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.008
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Funding sources This study is financed by national funds through FCT - Foundation for Science and Technology, I.P., in the scope of the project UID/Multi/04587/2019; Research in Education and Community Intervention (RECI). Declaration of Competing Interest None. Acknowledgments Ana Carolina Coelho, Sara Paulino for assisting in data collection. References [1] Scarabottolo C, Pinto R, Oliveira C, Zanuto E, Cardoso J, Christofaro D. Back and neck pain prevalence and their association with Physical inactivity domains in adolescents. Eur Spine J 2017 Sep;26(9):2274e80. [2] Manayesh K, Ciccarellia M, Falkmera T, Parsons R. Associations between exposure to information and communication Technology (ICT) and reported discomfort among adolescents. Work 2014;48(2):165e73. [3] Hogg-Johnson S, van der Velde G, Carroll L, Holm L, Cassidy J, Guzman J, et al. The burden and determinants of neck pain in the general population. Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. J Manip Physiol Ther 2008 Feb;32:S46e60. ~ oz I, Go mez-Conesa A, Sa nchez-Meca J. Prevalence of low back pain [4] Calvo-Mun in children and adolescents: a meta-analysis. BMC Pediatr 2013 Jan;13:14. [5] Kamper SJ, Henschke N, Hestbaek L, Dunn K, Williams C. Musculoskeletal pain in children and adolescents. Braz J Phys Ther 2016 May-Jun;20(3):275e84. [6] Silva G, Pitangui A, Xavier M, Correia-Júnior M, Araújo R. Prevalence of musculoskeletal pain in adolescents and association with computer and videogame use. J Pediatr 2016 Mar-Apr;92(2):188e96. [7] Namwongsa S, Puntumetakul R, Neubert M, Boucaut R. Factors associated with neck Disorders among university student smartphone users. Work 2018;61(3):367e78. [8] Palmer K, Ciccarelli M, Falkmer T, Parsons R. Associations between exposure to Information and Communication Technology (ICT) and reported discomfort among adolescents. Work 2014;48(2):165e73. [9] Myrtveit S, Sivertsen B, Skogen J, Frostholm L, Stormark K, Hysing M. Adolescent neck and shoulder pain: the association with depression, physical activity, screen-based activities, and use of health care services. J Adolesc Health 2014 Sep;55(3):366e72. [10] Chow D, Leung K, Holmes A. Changes in spinal curvature and proprioception of schoolboys carrying different weights of backpack. Ergonomics 2007 Dec;50(12):2148e56. [11] Trevelyan F, Legg S. Risk factors associated with back pain in New Zealand school children. Ergonomics 2011 Mar;54(3):257e62.
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Please cite this article as: Minghelli B, Musculoskeletal spine pain in adolescents: Epidemiology of non-specific neck and low back pain and risk factors, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.008
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original Article
Musculoskeletal spine pain in adolescents: Epidemiology of nonspecific neck and low back pain and risk factors Beatriz Minghelli* School of Health Jean Piaget Algarve, Piaget Institute Research in Education and Community Intervention (RECI), Portugal
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 July 2019 Received in revised form 5 September 2019 Accepted 15 October 2019 Available online xxx
Background: Neck pain (NP) and low back pain (LBP) have become a growing public health problem in adolescents that involve multiple factors, including modifiable factors, such as behavioral factors that include sedentary activities and adoption of inadequate postures. This study aimed to determine the prevalence of NP and LBP in adolescents and to investigate its association with sedentary activities and postures. Methods: The sample was comprised of 304 students, being 144 (47.4%) boys, aged between 10 and 17 years old (13.68 ± 2.02). The measurement instruments included a questionnaire, postural evaluation of some task and the transportation and weighing of the backpack. Results: The prevalence of NP and LBP were, respectively: in the lifetime: 51% and 65.1%; at the moment: 5.9% and 8.6%; and in a 12-month period: 39.8% and 47%. The older students (15e17 years old) had 3.03 times higher probability of developing LBP (95% CI (1.82e5.03; p 0.001) than the younger one (10e14 years), adolescents who used a mobile phone more than 10 h per week had 2.48 times higher probability of developing NP (95% CI: 1.29e4.75; p ¼ 0.006) than those who had used for a shorter period (until 10 h) and 2.39 more probability to developed the LBP (95% CI: 1.41e4.08; p ¼ 0.001). The students who sit with a spine in a wrong position had 3.24 more chances to have LBP (95% CI: 1.33e7.89; p ¼ 0.010). Conclusions: Data of this study showed a higher prevalence of NP and LBP in this sample and revealed that adolescents who used a mobile phone more than 10 h per week had more probability to develop both NP and LBP and older students and who sit with a spine in a wrong position had more chances to have LBP. © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Neck pain (NP) and low back pain (LBP) are symptoms experienced by individuals of all ages and have become a growing public health problem in adolescents [1,2] with prevalence estimates ranging from 21% to 42% [3] and 39% [4], respectively. Multiple factors, including nonmodifiable factors, such as gender, a previous history of NP and LBP and genetics, physiological, psychological and behavioral factors or a combination of these can be related to NP and LBP [5]. Currently, there has been an increase of sedentary activities associated with the use of electronic devices by adolescents that includes devices such as desktop and laptop computers, mobile
* Instituto Piaget, Escola Superior de Saúde Jean Piaget / Algarve, Enxerim, 8300025, Silves, Portugal. E-mail address: [email protected].
