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a Department of Epidemiology and Health Promotion, Municipal Health Service, Amsterdam, Netherlands
b Institute for Research in Extramural Medicine
c Department of Public and Occupational Health, VU University Medical Center, Amsterdam, Netherlands
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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METHODS. A school-based questionnaire survey in 2002 and 2003 of neck/shoulder, low back, and arm pain, computer use, physical activity, depression, and stress. The survey was given to 3485 adolescents aged 12 to 16 years who attended secondary schools in Amsterdam, Netherlands.
RESULTS. The overall prevalence of neck/shoulder, low back, and arm pain was 11.5%, 7.5%, and 3.9%, respectively. The prevalence of neck/shoulder pain was higher among girls and adolescents not living with both parents. The prevalence of low back pain also was higher among girls. Depressive symptoms were associated with neck/shoulder pain, low back pain, and arm pain. The stress experienced was associated with neck/shoulder pain and with low back pain.
CONCLUSIONS. This study strengthens the findings that musculoskeletal pain is common among adolescents and is associated with depression and stress but not with computer use and physical activity.
Key Words: neck pain • shoulder pain • arm pain • computer use • physical activity • depression
Abbreviations: MET—metabolic rate • CES-D—Center for Epidemiologic Studies Depression Scale • OR—odds ratio • CI—confidence interval
IN THE NETHERLANDS, as in other industrialized Western countries, back and neck/shoulder pain is one of the leading causes of inability to work and sick leave.1,2 Back or neck/shoulder pain already occurs in adolescence.3–5 Adolescents with such complaints are at risk of displaying similar symptoms in later life.6,7 The risk and protective factors of these pains can be divided into physical and psychosocial factors.8,9 For example, neck/shoulder pain is related to exercise3 but also to psychosomatic problems and depression.3,10,11
In the past decades there has been an increase in low back and neck/shoulder pain among adolescents.4,5 Little is known about what is causing this increase, but Vikat et al3 suggest that it might be the rise in psychosocial problems. Increased computer use among children12 might be another explanation. Two epidemiologic reviews concluded that in adults there is a relation between working at visual display units and having upper extremity musculoskeletal disorders.13,14 There is little information about the relation between computer use and musculoskeletal pain among children and adolescents.
In the current study we assessed the prevalence of neck/shoulder, low back, and arm pain among different sociodemographic groups. We furthermore investigated if neck/shoulder, low back, and arm pain were associated with computer use, physical activity and inactivity, depression, and stress among groups of schoolchildren.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Neck/shoulder, low back, and arm pain were gauged by using 3 preshaded manikin pictures showing (1) the neck/shoulder, (2) the low back (back pain caused by menstruation was excluded from this study), and (3) the arm area. The question posed was: "In the past month have you experienced pain lasting a day or longer in the indicated shaded area?" (yes/no). If the response was affirmative, the second question was: "How long, in terms of days, did you experience pain in this area during the past month?" To meet our neck/shoulder, low back, or arm pain criteria, participants had to experience pain for 
4 days per month in the neck/shoulder, low back, or arm area.
The following physical factors were measured: computer use, physical activity, and physical inactivity. Computer use was measured by asking 2 questions: "On average, how much time per day do you spend working or chatting on the computer?" and "On average how much time per day do you spend playing the PlayStation, Nintendo, or other computer games?" The total time (hours and minutes) was calculated (0–0.5, 0.51–1.5, 1.51–3.00, or >3 hours). Physical activity levels were assessed by using open-ended questions to determine the type, frequency, and duration of sporting activities during a normal week in the previous month. The total number of types of sporting activities was then calculated and transformed into a metabolic rate (MET).15 According to Dutch guidelines for healthy exercise, children and adolescents should have a moderate level of physical activity for at least 1 hour a day.16 Moderately intensive activities for children such as biking, swimming, and running have a MET of 21 to 33.6 kJ/kg per hour.15 The time spent on physical activities with a MET of 5 (0–0.5, 0.51–1.0, or >1 hour) was used in the analysis. Physical inactivity was measured by posing the question: "On average, how much time per day do you spend watching television or video?" (in hours and minutes) (0–1.50/1.51–2.50/2.51–4/>4 hours). Data relating to computer use and physical inactivity were divided into 4 groups of approximately the same size.
