The relationship between back pain and schoolbag use: a cross-sectional study of 5,318 Italian students

Association of postural education and postural hygiene with low back pain in schoolchildren: Cross-sectional results from the PEPE study

Background

Low back pain (LBP) is the leading cause of disability in the world that affects the population of all ages globally. The main aim of the present study was to analyze the cross-sectional association of postural education and postural hygiene habits with LBP, differentiating between frequency and intensity of pain.

Methods

This cross-sectional study assessed 849 students aged 10-12 years from primary schools. The study was based on four different structured and self-administered questionnaires: back pain questionnaire, Back Pain and Body Posture Evaluation Instrument (BackPEI), Frequency of Commuting to and from School Questionnaire, and the Hebacaknow questionnaire. In addition, height and weight were included to determine the body mass index (BMI).

Results

Participants with prevalence of LBP were significantly older (P=0.038), girls (P<0.001), taller (P=0.018), and practice active travelled back from school (P=0.016). Otherwise, participants with no prevalence of LBP sat correctly at the desk (P<0.001). Higher knowledge of postural education was associated with lower intensity of LBP (β=-0.07, CI=-0.12 - -0.02, P=0.004).

Conclusion

The knowledge related to postural education it is associated with less LBP. School interventions improving knowledge about postural education, ergonomics and postural hygiene are needed to address this important matter.

Epidemiology of Lumbar Degenerative Phenotypes of Children and Adolescents: A Large-Scale Imaging Study

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

Recently, there has been a rise in children and adolescents developing low back pain and/or sciatica. Degenerative lumbar spine MRI phenotypes can occur in this population but reports have been sporadic and the true incidence of such spine changes remains debatable. As such, the study aimed to address the epidemiology of MRI phenotypes of the lumbar spine in this young population.

METHODS

597 children and adolescents with lumbar MRIs were included in the study. T1- and T2-weighted lumbar images from L1/2 to L5/S1 were analyzed in axial and sagittal planes. Global phenotype assessment was performed of each level and based on established nomenclature protocols.

RESULTS

The cohort consisted of 57.3% (342) boys and 42.7% (255) girls, with a mean age of 10.75 ± 5.25 years (range: 0 to 18 years). The prevalence of imaging findings of lumbar disc degeneration (LDD) and lumbar disc herniation (LDH) were 2.2% (95% CI: 0.93-3.43) and 5.8% (95%CI: 2.58-8.99), respectively. There was significant difference between each disc segment from L1/2 to L5/S1 for both LDD and LDH. Schmorl's nodes were noted in 16 cases (2.7%, youngest case as 15 years), with 11 boys (68.8%) and most frequent segment as L3/4. Modic changes and high-intensity zones were absent in this cohort.

CONCLUSIONS

LDD can emerge as early as the first decade of life with Schmorl's nodes, without additional specific phenotypes, including Modic changes and high-intensity zones. The study provides valuable information of a unique age group that is often under-represented but equally important as adults.

Assessment of the elementary school students’ schoolbag weight in the urban environment in Poland: A cross-sectional study carried out as a part of the ‘Lightweight Schoolbag’ and ‘Let’s Get the Kids Moving’ projects

BACKGROUND: Carrying a properly weighted schoolbag is an important factor in preventing the occurrence of muscular skeletal disorder in early school age children. OBJECTIVE: The purpose of this cross- sectional observational study was to examine the schoolbag weight and to determine the percentage of children were carrying overloaded schoolbag. METHODS: The study group included pupils from five primary public schools in Wrocław, Poland. Anthropometrical measurements such body weight (BW) and height were conducted on 650 children (51.1% of boys). Children’s age, gender, Cole’s Index was juxtaposed with schoolbag weight. The mean age of the examined students was 8.7±0.8 years (range 7 to 10 years). RESULTS: The mean schoolbags weight was 3.7±0.92 kg, which represented 13.0±3.8% of pupils’ BW. The percentage of pupils carry the schoolbags weighing more than 10% of their BW was 77.9%. More than a quarter of Polish children carry school backpack above 15% of their BW. The majority (96.8%) had schoolbags which may be carried on both shoulders. A significant negative correlation was observed between relative schoolbag weight and Cole’s Index (rho = –0.44, p < 0.05). CONCLUSIONS: The problem of overloaded schoolbags among elementary school children was frequent. Pupils ought to be educated in the proper packing of their school backpacks. Additionally, parents and teachers should pay attention regarding the contents carried by children in their respective schoolbags.

