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Low Back Pain Prevalence among Distance Learning Students

Article in International Journal of Environmental Research and Public Health (IJERPH) · December 2022
DOI: 10.3390/ijerph20010342

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 International Journal of
Environmental Research
and Public Health

Article
Low Back Pain Prevalence among Distance Learning Students
Mohannad Hawamdeh 1,2 , Thamer A. Altaim 2, * , Amjad Shallan 1 , Riziq Allah Gaowgzeh 3 ,
Sakher M. Obaidat 1 , Saad Alfawaz 3 , Saad M. Al-Nassan 1,4 , Ziyad Neamatallah 3 , Owis Eilayyan 2 ,
Umar M. Alabasi 3 and Majed Albadi 3

1 Department of Physical and Occupational Therapy, Faculty of Applied Medical Sciences,

The Hashemite University, P.O. Box 330127, Zarqa 13133, Jordan
2 Physical Therapy Department, Faculty of Allied Medical Sciences, Aqaba University of Technology,
Aqaba 77110, Jordan
3 Department of Physical Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University,
Jeddah 21589, Saudi Arabia
4 Department of Physical Therapy, Faculty of Allied Health Sciences, Al-Ahliyya Amman University,
Amman 19328, Jordan
* Correspondence: [email protected]; Tel.: +962-77-53-11600

Abstract: Background: Low back pain as a symptom affects many individuals around the globe
regardless of their economic status or sociodemographic characteristics. During the 2019 COVID-19
pandemic, students found themselves obligated to sit down for long periods of time. The aim of
this current study is to investigate the impact of these prolonged periods of sitting down in front of
computers on developing a new episode of low back pain. Methods and Materials: This research
adopted an observational cross-section study design. Students who are currently enrolled or had
experienced distance learning classes in the last 6 months were eligible to participate. An online-based
questionnaire was developed by the investigators through reviewing the literature with relevant
objectives. McNemar’s test was used to compare certain variables between two periods before and
during online distance learning. We used paired t-tests to compare pain intensity before, during, and
after online learning, while a chi-square test was used to investigate correlations between factors
Citation: Hawamdeh, M.; Altaim,
influencing low back pain. Results: A total of 84 students participated in the study—46 (54.8%)
T.A.; Shallan, A.; Gaowgzeh, R.A.;
Obaidat, S.M.; Alfawaz, S.;
females and 38 (45.2%) males. Before online distance learning, only 42.9% of participants reported
Al-Nassan, S.M.; Neamatallah, Z.; low back pain, while only 20% had a back injury. The mean pain scores before, during, and after
Eilayyan, O.; Alabasi, U.M.; et al. online distance learning were (2.85 ± 2.16, 4.79 ± 2.6, and 4.76 ± 2.7), respectively. The pain scores
Low Back Pain Prevalence among before online learning were significantly lower than pain scores during and after online distance
Distance Learning Students. Int. J. learning (p < 0.05), respectively. Conclusion: The study findings suggested that low back pain
Environ. Res. Public Health 2023, 20, prevalence increased among students during the COVID-19 pandemic. Future research should study
342. https://doi.org/10.3390/ participants’ behavior during the online learning and assess the long-run impact of distance learning
ijerph20010342
among high-school and undergraduate students.
Academic Editor: Paul B. Tchounwou
Keywords: low back pain; students; online learning; COVID-19; posture
Received: 25 November 2022
Revised: 22 December 2022
Accepted: 23 December 2022
Published: 26 December 2022
1. Introduction
Low back pain (LBP) is considered one of the most common musculoskeletal disorders
that affect people of all ages around the world [1]. In addition, LBP is becoming a burden in
Copyright: © 2022 by the authors. many developing and low-income countries due to high healthcare costs for its treatment
Licensee MDPI, Basel, Switzerland. and management [2]. Prolonged sitting and computer use in the workplace, in addition to
This article is an open access article improper postures, may contribute to low back pain [2].
distributed under the terms and
During the COVID-19 pandemic, many governments worldwide made a series of
conditions of the Creative Commons
decisions to control the pandemic’s spread, such as quarantine, social distancing, and
Attribution (CC BY) license (https://
switching from traditional education to different forms of E-learning [3,4]. E-learning is
creativecommons.org/licenses/by/
referred to learning by using specific technologies and it is considered a type of distance
4.0/).

