Introduction:
The adolescent stage of life undergoes a lot of changes in the physical and mental health with musculoskeletal pain symptoms being one of the common conditions. These symptoms when neglected become a major contributor in the development of musculoskeletal disorders in adulthood.(1) Studies in recent times have shown an increasing prevalence of musculoskeletal pain among adolescents.(2,3) The psychological symptoms, prolonged use of smartphones, watching television for longer duration and lack of physical activity are considered risk factors in the development of musculoskeletal pain.(4-6) The aetiology of musculoskeletal pain in adolescents is multi-factorial.(7)
A study conducted on the Norwegian youth population suggested that multisite adolescent musculoskeletal pain was significantly associated with mental health disorders. Anxiety and mood disorders were risk factors in both genders.(4) An Australian study highlighted the psychosomatic components in children and adolescents having chronic nonspecific musculoskeletal pains. It revealed that those having increased levels of anxiety and depression had more complaints of somatic pain.(8)
Sedentary lifestyle and physical inactivity are considered major contributors to most chronic diseases.(9) High prevalence of low back pain among children and adolescents was found in females, adolescents and those with longer duration of watching TV (television) in a study done in Brazil.(10) It is quite evident that the number of smartphone users among adolescent school children has outgrown dramatically.(11) The study done in South Korea revealed that there is a significant relationship between smartphone use and musculoskeletal discomfort.(12) The number of hours consumed speaking on the phone was a predictor of upper back discomfort. The users tend to develop uncomfortable postures while using smartphones which leads to musculoskeletal disorders. World Health Organization has emphasized on moderate to vigorous level physical activity for 60-90 minutes for adolescents.(13) A study describing the physical activity levels for adults (15 years or older) from 122 countries and adolescents (13-15-years-old) from 105 countries found that the proportion of 13-15-year-old were doing less physical activity than the recommended guidelines.(14)
The present study is a sincere attempt to understand the prevalence of musculoskeletal pain and its association with various factors such as gender, age, psychological health (stress, anxiety, and depression), sedentary behaviour (time spent on smartphone and watching television) and physical activity among school-going adolescents in the urban area of Delhi.
Materials and Methods:
Study setting
This study was carried out between April 2018 to March 2019 after getting approval from the Human Ethics Committee of All India Institute of Medical Sciences, New Delhi. Although there are 1030 Government schools but the Directorate of Education, Government of National Capital Territory of Delhi granted permission to conduct the study in 101 schools in estimated population size of 758611 students. It was found that 23 schools were co-educational and 10 schools agreed to participate in the study where the estimated population size was 7511.
In this observational, cross-sectional study the adolescent school students between 10–19 years were included. Previously diagnosed pathological conditions related to musculoskeletal and mental disorders were excluded. The informed consent forms were duly signed by the parents/guardians of the students.
Data Collection
2083 students were eligible and gave consent to participate in the study but only 1600 (76%) students were selected by the “Random number generator software”. The sample size was estimated from a referenced study (15) considering the prevalence of 20% with an allowable error of 10% and 95% confidence interval. Each student was given 20 minutes to fill predesigned proforma which included demographic details, NMQ (Nordic Musculoskeletal Questionnaire)(16), DASS-21 (Depression, Anxiety and Stress Scale) Questionnaire(17), YPAQ (Youth Physical Activity Questionnaire)(18) and modified SBQ (Sedentary Behaviour Questionnaire comprising 2 item questionnaires about the duration of using smartphone and watching television).(19)
Study tools and study variables
The detailed demographic details were recorded on predesigned proforma. The weight and height of students was measured using a stadiometer and weighing scale. Nordic Musculoskeletal and Depression Anxiety Stress Scale 21 questionnaire was administered. The youth physical activity screening questionnaire developed by the Medical Research Council Epidemiology Unit; University of Cambridge was administered after validation. The YPAQ was used as a screening tool in this study to define mild, moderate and vigorous physical activity.(20) The mild physical activities included either playing indoor with toys, household work, doing homework, playing board games, sitting talking, listening to music, art and craftwork. The moderate and vigorous level physical activity included either playing football, cricket, hockey, swimming, skipping ropes, travel walking to school, travel cycling to school, physical activity classes at school and its duration performed per day were enquired from the study participants.
The sedentary behaviour questionnaire(10,19) was administered after validation in our study. The following questions were included in a sedentary behaviour questionnaire:
- In a normal school week do you watch TV? (Yes No).
- In a normal school week, how often do you watch TV? (Once, twice, three times, four times, five times or more per week).