Narrative review of the prevalence and distribution of acute pain in children in the self-care setting

Acute pain among children is common, yet it may be underestimated and undertreated if the pain is not recognized. Assessing and managing pediatric pain can be complicated, and as such, measuring the prevalence of acute pain in children can be challenging. We sought to provide a consolidated review of the available data on the prevalence of commonly occurring acute pain in children in the self-care setting. An extensive literature search was performed to determine the prevalence of acute pain at multiple bodily locations in children aged between 3 months and 18 years. We considered the influence of age, sex, and sociodemographic factors on prevalence estimates. We also sought to identify some of the challenges involved in assessing and managing pediatric pain, thus shedding light on areas where there may be clinical and medical unmet needs. In general, a high prevalence of acute pain in children was detected, particularly headache, menstruation-related pain, and dental and back pain. Older age, female sex, and lower socioeconomic status were associated with increased pain prevalence. Risk factors were identified for all pain types and included psychological issues, stress, and unhealthy lifestyle habits. Owing to the heterogeneity in study populations, the prevalence estimates varied widely; there was also heterogeneity in the pain assessment tools utilized. The paucity of information regarding pain prevalence appears to be out of proportion with the burden of acute pain in children. This could indicate that clinicians may not be equipped with an optimal pain management strategy to guide their practice, especially regarding the use of developmentally appropriate pain assessment tools, without which prevalence data may not be captured. If acute pain is not accurately identified, it cannot be optimally treated. Further investigation is required to determine how the information from prevalence studies translates to the real-world setting.

Evaluation of an ergonomically designed schoolbag: Heart rate variability and body discomfort rating

BACKGROUND: Unsuitable schoolbags may stress the spine and promote poor body posture, particularly for school students. Global recommendations have suggested that schoolbag weight must not exceed 10% of a healthy student’s body mass, which would need continuous monitoring and enforcement. OBJECTIVES: The present study presents a comparison between an ergonomically designed schoolbag, which helps reduce the potential effects of carrying a load, and a commercial one. METHODS: A total of 30 healthy male students were recruited for this experiment. Independent variables determined were schoolbag type (ergonomically designed and commercial schoolbags) and three load levels based on body mass percentage (i.e., 10%, 15%, and 20% of body mass). Heart rate variability (HRV) and body discomfort rating were then measured. RESULTS: Our results showed that the developed schoolbag promoted enhanced subjective measures and HRV response at 15% and 20% of body mass. Participants who wore the developed schoolbags experienced significantly lesser neck, shoulder, upper and lower trunk discomfort than those who wore the traditional ones. Changing the load percentage from 10% to 15% caused an increase in heart rate among participants carrying a commercial schoolbag but a decrease in heart rate among those carrying the developed schoolbag. CONCLUSIONS: The findings presented herein suggest introducing strategies for reducing the potential impact of load carrying through the combined effect of new educational inventions and policy changes.

School Bag-Related Factors and Their Implications for Walking and Cycling to School among New Zealand Adolescents

Excessive school bag weight may be a modifiable barrier to active transport to school. This study examined correlates of school bag weight and adolescents’ perceptions of excessive school bag weight for walking and cycling to school among New Zealand adolescents living in diverse settlement types. Adolescents (n = 1512; 15.0 ± 1.3 years) completed a questionnaire and had their bag weight (n = 1190) and body weight (n = 1038) measured. Adolescents using active transport and rural adolescents had lighter school bags compared to their counterparts. One-third of adolescents reported excessive school bag weight for walking (31.2%) and cycling (37.2%) to school. Positive correlates of relative school bag weight were female gender (regression coefficient (95% CI): 0.53 (0.13, 0.93)), and underweight (2.21 (1.39, 3.02)), whereas negative correlates were Māori ethnicity (−0.87 (−1.41, −0.32)), overweight (−1.84 (−2.35, −1.34)) and obesity (−3.57 (−4.26, −2.87)), and school location in small urban areas (−2.10 (−4.19, −0.01)), and rural settlements (−3.58 (−5.66, −1.49)). Older adolescents, females, those with greater relative school bag weight, and those experiencing school bag-related pain symptoms and/or fatigue were more likely to report excessive school bag weight for both walking and cycling to school. Future initiatives should target reducing excessive school bag weight, particularly in female and urban adolescents.

Does schoolbag carriage equally affect obese/overweight and healthy-weight children?

