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

Awab Musaad Mohamed; Mohamad Abdulkafi Abbara; Sara Alaaeldin Bashier; Danya Aasim Elkhidir; Amal Hussein; Anu Vinod Ranade

doi:10.12688/f1000research.145874.1

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Research Article

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

[version 1; peer review: 2 approved with reservations, 1 not approved]

Awab Musaad Mohamed¹, Mohamad Abdulkafi Abbara¹, Sara Alaaeldin Bashier¹, Danya Aasim Elkhidir¹, Amal Hussein¹, Anu Vinod Ranade^2,3

Awab Musaad Mohamed¹, Mohamad Abdulkafi Abbara¹, [...] Sara Alaaeldin Bashier¹, Danya Aasim Elkhidir¹, Amal Hussein¹, Anu Vinod Ranade^2,3

PUBLISHED 22 Apr 2024

Author details Author details

¹ College of Medicine, University of Sharjah, Sharjah, Sharjah, 27272, United Arab Emirates
² Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah, Sharjah, 27272, United Arab Emirates
³ Cardiovascular Research Group, Sharjah Institute for Medical Research,, University of Sharjah, Sharjah, Sharjah, 27272, United Arab Emirates

Awab Musaad Mohamed
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Writing – Original Draft Preparation, Writing – Review & Editing

Mohamad Abdulkafi Abbara
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing – Review & Editing

Sara Alaaeldin Bashier
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Writing – Original Draft Preparation

Danya Aasim Elkhidir
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation

Amal Hussein
Roles: Conceptualization, Software, Supervision, Validation, Visualization

Anu Vinod Ranade
Roles: Conceptualization, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Global Public Health gateway.

Abstract

Objective

The shift to online learning during COVID-19 led to increased musculoskeletal discomforts and impacted students’ quality of life. Neck pain, once a minor issue, has become more prevalent due to prolonged electronic device use in new learning methods. This study aims to measure the prevalence of neck pain among University of Sharjah (UOS) students during the COVID-19 online learning period and to investigate the factors that provoked it.

Methods

This cross-sectional study used an online survey distributed to UOS students via social media from February 16 to March 12, 2021. Demographic data, Neck Disability Index (NDI) assessments, and pain management information were gathered and analyzed using SPSS 24 through univariate and bivariate methods.

Results

The prevalence of neck pain during COVID-19, among 325 UOS students was found to be 62.7%, 64.41% of which had neck pain at the time of doing the survey. The mean NDI percentage point was 19.19%. The most common location of pain was the back of the neck 38.77%). Participants reported prolonged sitting (81.23%) while leaning forward as the most prevalent cause of their neck pain. Bivariate analysis showed that the most significant factors affecting the NDI were lifting, personal care, headaches, concentration, sleeping, recreational activities, reading, anxiousness, depression, and work. Moreover, subjects who did not seek medical attention treatment had significantly higher NDI scores as compared to those who did (83.89 vs 125.80, p=0.002).

Conclusion

By determining the prevalence of neck pain among UOS students, this research can attract attention to the importance of postural changes and time spent in e-learning on neck pain, and the gaps of previously published articles can be filled. Future studies about neck pain and additional preventative measures should be catalyzed in the UAE.

Keywords

Neck pain; COVID-19; E- learning; musculoskeletal disorders

Corresponding author: Anu Vinod Ranade

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Musaad Mohamed A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Musaad Mohamed A, Abdulkafi Abbara M, Alaaeldin Bashier S et al. Neck pain and distance learning: A pain in the neck for university students during COVID-19 [version 1; peer review: 2 approved with reservations, 1 not approved]. F1000Research 2024, 13:307 (https://doi.org/10.12688/f1000research.145874.1) First published: 22 Apr 2024, 13:307 (https://doi.org/10.12688/f1000research.145874.1) Latest published: 08 Nov 2024, 13:307 (https://doi.org/10.12688/f1000research.145874.2)

Introduction

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

In 2018, 440 randomly chosen medical students at Jazan University in Saudi Arabia reported a prevalence of neck pain of 53.5%.⁷ 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 neck pain.⁸

Students in the United Arab Emirates (UAE) commonly experience musculoskeletal disorders (MSP) as one of the primary occupational health concerns.

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.⁹ 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%.¹⁰

The prevalence of neck pain among 80 radiologists in the United Arab Emirates, comprising of male and female radiologists from nationalities, found a significant rise in the prevalence of neck pain after they started working in the radiology department in 2017. Also, the neck pain 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 neck pain.¹¹

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.¹²^,¹³

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.¹⁴

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.¹⁵ 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.¹⁶ 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 neck pain.¹⁷^,¹⁸ It is hypothesized that utilizing these devices may cause indirect tension in the neck muscles, eventually leading to neck pain and discomfort.⁶ According to a Hong Kong research, using electronic devices is associated with musculoskeletal disorders, particularly in the neck and shoulder region.¹¹

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.¹⁹ 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.²⁰^,²¹

Rationale

Although research has investigated the association between neck pain and electronic device use among university students, limited research has focused during the COVID-19 pandemic. University students may be more susceptible to neck pain 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 neck pain, 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 neck pain 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 neck pain among this population and help to inform interventions and preventative measures to reduce the incidence of neck pain and improve the overall health and well-being of students.

Significance

Gaining insight into the factors that increase the likelihood of neck pain 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.

Objectives

• To measure the prevalence of neck pain among UoS students during online learning.
• To identify factors that are associated with the intensity of the neck pain and to evaluate the psychosocial impact related to neck pain (interference of pain with daily activities and obligations, anxiousness, or depression).

Methods

Design, population, sampling method and sample size

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 18-24. 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.

Inclusion criteria

All UoS students aged 17-24 studying in the Sharjah campus and able to do the survey.

Exclusion criteria

Participants who reported neck pain prior to March 7th, 2020, which was determined based on their responses in the questionnaire; those who attributed their neck pain to events unrelated to online learning; individuals with recent trauma or surgery, and those with disabilities.

The expected prevalence of neck pain 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.

Data collection

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 neck pain on daily functioning²²^,²³ as well as additional questions exploring other factors associated with neck pain. Questionnaire was disseminated across various social media platforms, including WhatsApp, Facebook, Instagram, and others.

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 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. Furthermore, the researchers invited their close friends and colleagues to participate, as they were part of the target population.

Data analysis

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%.

Ethical consideration

The study obtained ethical clearance from the University of Sharjah research and graduate research ethics committee (REC-21-02-11-02-S) approval date 14.02.2021, with participation being voluntary, anonymous, and risk-free. Data collected were 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 neck pain among UoS students in general was 62.7%, most participants scored above 60 in the NDI (70.46%) (Table 2).

Table 1. Participants age groups and locations.

Age group
Less than 18 Years	10
18-24 Years	313
More than 24 Years	2

Location*
Abudhabi	54
Dubai	55
Sharjah	176
Other Emirates	29
Outside UAE	9

* Location of the student while filling the survey.

Table 2. Neck disability index scores.

Score n (%)
Less than 20	15 (4.61)
21-40	68 (20.92)
41-60	13 (4)
More than 60	229 (70.46)

According to the participants’ responses, the leading causes of neck pain were attributed to incorrect sitting posture and prolonged sitting. Nearly half (47.43%) of the participants experiencing neck pain 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 Neck Disability Index (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 neck pain (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 neck pain (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’ neck pain 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% of 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 neck pain 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).

