Neck pain and distance learning: A pain in the neck for university students during COVID-19

Introduction

Neck pain (NP) a common condition that affects a significant proportion of the population is characterized by a broad range of factors, including anatomical location, etiology, symptom severity, and duration.¹ Despite its prevalence, it can have a substantial negative impact on people’s lives, including their ability to work, sleep and participate in daily activities.² The global prevalence of NP was 3551.1 per 100 000 people in 2017 with a DALY (disability adjusted life years) prevalence of 352.0 per 100 000 people.³ Chronic NP presents a significant burden on societies all over the world.⁴ NP and other forms of chronic pain in general burdens the workers, increases sickness absence, and decreases productivity.⁵ Furthermore, it can exacerbate other co-existing conditions such as migraines,⁶ making it more challenging to manage these conditions effectively. NP may lead to change in muscle morphology such as hypertrophy or atrophy, alteration in muscle fiber type, and reduced muscle strength.⁷

In 2018, 440 randomly chosen medical students at Jazan University in Saudi Arabia reported a prevalence of NP of 53.5%.⁸ According to other studies, using laptops and smartphones which many university students depend on all the time, has been identified as a significant risk factor of NP.⁹

Students in the United Arab Emirates (UAE) commonly experience musculoskeletal disorders (MSP) as one of the primary occupational health concerns. Existing research indicates that NP is a prevalent condition among undergraduate students, frequently persisting beyond graduation.^10,11 Studies focusing on the prevalence of NP in undergraduate populations, particularly healthcare students, consistently demonstrate a high incidence of this condition.^12–14 Although research on musculoskeletal pain (MSP) is extensive, studies specifically focusing on NP in the United Arab Emirates are relatively scarce.

A study conducted in February 2020 among 368 dental students from Ajman University and Ras Al Khaimah College of Dental Sciences reported a prevalence of MSP 48.5% and 68.3% in the past week and year, respectively based on responses to questionnaire.¹⁵ The most frequent occupational health hazards faced by newly graduated dentists working in Abu Dhabi, Dubai and Sharjah, as reported in a study conducted on 733 individuals, are musculoskeletal disorders (MSP) at 68% and percutaneous injury at 42%.¹⁶

The prevalence of NP among 80 radiologists in the United Arab Emirates, comprising of male and female radiologists from nationalities, found a significant rise in the prevalence of NP after they started working in the radiology department in 2017. Also, the NP surpassed other common work-related symptoms such as back pain, knee pain and vision issues. The researchers speculated that poor body mechanics such as improper posture, repetitive movements and inadequate support may contribute to the development of NP.¹⁷

The COVID-19 pandemic, which was officially declared on March 11, 2020, has brought about extraordinary challenges in various aspects of life. Outbreaks have led to increased unemployment as well as compromise in education, physical and mental health, resulting in a profound impact on the world.^18,19

Education was one of the fields that has been extremely affected during the COVID-19 pandemic with schools and universities globally have transitioned to distance education.²⁰

Blended and hybrid learning have continued to gain popularity and increase in value beyond the pandemic, mainly due to the necessity for novel and innovative teaching techniques, the potential of cloud-based applications, enhanced collaboration, and creativity.²¹ Additionally, lack of adherence to good ergonomic practices during online learning at home has led to an increase in reported cases of back pain and fibromyalgia pains.²² Unlike in the classroom, students are not obligated to follow proper ergonomics at home and take online classes while sitting on beds or sofas. These inappropriate prolonged sitting and studying posture have led to the development of musculoskeletal discomfort and complaints including NP.^23,24 Enhancing student awareness of postural changes and risk factors, coupled with the implementation of ergonomic practices, can significantly mitigate musculoskeletal symptoms, including NP.^25–27

It is hypothesized the use of electronic devices can indirectly strain neck muscles potentially contributing to NP and discomfort.⁷ A study conducted in Hong Kong found a correlation between the use of electronic devices and musculoskeletal disorders, particularly in the neck and shoulder region.¹⁷

Studies have indicated that a lack of knowledge regarding effective strategies for pain management among university students can result in negative consequences for their musculoskeletal pain, leading to a decline in quality of life and potentially significant socioeconomic issues.²⁸ Furthermore, students experiencing musculoskeletal pain, such as low back pain, may have poorer academic performance and higher levels of absenteeism compared to those without pain.^29,30

Although research has investigated the association between NP and electronic device use among university students, limited research has focused during the COVID-19 pandemic. University students may be more susceptible to NP due to the high demands of their academic work, which often require long periods of concentration in front of electronic devices. Furthermore, it is well-established that poor posture, such as slouching or holding the head in a forward position, can place significant stress on the neck and lead to pain and discomfort. However, despite the high prevalence of NP, there is limited research on the factors that may contribute to it, especially among the UAE population, and specifically among university students. Therefore, it is vital to investigate the potential risk factors for NP among university students, including the amount of time spent on electronic devices, the type of devices used, and the posture adopted during use.