Depressive symptoms were measured by using the Center for Epidemiologic Studies Depression Scale (CES-D).17 The CES-D is a 20-item self-report scale that was designed to measure depressive symptoms in the general population. The total score ranges from 0 to 60 and is calculated by summing all items. The CES-D has been validated previously in adolescents.18 Adolescents who scored 16 were classified as being depressed. Perceived stress was measured by asking the question: "Have you experienced stress in the past week" (no = never/sometimes; yes = often/always).
Sociodemographic information included gender, family structure (whether the child was living with both of his or her natural/adoptive parents), and education level (low = [specific] prevocational education; intermediate = junior [intermediate] general secondary education; high = senior [higher] general secondary education). Ethnic origin was defined according to the mother and father's country of birth: Netherlands, Surinam/Antilles, Morocco, Turkey, or other countries. A child was classified as non-Dutch if 1 or both parents were foreign-born. The questionnaire was pilot tested on a few students with different ethnic backgrounds and education levels for comprehension and applicability. Logistic-regression analyses were used to examine univariate associations between neck/shoulder, low back, and arm pain, and sociodemographic characteristics (gender, ethnicity, family structure, and education level), computer use, physical activity, physical inactivity, depressive symptoms, and perceived stress. By means of forward stepwise logistic regression, multivariate analyses were performed. At each step, we included variables with a 5% level of significance.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The prevalence of neck/shoulder, low back, and arm pain in this study was 11.5%, 7.5%, and 3.9%, respectively. Table 1 shows that the prevalence of neck/shoulder pain was higher among girls (odds ratio [OR]: 1.4; 95% confidence interval [CI]: 1.2–1.8) and adolescents who do not live with both of their parents (OR: 1.4; 95% CI: 1.1–1.8) than among boys and adolescents who do live with both parents. Adolescents coming from "other countries" reported more neck/shoulder pain (OR after univariate logistic regression: 1.5; 95% CI: 1.1–2.1) than "Dutch" adolescents. However, this association was not significant after correction for other variables.
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Depressive symptoms were associated with neck/shoulder pain (OR: 1.9; 95% CI: 1.5–2.5) as well as low back (OR: 2.5; 95% CI: 1.8–3.4) and arm (OR: 2.1; 95% CI: 1.4–3.1) pain. Stress experienced was associated with neck/shoulder (OR: 2.0; 95% CI: 1.5–2.7) and back (OR: 1.6; 95% CI: 1.1–2.2) pain.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In total, 1030 adolescents of the 4515 adolescents who took part in the survey did not complete the questionnaire fully. It is possible that the prevalence of musculoskeletal pain is overestimated because the adolescents with pain were more motivated to complete the questionnaire. However, no significant differences in the prevalence of neck/shoulder, low back, and arm pain were found among the adolescents who did or did not complete the questionnaire fully (results not presented). Therefore, and because of the overall good response rate and number of adolescents included, this study can be considered representative of the prevalence of neck/shoulder, low back, and arm pain and the associations found. It is possible that the prevalences are slightly higher, because 241 adolescents called in sick on the day of the survey, some of whom could have been absent because of neck/shoulder, low back, or arm pain complaints.
More girls than boys reported having neck/shoulder and low back pain. This result is in accordance with previous cross-sectional studies that showed a greater female predisposition to musculoskeletal pain.3–5,8–11 The reasons for this remain speculative. Pain prevalence may indeed be higher, but it is also possible that it may be more acceptable for girls to complain about pain than boys. After univariate analyses, we found that adolescents coming from "other countries" had more neck/shoulder pain. After multivariate analyses, this association was no longer significant. Adolescents in this ethnicity group with neck/shoulder pain were more often stressed and depressed (results not presented). A portion of these adolescents were (children of) asylum seekers and refugees. A lot of these adolescents had been traumatized.19 It therefore is conceivable that neck/shoulder pain in these adolescents is more a result of (posttraumatic) stress and depression.