Discussion

This study indicates that the prevalence of neck pain among University of Sharjah students during the COVID-19 pandemic-related lockdown period was 62.7%. Of these students, 47.43% experienced neck pain 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 neck pain during the unprecedented era of online learning.⁸^,²⁴^,²⁵ The prevalence of neck pain among undergraduate students in this study is higher than countries, such as Ethiopia (49.2%),²⁶ India (46.9%),²⁷ Singapore (74%)²⁸ and Taiwan (52%)²⁹ and lower than a study conducted in China (72.9%).³⁰ However, the findings is in accord with a study conducted in Brazil (66.7%),³¹ Pakistan (69%)³² and Malaysia (65.1%). 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.³³^,³⁴ 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.³³

A study conducted in Australia, among the medical undergraduates, showed neck as the most frequently affected region by musculoskeletal pain.³⁵ Likewise, a study in Thailand reported a significant prevalence of neck pain (46%) among undergraduate students, with various risk factors identified as contributors to persistent neck pain.³⁶ 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%).³⁷ 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%).³⁸ Likewise, Olayinka et al. (2013) found that 75.7% of participants reported shoulder complaints.³⁹ Eugenia et al. (2016) also reported that 49.9% of respondents experienced upper limb musculoskeletal symptoms, particularly in the neck and shoulder regions⁴⁰ which is comparable to the findings of the present investigation, where 38.77% reported back of the neck and 32.92% right lower trapezius. Extended use of electronic devices can lead to “text neck,” characterized by prolonged neck flexion, which can cause inflammation in neck ligaments, muscles, and nerve irritation. If not addressed, this condition can result in permanent arthritic damage and an increased spinal curvature.¹⁸ 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 neck pain can significantly disrupt daily activities, potentially hindering individual participation and causing work-related disabilities. Previous reports have conclusively demonstrated the link between neck pain and headaches.⁴²^,⁴³ This study also reveals a simultaneous relationship between activities that induce neck pain, unsteadiness, and headaches among university students. The coexistence of neck pain 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.⁴⁴ Furthermore, this study shows a significant correlation between the neck disability index 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.

Maysoun et al. noted that students using electronic devices in Jordan exhibited severe to extremely severe symptoms of stress, anxiety, and depression, along with moderate to severe insomnia.⁴⁵ A systematic review and meta-analysis comparing the central processing of pain between individuals with non-traumatic neck pain 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.⁴⁶

Additionally, studies from China have indicated that mood disorders are more commonly coexistent with neck pain compared to other mental disorders. Specifically, major depressive disorder exhibited a notably higher association with neck pain than other mood-related conditions.⁴⁷ This suggests the possibility that the neck pain reported by participants in this study might be linked to mental disorders that emerged during the COVID-19 period.

The rising prevalence of musculoskeletal pain, particularly neck pain among students, calls for urgent preventive measures and proper guidance on posture.

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.⁴⁸^,⁴⁹

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.

This study also provides new insight into the importance of implementing more breaks for neck exercises in between class times, scheduling automatic reminders to adjust postures on all online learning platforms, and apply other standard practices done to manage neck pain like proper positioning of the computers and laptops, as it has been reported to be effective in improving neck function and quality of life.⁵⁰

Additionally, this study fills in the gaps left by earlier studies that concentrated on either back pain or musculoskeletal pain in general and suggests that future studies concentrate on ergonomic factors like posture and study time, as they believed to be the causes of neck pain according to the students.

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

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

Data availability statement

All data generated and analyzed during this study have been deposited in the Zenodo database.

Zenodo: Questionnaire and Data of Neck Pain and Distance learning among university Students During COVID-19, DOI: https://doi.org/10.5281/zenodo.10278960.⁵¹

This project contains the following underlying data:

1. Excel for charts.xlsx
2. Questionaire.pdf

Creative Commons Attribution 4.0 International

Acknowledgment

The authors extend their gratitude to the participants for their cooperation throughout the study, and to the University of Sharjah for providing the opportunity to conduct this research.

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Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 22 Apr 2024

Author details Author details

Mohamad Abdulkafi Abbara
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing – Review & Editing

Sara Alaaeldin Bashier
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Writing – Original Draft Preparation

Danya Aasim Elkhidir
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation

Amal Hussein
Roles: Conceptualization, Software, Supervision, Validation, Visualization

Anu Vinod Ranade
Roles: Conceptualization, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

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Published: 08 Nov 2024, 13:307

https://doi.org/10.12688/f1000research.145874.2

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https://doi.org/10.12688/f1000research.145874.1

© 2024 Musaad Mohamed A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Musaad Mohamed A, Abdulkafi Abbara M, Alaaeldin Bashier S et al. Neck pain and distance learning: A pain in the neck for university students during COVID-19 [version 1; peer review: 2 approved with reservations, 1 not approved]. F1000Research 2024, 13:307 (https://doi.org/10.12688/f1000research.145874.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

Version 1

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Reviewer Report 22 Jul 2024

Fairus Fariza Zainudin, Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia

Approved with Reservations

https://doi.org/10.5256/f1000research.159890.r290872

Title:
It concisely captures the main focus of the study, using appropriate scientific terminology.

Abstract:
"Include ethical approval details, participant demographics (age, gender distribution, and faculty representation), and specify whether participants were athletes or non-athletes. Report the mean and standard deviation of NDI scores, both overall and stratified by age groups. Provide information on neck pain severity using validated scales (e.g., VAS or NRS). Briefly describe the methodology for assessing factors affecting neck pain, including questionnaire design. Clarify the NDI scoring system, as the current abstract reports values that exceed 100% (83.89 vs 125.80, p=0.002). In the conclusion, justify the focus on the UAE and articulate the practical implications of this research."

Results:
"Address the inclusion of participants under 18 (n=10) and over 24 (n=2) years of age, as these fall outside the stated inclusion criteria. Consider removing these data points and reassessing the findings. Given the established pattern of increasing neck pain prevalence, consider adopting a more stringent significance level (p < 0.025). Provide a detailed explanation of the NDI scoring system and severity classification, citing relevant normative data. Elucidate the process for selecting neck pain-related factors during the pandemic. Report the results of pilot testing and tester reliability. In Table 2, include mean and standard deviation for NDI scores."

Discussion:
"Revise the statement on 'rising prevalence' to reflect the cross-sectional nature of this study, acknowledging that trend analysis would require longitudinal data from multiple institutions. Elaborate on the biomechanical and ergonomic factors contributing to prolonged poor posture among students. Reconsider the phrase 'new insight' regarding the importance of breaks for neck exercises, as this is a well-established principle in ergonomics and occupational health. Deepen the discussion by incorporating physiological, behavioral, biomechanical, and psychological perspectives when comparing results to existing literature. Enhance the practical implications section to provide clear, actionable recommendations based on the study findings."

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: injury pattern and profiling, sports rehabilitation, musculoskeletal pain, sports concussion, Cardiopulmonary resuscitation education.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 08 Nov 2024

Anu V, Basic Sciences, University of Sharjah, Sharjah, United Arab Emirates

08 Nov 2024

Author Response
Abstract:
1. Reviewers comment: "Include ethical approval details, participant demographics (age, gender distribution, and faculty representation), and specify whether participants were athletes or non-athletes.
  Response: Included in the manuscript
... Continue reading
Abstract:

Reviewers comment: "Include ethical approval details, participant demographics (age, gender distribution, and faculty representation), and specify whether participants were athletes or non-athletes.
Response: Included in the manuscript as suggested. (This cross-sectional study used an online survey distributed to University of Sharjah students via social media from February 16 to March 12, 2021, following ethical approval. The study participants were young adults aged 18 to 26. Due to the predominantly female demographic of the university student population and pandemic-related restrictions, gender and athletic status were not considered significant variables in this research.)

Reviewers comment: Report the mean and standard deviation of NDI scores, both overall and stratified by age groups.
Response: Included in the manuscript as suggested ("Participants who did not seek medical attention had significantly higher levels of neck pain disability, as measured by the NDI. The median NDI score for those who did not seek treatment was 20, with an interquartile range of 16.89. In contrast, the median NDI score for those who did seek medical attention was 34.00, with an interquartile range of 22.")

Reviewers comment: Provide information on neck pain severity using validated scales (e.g., VAS or NRS). Briefly describe the methodology for assessing factors affecting neck pain, including questionnaire design.
Response: Since our objective was to identify factors that are associated with the intensity of the neck pain rather than the intensity itself. The question in the questionnaire was added to get a subjective view of how participants express their neck pain intensity.

Reviewers comment: Clarify the NDI scoring system, as the current abstract reports values that exceed 100% (83.89 vs 125.80, p=0.002). In conclusion, justify the focus on the UAE and articulate the practical implications of this research.
Response: Thank you for bringing this to our notice. The mean rank was reported by mistake. Since the data is skewed in this question, the median and interquartile range were added. Justifications were added to the conclusion as requested.