Such research can provide valuable insights into the prevalence and potential causes of NP among this population and help to inform interventions and preventative measures to reduce the incidence of NP and improve the overall health and well-being of students.

Gaining insight into the factors that increase the likelihood of NP in university students can help create interventions such as modifying workstations, increasing breaks, setting reminders to adjust posture, and practicing exercises to improve posture and reduce muscle tension. In this study, NP is specifically defined as non-specific NP, which refers to pain localized to the cervical spine.

Objectives

Methods

The study utilized an observational cross-sectional design using STROBE guidelines. The data was collected through questionnaires from a specific target population, which are the UOS students aged between 17-26. The accessible population was limited to students who were available on social media platforms since the questionnaire was posted online. Non-probability volunteer sampling was the chosen sampling method due to the challenges in accessing a vast number of UOS students and young adults during the study period. Moreover, the online questionnaire was disseminated through various social media platforms, and participation was voluntary.

Our sample size (n) was determined to be 400 based on a 50% prevalence (P) and a 5% margin of error (ME), using the formula n=4P(1-P)/SE2.

All UOS students aged 17-26 studying in the Sharjah campus and able to participate in the survey were included. Participants who reported experiencing NP before March 7th, 2020, attributed their NP to factors unrelated to online learning, had recent trauma or surgery, or had disabilities were excluded.

The expected prevalence of NP was set at 50% as no previous studies in the UAE had been found to address the issue. Using 50% as the expected prevalence, the highest possible value, ensured that the minimum required sample size could be achieved. However, the research team ensured that the questionnaire was made available to the largest possible number of individuals to reach the minimum required sample size and to increase the accuracy of the study.

For this study, a self-administered questionnaire was utilized to gather data. It consisted of the Neck Disability Index (NDI) questionnaire, designed to assess the impact of NP on daily functioning as well as additional questions exploring other factors associated with NP.^31,32 NDI is a well-established and validated instrument for assessing self-reported disability related to NP. It has been translated into numerous languages and widely used in diverse research settings, demonstrating consistent psychometric properties.²³ The NDI had 10-item questionnaire for assessing the impact of NP on daily activities. Each item, such as pain intensity, personal care, and work, was rated on a scale of 0 to 5, with a total score ranging from 0 to 50. Higher scores indicated greater disability.³³ A study by Cleland et al. found that individuals with chronic NP often had significantly higher NDI scores than healthy adults, suggesting substantial limitations in daily life.³⁴

In addition to the NDI, our study aimed to explore the psychological effects of NP, the seeking of medical treatment, and the relationship between NP and the e-learning environment. We included questions about participants’ mood (anxiety and depression), e-learning habits (time spent, devices used, posture), and any medical interventions sought for NP.

To facilitate data collection for this study, questionnaires and consent forms were disseminated through various social media platforms, including WhatsApp, Facebook, Instagram, and others. These documents were provided in both English and Arabic.

Comprising of five sections, the questionnaire consisted of 27 questions covering demographics, pain history, impact on daily activities and mental health, e-learning environment, and management. Most of the questions were close ended, designed to simplify the survey. Nevertheless, three questions were open-ended to provide participants the opportunity to provide comprehensive answers.

Prior to commencing data collection, a pilot study involving 10-15 subjects to assure comprehensibility of the questionnaire. It was carried out in the 2020/2021 academic year. Upon receiving ethical approval, the questionnaire was distributed via social media platforms by each researcher during the spring semester of 2020/2021. Data about the pilot study was not documented. Furthermore, the researchers invited their close friends and colleagues to participate, as they were part of the target population.

SPSS 24 (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp.) was used to analyze the data, employing univariate analysis to generate descriptive statistics, such as frequency and measures of central tendency, as well as bivariate analysis to examine variable relationships. The SPSS license was obtained through the institutional SPSS software license of the University of Sharjah.

Inferential statistical tests, such as Chi-square, t-test, and Pearson correlation, were utilized based on the type of variables, with a significance level set at 5%.