- On a normal school day, how many hours do you watch TV? (Less than one hour, two hours, three hours, four hours, five hours or more per day).
- In a normal school week, how often do you use a smartphone at home? (Once, twice, three times, four times, five times or more per week).
- On a normal school day, how many hours do you use smartphones at home? (Less than one hour, two hours, three hours, four hours, five hours or more per day).
Statistical analysis
The data collected from participants were entered into excel and subjected to statistical analysis using Stata Version 14 (Stata Corp. 2015. Stata Statistical Software: Release 14. College Station, TX: Stata Corp LP). The descriptive analysis was done to evaluate the characteristics of the students.
The prevalence of musculoskeletal pain was determined. Stress, anxiety, depression, duration of time spent on TV, smartphone, and moderate to vigorous level of physical activity was considered independent variable and musculoskeletal pain reported in the past 12 months and 7 days was considered as a dependent variable. The Chi-square (Χ2) analysis was done to analyse the association between two variables. Univariate logistic regression was used to calculate the odds ratio for studied risk factors associated with musculoskeletal pain. The multivariate logistic regression model was applied to avoid the confounding effect amongst various risk factors of musculoskeletal pain. The p-value < 0.05 was considered statistically significant.
Results
Sample characteristics
Out of the 1600 adolescent students, 855 (53%) were males and 745 (47%) were females of age group 10-19 years with mean age of boys as 13.6±2 years and girls as 13.4±2 years. The height and weight for males were 148.7 ± 10.0 cm and 39.43 ± 9.16 Kg and for females were 147.9 ± 9.0 cm and 42.57±12.45 Kg respectively. The BMI calculated among boys and girls was 17.58 ± 3.71 and 17.83 ± 3.20 respectively. The characteristics of the participants are mentioned in Table 1.
| Table 1: Characteristics and distribution of frequencies of gender, adolescent age, nutritional status, stress, anxiety, depression, physical activity and sedentary behaviours among studied population. |
|
Response |
Total Participants
=1600 n (%) |
No. of Males =855 n (%) |
No. of Females
=745 n (%) |
Age |
Early adolescent |
1107 (69%) |
574 (67.1%) |
533 (71.5%) |
Late adolescent |
493 (31%) |
281 (32.8%) |
212 (28.4%) |
Nutritional status |
Normal |
457 (28%) |
213 (13%) |
244 (15%) |
Underweight |
1089 (68%) |
608 (38%) |
481 (30%) |
Overweight |
48 (3%) |
31 (1.9%) |
17 (1%) |
Obese |
6 (0.37%) |
3 (0.1%) |
3 (0.1%) |
Stress |
Normal |
1305(81.5%) |
750(87.7%) |
555 (74.4%) |
Yes |
295 (18.4%) |
105(12.2%) |
190 (25.5%) |
Anxiety |
Normal |
1191(74.4%) |
706(82.5%) |
485 (65.1%) |
Yes |
409 (25.5%) |
149(17.4%) |
260 (34.8%) |
Depression |
Normal |
1325(82.8%) |
758(88.6%) |
567 (76.1%) |
Yes |
275 (17.1%) |
97 (11.3%) |
178 (23.8%) |
Duration of Moderate & Vigorous Physical activity (60-90 mins per day) |
No |
913 (57%) |
478(55.9%) |
435 (58.3%) |
Yes |
687 (42%) |
377(44.0%) |
310 (41.6%) |
Watches television
|
No |
200 (12%) |
108 (12.6%) |
92 (12.3%) |
Yes |
1400 (87%) |
747 (87.3%) |
653 (87.6%) |
No. of times in a week |
Once |
173 (10%) |
114 (13.3%) |
59 (7.9%) |
Twice |
171 (10 %) |
101 (11.8%) |
70 (9.3%) |
Three times |
90 (5%) |
63 (73.6%) |
27 (3.6%) |
Four times |
54 (3%) |
38 (44.4%) |
16 (2.1%) |
Five times or more per week |
912 (57%) |
431 (50.4%) |
481 (64.5%) |
No of hours in a day |
Less than one hour |
563 (35%) |
328 (38.3%) |
235 (31.5%) |
Two hours |
534 (33%) |
244 (28.5%) |
290 (38.9%) |
Three hours |
101 (6%) |
60 (7%) |
41 (5.5%) |
Four hours |
35 (2%) |
18 (2.1%) |
17 (2.2%) |
Five hours or more per day |
167 (10%) |
97 (11.3%) |
70 (9.3%) |
Uses Smart Phones |
No |
346 (21%) |
132 (15.4%) |