Results:

Reviewers comment: "Address the inclusion of participants under 18 (n=10) and over 24 (n=2) years of age, as these fall outside the stated inclusion criteria. Consider removing these data points and reassessing the findings. Given the established pattern of increasing neck pain prevalence, consider adopting a more stringent significance level (p < 0.025). Provide a detailed explanation of the NDI scoring system and severity classification, citing relevant normative data. Elucidate the process for selecting neck pain-related factors during the pandemic. Report the results of pilot testing and tester reliability.
Response: Included as suggested. (NDI scores were found to be skewed. The median is 16% which indicates mild neck pain. The interquartile range is 19.11. Participants who did not seek medical attention had significantly higher levels of neck pain disability, as measured by the NDI. The median NDI score for those who did not seek treatment was 20, with an interquartile range of 16.89. In contrast, the median NDI score for those who did seek medical attention was 34.00, with an interquartile range of 22).

Reviewers comment: In Table 2, include mean and standard deviation for NDI scores.
Response: As stated earlier, the NDI scores were found to be skewed. The median and interquartile range were added to table 2.

Discussion:

Reviewers comment: "Revise the statement on 'rising prevalence' to reflect the cross-sectional nature of this study, acknowledging that trend analysis would require longitudinal data from multiple institutions.
Our response: Modified as in the manuscript as suggested (The observed prevalence of musculoskeletal pain, particularly neck pain, 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.)

Reviewers comment: Elaborate on the biomechanical and ergonomic factors contributing to prolonged poor posture among students. Reconsider the phrase 'new insight' regarding the importance of breaks for neck exercises, as this is a well-established principle in ergonomics and occupational health.
Our response: Modified in the manuscript as suggested (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. Biomechanical factors, such as repetitive strain on neck muscles from prolonged forward head posture (Goodarzi et al., 2018), and ergonomic factors, such as the use of poorly designed furniture and inadequate lighting (Eldho & Muthukumar, 2022; Meshram et al., 2021; Brewer, 2006), 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. 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. [50]. These interventions, when combined with neck exercises, can effectively alleviate NP and discomfort among students.)

Reviewers comment: Deepen the discussion by incorporating physiological, behavioral, biomechanical, and psychological perspectives when comparing results to existing literature. Enhance the practical implications section to provide clear, actionable recommendations based on the study findings."
Our response: Incorporated in the manuscript as suggested. (The 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. Biomechanical factors, 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 (McLean SM et al., 2010). Additionally, environmental factors, such as the physical layout of a workplace or the nature of tasks performed, can influence the likelihood of its occurrence (Kanchanomai et al., 2011; Razvi et al., 2018; Kalirathinam et al., 2017; Lee et al., 2018).Biomechanical factors, such as repetitive strain on neck muscles from prolonged forward head posture (Goodarzi et al., 2018), and ergonomic factors, such as the use of poorly designed furniture and inadequate lighting (Eldho & Muthukumar, 2022; Meshram et al., 2021; Brewer, 2006), 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. 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 (Pamela, L. 2009). Studies have linked high levels of mental stress among students to an increased risk of musculoskeletal disorders, such as low-back pain and neck pain (Lundberg U, et al., 2002). 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 (Birch et al., 2003), which can contribute to strain and discomfort in the neck, shoulders, and upper back.
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.)
Abstract:

Reviewers comment: "Include ethical approval details, participant demographics (age, gender distribution, and faculty representation), and specify whether participants were athletes or non-athletes.
Response: Included in the manuscript as suggested. (This cross-sectional study used an online survey distributed to University of Sharjah students via social media from February 16 to March 12, 2021, following ethical approval. The study participants were young adults aged 18 to 26. Due to the predominantly female demographic of the university student population and pandemic-related restrictions, gender and athletic status were not considered significant variables in this research.)

Reviewers comment: Report the mean and standard deviation of NDI scores, both overall and stratified by age groups.
Response: Included in the manuscript as suggested ("Participants who did not seek medical attention had significantly higher levels of neck pain disability, as measured by the NDI. The median NDI score for those who did not seek treatment was 20, with an interquartile range of 16.89. In contrast, the median NDI score for those who did seek medical attention was 34.00, with an interquartile range of 22.")

Reviewers comment: Provide information on neck pain severity using validated scales (e.g., VAS or NRS). Briefly describe the methodology for assessing factors affecting neck pain, including questionnaire design.
Response: Since our objective was to identify factors that are associated with the intensity of the neck pain rather than the intensity itself. The question in the questionnaire was added to get a subjective view of how participants express their neck pain intensity.

Reviewers comment: Clarify the NDI scoring system, as the current abstract reports values that exceed 100% (83.89 vs 125.80, p=0.002). In conclusion, justify the focus on the UAE and articulate the practical implications of this research.
Response: Thank you for bringing this to our notice. The mean rank was reported by mistake. Since the data is skewed in this question, the median and interquartile range were added. Justifications were added to the conclusion as requested.

Results:

Reviewers comment: "Address the inclusion of participants under 18 (n=10) and over 24 (n=2) years of age, as these fall outside the stated inclusion criteria. Consider removing these data points and reassessing the findings. Given the established pattern of increasing neck pain prevalence, consider adopting a more stringent significance level (p < 0.025). Provide a detailed explanation of the NDI scoring system and severity classification, citing relevant normative data. Elucidate the process for selecting neck pain-related factors during the pandemic. Report the results of pilot testing and tester reliability.
Response: Included as suggested. (NDI scores were found to be skewed. The median is 16% which indicates mild neck pain. The interquartile range is 19.11. Participants who did not seek medical attention had significantly higher levels of neck pain disability, as measured by the NDI. The median NDI score for those who did not seek treatment was 20, with an interquartile range of 16.89. In contrast, the median NDI score for those who did seek medical attention was 34.00, with an interquartile range of 22).

Reviewers comment: In Table 2, include mean and standard deviation for NDI scores.
Response: As stated earlier, the NDI scores were found to be skewed. The median and interquartile range were added to table 2.

Discussion:

Reviewers comment: "Revise the statement on 'rising prevalence' to reflect the cross-sectional nature of this study, acknowledging that trend analysis would require longitudinal data from multiple institutions.
Our response: Modified as in the manuscript as suggested (The observed prevalence of musculoskeletal pain, particularly neck pain, 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.)

Reviewers comment: Elaborate on the biomechanical and ergonomic factors contributing to prolonged poor posture among students. Reconsider the phrase 'new insight' regarding the importance of breaks for neck exercises, as this is a well-established principle in ergonomics and occupational health.
Our response: Modified in the manuscript as suggested (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. Biomechanical factors, such as repetitive strain on neck muscles from prolonged forward head posture (Goodarzi et al., 2018), and ergonomic factors, such as the use of poorly designed furniture and inadequate lighting (Eldho & Muthukumar, 2022; Meshram et al., 2021; Brewer, 2006), 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. 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. [50]. These interventions, when combined with neck exercises, can effectively alleviate NP and discomfort among students.)