The study obtained ethical clearance from the University of Sharjah research and graduate research ethics committee (REC-21-02-11-02-S), with participation being voluntary, anonymous, and risk-free. Participants included in the study were between the ages of 16 and 26 years. Since most of the university students are females, we diverted from asking about gender or stratifying data based on gender. There are two post graduate studies participants, but no faculty were involved as participants. Due to the restraints at the time of the pandemic, we preferred not to ask about the athletic statues of the participants.

Data collected was confidential and used exclusively for research purposes.

Results

Table 1 indicates that a vast majority of the participants, accounting for 98.15%, were University of Sharjah (UOS) students residing in various locations, including different emirates in the UAE and overseas. Of these, 96.31% (313 participants) fell within the age range of the study, which was 18 to 24 years. The prevalence of NP among UOS students in general was 62.7%. NDI scores were found to be skewed. The median was 16% which indicated mild NP. The interquartile range was 19.11 (Table 2).

According to the participants’ responses, the leading causes of NP were attributed to incorrect sitting posture and prolonged sitting. Nearly half (47.43%) of the participants experiencing NP described it as the worst pain imaginable (Figure 1A). Regarding the pain location, 38.77% identified location A (Figure 1B) at the back of the neck as the primary area, while 32.92% chose location F, representing the right lower trapezius, as the source of pain.

Figure 1. Students’ response to intensity and location of pain.

According to the NDI results, a significant majority of participants were able to lift only light weights (60%) (Figure 2A), needed assistance with personal care (85.71%) (Figure 2B), and reported having constant headaches (47.52%) (Figure 2C). Despite feeling slightly anxious due to NP (47.51%) (Figure 3A), the participants did not report experiencing depression because of it (50.84%) (Figure 3B).

Figure 2. Students’ response to effect of neck pain on lifting weights, personal care and headache.

Figure 3. Students’ response to effect of neck pain on anxiousness, depression, and concentration.

Furthermore, the findings revealed that 51.00% faced difficulty concentrating on their day-to-day activities (Figure 3C), 54.92% of the participants were unable to work (Figure 4A), and 25.74% managed to drive their vehicle with slight NP (Figure 4B). Moreover, the participants reported experiencing disturbed sleep (54.92%) (Figure 5A), difficulty engaging in recreational activities (55.77%) (Figure 5B), and inability to read (51.00%) (Figure 5C). These results demonstrate the gravity of the subjects’ NP and its impact on their daily routine and tasks.

Figure 4. Students’ response to effect of neck pain on work and driving.

Figure 5. Students’ response to effect of neck pain on sleeping, recreation and reading.

Regarding the online learning component, 39.56% of participants reported spending 11 to 20 hours per week on online learning (Figure 6A), with the laptop being the primary device used. The participants’ most common sitting positions (Figure 6B) were position 2 (32%), where they lean forward onto the device, and position 4 (28%), involving arching the neck and not using the chair to support the back. Positions 1, 3, and 5 were selected by 24%, 23%, and 10% o the participants, respectively.

Figure 6. Students’ response to time and the posture used during E-learning.

Merely 32.77% of the participants attempted to mitigate their pain through either medication or exercises (7.38% and 6.77%, respectively). The study revealed that NP is often dismissed and considered trivial, as evidenced by 91.48% of the participants not seeking medical assistance to alleviate their pain, and of those who did, only 26.14% were prescribed medication.

The Kruskal-Wallis test results revealed that various lifestyle factors had a substantial impact on the Neck Disability Index (NDI), including lifting, personal care, headaches, anxiousness and depression, work, concentration, sleep, recreational activities, and reading (p>0.005). Notably, driving did not have a significant effect on the NDI score (p=0.186) since most of the participants (58.09%) did not drive. Additionally, participants who did not seek medical attention or receive medical treatment had significant NDI scores (p=0.002). The study did not include information regarding the doctor’s consultation, radiographs, MRI neck, or the use of a cervical collar.