telephones, television and electronic game consoles [6e8]. Lack of physical activity, which implies less muscle flexibility and strength, associated with static posture and with insufficient recovery after local muscle fatigue because of static positions maintained for an extended period are factors that contribute to the development of NP and LBP. If these factors are associated with poor posture, the symptomatology may be aggravated. However, the data from studies are contradictory [9e15]. It is important to understand which factors are associated with these symptoms to avoid the chronicity of them. Besides that, the adolescents who experiencing NP and LBP in their teens have an increased risk of developing these symptoms in adult life [16,17]. Thus, the knowledge of musculoskeletal pain in adolescents is necessary not only because it impairs their health as a young person but predisposes them to the development of chronic pain in adulthood [18]. This study aimed to determine the prevalence of NP and LBP in adolescents and to investigate whether NP and LBP are associated with sedentary activities and postures.
https://doi.org/10.1016/j.jos.2019.10.008 0949-2658/© 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Minghelli B, Musculoskeletal spine pain in adolescents: Epidemiology of non-specific neck and low back pain and risk factors, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.008
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2. Methods An epidemiological and cross-sectional study was conducted to gather data on musculoskeletal spine pain in adolescents. This research has been approved by the IRB of the authors’ affiliated institutions and by School Direction. Written informed consent was obtained from all parents or guardians of the students. 2.1. Population The population included students from the 5th and 7th-grades of the public elementary school E.B. 2,3 Dr Garcia Domingues in Silves city, and 8th and 10th-grades of the public schools E.B. 2,3 D. nio Martinho Castelo Branco, elementary school, and Poeta Anto ~o city, south of Portugal. All Aleixo, high school, both in Portima schools are located in the south of Portugal. Silves is a city with about 6300 inhabitants and it is the seat of a municipality with an area of 680.06 km2 and 37,126 inhabitants. ~o has about 40,000 inhabitants, seat of a municipality with Portima an area of 182.06 km2 and 55,614 inhabitants; the city center is situated about 2 km from the sea and is an important center for fishing and tourism. The sample selection process was done taking into account the logistic questions of the schedules of the schools that participated in this study. Inclusion criteria involved cumulatively students of both sexes, until 17 years old, whose sponsor of education authorised study participation, and who were present on the days of the evaluations. 2.2. Measurement instrument The measurement instruments were applied in a single session by the investigator and included a questionnaire, postural evaluation of sitting posture and mobile phone use and the transportation and weighing of the backpack.