Reviewers comment: Deepen the discussion by incorporating physiological, behavioral, biomechanical, and psychological perspectives when comparing results to existing literature. Enhance the practical implications section to provide clear, actionable recommendations based on the study findings."
Our response: Incorporated in the manuscript as suggested. (The 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. Biomechanical factors, 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 (McLean SM et al., 2010). Additionally, environmental factors, such as the physical layout of a workplace or the nature of tasks performed, can influence the likelihood of its occurrence (Kanchanomai et al., 2011; Razvi et al., 2018; Kalirathinam et al., 2017; Lee et al., 2018).Biomechanical factors, such as repetitive strain on neck muscles from prolonged forward head posture (Goodarzi et al., 2018), and ergonomic factors, such as the use of poorly designed furniture and inadequate lighting (Eldho & Muthukumar, 2022; Meshram et al., 2021; Brewer, 2006), 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. 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 (Pamela, L. 2009). Studies have linked high levels of mental stress among students to an increased risk of musculoskeletal disorders, such as low-back pain and neck pain (Lundberg U, et al., 2002). 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 (Birch et al., 2003), which can contribute to strain and discomfort in the neck, shoulders, and upper back.
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.)
Competing Interests: No competing interests were disclosed. Close
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Respond or Comment

COMMENTS ON THIS REPORT

Author Response 08 Nov 2024

Anu V, Basic Sciences, University of Sharjah, Sharjah, United Arab Emirates

08 Nov 2024

Author Response
Abstract:
1. Reviewers comment: "Include ethical approval details, participant demographics (age, gender distribution, and faculty representation), and specify whether participants were athletes or non-athletes.
  Response: Included in the manuscript
... Continue reading
Abstract:

Reviewers comment: "Include ethical approval details, participant demographics (age, gender distribution, and faculty representation), and specify whether participants were athletes or non-athletes.
Response: Included in the manuscript as suggested. (This cross-sectional study used an online survey distributed to University of Sharjah students via social media from February 16 to March 12, 2021, following ethical approval. The study participants were young adults aged 18 to 26. Due to the predominantly female demographic of the university student population and pandemic-related restrictions, gender and athletic status were not considered significant variables in this research.)

Reviewers comment: Report the mean and standard deviation of NDI scores, both overall and stratified by age groups.
Response: Included in the manuscript as suggested ("Participants who did not seek medical attention had significantly higher levels of neck pain disability, as measured by the NDI. The median NDI score for those who did not seek treatment was 20, with an interquartile range of 16.89. In contrast, the median NDI score for those who did seek medical attention was 34.00, with an interquartile range of 22.")

Reviewers comment: Provide information on neck pain severity using validated scales (e.g., VAS or NRS). Briefly describe the methodology for assessing factors affecting neck pain, including questionnaire design.
Response: Since our objective was to identify factors that are associated with the intensity of the neck pain rather than the intensity itself. The question in the questionnaire was added to get a subjective view of how participants express their neck pain intensity.

Reviewers comment: Clarify the NDI scoring system, as the current abstract reports values that exceed 100% (83.89 vs 125.80, p=0.002). In conclusion, justify the focus on the UAE and articulate the practical implications of this research.
Response: Thank you for bringing this to our notice. The mean rank was reported by mistake. Since the data is skewed in this question, the median and interquartile range were added. Justifications were added to the conclusion as requested.

Results:

Reviewers comment: "Address the inclusion of participants under 18 (n=10) and over 24 (n=2) years of age, as these fall outside the stated inclusion criteria. Consider removing these data points and reassessing the findings. Given the established pattern of increasing neck pain prevalence, consider adopting a more stringent significance level (p < 0.025). Provide a detailed explanation of the NDI scoring system and severity classification, citing relevant normative data. Elucidate the process for selecting neck pain-related factors during the pandemic. Report the results of pilot testing and tester reliability.
Response: Included as suggested. (NDI scores were found to be skewed. The median is 16% which indicates mild neck pain. The interquartile range is 19.11. Participants who did not seek medical attention had significantly higher levels of neck pain disability, as measured by the NDI. The median NDI score for those who did not seek treatment was 20, with an interquartile range of 16.89. In contrast, the median NDI score for those who did seek medical attention was 34.00, with an interquartile range of 22).

Reviewers comment: In Table 2, include mean and standard deviation for NDI scores.
Response: As stated earlier, the NDI scores were found to be skewed. The median and interquartile range were added to table 2.

Discussion:

Reviewers comment: "Revise the statement on 'rising prevalence' to reflect the cross-sectional nature of this study, acknowledging that trend analysis would require longitudinal data from multiple institutions.
Our response: Modified as in the manuscript as suggested (The observed prevalence of musculoskeletal pain, particularly neck pain, 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.)

Reviewers comment: Elaborate on the biomechanical and ergonomic factors contributing to prolonged poor posture among students. Reconsider the phrase 'new insight' regarding the importance of breaks for neck exercises, as this is a well-established principle in ergonomics and occupational health.
Our response: Modified in the manuscript as suggested (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. Biomechanical factors, such as repetitive strain on neck muscles from prolonged forward head posture (Goodarzi et al., 2018), and ergonomic factors, such as the use of poorly designed furniture and inadequate lighting (Eldho & Muthukumar, 2022; Meshram et al., 2021; Brewer, 2006), 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. 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. [50]. These interventions, when combined with neck exercises, can effectively alleviate NP and discomfort among students.)

Reviewers comment: Deepen the discussion by incorporating physiological, behavioral, biomechanical, and psychological perspectives when comparing results to existing literature. Enhance the practical implications section to provide clear, actionable recommendations based on the study findings."
Our response: Incorporated in the manuscript as suggested. (The 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. Biomechanical factors, 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 (McLean SM et al., 2010). Additionally, environmental factors, such as the physical layout of a workplace or the nature of tasks performed, can influence the likelihood of its occurrence (Kanchanomai et al., 2011; Razvi et al., 2018; Kalirathinam et al., 2017; Lee et al., 2018).Biomechanical factors, such as repetitive strain on neck muscles from prolonged forward head posture (Goodarzi et al., 2018), and ergonomic factors, such as the use of poorly designed furniture and inadequate lighting (Eldho & Muthukumar, 2022; Meshram et al., 2021; Brewer, 2006), 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. 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 (Pamela, L. 2009). Studies have linked high levels of mental stress among students to an increased risk of musculoskeletal disorders, such as low-back pain and neck pain (Lundberg U, et al., 2002). 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 (Birch et al., 2003), which can contribute to strain and discomfort in the neck, shoulders, and upper back.
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.)
Abstract:

Reviewers comment: "Include ethical approval details, participant demographics (age, gender distribution, and faculty representation), and specify whether participants were athletes or non-athletes.
Response: Included in the manuscript as suggested. (This cross-sectional study used an online survey distributed to University of Sharjah students via social media from February 16 to March 12, 2021, following ethical approval. The study participants were young adults aged 18 to 26. Due to the predominantly female demographic of the university student population and pandemic-related restrictions, gender and athletic status were not considered significant variables in this research.)

Reviewers comment: Report the mean and standard deviation of NDI scores, both overall and stratified by age groups.
Response: Included in the manuscript as suggested ("Participants who did not seek medical attention had significantly higher levels of neck pain disability, as measured by the NDI. The median NDI score for those who did not seek treatment was 20, with an interquartile range of 16.89. In contrast, the median NDI score for those who did seek medical attention was 34.00, with an interquartile range of 22.")

Reviewers comment: Provide information on neck pain severity using validated scales (e.g., VAS or NRS). Briefly describe the methodology for assessing factors affecting neck pain, including questionnaire design.
Response: Since our objective was to identify factors that are associated with the intensity of the neck pain rather than the intensity itself. The question in the questionnaire was added to get a subjective view of how participants express their neck pain intensity.

Reviewers comment: Clarify the NDI scoring system, as the current abstract reports values that exceed 100% (83.89 vs 125.80, p=0.002). In conclusion, justify the focus on the UAE and articulate the practical implications of this research.
Response: Thank you for bringing this to our notice. The mean rank was reported by mistake. Since the data is skewed in this question, the median and interquartile range were added. Justifications were added to the conclusion as requested.

Results:

Reviewers comment: "Address the inclusion of participants under 18 (n=10) and over 24 (n=2) years of age, as these fall outside the stated inclusion criteria. Consider removing these data points and reassessing the findings. Given the established pattern of increasing neck pain prevalence, consider adopting a more stringent significance level (p < 0.025). Provide a detailed explanation of the NDI scoring system and severity classification, citing relevant normative data. Elucidate the process for selecting neck pain-related factors during the pandemic. Report the results of pilot testing and tester reliability.
Response: Included as suggested. (NDI scores were found to be skewed. The median is 16% which indicates mild neck pain. The interquartile range is 19.11. Participants who did not seek medical attention had significantly higher levels of neck pain disability, as measured by the NDI. The median NDI score for those who did not seek treatment was 20, with an interquartile range of 16.89. In contrast, the median NDI score for those who did seek medical attention was 34.00, with an interquartile range of 22).