214 (28.7%) |
Yes |
1254 (78%) |
723 (84.5%) |
531 (71.2%) |
No. of times in a week |
Once |
158 (9%) |
98 (11.4%) |
60 (8.0%) |
Twice |
119 (7%) |
72 (8.4%) |
47 (6.3%) |
Three times |
65 (4%) |
46 (5.3%) |
19 (2.5%) |
Four times |
38 (2%) |
26 (3.0%) |
12 (1.6%) |
Five times or more per week |
874 (54%) |
481 (56.2%) |
393 (52.7%) |
No of hours in a day |
Less than one hour |
468 (29%) |
322 (37.6%) |
146 (19.5%) |
Two hours |
315 (19%) |
249 (29.1%) |
66 (8.8%) |
Three hours |
41 (2%) |
31 (3.6%) |
10 (1.3%) |
Four hours |
15 (0.9%) |
12 (1.2%) |
3 (0.4%) |
Five hours or more per day |
160 (10%) |
98 (11.4%) |
62 (8.3%) |
It was observed that 1089 (68%) participants were underweight. As per the DASS-21 questionnaire, the scores of 1305 (81.5%) participants in domains of stress, anxiety and depression were normal. 200 (12%) participants did not watch television and 346 (21%) did not use smartphones as these electronic gadgets were not available in their homes. 411 (25%) participants did physical activity less than 60 minutes and they had no interest in games involving moderate to vigorous physical activity.
Prevalence of musculoskeletal pain
The prevalence of musculoskeletal pain was 55.2% in the past 12 months, 46.6% in the past 7 days. The pain prevalence at least in one part of the body was present among 63% at 95% CI (55-70) in the past 12 months and 7 days (Figure 1).
 |
Figure 1 : Prevalence of pain as per the site defined in Nordic Musculoskeletal Questionnaire in past 12 months and 7 days among adolescents. |
The lower back was the most common site of musculoskeletal pain which was 32% at 95% CI (23-41) followed by shoulder pain 11% at 95% CI (6-19) in the past 12 months. However, in the past 7 days the common site of pain remained as low back pain {31% at 95% CI (28-34)} which was followed by knee pain {7% at 95% CI (3-12)}.
Risk factors for musculoskeletal pain
Musculoskeletal pain was associated with the female gender, late adolescence stage, stress, anxiety, depression, duration of moderate and vigorous level physical activity, duration of watching TV and smartphone usage in Chi-square (Χ2) analysis (Table 2).
Table 2: Factors associated with musculoskeletal pain |
Variables |
Pain |
No Pain |
Χ2 P value |
Gender |
Male |
489 (57.19%) |
366 (42.81%) |
Χ2=29.60; p=<0.0001* |
Female |
524 (70.34%) |
221 (29.66%) |
Age |
10-14 years |
279 (56.70%) |
213 (43.29%) |
Χ2=12.92; p=<0.0001* |
15-19 years |
733 (66.15%) |
375 (33.80%) |
Nutritional status |
Normal |
275(60.18%) |
182 (39.82%) |
Χ2=4.23; p=0.238 |
Underweight |
699 (64.19%) |
390 (35.81%) |
Overweight |
35 (72.92%) |
13 (27.08%) |
Obese |
4 (66.67%) |
2 (33.33%) |
Stress |
No |
810 (62.12%) |
494 (37.88%) |
Χ2=4.34; p=0.037* |
Yes |
203 (68.58%) |
93 (31.42%) |
Anxiety |
No |
736 (61.80%) |
455 (38.20%) |
Χ2=4.60; p=0.032* |
Yes |
277 (67.73%) |
132 (32.27%) |
Depression |
No |
825 (62.26%) |
500 (37.74%) |
Χ2=3.64; p=0.056* |
Yes |
188 (68.36%) |
87 (31.64%) |
Duration of Moderate & Vigorous Physical activity (60-90 mins per day) |
Yes |
476 (69.29%) |
211 (30.71%) |
Χ2=18.49; p=<0.0001* |
No |
537 (58.82%) |
376 (41.18%) |
Duration of watching TV |
= 5 days a week = 1hour |
333 (65.94%) |
172 (34.06%) |
Χ2=6.85; p=0.033* |
=5 days a week =2 hours |
360 (65.22%) |
192 (34.78%) |
= Once-four times a week & = 2hours |
320 (58.93%) |
223 (41.07%) |
Duration of smart phone usage |
= 5 days a week = 1hour |
217 (71.62%) |
86 (28.38%) |
Χ2=23.36; p=<0.0001* |
= 5 days a week =2 hours |
290 (68.08%) |
136 (31.92%) |
= Once-four times a week & = 2hours |
506 (58.09%) |
365 (41.91%) |
*p<0.05 |
On applying univariate regression analysis female gender, late adolescent age, duration of physical activity level, screen time spent on TV and smartphone predicted the risk for development of musculoskeletal pain among adolescent students (Table 3).