Discussion

This study indicates that the prevalence of NP among UOS students during the COVID-19 pandemic-related lockdown period was 62.7%. Of these students, 47.43% experienced NP as the worst pain comprehendible. The analysis of the study supports the theory that prolonged sitting for long periods (11-20 hours per week) in front of electronic devices could be a significant cause of NP during the unprecedented era of online learning.^9,35,36 Studies have demonstrated that development of NP is influenced by a multifaceted interplay of factors. Demographic factors, such as age, gender, height, and weight, can predispose individuals to NP.³⁷ Biomechanical factors³⁸ including forceful exertions, repetitive movements, and awkward postures, can exacerbate existing conditions or contribute to the development of new ones. Psychosocial factors, such as job stress, work dissatisfaction, and poor ergonomic practices, and behavioral factors, such as tobacco use, alcohol consumption, physical activity levels, stress management, and sleep hygiene, can all contribute to the risk of NP.³⁹ Additionally, environmental factors, such as the physical layout of a workplace or the nature of tasks performed, can influence the likelihood of its occurrence.^40–42 The prevalence of NP among undergraduate students in this study is higher than countries, such as Ethiopia (49.2%),⁴³ India (46.9%),⁴⁴ Singapore (74%)⁴⁵ and Taiwan (52%)⁴⁶ and lower than a study conducted in China (72.9%).⁴⁷ However, the findings is in accord with a study conducted in Brazil (66.7%),⁴⁸ Pakistan (69%)⁴⁹ and Malaysia (65.1%).¹² The observed variability in the prevalence rate of NP across studies could be attributed to disparities in multiple factors, including the geographical setting of the study, the size of the sample population, the methodology employed for sampling, and the assessment instruments utilized.

Several studies have established a clear association between the duration of device usage and the occurrence of musculoskeletal pain.^50,51 These findings consistently indicate that as the amount of time spent using devices increases, the risk of developing musculoskeletal injuries also rises. In a study by Berolo et al. (2011) 84% of respondents reported pain in various body regions, with the right hand and thumb being the most frequently affected.⁵⁰

A study conducted in Australia, among the medical undergraduates, showed neck as the most frequently affected region by musculoskeletal pain.⁵² Likewise, a study in Thailand reported a significant prevalence of NP (46%) among undergraduate students, with various risk factors identified as contributors to persistent NP.⁴⁰ Another study by Alzhrani et al. (2019) 80.1% of participants reported musculoskeletal discomfort, with the most commonly affected areas being the neck (64.7%), back (53.8%), and dominant shoulder (38.8%).⁵³ In similar study by Blair et al. (2015,) 67.9% of participants experienced musculoskeletal symptoms with 70.5% reporting discomfort in the neck (86.4%), lower back (75.9%), and right/left shoulders (76.2%).⁵⁴ Likewise, Olayinka et al. (2013) found that 75.7% of participants reported shoulder complaints.⁵⁵ Eugenia et al. (2016) also reported that 49.9% of respondents experienced upper limb musculoskeletal symptoms, particularly in the neck and shoulder regions⁵⁶ which is comparable to the findings of the present investigation, where 38.77% reported back of the neck and 32.92% right lower trapezius. The excessive use of electronic devices can lead to “text neck,” a condition characterized by chronic neck flexion. This can result in inflammation of the neck’s ligaments, muscles, and nerves, potentially leading to long-term consequences such as permanent arthritic damage and an increased spinal curvature.²⁴ Biomechanical factors, such as repetitive strain on neck muscles from prolonged forward head posture⁵⁷ and ergonomic factors, such as the use of poorly designed furniture and inadequate lighting (59-61) can contribute to poor posture and exacerbate the development of text neck. These combined factors can increase the risk of musculoskeletal pain and discomfort among students.

Our findings add to the growing body of research showing that using electronic devices while studying and adopting bad head position can worsen musculoskeletal pain.⁴¹

Also, NP can significantly disrupt daily activities, potentially hindering individual participation and causing work-related disabilities. Previous reports have conclusively demonstrated the link between NP and headaches.^42,57 This study also reveals a simultaneous relationship between activities that induce NP, unsteadiness, and headaches among university students. The coexistence of NP and headache may stem from the compression of the lesser and greater occipital nerves by posterior cervical muscles, with their fascial attachments at the occipital ridge causing local perineural inflammation.⁵⁸ Furthermore, this study shows a significant correlation between the NDI and various lifestyle factors, including lifting, personal care, recreational activities, in addition to symptoms like anxiety and depression. These factors also impacted the students’ ability to work, perform daily chores, and drive.