without flexion in the front plane and/or with a lateral deviation in the sagittal plane. Next, the student was asked to write a text message using his/her mobile phone. Postures analysis were considered correct if the student kept the spine in an extension position. For logistic reasons, the evaluation of the use of the mobile phone was only realized to the students of the 8th and 10th-grades. The evaluator requested that each task be performed; no demonstration was provided. Each student performed the test individually. 2.2.3. Backpack evaluation The student was asked about which was the most frequent way of transporting his/her backpack. After that, the backpack and student were weighed using a SECA 780 digital scale with a capacity of 150 kg and a precision of 100 g. A backpack was classified as having excessive weight if it was more than 10% of the individual's body weight [21]. 2.3. Data analysis First, descriptive statistical data were obtained regarding all the variables in the study through measures of central tendency and dispersion. Subsequently, the influence of the included variables on the presence of NP and LBP was assessed using binary logistic regressions, based on the Enter method; crude odds ratios (OR) and respective confidence intervals (CI) were also calculated. A final multivariate model was developed, using the Forward Likelihood Method, and its validity, quality of fitting and predictive capacity were assessed by Omnibus and the Nagelkerke correlation coefficient. In all inferential analysis, statistical significance was set at 0.05. Statistical analysis was performed with Statistical Package for Social Sciences (SPSS), version 24.0. 3. Results
2.2.1. Neck and Low back pain questionnaire The questionnaire was applied in the form of a structured interview, which could clarify doubts that emerged without interfering with their opinions or producing biased answers. The questionnaire included questions about the biological characteristics of the students (gender and the student's age), hours of sedentary habits practice, practice of sports with a frequency of at least 2 times a week, and about the occurrence of NP and LBP in different periods: at the moment of application of the questionnaire, lifetime prevalence (throughout all life), in the last 6 months and in the last 12 months. Students who presented NP and LBP within the last 12 months were asked to continue and fill out the questionnaire answering if he/she has sought a health professional because of the pain, and if so, should indicate which, and if there was any treatment and if so, what kind of treatment was applied. The students who reported LBP were asked if their parents had back pain. LBP was characterized by the presence of symptoms in the lumbar region (lower part of the spine), between the costal margin and the inferior gluteal folds, including pain, muscle tension or stiffness [19]. Neck pain was defined as neck pain felt in the cervical and upper trapezius region [20]. This definition was presented in the questionnaire. Besides that, the evaluator showed the student where to report the pain. 2.2.2. Postural habits evaluation To evaluate the seated posture during the writing task, the student was asked to sit in a chair and write some data. The standard posture considered was sitting with the spine extended
The sample was comprised of 304 students, being 144 (47.4%) boys and 160 (52.6%) girls, aged between 10 and 17 years old (13.68 ± 2.02). Fifty (16.4%) were enrolled in the 5th-grade, 46 (15.1%) in 7th-grade, 105 (34.5%) in the 8th-grade, and 103 (33.9%) in the 10th-grade. One hundred eighty-six (61.2%) students referred that who practiced some kind of sport at least twice a week. Table 1 shows the hours per week of sedentary habits. The values of the prevalence of NP and LBP are presented in Table 2. One hundred forty-nine (49%) adolescents referred that his/her father reported LBP in a period of his life, 114 (37.5%) said they never felt, and 41 (13.5%) said they did not know if their father complained of back pain. One hundred seventy (55.9%) said that his/her mother already complained of back pain, 99 (32.6%) said the mother never felt LBP, and 35 (11.5%) did not know. Only the students who referred NP and/or LBP were asked if they sought health care professionals and/or had some kind of treatment for pain. Thus, the following percentages takes into account the total number of students presenting both NP and LBP or presenting only one of the symptoms, totaling 190 students. Fortyeight (25.3%) adolescents of 190 (100%) had sought out a health professional because of the NP and/or LBP. Of those (n ¼ 48; 100%), 18 (37.5%) went to the doctor, 21 (43.8%) sought a physiotherapist, 5 (10.4%) had osteopaths, and 4 (8.3%) other professionals. LBP was the main cause of demand for health services (32; 66.7%), NP was responsible by 18.8% (n ¼ 9) and 7 (14.6%) individuals sought a health professional because of both pains.
Please cite this article as: Minghelli B, Musculoskeletal spine pain in adolescents: Epidemiology of non-specific neck and low back pain and risk factors, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.008
B. Minghelli / Journal of Orthopaedic Science xxx (xxxx) xxx
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Table 1 Hours per week of sedentary habits. Sedentary habits (hours per week)
Not use
up to 5 h
6e10 h
11e15 h
16 h
Watching television Mobile phones use Console/computer games
44 (14.5%) 13 (4.3%) 132 (43.4%)
137 (45.1%) 33 (10.9%) 96 (31.6%)
70 (23%) 49 (16.1%) 31 (10.2%)
38 (12.5%) 75 (24.7%) 29 (9.5%)
15 (4.9%) 134 (44.1%) 16 (5.3%)
Table 2 Prevalence values of NP and LBP. Spine musculoskeletal pain
Prevalence values Lifetime
At the moment
6-month period
12-month period
Low back pain Neck pain
198 (65.1%) 155 (51%)
26 (8.6%) 18 (5.9%)
119 (39.1%) 104 (34.2%)
143 (47%) 121 (39.8%)
One hundred eight (56.8%) of 190 (100%) students underwent some type of treatment. Of these (n ¼ 108; 100%), 48 (44.4%) took medication, 23 (21.3%) did physiotherapy, 14 (13%) rested, 5 (4.6%) stop their activities, and 18 (16.7%) had another type of treatments. Fifty-three (49.1%) students underwent some type of treatment because of LBP, 31 (28.7%) because of neck pain and 24 (22.2%) because of both. Regarding the practical postural evaluation, 270 (88.8%) adolescents sat in an inadequate form (with spine flexion in the front plane and/or with a lateral deviation in the sagittal plane). One hundred ninety-seven of 206 students (95.6%) used the mobile phone in the wrong way, with flexion of the spine, mainly of the cervical region. Ninety-one (29.9%) students reported carrying the backpack with one handle, and 98 (32.2%) presented excess of weight in his/ her backpack. Table 3 shows the values of backpack weight distributed by school grades.