Reviewers comment: In Table 2, include mean and standard deviation for NDI scores.
Response: As stated earlier, the NDI scores were found to be skewed. The median and interquartile range were added to table 2.

Discussion:

Reviewers comment: "Revise the statement on 'rising prevalence' to reflect the cross-sectional nature of this study, acknowledging that trend analysis would require longitudinal data from multiple institutions.
Our response: Modified as in the manuscript as suggested (The observed prevalence of musculoskeletal pain, particularly neck pain, 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.)

Reviewers comment: Elaborate on the biomechanical and ergonomic factors contributing to prolonged poor posture among students. Reconsider the phrase 'new insight' regarding the importance of breaks for neck exercises, as this is a well-established principle in ergonomics and occupational health.
Our response: Modified in the manuscript as suggested (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. Biomechanical factors, such as repetitive strain on neck muscles from prolonged forward head posture (Goodarzi et al., 2018), and ergonomic factors, such as the use of poorly designed furniture and inadequate lighting (Eldho & Muthukumar, 2022; Meshram et al., 2021; Brewer, 2006), 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. 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. [50]. These interventions, when combined with neck exercises, can effectively alleviate NP and discomfort among students.)

Reviewers comment: Deepen the discussion by incorporating physiological, behavioral, biomechanical, and psychological perspectives when comparing results to existing literature. Enhance the practical implications section to provide clear, actionable recommendations based on the study findings."
Our response: Incorporated in the manuscript as suggested. (The 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. Biomechanical factors, 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 (McLean SM et al., 2010). Additionally, environmental factors, such as the physical layout of a workplace or the nature of tasks performed, can influence the likelihood of its occurrence (Kanchanomai et al., 2011; Razvi et al., 2018; Kalirathinam et al., 2017; Lee et al., 2018).Biomechanical factors, such as repetitive strain on neck muscles from prolonged forward head posture (Goodarzi et al., 2018), and ergonomic factors, such as the use of poorly designed furniture and inadequate lighting (Eldho & Muthukumar, 2022; Meshram et al., 2021; Brewer, 2006), 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. 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 (Pamela, L. 2009). Studies have linked high levels of mental stress among students to an increased risk of musculoskeletal disorders, such as low-back pain and neck pain (Lundberg U, et al., 2002). 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 (Birch et al., 2003), which can contribute to strain and discomfort in the neck, shoulders, and upper back.
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.)
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 04 Jul 2024

Tomas Nakazato, School of Medicine, Universidad de Piura, Lima Campus, Lima, Peru

Not Approved

https://doi.org/10.5256/f1000research.159890.r290876

The objective of the study is remarkably interesting and worthy, and I appreciate the effort the authors have put into this work; however, I have several observations and found many fundamental flaws.

Among the several observations and ... Continue reading

Authors do not use abbreviations as customary. For example, neck pain may be NC, to avoid repetition and to improve clarity and conciseness of the paper.
Some paragraphs are very short; they could be merged for better redaction.
Many references discuss musculoskeletal pain in general, rather than specifically focusing on neck pain (Ref. 9, 10, 11, 16, 17, 18, 19, 20), and not related to university students or the young population.

METHODS.

The study aims to measure the prevalence of neck pain among University of Sharjah (UOS) students during the online learning period for the COVID-19 pandemics and to investigate the factors that caused it. In our opinion, the method to obtain the prevalence was not appropriate, since the authors used a questionnaire posted online on different platforms (Facebook, WhatsApp, Instagram, and “others”). We do not know if the 'others' social media platforms are reliable to collect information.
As participants were volunteers, we consider that people with neck pain were more likely to participate than healthy individuals, increasing the sampling bias of neck pain conditions.
As researchers called their close friends and colleagues to participate, it may increase the response bias of the study.
There is no definition of 'neck pain': the main variable. There is a huge difference between acute and chronic neck pain, neck pain that radiates to the upper limb, neck pain that radiates to the head, etc. Acute neck pain usually resolves spontaneously and does not condition disability in most cases. Radiculopathic neck pain is very different from non-specific neck pain, and so on.
The target population was first defined as UoS students aged 18-24. Then, the inclusion criteria comprised all UoS students aged 17-24 studying at the Sharjah campus. Subsequently, in the results authors accounted that 98.15% were UoS students (so 1.85% were not UoS students? And if that was the case, why did the authors include these data?).
The authors used a self-administered questionnaire. The problem we see is that it consisted of a "modified" Neck Disability Index (NDI), adding additional questions to explore other factors associated with neck pain. We should be very careful if we modify standardized instruments to collect information. We do not know whether this modified NDI was validated. Furthermore, we do not know if it was administered in English or the official language of the UAE. There is a reference (23) on the validation of the Neck Disability Index in Serbian patients and another on the comparison of the NDI vs. other pain questionnaires (22), both of which do not clarify our doubts. These may result in improper answers from participants.
In the questionnaire, the authors try to explore the effects of neck pain on the anxiousness and depression of participants. In our opinion, we do not agree to explore complex conditions such as anxiousness and depression with two simple questions. If self-reported, these conditions should be explored with standardized questionnaires evaluating different aspects to conclude if the participant has some degree of anxiousness, anxiety and/or depression in the survey.
We checked the drawing to detect the location of the pain in the original questionnaire, which was different from that presented in the manuscript. In our view, the original drawing was not suitable for the appropriate location of neck pain by the participants.

RESULTS

For the reasons mentioned above, we have doubts about many of the results presented in this study. For example, it is very difficult for us to accept that nearly half of the participants experienced neck pain described as the 'worst pain imaginable' (47.43%), more than half of the participants ´could not concentrate at all´ (51.80%) or had 'completely disturbed sleep' (54.92%). These results mean that half of the students were unable to study or even function at all, which seems unrealistic to us. Furthermore, with that level of pain and disability reported, in our opinion, it is not conceivable that 91.48% of participants did not seek medical assistance (most individuals with that level of compromise should have sought at least an online medical consultation, according to our clinical practice). In addition, using the same logic, it is inconceivable that only 32.77% of cases tried to alleviate their pain.
“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”. To our knowledge, NDI does not measure anxiousness or depression. This modification was apparently made by the authors and should have been shown separately.
We believe that the figures are not presented properly. For example, we do not understand the criterion why Figures 2, 3, 4, and 5 are grouped separately with pie charts named A, B, and C. If results are part of a standardized questionnaire (NDI Score), graphics from this source of data should be presented as a whole (an individual figure with pie charts).

DISCUSSION

Discussion does not highlight the (several) limitations of the study. The only limitation presented was the recall bias.
The comparison of the prevalence of neck pain in this study with other countries is inaccurately presented.
Same observation as in the Introduction: Some paragraphs are short; they could be merged for better redaction.

CONCLUSION

The conclusion does not reflect the results of the study, but rather contains comments or opinions from the authors.

Statistical analysis and its interpretation:
Based on numerous observations, we deemed a review of statistical analysis and interpretation unnecessary at this time.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Physical Medicine and Rehabilitation. Musculoskeletal Pain.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Reviewer Report 25 May 2024

B.V. Murlimanju, Department of Anatomy, Kasturba Medical College , Manipal Academy of Higher Education, Manipal, Karnataka, India

Approved with Reservations

https://doi.org/10.5256/f1000research.159890.r275293

This manuscript is very interesting and offers a novel information to the scientific community. I could suggest only few changes.
1. The subheadings in the background/introduction could be removed.
2. The recent articles about the ergonomics of a university students can be cited.
3. Any details of the doctors consultation, radiographs, MRI neck taken, usage of cervical collar can be added in the results section.
4. If not advised/used, this can be mentioned.
5. The comparison between male and female need to be added.
6. The conclusion section to be included. This can be a reflection of the objectives.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Morphology, Clinical Anatomy, Neurosurgery

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Author Response 08 Nov 2024

Anu V, Basic Sciences, University of Sharjah, Sharjah, United Arab Emirates

08 Nov 2024

Author Response
1. Reviewers comment: The subheadings in the background/introduction could be removed.
  Our response: Removed as suggested
2. .Reviewers comment: The recent articles about the ergonomics of a university
... Continue reading
Reviewers comment: The subheadings in the background/introduction could be removed.
Our response: Removed as suggested

.Reviewers comment: The recent articles about the ergonomics of a university students can be cited.
Our response: Articles related to ergonomics of a university students are included in the manuscript as per the reviewer’s suggestion. (Enhancing student awareness of postural changes and risk factors, coupled with the implementation of ergonomic practices, can significantly mitigate musculoskeletal symptoms, including neck pain (Kilroy, et al., 2000; Bansode et al., 2016; Naik Prashant et al., 2017)).