University students frequently experience significant perceived stress, particularly in the form of academic stressors. These stressors can include academic demands, financial concerns, time pressures, health issues, and self-imposed pressures.⁵⁹ Studies have linked high levels of mental stress among students to an increased risk of musculoskeletal disorders, such as low-back pain and NP.⁶⁰ Additionally, research has demonstrated that time pressure can increase the activity of various muscles, potentially leading to increased biomechanical load and musculoskeletal disorders. For example, studies have shown that time pressure can increase the activity of the trapezius, infraspinatus, deltoid, and extensor digitorum muscles,⁶¹ which can contribute to strain and discomfort in the neck, shoulders, and upper back. Students using electronic devices in Jordan exhibited severe to extremely severe symptoms of stress, anxiety, and depression, along with moderate to severe insomnia.⁶² A systematic review and meta-analysis comparing the central processing of pain between individuals with non-traumatic NP and healthy subjects revealed that symptoms of depression, which are processed at the spinal, cortical, and brainstem levels, manifest as increased sensitivity to pain in the peripheral regions.⁶³

Additionally, studies from China have indicated that mood disorders are more commonly coexistent with NP compared to other mental disorders. Specifically, major depressive disorder exhibited a notably higher association with NP than other mood-related conditions.⁶⁴ This suggests the possibility that the NP reported by participants in this study might be linked to mental disorders that emerged during the COVID-19 period.

The observed prevalence of musculoskeletal pain, particularly NP, among students in this cross-sectional study necessitates further investigation. Longitudinal data from multiple institutions are essential to establish definitive trends and inform comprehensive interventions. Improper postures like sitting with crossed legs, hunching while walking, and forward neck leaning with rounded shoulders not only lead to neck and shoulder discomfort but can also cause imbalanced spinal pressure, possibly resulting in persistent lower back pain.^65,66

In the present study, most participants leaned forward onto the device or were arching their neck and not using the chair to support the back while sitting.

Effective strategies like exercise can reduce pain intensity, and educational health programs should inform students about the risks of prolonged computer use, though more research is needed to understand pain development and its contributing factors among undergraduates.

While the efficacy of incorporating neck exercise breaks is well-established in ergonomics and occupational health literature, this study further underscores its significance in mitigating the negative effects of prolonged sedentary behavior on student health. In addition to regular breaks, implementing strategies such as scheduling automatic reminders to adjust posture on online learning platforms and adopting proper computer and laptop positioning can significantly enhance neck function and quality of life.⁶⁷

These interventions, when combined with neck exercises, can effectively alleviate NP and discomfort among students. The reliability of this data is limited by recall bias. By determining the prevalence of NP among UOS students, this research can attract attention to the importance of postural changes and time spent studying on the severity of NP, and the gaps of previously published articles can be filled. To further reduce the morbidity of such avoidable pain, additional preventative interventions, and future NP research should be conducted with relation to the UAE.

Conclusion

This study underscores the prevalence of NP among University of Sharjah students during the COVID-19 pandemic. Prolonged electronic device use and poor posture were identified as primary contributors. Given the limited local research in this area, the study focused on the United Arab Emirates. The findings highlight the necessity for implementing preventive measures, raising awareness, and establishing regulations to mitigate the adverse health effects of distance learning. These measures should include promoting proper posture, encouraging regular breaks, and providing educational resources. Further research is imperative to address this emerging health concern.

Ethics approval and consent to participate

The study protocol was approved by the University of Sharjah research and graduate research ethics committee Reference number: REC-21-02-11-02-S approval date 14.02.2021), in agreement with accepted international standards.

Consent for publication

Written consent was taken for publishing the image of the participant.

Authors’ contribution

Conceptualization: Amal Hussein & Anu V Ranade.

Data curation: Awab Musaad, Mohamed, Sara Alaaeldin Bashier, Danya Aasim Elkhidir, Mohamad Abdulkafi

Formal analysis: Awab Musaad, Mohamed, Sara Alaaeldin Bashier, Danya Aasim Elkhidir, Mohamad Abdulkafi

Investigation: Awab Musaad, Mohamed, Sara Alaaeldin Bashier, Danya Aasim Elkhidir, Mohamad Abdulkafi

Methodology: Awab Musaad, Mohamed, Sara Alaaeldin Bashier, Danya Aasim Elkhidir, Mohamad Abdulkafi

Project administration: Awab Musaad, Mohamed, Sara Alaaeldin Bashier, Danya Aasim Elkhidir, Mohamad Abdulkafi

Resources: Awab Musaad Mohamed, Sara Alaaeldin Bashier, Anu V Ranade

Supervision: Anu V Ranade & Amal Hussein

Software: Awab Musaad Mohamed & Amal Hussein

Validation: Amal Hussein & Anu V Ranade

Visualization: Amal Hussein & Anu V Ranade

Writing – original draft: Awab Musaad, Mohamed, Sara Alaaeldin Bashier, Danya Aasim Elkhidir, Anu V Ranade

Writing – review & editing: Anu V Ranade, Awab Musaad Mohamed, Mohamad Abdulkafi