Table 3: Results of univariate logistic regression of factors associated with musculoskeletal pain among school students. |
Variables |
Univariate Logistic Regression |
COR |
95% CI |
P |
Gender |
Male
Female |
1.77 |
1.31-2.38 |
0.006* |
Age |
10-14 years
15-19 years |
0.67 |
0.49-0.91 |
0.023* |
Stress |
No
Yes |
1.33 |
0.73-2.40 |
0.25 |
Anxiety |
No
Yes |
1.29 |
0.88-1.90 |
0.13 |
Depression |
No
Yes |
1.30 |
0.77-2.20 |
0.22 |
Duration of Moderate & Vigorous Physical activity (60-90 mins per day) |
Yes
No |
1.57 |
1.17-2.11 |
0.012* |
Duration of watching TV. |
≥ 5 days a week ≤1hour
≥5 days a week ≥2 hours
≤ Once-four times a week & ≥ 2hours |
1
1.34
1.30 |
1
1.04-1.74
0.77-2.19 |
0.03*
0.22 |
Duration of smart phone usage |
≥ 5 days a week ≤1hour
≥5 days a week ≥2 hours
≤ Once-four times a week & ≥ 2hours |
1
1.82
1.53 |
1
1.18-2.79
1.02-2.31 |
0.01*
0.04* |
*p<0.05, CI Confidence Interval, COR Crude Odds Ratio |
The adjusted odds ratio in multivariate logistic regression indicated that female participants had a 1.8 times higher risk of musculoskeletal pain as compared to male participants (Table 4).
| Table 4: Results of multivariate logistic regression of factors associated with musculoskeletal pain among school students. |
Variables |
Multivariate Logistic Regression |
AOR |
95% CI |
p |
Gender |
Male
Female |
1.89 |
1.32-2.69 |
0.008* |
Age |
10-14 years
15-19 years |
0.71 |
0.49-1.02 |
0.06 |
Duration of Moderate & Vigorous Physical activity (60-90 mins per day) |
Yes
No |
1.50 |
1.32-2.69 |
0.017* |
Duration of watching TV. |
≥ 5 days a week ≤ 1hour
≥5 days a week ≥2 hours
≤ Once-four times a week & ≥ 2hours |
1
1.07
0.97 |
1
0.96-1.20
0.55-1.73 |
0.13
0.92 |
Duration of smart phone usage |
≥ 5 days a week ≤ 1hour
≥5 days a week ≥2 hours
≤ Once-four times a week & ≥ 2hours |
1
1.82
1.55 |
1
1.16-2.85
1.15-2.08 |
0.02*
0.01* |
Constant |
0.96 |
|
0.75 |
*p<0.05, CI Confidence Interval, AOR Adjusted Odds Ratio |
The participants not engaging themselves in moderate to vigorous level physical activity 60- 90 minutes per day had 1.5 times higher risk of getting musculoskeletal pain (p= 0.017). The participants spending time ≥ 2 hours a day and ≥ five days a week on smartphones were at 1.8 times higher risk of developing pain as compared with the reference (using smartphone ≤1 hour and ≥ 5 days in a week; p=0.02).
Discussion
The prevalence of musculoskeletal pain at least in one body part was present among 55.2% in 12 months, 46.6% in 7 days and 63% in the past 12 months and 7 days period. Keeratisiroj & Siritaratiwat (21) also reported a high prevalence of musculoskeletal pain which was 73% in the past 12 months, 76.1% in the past 7 days and 83.8% in both 7 days and 12 months period. Various studies had reported the prevalence of musculoskeletal pain ranging from 65.1% to 72.1% among adolescent school children.(15,22) Further in our study, participants had a higher prevalence of low back pain in the past 12 months as 32% and 31% in the past 7 days period. The Global Burden of Disease Study 2016 had also emphasized that low back was the leading cause of disability.(23) The prevalence of shoulder pain was found 11% in the past 12 months and 6% in the past 7 days period. However, the pain complaints reported by the participants in the neck, upper back, elbows, wrists/hands, hips/thighs, knees and ankles were similar in both periods.