Int. J. Environ. Res. Public Health 2023, 20, 342. https://doi.org/10.3390/ijerph20010342 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023, 20, 342 2 of 10

learning, as opposed to traditional classroom learning [5]. E-learning has some advantages
such as students having more flexibility in terms of choosing the place and time for
learning, as well as cost effectiveness for both students and education systems [6]; however,
E-learning has many disadvantages that should be addressed. For example, E-learning
may decrease communication between students and teachers [7]. Additionally, E-learning
methods usually require students to stay sitting for a long time on their laptops and smart
devices, which may lead to different health problems [8].
Many studies have found a strong correlation between using advanced technology,
such as smartphones, and spine disorders [9–11]. A systematic review was conducted
to evaluate the impact of using smart devices on musculoskeletal complaints, and it
showed there was a strong relationship between the duration smartphone use and spine
disorders [12]. Moreover, most students are seated on non-ergonomic tables and chairs
during E-learning, which may lead to bad postures, and thus could lead to some problems
in the lumbar spine region such as stiffness and abnormal muscle activation [13–15]. Several
studies found that students who spent more than 3 h per day on their laptops suffered
from neck and back pain; however, this musculoskeletal pain was more evident in inactive
students compared to active ones [16,17]. Moreover, several studies found that there are
many factors that could contribute to musculoskeletal pain in university students engaging
in E-learning methods, including psychosocial and environmental factors [18]. These
factors could contribute to musculoskeletal pain either directly or indirectly [6].
Usually, university students have little knowledge regarding effective strategies for
pain management, which may lead to a negative impact on their musculoskeletal pain [19].
In addition, university students with musculoskeletal pain such as low back pain may
experience some interference with their academic performance [19]. Therefore, atten-
tion should be paid to address this issue, especially in Middle East countries, where the
age-standardized point prevalence of LBP was highest at 14.8% [20]. However, to our
knowledge, few studies have been conducted to measure the impact of E-learning on LBP
among university students in developing and low-income countries. Therefore, the aim of
this study was to investigate the prevalence of low back pain among university students
attending virtual classes during the COVID-19 pandemic.

2. Materials and Methods

2.1. Design and Population of the Study
This was a cross-sectional observational study. All students at high school level or
university level who are currently enrolled or had experienced distance learning classes in
the last 6 months were eligible to participate. Participation was exclusive for students at
Jordanian universities and high schools.

2.2. The Questionnaire

An online-based questionnaire was developed by the investigators through reviewing
the literature with relevant objectives; the questionnaire used and revised by experts was
inspired by Abbas et al. (2021) [21]. A pilot test was performed on a small group of
university students to test the clarity, ease, and time needed to complete the questionnaire.
The questionnaire required about 15 min to complete. A panel of experts in the fields
of physical therapy and rehabilitation reviewed the questionnaire and provided their
feedback regarding the face and content validity of the included items and questions. The
final version of the questionnaire was developed electronically through Google Forms
and included 26-closed-ended items divided into 3 main parts. The first part (5 items)
included basic demographic questions, the second part (4 items) asked about lifestyle and
daily habits, while the third part (17 items) included general and low back pain-related
questions. An electronic link to the questionnaire was shared with the participants through
social media networks. A cover letter of the questionnaire was enclosed within the link
of the questionnaire to ensure eligibility of participation and a pledge of confidentiality
of participants’ information. The questionnaire was delivered in the Arabic language
Int. J. Environ. Res. Public Health 2023, 20, 342 3 of 10

(Supplementary File), and the study protocol was approved by the institutional review
board at The Hashemite University.