Discrepancies exist in backpack load recommendations for obese/overweight children, and the recommendations do not consider school trolleys. This study analysed obese/overweight and healthy-weight students' perceived load and fatigue when carrying schoolbags and their gait kinematics and rate of perceived exertion (RPE) when carrying backpacks or pulling school trolleys with different loads. Twelve obese/overweight and 36 healthy-weight students were asked about their perceived load and fatigue in carrying their schoolbags to school. Then, a kinematic gait analysis was completed in students walking unloaded or transporting 10%, 15% or 20% of their bodyweight (BW) in a backpack or trolley. RPE was recorded after each condition. The average hip rotation and knee adduction angles differed between body mass index (BMI) groups. The healthy-weight group reported higher RPEs than the overweight/obese group when pulling a trolley with 10-15% BW. In conclusion, both BMI groups responded similarly to load and schoolbag type.

Optimization of backpack loads using gait parameters in school boys

BACKGROUND

Backpacks are an efficient way of manual carriage used by people of all ages, and is commonly used by schoolchildren. Carrying heavy backpacks may result in cumulative trauma later in life due to biomechanical adaptations during gait. Gait parameters are known to be sensitive to force vectors, which can be altered by load carrying. This study attempts to find the most favorable backpack weight using gait changes as an indicator.

METHODS

This was an observational study conducted on twenty typically developing boys aged between 9 and 14 years. Gait analysis was done using standard recommendations, with increasing backpack loads with respect to their body weights. Gait cycles were captured using video cameras and analyzed using Kinovea0.8.25 motion analyzing software.

RESULTS

As the backpack load increased, significant kinematic changes were noted in the child's ankle, knee, and hip joints. These changes were evident when the backpack load increased beyond 15% of their body weight.

CONCLUSIONS

This study concludes that the optimum weight that can be carried without having an impact on dynamic posture will be less than 15% of the body weight.

Continuity of physical activity practice from childhood to adolescence is associated with lower neck pain in both sexes and lower back pain in girls

BACKGROUND

The literature on physical activity practice through sports as a protective factor for back pain in adolescents is conflicting. However, few studies have aimed to verify if continuity of the practice of physical activity from childhood to adolescence may be related to lower chances of back pain in adolescents.

OBJECTIVES

The objective of this study was to analyze the association between physical activity practice from childhood to adolescence and back pain in adolescents.

METHODS

The random sample was composed of 870 adolescents with a mean age of 13.7 ± 2.0 years. The continuity of physical activity practice was assessed through the continuity of sports practice from childhood to adolescence. Pain in the neck and low back were evaluated through a questionnaire.

RESULTS

The prevalence of neck pain and low back pain in boys was 17.5% and in girls was 20.9% for neck pain and 21.9% for low back pain. Physical activity practice during childhood to adolescence was a protective factor for neck pain (OR = 0.57 [CI = 0.35-0.94]) and low back pain (OR = 0.53 [CI = 0.33-0.86]) in girls and neck pain in boys (OR = 0.52 [CI = 0.30-0.90]), even after adjusting for confounding factors.

CONCLUSION

Girls with physical activity practice during childhood to adolescence were less likely to develop neck pain and back pain when compared to girls who did not maintain practice of physical activity. Similar results were observed in boys considering neck pain.

One-shoulder carrying school backpack strongly affects gait swing phase and pelvic tilt: a case study

The use of backpacks is common to both adults and children and often leads to the onset of musculoskeletal discomforts. Although a large number of studies have focused on the optimal load for children schoolbags, there is no general consensus. Here we report a 13-yr old girl case study, showing the impact of weight and wearing the school backpack on gait parameters. The variation of gait parameters and pelvis angles in different conditions were studied: without backpack (CTRL), or with backpack at 10% Body Weight (10BW), 15% BW (15BW) and 20% BW (20BW), carried “on both shoulders” (2S), “on one shoulder” (1S), or “with one hand” (1H). Swing phase was comparably modified by 2S/20BW and 1S/10BW conditions, suggesting that a lower backpack weight was sufficient to induce gait alterations when carried in asymmetrical conditions. Pelvic tilt, which was preserved by a two-shoulders distributed 10% BW load (2S/10BW), was strongly reduced in asymmetrical condition (1S/10BW), suggesting that a low weight carried on a single shoulder generates postural modifications including reduction of pelvic tilting, which is known to be associated to low back pain.