Reviewers comment: Any details of the doctor’s consultation, radiographs, MRI neck taken, usage of cervical collar can be added in the results section. If not advised/used, this can be mentioned.
Our response: Mentioned in the manuscript as suggested (Since the study did not include information regarding the doctor's consultation, radiographs, MRI neck, or the use of a cervical collar, we have incorporated the same in the results section.

Reviewers comment: The comparison between male and female needs to be added.
Our response: Thank you for raising this important comment. We agree that a comparison between male and female students would have been necessary to investigate whether sex is a factor associated with the prevalence of neck pain and/or its intensity. Yet, as related to the context of this study, knowing that the majority of the student population at the University of Sharjah, from which the study sample was selected, includes females, thus the variation concerning sex distribution is minimal. Sex was not among the measured variables and therefore, conducting this comparison will not be possible at this point due to data anonymity. In response to the reviewer's comment, we have added a statement under the study limitations to reflect this gap. (Limitations: This study is subject to several limitations. Firstly, self-selection bias may have influenced the results, as individuals with neck pain may be more likely to participate in an online survey than those without symptoms. This could potentially contribute to the observed high prevalence of neck pain in the study population. Secondly, the targeted recruitment of University of Sharjah students, friends, and colleagues may have introduced response bias. Lastly, in this study, comparing the prevalence of neck pain between male and female students was not done due to the lack of sufficient diversity in the study population with respect to sex distribution. Therefore, we recommend future research to investigate this association.)

Reviewers comment: The conclusion section to be included. This can be a reflection of the objectives.
Our response: Included in the manuscript as suggested (This study highlights the significant prevalence of neck pain among University of Sharjah students during the COVID-19 pandemic. Prolonged electronic device use and poor posture were identified as primary causes. The findings underscore the need for preventive measures, including promoting proper posture, encouraging regular breaks, and providing educational resources. Further research is necessary to address this growing health concern.)
Reviewers comment: The subheadings in the background/introduction could be removed.
Our response: Removed as suggested

.Reviewers comment: The recent articles about the ergonomics of a university students can be cited.
Our response: Articles related to ergonomics of a university students are included in the manuscript as per the reviewer’s suggestion. (Enhancing student awareness of postural changes and risk factors, coupled with the implementation of ergonomic practices, can significantly mitigate musculoskeletal symptoms, including neck pain (Kilroy, et al., 2000; Bansode et al., 2016; Naik Prashant et al., 2017)).

Reviewers comment: Any details of the doctor’s consultation, radiographs, MRI neck taken, usage of cervical collar can be added in the results section. If not advised/used, this can be mentioned.
Our response: Mentioned in the manuscript as suggested (Since the study did not include information regarding the doctor's consultation, radiographs, MRI neck, or the use of a cervical collar, we have incorporated the same in the results section.

Reviewers comment: The comparison between male and female needs to be added.
Our response: Thank you for raising this important comment. We agree that a comparison between male and female students would have been necessary to investigate whether sex is a factor associated with the prevalence of neck pain and/or its intensity. Yet, as related to the context of this study, knowing that the majority of the student population at the University of Sharjah, from which the study sample was selected, includes females, thus the variation concerning sex distribution is minimal. Sex was not among the measured variables and therefore, conducting this comparison will not be possible at this point due to data anonymity. In response to the reviewer's comment, we have added a statement under the study limitations to reflect this gap. (Limitations: This study is subject to several limitations. Firstly, self-selection bias may have influenced the results, as individuals with neck pain may be more likely to participate in an online survey than those without symptoms. This could potentially contribute to the observed high prevalence of neck pain in the study population. Secondly, the targeted recruitment of University of Sharjah students, friends, and colleagues may have introduced response bias. Lastly, in this study, comparing the prevalence of neck pain between male and female students was not done due to the lack of sufficient diversity in the study population with respect to sex distribution. Therefore, we recommend future research to investigate this association.)

Reviewers comment: The conclusion section to be included. This can be a reflection of the objectives.
Our response: Included in the manuscript as suggested (This study highlights the significant prevalence of neck pain among University of Sharjah students during the COVID-19 pandemic. Prolonged electronic device use and poor posture were identified as primary causes. The findings underscore the need for preventive measures, including promoting proper posture, encouraging regular breaks, and providing educational resources. Further research is necessary to address this growing health concern.)
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 08 Nov 2024

Anu V, Basic Sciences, University of Sharjah, Sharjah, United Arab Emirates

08 Nov 2024

Author Response
1. Reviewers comment: The subheadings in the background/introduction could be removed.
  Our response: Removed as suggested
2. .Reviewers comment: The recent articles about the ergonomics of a university
... Continue reading
Reviewers comment: The subheadings in the background/introduction could be removed.
Our response: Removed as suggested

.Reviewers comment: The recent articles about the ergonomics of a university students can be cited.
Our response: Articles related to ergonomics of a university students are included in the manuscript as per the reviewer’s suggestion. (Enhancing student awareness of postural changes and risk factors, coupled with the implementation of ergonomic practices, can significantly mitigate musculoskeletal symptoms, including neck pain (Kilroy, et al., 2000; Bansode et al., 2016; Naik Prashant et al., 2017)).

Reviewers comment: Any details of the doctor’s consultation, radiographs, MRI neck taken, usage of cervical collar can be added in the results section. If not advised/used, this can be mentioned.
Our response: Mentioned in the manuscript as suggested (Since the study did not include information regarding the doctor's consultation, radiographs, MRI neck, or the use of a cervical collar, we have incorporated the same in the results section.

Reviewers comment: The comparison between male and female needs to be added.
Our response: Thank you for raising this important comment. We agree that a comparison between male and female students would have been necessary to investigate whether sex is a factor associated with the prevalence of neck pain and/or its intensity. Yet, as related to the context of this study, knowing that the majority of the student population at the University of Sharjah, from which the study sample was selected, includes females, thus the variation concerning sex distribution is minimal. Sex was not among the measured variables and therefore, conducting this comparison will not be possible at this point due to data anonymity. In response to the reviewer's comment, we have added a statement under the study limitations to reflect this gap. (Limitations: This study is subject to several limitations. Firstly, self-selection bias may have influenced the results, as individuals with neck pain may be more likely to participate in an online survey than those without symptoms. This could potentially contribute to the observed high prevalence of neck pain in the study population. Secondly, the targeted recruitment of University of Sharjah students, friends, and colleagues may have introduced response bias. Lastly, in this study, comparing the prevalence of neck pain between male and female students was not done due to the lack of sufficient diversity in the study population with respect to sex distribution. Therefore, we recommend future research to investigate this association.)

Reviewers comment: The conclusion section to be included. This can be a reflection of the objectives.
Our response: Included in the manuscript as suggested (This study highlights the significant prevalence of neck pain among University of Sharjah students during the COVID-19 pandemic. Prolonged electronic device use and poor posture were identified as primary causes. The findings underscore the need for preventive measures, including promoting proper posture, encouraging regular breaks, and providing educational resources. Further research is necessary to address this growing health concern.)
Reviewers comment: The subheadings in the background/introduction could be removed.
Our response: Removed as suggested

.Reviewers comment: The recent articles about the ergonomics of a university students can be cited.
Our response: Articles related to ergonomics of a university students are included in the manuscript as per the reviewer’s suggestion. (Enhancing student awareness of postural changes and risk factors, coupled with the implementation of ergonomic practices, can significantly mitigate musculoskeletal symptoms, including neck pain (Kilroy, et al., 2000; Bansode et al., 2016; Naik Prashant et al., 2017)).