Table 4 shows the relationship between the occurrence of NP and LBP over the last 12-month period and sex, age group, sedentary habits, physical activity practice, and postural habits, obtained by application of the binary logistic regression model. The final model was considered mathematically valid (Omnibus, HosmereLemeshow and Nagelkerke: p ¼ 0.005, p < 0.001 and R2 ¼ 0.50). It was found that older students (15e17 years old) had a 3.03 times higher probability of developing LBP (95% CI (1.82e5.03; p 0.001) than the younger one (10e14 years old). Additionally, adolescents who used a mobile phone more than 10 h per week had a 2.48 times higher probability of developing NP (95% CI: 1.29e4.75; p ¼ 0.006) than those who had used for a shorter period (until 10 h) and the same was observed regarding LBP with a 2.39 more probability to developed this symptom in lower back (95% CI: 1.41e4.08; p ¼ 0.001). The students who sit with a spine in a wrong position had 3.24 more chances to have LBP (95% CI: 1.33e7.89; p ¼ 0.010).
Table 3 Values of backpack weight for grades groups. School grades
Backpack weight Mean ± standard deviation (kg)
Minimum e Maximum (kg)
Excess of weight
5th grade 7th grade 8th grade 10th grade
5.29 ± 1.33 5.52 ± 1.26 4.61 ± 1.28 3.0 ± 1.09
2.2e8 2.1e7.7 1.3e9.5 0.8e5.8
39 (78%) 27 (58.7%) 26 (24.8%) 6 (5.8%)
Table 4 Relationship between the event the presence of spine musculoskeletal pain and variables about non-modifiable and modifiable risk factors. Spine musculoskeletal pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain Neck pain Low back pain a
Variables a
Gender (boys) girls a
Age group (10e14 years) 15e17 years Watching television (per week) (>10 h)a until 10 h Mobile phones use (per week) (until 10 h)a > 10 h Console games (per week) (>10 h)a until 10 h Physical activity practice (yes)a no Physical activity practice (no)a yes Posture with the use of mobile phones (incorrect)a correct Sitting posture (spine evaluated) (correct)a incorrect Backpack weight (adequate)a excess Backpack weight (excess)a adequate
OddsRatiocrude (CI 95%); p-value
Multivariable (CI 95%); p-value
1.42 1.29 1.25 3.38 1.01 1.09 1.79 2.38 1.11 1.13 1.12 1.03 2.58 3.92 1.00 0.57
e e e 3.03 e e 2.48 2.39 e e e e e 3.24 e e
(0.89e2.25); 0.139 (0.82e2.02); 0.276 (0.78e2.01); 0.353 (2.07e5.51); 0.001 (0.55e1.85); 0.976 (0.60e1.98); 0.778 (1.07e2.99); 0.027 (1.44e3.96); 0.001 (0.58e2.12); 0.764 (0.59e2.14); 0.706 (0.70e1.79); 0.625 (0.65e1.63); 0.905 (0.63e10.62); 0.189 (1.65e9.29); 0.002 (0.61e1.63); 0.999 (0.35e0.94); 0.026
(1.82e5.03); 0.001
(1.29e4.75); 0.006 (1.41e4.08); 0.001
(1.33e7.89); 0.010
Reference class.