The current study showed the female participants have a higher risk of developing musculoskeletal pain than male students in the multivariate regression model (p =0.008 AOR=1.89; 95% CI 1.32-2.69). Our findings supported the study conducted by Saueressig et al. in which female participants had 10.66 times higher chances of reporting musculoskeletal pain.(22) A systemic review also reported that self-reported musculoskeletal pain among teenage girls were comparatively higher than the boys.(24) The developmental changes in psychology and physiology of females during puberty may be the possible reason for higher reporting of pain complaints during the adolescent stage.(25)
The Global Burden of Disease data from the World Health Organization suggested that musculoskeletal conditions, particularly back and neck pain among 15 to19 year olds have approximately 10% of years lived with disability globally than 10 to14 year olds who have 5% of years lived with disability globally.(23) It has been observed in our study that students in the late adolescent stage have a higher prevalence of musculoskeletal pain than the early adolescent stage which is highly significant (p=<0.0001). This is with accordance with a previous study where neck and shoulder pain were reported by 36% in 14 years old group and 54% in 16 years old group.(3)
Previous studies reported that obese and overweight adolescents had a higher prevalence of musculoskeletal pain as compared to non-overweight adolescents. In our study, 3.3% of the students are overweight and obese. This may be one of the factors for musculoskeletal pain however, it is not found to be significant.
Our analysis revealed that the stress(p=<0.037), anxiety(p=0.032) and depression(p=0.056) component of the DASS-21 was significantly associated with musculoskeletal pain. Eckhoff et al. also found a significant association between multisite musculoskeletal pain and mental health disorders in population-based registry among Norwegian youth.(4) In another study, 22% of the adolescent population reported moderate to severe stress, out of which 79.6% had musculoskeletal pain. It was reported that there was a significant relationship between perceived stress and musculoskeletal pain.(28)
In our study, the adolescent school students who engaged themselves in the moderate to vigorous level physical activity of duration 60-90 minutes per day had a low prevalence of musculoskeletal pain. (p=0.017, AOR = 1.50; 95% CI 1.32-2.69). World Health Organisation recommends moderate-to-vigorous physical activity daily for 60-90 minutes for children and adolescents.(12) It was evident in the “Young-HUNT Study” that the moderate physical activity level particularly endurance sport was associated with less neck, shoulder pain, and low back pain whereas a high level of physical activity can cause pain in lower extremities.(29) American Academy of Paediatrics public health issued a guideline in 2001 and recommended that the screen time duration of television/video game in adolescents should not exceed more than 2 hours per day.(30,31) Our study also revealed that adolescents watching television more than or equal to 2 hours per day and ≥ 5 days a week were more likely to have musculoskeletal pain and discomfort in univariate analysis. (p= 0.03, COR=1.34; 95% CI 1.04-1.74). Also, there was a significant association of musculoskeletal pain in adolescents using smartphones more than or equal to 2 hours a day and ≥ 5 times in a week. (p= 0.02, AOR=1.82; 95% CI 1.16-2.85). In a Brazilian study, low back pain among children was found to be associated with watching television more than three times a week and more than three hours in a day.(10) Few other studies had also endorsed the association of the excessive use of smartphone and musculoskeletal problems in young adults.(12,32)
This study has certain limitations. 1. Since only government schools were included, findings cannot be generalized to private schools. 2. Data was based on recall memory of the students, therefore recall bias may be present. 3. The participation of the 10th and 12th standard classes were not permitted by the Directorate of education due to their strict school study regimen.
The speculation of time and technology is interchangeable in the overall population of urban school-going adolescents in India. Therefore, our study results remain significant for the school administration and health workers who can monitor the musculoskeletal health and try to mitigate its risk factors.
Conclusion
We conclude that the female gender and age group 15-19 years (late adolescence) have more risk of developing musculoskeletal pain. Excessive use of smartphones, watching television more than the recommended screen time per day and level of physical activity significantly predict the occurrence of musculoskeletal pain among adolescents. Stress, anxiety and depression also play a role in the development of musculoskeletal pain up. However, more studies are required to further elucidate the role of mental health issues in the occurrence of musculoskeletal pain in adolescents.
Acknowledgement
We are thankful to the Directorate of Education, Delhi for permitting to conduct the study. We thank the headmasters and headmistresses of the selected schools in Delhi for their logistical support in conducting this study and the students for their participation.
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