Reviewers comment: Any details of the doctor’s consultation, radiographs, MRI neck taken, usage of cervical collar can be added in the results section. If not advised/used, this can be mentioned.
Our response: Mentioned in the manuscript as suggested (Since the study did not include information regarding the doctor's consultation, radiographs, MRI neck, or the use of a cervical collar, we have incorporated the same in the results section.

Reviewers comment: The comparison between male and female needs to be added.
Our response: Thank you for raising this important comment. We agree that a comparison between male and female students would have been necessary to investigate whether sex is a factor associated with the prevalence of neck pain and/or its intensity. Yet, as related to the context of this study, knowing that the majority of the student population at the University of Sharjah, from which the study sample was selected, includes females, thus the variation concerning sex distribution is minimal. Sex was not among the measured variables and therefore, conducting this comparison will not be possible at this point due to data anonymity. In response to the reviewer's comment, we have added a statement under the study limitations to reflect this gap. (Limitations: This study is subject to several limitations. Firstly, self-selection bias may have influenced the results, as individuals with neck pain may be more likely to participate in an online survey than those without symptoms. This could potentially contribute to the observed high prevalence of neck pain in the study population. Secondly, the targeted recruitment of University of Sharjah students, friends, and colleagues may have introduced response bias. Lastly, in this study, comparing the prevalence of neck pain between male and female students was not done due to the lack of sufficient diversity in the study population with respect to sex distribution. Therefore, we recommend future research to investigate this association.)

Reviewers comment: The conclusion section to be included. This can be a reflection of the objectives.
Our response: Included in the manuscript as suggested (This study highlights the significant prevalence of neck pain among University of Sharjah students during the COVID-19 pandemic. Prolonged electronic device use and poor posture were identified as primary causes. The findings underscore the need for preventive measures, including promoting proper posture, encouraging regular breaks, and providing educational resources. Further research is necessary to address this growing health concern.)
Competing Interests: No competing interests were disclosed. Close
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VERSION 2 PUBLISHED 22 Apr 2024

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B.V. Murlimanju, Kasturba Medical College , Manipal Academy of Higher Education, Manipal, India
Tomas Nakazato, Universidad de Piura, Lima Campus, Peru
Fairus Fariza Zainudin, Universiti Pendidikan Sultan Idris, Tanjong Malim, Malaysia

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12 Dec 2024 | for Version 2

Fairus Fariza Zainudin, Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia

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Approved

Accepted the feedback from authors.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

injury pattern and profiling, sports rehabilitation, musculoskeletal pain, sports concussion, Cardiopulmonary resuscitation education.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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12 Nov 2024 | for Version 2

B.V. Murlimanju, Department of Anatomy, Kasturba Medical College , Manipal Academy of Higher Education, Manipal, Karnataka, India

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Approved

Dear Editor,
The authors have revised the manuscript as per the comments. There are few comments which were not addressed, however they are listed now as the limitations of this study. The changes performed and the scientific contents of this article merit indexing of this article.

Competing Interests

No competing interests were disclosed.

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Morphology, Clinical Anatomy, Neurosurgery

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22 Jul 2024 | for Version 1

Fairus Fariza Zainudin, Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia

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Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

injury pattern and profiling, sports rehabilitation, musculoskeletal pain, sports concussion, Cardiopulmonary resuscitation education.

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Author Response

08 Nov 2024

Anu V, Basic Sciences, University of Sharjah, Sharjah, United Arab Emirates

Abstract:

Reviewers comment: "Include ethical approval details, participant demographics (age, gender distribution, and faculty representation), and specify whether participants were athletes or non-athletes.
Response: Included in the manuscript as suggested. (This cross-sectional study used an online survey distributed to University of Sharjah students via social media from February 16 to March 12, 2021, following ethical approval. The study participants were young adults aged 18 to 26. Due to the predominantly female demographic of the university student population and pandemic-related restrictions, gender and athletic status were not considered significant variables in this research.)
Reviewers comment: Report the mean and standard deviation of NDI scores, both overall and stratified by age groups.
Response: Included in the manuscript as suggested ("Participants who did not seek medical attention had significantly higher levels of neck pain disability, as measured by the NDI. The median NDI score for those who did not seek treatment was 20, with an interquartile range of 16.89. In contrast, the median NDI score for those who did seek medical attention was 34.00, with an interquartile range of 22.")
Reviewers comment: Provide information on neck pain severity using validated scales (e.g., VAS or NRS). Briefly describe the methodology for assessing factors affecting neck pain, including questionnaire design.
Response: Since our objective was to identify factors that are associated with the intensity of the neck pain rather than the intensity itself. The question in the questionnaire was added to get a subjective view of how participants express their neck pain intensity.
Reviewers comment: Clarify the NDI scoring system, as the current abstract reports values that exceed 100% (83.89 vs 125.80, p=0.002). In conclusion, justify the focus on the UAE and articulate the practical implications of this research.
Response: Thank you for bringing this to our notice. The mean rank was reported by mistake. Since the data is skewed in this question, the median and interquartile range were added. Justifications were added to the conclusion as requested.

Results:

Reviewers comment: "Address the inclusion of participants under 18 (n=10) and over 24 (n=2) years of age, as these fall outside the stated inclusion criteria. Consider removing these data points and reassessing the findings. Given the established pattern of increasing neck pain prevalence, consider adopting a more stringent significance level (p < 0.025). Provide a detailed explanation of the NDI scoring system and severity classification, citing relevant normative data. Elucidate the process for selecting neck pain-related factors during the pandemic. Report the results of pilot testing and tester reliability.
Response: Included as suggested. (NDI scores were found to be skewed. The median is 16% which indicates mild neck pain. The interquartile range is 19.11. Participants who did not seek medical attention had significantly higher levels of neck pain disability, as measured by the NDI. The median NDI score for those who did not seek treatment was 20, with an interquartile range of 16.89. In contrast, the median NDI score for those who did seek medical attention was 34.00, with an interquartile range of 22).
Reviewers comment: In Table 2, include mean and standard deviation for NDI scores.
Response: As stated earlier, the NDI scores were found to be skewed. The median and interquartile range were added to table 2.

Discussion:

Reviewers comment: "Revise the statement on 'rising prevalence' to reflect the cross-sectional nature of this study, acknowledging that trend analysis would require longitudinal data from multiple institutions.
Our response: Modified as in the manuscript as suggested (The observed prevalence of musculoskeletal pain, particularly neck pain, 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.)
Reviewers comment: Elaborate on the biomechanical and ergonomic factors contributing to prolonged poor posture among students. Reconsider the phrase 'new insight' regarding the importance of breaks for neck exercises, as this is a well-established principle in ergonomics and occupational health.
Our response: Modified in the manuscript as suggested (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. Biomechanical factors, such as repetitive strain on neck muscles from prolonged forward head posture (Goodarzi et al., 2018), and ergonomic factors, such as the use of poorly designed furniture and inadequate lighting (Eldho & Muthukumar, 2022; Meshram et al., 2021; Brewer, 2006), 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. 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. [50]. These interventions, when combined with neck exercises, can effectively alleviate NP and discomfort among students.)
Reviewers comment: Deepen the discussion by incorporating physiological, behavioral, biomechanical, and psychological perspectives when comparing results to existing literature. Enhance the practical implications section to provide clear, actionable recommendations based on the study findings."
Our response: Incorporated in the manuscript as suggested. (The 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. Biomechanical factors, 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 (McLean SM et al., 2010). Additionally, environmental factors, such as the physical layout of a workplace or the nature of tasks performed, can influence the likelihood of its occurrence (Kanchanomai et al., 2011; Razvi et al., 2018; Kalirathinam et al., 2017; Lee et al., 2018).Biomechanical factors, such as repetitive strain on neck muscles from prolonged forward head posture (Goodarzi et al., 2018), and ergonomic factors, such as the use of poorly designed furniture and inadequate lighting (Eldho & Muthukumar, 2022; Meshram et al., 2021; Brewer, 2006), 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. 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 (Pamela, L. 2009). Studies have linked high levels of mental stress among students to an increased risk of musculoskeletal disorders, such as low-back pain and neck pain (Lundberg U, et al., 2002). 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 (Birch et al., 2003), which can contribute to strain and discomfort in the neck, shoulders, and upper back.
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.)