Relationship between School Backpacks and Musculoskeletal Pain in Children 8 to 10 Years of Age: An Observational, Cross-Sectional and Analytical Study

Back pain in children is a reality and various factors are involved in its etiology. The study’s aim was to analyze the relationship between the use and type of backpack and pain in children. An analytical observational cross-sectional study was conducted among 123 schoolchildren between 8–10 years. Data on the participants’ weight and height and their backpacks were collected, as well as the way of travel to school and their physical activity during the week. The results indicated that all backpacks were large because the backpack’s height is longer than torso length. Participants who studied in a traditional educational system (62.60%) carried backpacks that exceeded 10% of their body weight. Additionally, 31.7% of the students presented pain. There is no significant correlation between the weight or type of backpack and the pressure pain threshold collected from shoulders muscles. Participants who carried backpacks heavier than 10% of their body weight did not have more musculoskeletal pain or a lower pressure pain threshold than the others, although they did report greater fatigue. All these topics should be debated considering the student’s social environment and the backpack’s discomfort to the children, even though no relationship was found between musculoskeletal pain and backpack weight.

Back Pain and Schoolbags among Adolescents in Abha City, Southwestern Saudi Arabia

The incorrect carriage of schoolbags and heavy bags may result in back pain (BP) in adolescents. Our objective was to assess the problem of BP and associated factors among adolescents. This was a cross-sectional study targeting intermediate and secondary school adolescents in Abha City, Saudi Arabia. An anonymous questionnaire for BP was used. Student body weight and the weight of their full schoolbag were measured. The study included 876 adolescents. An overall prevalence of BP of 39.4% (95% CI: 35.3-43.7) was found. Upper BP (UBP), middle BP (MBP), and lower BP (LBP) amounted to 14.5%, 13.4%, and 11.5%, respectively. Associated significant factors with MBP were carrying the bag on one side compared to on the back (adjusted odds ratio (aOR) = 2.13, 95% CI: 1.20-3.73) and being at intermediate level compared to secondary (aOR = 1.56, 95% CI: 1.04-2.40). On the other hand, gender and schoolbag weight/body weight percent were not found to be significantly associated with MBP. None of the studied factors were significantly associated with overall BP, UBP, or LBP. BP is a prevalent among adolescents in southwest Saudi Arabia. One-sided schoolbag carriage is a significant associated factor for middle back pain. Parents and teachers should encourage students to consider the correct way to carry schoolbag.

Back pain and school bag weight - a study on Indian children and review of literature

Back pain in children is a complex phenomenon, which has been shown to be associated with physical and psychosocial factors. None of the studies on Indian children have investigated the possible association between back pain and psychosocial factors. We decided to determine the prevalence of back pain in students and association with both physical and psychosocial factors. A cross-sectional study was conducted on 163 students from two city schools. Physical factors were evaluated using a structured questionnaire. Strengths and difficulties questionnaire was used to assess psychosocial factors. The studied sample consisted of 49.7% boys and 50.3% girls. Mean school bag weight was 6.1±2.4 kg (range: 2.2-15.6 kg). Mean weight of school bag as a percentage of body weight was 13.5±6.2%. Approximately 76% students carried more than 10% of their body weight. The prevalence of back pain (over last 1 month) was 53.9%. No associations were found between back pain and weight of school bag, weight of school bag as a percentage of body weight and physical activities. Significant associations were found between back pain and number of hours spent watching television [odds ratio (OR): 3.3, 95% confidence interval (CI): 1.5-7.5; P=0.003], history of injury to the back (OR: 4.8, 95% CI: 1.47-15.8, P=0.003), presence of a family member complaining of back pain (OR: 1.98, 95% CI: 1.25-3.14, P=0.002), conduct (P=0.042) and hyperactivity problems (P=0.045). Thus, there appears a need to consider psychosocial factors along with physical factors when evaluating a young student with back pain.

Cluster-randomized, controlled evaluation of a teacher led multi factorial school based back education program for 10 to 12-year old children

BACKGROUND

The aim of this cluster-randomised, controlled study was to examine whether a teacher-led multifactorial back education programme could improve back pain in pupils, motor skills, back behaviour, and back knowledge over a 10-month period.

METHODS

There were 176 children from two schools, who were cluster-randomised into intervention and control groups. The intervention programme consisted of 3 parts: 1) knowledge improvement, 2) posture awareness training, and 3) reducing imbalance of core muscles through mandatory back and abdominal muscle exercises at the beginning of each physical education lesson. Outcome measures included a clinical orthopaedic examination, a health questionnaire, a motor test, a back-behaviour trial, and a knowledge test.

RESULTS

Clinical examination showed a reduction of orthopaedic abnormalities in both groups, from 90.5 to 42%, with a posture test showing an improvement in both groups at the post-test. However, the rate of children reporting back pain at least once a month could not be reduced below 30%. Long lasting physical activity, carrying heavy schoolbags, and long periods of sitting were the top three causes for back pain. Push-up number and balancing skills improved significantly in both groups from pre- to post-test. In the water crate carrying task and knowledge test, only the intervention group (IG) showed a statistically significant improvement from pre- to post-test.