Please cite this article as: Minghelli B, Musculoskeletal spine pain in adolescents: Epidemiology of non-specific neck and low back pain and risk factors, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.008
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4. Discussion This study revealed a high prevalence of NP and LBP in the sample analyzed of students living in south of Portugal. Similar data were obtained in Minghelli et al. study [12] who also evaluated students of South region of Portugal, with ages between 10 and 16 years old (n ¼ 966), and verified a prevalence of LBP in 12-month period in 47.2% of the adolescents; it is noteworthy that the data collection was 7 years ago (between 2011 and 2012) and the results values stays the same (47%) in other adolescents analyzed in this study (2019). Data of lifetime prevalence of LBP showed a slight increase in values between these studies from 62.1% from the old study [12] to 65.1% in this recent study. Akbar et al. [22] revealed a lifetime prevalence of 70.3% in 950 adolescents in Kuwait, aged 14e19 years old. Regarding the prevalence of LBP in 6-month period, our data (39.1%) were close those verified in Shan et al. study [15] that analyzed 3600 adolescents in Shanghai, aged between 15 and 19 years old, and showed a prevalence of 33.1%. Akbar et al. [22] revealed higher values in the same period (49.1%). Relatively to NP in 6-month period, our data (34.2%) is higher than obtained in Myrtveit et al. study [9] that evaluated 8900 Norwegian students and revealed a prevalence of 20%; but in this cited study the age of the sample varied between 17 and 19 years old differing from the analyzed age of our study. Silva et al. [6] also presented a lower value than our study (18.5%), in the same period analyzed, in 961 Brazilian adolescents, aged 14e19 years. Shan et al. [15] study showed a higher prevalence in this same period (40.8%). Considering the study of Shan et al. [15], it was observed that symptoms of NP already start to have a higher percentage than the LBP (40.8% versus 33.1%). The same was observed in Joergensen et al. study [23] that evaluated a lifetime prevalence of spinal pain among 46,726 Danish adolescentes, aged 11 to 14-year-olds and revealed 31.9% of NP and 14.1% of LBP. Manayesh et al. [2] revealed results of NP in 14.2% and LBP in 6.9% (previous 12 months) in 723 Ethiopian adolescentes with mean age of 11.5 years (SD 2.7 years). Comparing the results of all prevalence periods analyzed in our study, we can see that the percentage of LBP presence is higher than NP, but the percentages differ by only 5 to 14 percentage points. Our lifetime prevalence of NP (51%) were similar to those obtained in Straker et al. study [24] who evaluated 1597 adolescents with a mean age of 14.1 years and obtained a lifetime prevalence of neck/shoulder pain of 47%. Static postures held for long periods and wrongly may also be factors that may contribute to the development of NP and LBP. This study verified that the adoption of incorrect posture for sitting can increase a probability to develop LBP (p ¼ 0.002). Minghelli et al. [12] revealed that students who sit with the spine incorrectly positioned presented 2.49 greater probability of having LBP (95% CI 1.91e3.2; p 0.001), as well as students adopted improper positions for watching televison or playing games have 2.01 greater chances (95% CI 1.55e2.61; p 0.001). Grimmer and Williams [25] found associations between recent LBP and the amount of time spent in seated posture. Regarding the mobile phone use, the data of this study did not present a statistical significance between NP and the wrong posture for use the phone (with flexion of cervical) but showed significant association with the time of use, revealing that adolescents who use more than 10 h per week may be an increased risk of developing both NP and LBP. Similar results were obtained by Shan et al. [15] who period of mobile phone use longer than 2 h per day were related to a significant increase in the prevalence of NP and LBP (p < 0.05) and by Silva et al. [26] who revealed that the use of mobile phones for 5 h or more was significantly associated with increased odds of pain in the last 7-days for the LBP (OR ¼ 3.20; p < 0.05).