We did not find an association between computer use and musculoskeletal pain. In our study, computer use was self-reported. Faucett and Rempel20 found that self-reported computer use was overestimated in general. Overestimation, however, was not associated with having musculoskeletal symptoms. Several studies that were conducted among adults indicate that computer use can be a risk factor in the development of upper extremity musculoskeletal pain.13,14 There is little information about the relation between computer use and musculoskeletal pain among children and adolescents. In a small sample study, Jacobs and Baker21 found that musculoskeletal discomfort was associated with the number of hours spent on the computer. Harreby et al22 found no relation between computer use and low back pain. It is possible that we did not find an association between computer use and musculoskeletal pain because our definition of musculoskeletal pain was stricter than the definition that Jacobs and Baker used. It is also probable that children and adolescents are less prone to musculoskeletal pain than adults, because they use computers mostly for fun and therefore do not experience pain, or they do not consider it as pain but more as a discomfort, as Jacobs and Baker used in their definition. However, it is possible that there is an association between computer use and musculoskeletal pain. It is likely that adolescents with pain are using the computer less than they did before they experienced pain, possibly because they know or think that excessive computer use can be harmful.
In line with Ehrmann Feldman et al,23 we did not find an association between physical activity and musculoskeletal pain. However, Harreby et al22 found that students who considered themselves to be physically fit experienced less low back pain. It is conceivable that we did not find a comparable association in our study because in our study physical activity was assessed more objectively by the amount of time that students spent on (21 kJ/kg per hour MET) activities.
It is surprising that students who spent 1.5 to 2.5 hours per day watching television experienced less low back pain than students who watched less television. After forward stepwise logistic regression, television-watching was no longer significantly associated with low back pain. Depression, stress, and gender were not confounding factors. After additional analyses among adolescents who were not depressed or stressed, the adolescents who watched <1.5 hours of television per day experienced more low back pain than adolescents who watched 1.5 to 2.5 hours of television per day (results not presented). It is possible that adolescents who are not stressed or depressed and have low back pain are more often advised to watch less television than stressed or depressed adolescents with low back pain. However, no significant interaction effects between depression and television-watching or stress and television-watching concerning low back pain were found.
Depressive symptoms were associated with an increased prevalence of neck/shoulder, low back, and arm pain. Stress was associated with a higher prevalence of neck/shoulder and low back pain. These results correspond to other cross-sectional findings among young populations.10,11 In view of the cross-sectional nature of this study, we are unable to determine whether depressive symptoms are consequences or causes of musculoskeletal pain in schoolchildren or whether they are all components of a more generalized syndrome. Siivola et al24 found, however, that psychosocial symptoms in adolescence predicted neck/shoulder pain in adulthood among those who were symptom-free at baseline. Furthermore, in children who were initially free of low back pain, adverse psychosocial factors were predictive of future low back pain.25 These results suggest that depressive symptoms and stress are more likely to be causes rather than consequences of neck/shoulder, low back, and arm pain.
The association between musculoskeletal pain and psychosocial factors would suggest that psychotherapy might be effective in adolescents with musculoskeletal pain, provided that possible medical grounds are excluded first. In a Dutch randomized, controlled trial, cognitive behavioral therapy proved to be an effective form of treatment for adults with medically unexplained physical symptoms such as musculoskeletal pain.26 At 6 and 12 months of follow-up, those in the intervention group reported a significant higher recovery rate and less physical symptoms than those in the control group. Eccleston et al27 found also physical improvement among adolescents with chronic pain after cognitive behavior therapy.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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4 days per month is high. Neck/shoulder and low back pain are associated with depression and stress but not with computer use, which indicates that improving mental health could be a key issue for preventing musculoskeletal pain. Additional study is necessary to assess the effect of psychotherapy on musculoskeletal pain in adolescents.
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FOOTNOTES |
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Address correspondence to A.C.M. Diepenmaat, MSC, Municipal Health Service Amsterdam, Department of Epidemiology and Health Promotion, PO Box 2200, 1000 CE Amsterdam, Netherlands. E-mail: adiepenmaat{at}ggd.amsterdam.nl
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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