CONCLUSIONS

The results show that back pain rate could not be decreased. However, back care knowledge and parts of back-friendly behaviour could be significantly improved. On the other hand, the problem of prolonged sitting and using heavy schoolbags persists.

TRIAL REGISTRATION

Deutsches Register Klinische Studien DRKS00013794 ; Date of Registration: 15.1.2018; Retrospectively registered.

School Bag Weight as a Barrier to Active Transport to School among New Zealand Adolescents

Background: Excessive school bag weight is a barrier to active transport to school (ATS). This study examined parents’ and adolescents’ perceptions of school bag weights and actual school bag weights for adolescents in New Zealand. Methods: Parents (n = 331; 76.7% women) completed a survey. Adolescents (n = 682; age 15.1 ± 1.4 years; 57.3% boys) completed a survey, underwent anthropometry, and had their school bags weighed. Results: Overall, 68.3% of parents perceived that adolescents’ school bags were too heavy to carry to school. This parental perception differed by adolescents’ mode of transport to school (active/motorized/combined: 35.1%/78.4%/68.8%, p < 0.001). Adolescents perceived that their school bags were too heavy to carry to walk (57.8%) or cycle (65.8%) to school. Adolescent perceptions differed by mode of transport to school (for walking (active/motorized/combined): 30.9%/69.2%/55.9% agree, p < 0.001; for cycling: 47.9%/72.8%/67.7%; p < 0.001). Actual school bag weight was, on average, 5.6 ± 2.1 kg. Relative school bag weight (% of body weight) was higher for boys and underweight adolescents compared to their counterparts. Neither absolute nor relative school bag weight differed by mode of transport to school. Conclusions: School bag weight was perceived a barrier to ATS and was a greater perceived barrier among users of motorized versus active transport. Perceptions of school bag weights should be considered in future ATS interventions.

Do schoolbags cause back pain in children and adolescents? A systematic review

OBJECTIVE

To investigate whether characteristics of schoolbag use are risk factors for back pain in children and adolescents.

DATA SOURCES

Electronic searches of MEDLINE, EMBASE and CINAHL databases up to April 2016.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Prospective cohort studies, cross-sectional and randomised controlled trials conducted with children or adolescents. The primary outcome was an episode of back pain and the secondary outcomes were an episode of care seeking and school absence due to back pain. We weighted evidence from longitudinal studies above that from cross-sectional. The risk of bias of the longitudinal studies was assessed by a modified version of the Quality in Prognosis Studies tool.

RESULTS

We included 69 studies (n=72 627), of which five were prospective longitudinal and 64 cross-sectional or retrospective. We found evidence from five prospective studies that schoolbag characteristics such as weight, design and carriage method do not increase the risk of developing back pain in children and adolescents. The included studies were at moderate to high risk of bias. Evidence from cross-sectional studies aligned with that from longitudinal studies (ie, there was no consistent pattern of association between schoolbag use or type and back pain). We were unable to pool results due to different variables and inconsistent results.

SUMMARY/CONCLUSION

There is no convincing evidence that aspects of schoolbag use increase the risk of back pain in children and adolescents.

Effects of backpack load and position on body strains in male schoolchildren while walking

Data regarding the effects of backpack carriage on children’s body strains while walking are limited. This study measured the body posture, muscle activation, and subjective discomfort scores of 12 male schoolchildren (age: 12.3 (range 12.1–13.0) y, height: 151.3 (range 144.2–154.6) cm, weight: 46.6 (range 43.6–49.7) kg) carrying backpacks weighing 5%, 10%, and 15% of their respective body weights (BWs) and walking for 10 min on a treadmill. For each load, three positions along the spinal column (T7, T12, and L3) were examined. Participants carrying a backpack weighing 15% of BW exhibited higher head flexion, trunk flexion, and corresponding muscle activation, and a lower lumbosacral angle compared with those carrying loads of 5% and 10% of BW. The waist received the highest discomfort scores when the backpacks were carried at the L3 position. Conversely, the discomfort rating for the neck and shoulders where the highest when the backpack was at the T7 position; this high backpack position also caused more head flexion than the other two positions. For the musculoskeletal health of children, the findings suggest that carrying a school backpack weighing 15% of BW should be avoided, and carrying at the T12 position may be recommended for schoolboys.