Prevalence and risk factors associated with spinal pain in adolescent computer users: a systematic review

Abstract

Review question/objective The questions that will guide the systematic review are: What is the evidence on the estimates of the prevalence of spinal pain in adolescent computer users? What is the evidence on identification of risk factors associated with the spinal pain among adolescent computer users? Background Musculoskeletal discomfort, such as neck and back pain, is common in the general population.1-3 More than 50% of adults reported that they experience at least one episode of neck or back pain during their lifetime.3 Although less common, adolescents are not exempted from spinal pain. A national survey study in Finland4 reported that 12-45% of adolescents experienced neck and shoulder pain and 7-17% had back pain. Similar results were reported in US5, 6 and Netherlands7. However, the prevalence of spinal pain appears to be higher in Asian.8, 9 In Taiwan, 59% of high school students had neck pain and 44% had back pain.9 Most studies investigating spinal pain have focused on adults and the working population, and few address this problem in adolescents.3 A concerning issue raised by the Finnish survey4 is that the prevalence of neck and back pain in adolescents has rapidly increased in the late 1990s and the beginning of 2000. In that study, the researchers suggested that the increase in computer use might have contributed to the increase in musculoskeletal pain. As some studies demonstrated that neck and back pain in adolescents were likely to be associated with adulthood spinal pain.10, 11 The socio-economic burden of spinal pain and associated impaired physical function are expected to grow enormously in the future. Therefore, it is critical to understand the prevalence and risk factors of spinal pain in adolescent computer users, and to develop evidence-based preventative and treatment strategies for this population.12 Computer and information technology are becoming an important part of everyday life. Nowadays, adolescents are exposed to computer at a much earlier age than their parents. Many children learn to play educational games on the computer before they even attend the primary school. Adolescents use computer at school for education but also at home for entertainment and communication. Studies reported that, on the average, adolescents spent approximately 1.25-3.2 hours per day using computer.6, 12-14 The duration of computer use15, 16 is one of the frequently identified risk factors for the development of spinal pain among adolescents. During prolonged use of computer, static postures of the head, neck and trunk could cause excessive loading on certain muscles and joints, which may lead to musculoskeletal discomfort. Hakala et al15 reported that adolescents whose daily use of computers exceeded 2-3 and 5 hours had a higher risk of developing neck and back pain, respectively. However, Diepenmaat et al7 found that increased computer use was not associated with musculoskeletal discomfort. This difference may be due to different time frames of the question and different definitions of neck or back pain used in the studies. Inconsistent findings were also present in the association between posture assumed at the computer workstation and musculoskeletal discomfort.5, 16, 17 The furniture (chair and desk) or equipment (keyboard and mouse) of the computer workstation is often designed to accommodate the anthropometric measurement of adults. The lack of adjustable features and the inappropriate layout of the computer workstation forces adolescents to place their own body in an awkward position when using the computer. As a result, it may lead to musculoskeletal discomfort. However, while a three-year longitudinal survey found that that the better contour of the chair backrest and the appropriate seat height (allowing the student's feet flat on the floor) were significantly correlated to the lower prevalence of self-reported discomfort among middle school students,16 the finding of an observational study did not support such an association.17 This may be explained by the difference in postural measurement. However, these conflicted findings could cause great confusion for parents, teachers and clinicians directly involving in the care of children and adolescents, who often have ineffective self-management of discomfort and pain. Numerous risk factors have also be proposed or identified in the literature that may lead to musculoskeletal discomfort in adolescent computer users. These factors include physical factors (high body mass index, decreased joint range of motion, and decreased muscle strength), behaviour factors (sedentary lifestyle and ineffective pain management) and psychological factors (depression and stress).7, 16 In an unpublished mater thesis,18 a systematic review was conducted to assess the impact of computer exposure on musculoskeletal discomfort in children and adolescents. The prevalence of general musculoskeletal discomfort was found to range from 27% to 60%, and only three of the review studies identified the duration of computer use as a risk factor for musculoskeletal discomfort. There are some methodological problem and limitation in that review. First of all, only a small number (3 out of 12) of the review studies were critically appraised by two independent reviewers, and the rest of the review studies were appraised by only one reviewer. This might have introduced some bias in assessment of methodological quality of the study. Secondary, that review did not search unpublished studies, and was limited to English articles dated from 1998 to 2006. A more recent systematic review19 also evaluated the evidence of contributing factors for musculoskeletal pain in children and adolescents. However, this recent review only focused on posture and psychosocial factors and limited to musculoskeletal pain in the upper quadrant. Without considering other possible factors related to computer exposure, such as the habit of computer use, the computer workstation and environment, it is not possible to gain a more thorough understanding of spinal discomfort in adolescent computer users. Therefore, the overall objective of this review will be to evaluate the available literature on the prevalence of and risk factors associated with spinal discomfort in adolescent computer users. For this systematic review, adolescent computer users will be defined as those who use computer at school and/or home for more than 30 minutes per week.20 Spinal pain will be defined as symptoms of soreness, aching, tingling, numbness or discomfort pertaining to the skeleton and muscles21, 22 in the cervical, thoracic or lumbar spine regions within the last year, but not related to trauma or scoliosis.23 Inclusion Criteria Types of participants This review will consider studies that include adolescents aged 13-18 years who use computer at school and/or home and have no musculoskeletal injuries or scoliosis. Types of exposures All studies evaluating the exposure to computer use at school and/or home for more than 30 minutes per week will be considered for inclusion in the review. In order to include all ranges of studies regarding to spinal pain among adolescent computer users, co-exposure to other human/ergonomic factors, such as chair and furniture design, will not be considered in the stage of literature search but will be classified afterwards if needed. Types of outcomes This review will consider studies that report prevalence and/or risk factors associated with spinal pain and the relation to computer use. The classification of spinal pain in terms of body areas affected will also be assessed. Types of studies This review will consider any cross-sectional, case-control, or cohort studies that report either prevalence or risk factors associated with spinal pain in adolescent computer users. Experimental, case series or single case studies will not be included in this review. Search strategy The search strategy aims to find both published and unpublished studies. The search will be limited to English and Chinese language reports. All available years will be searched for each database. A three-step search strategy will be utilized in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched will include the Cochrane Library, JBI Systematic Review Library, PEDro, PubMed, CINAHL, ISI Web of Science, ERIC, Science Direct, PsychINFO, Proquest, Expanded Academic ASAP, EMBASE, BioMed Central, and CEPS. The search for unpublished studies will include ProQuest Dissertations & Theses, National Digital Library of Theses and Dissertations in Taiwan, and conference proceedings (International conference on applied human factors and ergonomics, world congress of ergonomics). Initial search strings to be used will be: (adolescent* or schoolchild* or student* or learner*) AND (computer* or information technolog* or technology) AND (spine or back or neck) AND (pain or discomfort or back pain or musculoskeletal disorder* or dysfunction or symptoms or cumulative trauma disorder*) AND (causality or cohort stud* or cross-sectional stud* or epidemiolog* or epidemiologic factor* or follow-up study or incidence or incidence studies or prevalence or prevalence studies or prospective studies or risk or risk factor or survey). Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (see Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (see Appendix II). The following data will be extracted: study population including ethnicity, participant numbers, gender, and age; mode of spinal pain data collection; location of computer use; operational definition of spinal pain; prevalence of spinal pain as percentages; correlations/associations investigated; measurement of association used (odds ratio, relative risk, prevalence odds ratio etc); statistical tests used. Data synthesis Quantitative papers will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Conflicts of interest No conflict of interest can be reported at this time.