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No competing interests were disclosed.

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Reviewer Report

10 Views

04 Jul 2024 | for Version 1

Tomas Nakazato, School of Medicine, Universidad de Piura, Lima Campus, Lima, Peru

10 Views Cite this report Responses(0)

Not Approved

Authors do not use abbreviations as customary. For example, neck pain may be NC, to avoid repetition and to improve clarity and conciseness of the paper.
Some paragraphs are very short; they could be merged for better redaction.
Many references discuss musculoskeletal pain in general, rather than specifically focusing on neck pain (Ref. 9, 10, 11, 16, 17, 18, 19, 20), and not related to university students or the young population.

METHODS.

The study aims to measure the prevalence of neck pain among University of Sharjah (UOS) students during the online learning period for the COVID-19 pandemics and to investigate the factors that caused it. In our opinion, the method to obtain the prevalence was not appropriate, since the authors used a questionnaire posted online on different platforms (Facebook, WhatsApp, Instagram, and “others”). We do not know if the 'others' social media platforms are reliable to collect information.
As participants were volunteers, we consider that people with neck pain were more likely to participate than healthy individuals, increasing the sampling bias of neck pain conditions.
As researchers called their close friends and colleagues to participate, it may increase the response bias of the study.
There is no definition of 'neck pain': the main variable. There is a huge difference between acute and chronic neck pain, neck pain that radiates to the upper limb, neck pain that radiates to the head, etc. Acute neck pain usually resolves spontaneously and does not condition disability in most cases. Radiculopathic neck pain is very different from non-specific neck pain, and so on.
The target population was first defined as UoS students aged 18-24. Then, the inclusion criteria comprised all UoS students aged 17-24 studying at the Sharjah campus. Subsequently, in the results authors accounted that 98.15% were UoS students (so 1.85% were not UoS students? And if that was the case, why did the authors include these data?).
The authors used a self-administered questionnaire. The problem we see is that it consisted of a "modified" Neck Disability Index (NDI), adding additional questions to explore other factors associated with neck pain. We should be very careful if we modify standardized instruments to collect information. We do not know whether this modified NDI was validated. Furthermore, we do not know if it was administered in English or the official language of the UAE. There is a reference (23) on the validation of the Neck Disability Index in Serbian patients and another on the comparison of the NDI vs. other pain questionnaires (22), both of which do not clarify our doubts. These may result in improper answers from participants.
In the questionnaire, the authors try to explore the effects of neck pain on the anxiousness and depression of participants. In our opinion, we do not agree to explore complex conditions such as anxiousness and depression with two simple questions. If self-reported, these conditions should be explored with standardized questionnaires evaluating different aspects to conclude if the participant has some degree of anxiousness, anxiety and/or depression in the survey.
We checked the drawing to detect the location of the pain in the original questionnaire, which was different from that presented in the manuscript. In our view, the original drawing was not suitable for the appropriate location of neck pain by the participants.

RESULTS

For the reasons mentioned above, we have doubts about many of the results presented in this study. For example, it is very difficult for us to accept that nearly half of the participants experienced neck pain described as the 'worst pain imaginable' (47.43%), more than half of the participants ´could not concentrate at all´ (51.80%) or had 'completely disturbed sleep' (54.92%). These results mean that half of the students were unable to study or even function at all, which seems unrealistic to us. Furthermore, with that level of pain and disability reported, in our opinion, it is not conceivable that 91.48% of participants did not seek medical assistance (most individuals with that level of compromise should have sought at least an online medical consultation, according to our clinical practice). In addition, using the same logic, it is inconceivable that only 32.77% of cases tried to alleviate their pain.
“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”. To our knowledge, NDI does not measure anxiousness or depression. This modification was apparently made by the authors and should have been shown separately.
We believe that the figures are not presented properly. For example, we do not understand the criterion why Figures 2, 3, 4, and 5 are grouped separately with pie charts named A, B, and C. If results are part of a standardized questionnaire (NDI Score), graphics from this source of data should be presented as a whole (an individual figure with pie charts).

DISCUSSION

Discussion does not highlight the (several) limitations of the study. The only limitation presented was the recall bias.
The comparison of the prevalence of neck pain in this study with other countries is inaccurately presented.
Same observation as in the Introduction: Some paragraphs are short; they could be merged for better redaction.

CONCLUSION

The conclusion does not reflect the results of the study, but rather contains comments or opinions from the authors.

Statistical analysis and its interpretation:
Based on numerous observations, we deemed a review of statistical analysis and interpretation unnecessary at this time.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Physical Medicine and Rehabilitation. Musculoskeletal Pain.

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Reviewer Report

14 Views

25 May 2024 | for Version 1

B.V. Murlimanju, Department of Anatomy, Kasturba Medical College , Manipal Academy of Higher Education, Manipal, Karnataka, India

14 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Morphology, Clinical Anatomy, Neurosurgery

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Author Response

08 Nov 2024

Anu V, Basic Sciences, University of Sharjah, Sharjah, United Arab Emirates

Reviewers comment: The subheadings in the background/introduction could be removed.
Our response: Removed as suggested
.Reviewers comment: The recent articles about the ergonomics of a university students can be cited.
Our response: Articles related to ergonomics of a university students are included in the manuscript as per the reviewer’s suggestion. (Enhancing student awareness of postural changes and risk factors, coupled with the implementation of ergonomic practices, can significantly mitigate musculoskeletal symptoms, including neck pain (Kilroy, et al., 2000; Bansode et al., 2016; Naik Prashant et al., 2017)).
Reviewers comment: Any details of the doctor’s consultation, radiographs, MRI neck taken, usage of cervical collar can be added in the results section. If not advised/used, this can be mentioned.
Our response: Mentioned in the manuscript as suggested (Since the study did not include information regarding the doctor's consultation, radiographs, MRI neck, or the use of a cervical collar, we have incorporated the same in the results section.
Reviewers comment: The comparison between male and female needs to be added.
Our response: Thank you for raising this important comment. We agree that a comparison between male and female students would have been necessary to investigate whether sex is a factor associated with the prevalence of neck pain and/or its intensity. Yet, as related to the context of this study, knowing that the majority of the student population at the University of Sharjah, from which the study sample was selected, includes females, thus the variation concerning sex distribution is minimal. Sex was not among the measured variables and therefore, conducting this comparison will not be possible at this point due to data anonymity. In response to the reviewer's comment, we have added a statement under the study limitations to reflect this gap. (Limitations: This study is subject to several limitations. Firstly, self-selection bias may have influenced the results, as individuals with neck pain may be more likely to participate in an online survey than those without symptoms. This could potentially contribute to the observed high prevalence of neck pain in the study population. Secondly, the targeted recruitment of University of Sharjah students, friends, and colleagues may have introduced response bias. Lastly, in this study, comparing the prevalence of neck pain between male and female students was not done due to the lack of sufficient diversity in the study population with respect to sex distribution. Therefore, we recommend future research to investigate this association.)
Reviewers comment: The conclusion section to be included. This can be a reflection of the objectives.
Our response: Included in the manuscript as suggested (This study highlights the significant prevalence of neck pain among University of Sharjah students during the COVID-19 pandemic. Prolonged electronic device use and poor posture were identified as primary causes. The findings underscore the need for preventive measures, including promoting proper posture, encouraging regular breaks, and providing educational resources. Further research is necessary to address this growing health concern.)

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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

Abstract

Objective

Methods

Results

Conclusion

Keywords

Introduction

Rationale

Significance

Objectives

Methods

Design, population, sampling method and sample size

Inclusion criteria

Exclusion criteria

Data collection

Data analysis

Ethical consideration

Results

Table 1. Participants age groups and locations.

Table 2. Neck disability index scores.

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

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.

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.

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

Discussion

Ethics approval and consent to participate

Consent for publication

Authors’ contribution

Data availability statement

Acknowledgment

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