Several studies showed a relationship with mobile phone use associated with flexion of cervical posture to view the display, however, the association between neck flexion during mobile phone use and neck disability has not been scientifically confirmed to date. Namwongsa et al. study [7] verified that flexed neck posture was associated with neck disorders (OR ¼ 2.44; CI ¼ 1.21e4.90). This study also verified that older students have more chances to developed NP and LBP, data similar to other studies [1,12,15,27]. Older adolescents may be more exposed to physical and environmental aggression because of their increasing range of activity in terms of frequency and intensity than the younger one. Besides that, older adolescents tend to show a greater propensity for pain because of their uncertainties in conceptualizing a multitude of bodily sensations associated with puberty [28]. Other variable that revealed statistically significant association with LBP was the backpack weight which revealed an unexpected result in which students carrying the properly weighted backpack were most likely to have LBP. Several studies did not find an association between the excess of weight on backpack and the LBP [11,29]. This result can be explained by the fact that the time each student carries the school bag has not been evaluated. That is, students who had adequate weight in the backpack could carry it for long periods leading to the occurrence of pain. Akbar et al. [22] suggested that the perceived heaviness of school bag is far more important than the actual bag weight. This study showed some limitations including the self-reported questionnaire, the memory bias, the evaluation of posture in just a moment (may not be the posture that corresponds to that adopted most of the time), not being analyzed over a day and the backpack weighing was not done on more days to calculate the week average. However, these limitations are difficult to overcome because of logistical school issues and children's privacy and parental consent so that children could be observed on homework. Future studies that evaluated the frequencies and durations of exposure of mobile and screens devices are suggested. 5. Conclusions Data of this study showed a higher prevalence of NP and LBP in the analyzed sample and revealed that adolescents who used a mobile phone more than 10 h per week had more probability to develop both NP and LBP and older students and who sit with a spine in a wrong position had more chances to have LBP. This increased prevalence of NP and LBP in adolescents implies an increase in medication use, consultations with health professionals, overloading the health system, increase of school absenteeism and physical inactivity, leading to greater use of electronic devices. Since many of these variables are risk factors that can be modifiable through an intervention, educational sessions need to be implemented in schools. Theoretical-practical sessions to teaching the best posture to be adopted during sitting position at school (which implies a static posture maintained for long periods), stretching exercises to be implemented after being in a long posture, alternating positions, explanations about the spinal anatomy for better understanding of our body, as well as the consequences of a posture maintained for a long period. Mobile phone use can be reduced by encouraging sports activities and performing breaks after long periods of use. Study design Epidemiological and cross-sectional.
Please cite this article as: Minghelli B, Musculoskeletal spine pain in adolescents: Epidemiology of non-specific neck and low back pain and risk factors, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.008
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Funding sources This study is financed by national funds through FCT - Foundation for Science and Technology, I.P., in the scope of the project UID/Multi/04587/2019; Research in Education and Community Intervention (RECI). Declaration of Competing Interest None. Acknowledgments Ana Carolina Coelho, Sara Paulino for assisting in data collection. References [1] Scarabottolo C, Pinto R, Oliveira C, Zanuto E, Cardoso J, Christofaro D. Back and neck pain prevalence and their association with Physical inactivity domains in adolescents. Eur Spine J 2017 Sep;26(9):2274e80. [2] Manayesh K, Ciccarellia M, Falkmera T, Parsons R. Associations between exposure to information and communication Technology (ICT) and reported discomfort among adolescents. Work 2014;48(2):165e73. [3] Hogg-Johnson S, van der Velde G, Carroll L, Holm L, Cassidy J, Guzman J, et al. The burden and determinants of neck pain in the general population. Results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. J Manip Physiol Ther 2008 Feb;32:S46e60. ~ oz I, Go mez-Conesa A, Sa nchez-Meca J. Prevalence of low back pain [4] Calvo-Mun in children and adolescents: a meta-analysis. BMC Pediatr 2013 Jan;13:14. [5] Kamper SJ, Henschke N, Hestbaek L, Dunn K, Williams C. Musculoskeletal pain in children and adolescents. Braz J Phys Ther 2016 May-Jun;20(3):275e84. [6] Silva G, Pitangui A, Xavier M, Correia-Júnior M, Araújo R. Prevalence of musculoskeletal pain in adolescents and association with computer and videogame use. J Pediatr 2016 Mar-Apr;92(2):188e96. [7] Namwongsa S, Puntumetakul R, Neubert M, Boucaut R. Factors associated with neck Disorders among university student smartphone users. Work 2018;61(3):367e78. [8] Palmer K, Ciccarelli M, Falkmer T, Parsons R. Associations between exposure to Information and Communication Technology (ICT) and reported discomfort among adolescents. Work 2014;48(2):165e73. [9] Myrtveit S, Sivertsen B, Skogen J, Frostholm L, Stormark K, Hysing M. Adolescent neck and shoulder pain: the association with depression, physical activity, screen-based activities, and use of health care services. J Adolesc Health 2014 Sep;55(3):366e72. [10] Chow D, Leung K, Holmes A. Changes in spinal curvature and proprioception of schoolboys carrying different weights of backpack. Ergonomics 2007 Dec;50(12):2148e56. [11] Trevelyan F, Legg S. Risk factors associated with back pain in New Zealand school children. Ergonomics 2011 Mar;54(3):257e62.
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Please cite this article as: Minghelli B, Musculoskeletal spine pain in adolescents: Epidemiology of non-specific neck and low back pain and risk factors, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2019.10.008