2.3. Statistical Analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences
(SPSS) Software version 25 for Windows (Chicago, IL, USA). Mean and standard deviation
for quantitative variables and counts (%) for qualitative variables were used to summarize
data. The normality of continuous variables was examined using Shapiro–Wilk test. The
level of significance was set at p ≤ 0.05.

3. Results
3.1. Demographic Data
A total of 84 students participated in the study—46 (54.8%) females and 38 (45.2%)
males. Most of the students were studying bachelor’s degrees (86.9%); 79.8% were in the
age range of 18 to 22. Participants’ BMIs were categorized into four categories: under-
weight (BMI < 18.5), healthy weight (BMI 18.5–24.9), overweight (BMI 25–29.9), and obese
(BMI > 30). We found that 51.1% of students were within the healthy weight range (see
Table 1).

Table 1. Demographic data.

Total n (%)
Gender 84
Female 46 (54.8%)
Male 38 (45.2%)
Educational level
High School 5 (6.00%)
Diploma 4 (4.8%)
Undergraduate BSc 73 (86.9%)
Graduate 2 (2.4%)
BMI level
Underweight 5 (6.00%)
Healthy weight 43 (51.2%)
Overweight 28 (33.3%)
Obese 8 (9.5%)
Age groups
18–22 67 (79.8%)
23–28 12 (14.3%)
>28 5 (6.00%)
Abbreviations: BMI, Body mass index.

3.2. Lifestyle before and during Online Distance Learning

Before online distance learning, 26.2% of students did not exercise at all. During
online distance learning, 35.7% did not exercise at all. However, this difference was not
statistically significant (p = 0.115) (see Table 2). Our results found that students used to
spend an average of 7.7 h daily using electronic devices during online distance learning,
where most of them (51.2%) reported that they spent more than 6 h a day using electronic
devices (see Table 2).
Int. J. Environ. Res. Public Health 2023, 20, 342 4 of 10

Table 2. Lifestyle before and during online distance learning.

Before Online Learning During Online Learning

p-Value
n (%) n (%)
Exercise
Yes 62 (73.8%) 54 (64.3%) 0.115
No 22 (26.2%) 30 (35.7%)
Electronic devices
hours
<6 41 (48.8%)
<6 43 (51.2%)
Abbreviations: p, Probability value (according to McNemar test).

The high usage of electronic devices during online distance learning could be at-
tributed not only to using devices for attending lectures and studying but also for watching
TV or spending time via social media.

3.3. Low Back Pain Incidence and Intensity before and during Online Distance Learning
Before online distance learning, only 42.9% (see Table 3) of participants reported low
back pain, while only 20% had a back injury. The mean pain scores before, during, and
after online distance learning were (2.85 ± 2.16, 4.79 ± 2.6, and 4.76 ± 2.7), respectively.
The pain scores before online learning were significantly lower than pain scores during and
after online distance learning (p < 0.05), respectively (see Table 4).

Table 3. Low back pain prevalence, duration, and nature, and associated disabilities.

n (%)
Low back pain
Yes 48 (57.1%)
No 36 (42.9%)
Duration of pain
Discontinuous 67 (79.8%)
No pain 12 (14.3%)
Permanent 5 (6.00%)
Nature of pain
Burning pain 4 (4.8%)
Like a shock 4 (4.8%)
Like an appeal 11 (13.1%)
no pain 11 (13.1%)
numbness 6 (7.1%)
prick 14 (16.7%)
stiffen 34 (40.5%)
Pain hindering movement
Yes 29 (34.5%)
No 55 (65.5%)
Pain relief medications
Yes 20 (23.8%)
No 64 (76.2%)
Physiotherapy for LBP
Yes 11 (13.1%)
No 73 (86.9%)
COVID-19 infection
Yes 29 (34.5%)
No 55 (65.5%)
Abbreviations: BMI, Body mass index; LBP, LowbBack pain.
Int. J. Environ. Res. Public Health 2023, 20, 342 5 of 10

Table 4. Low back pain severity before, during, and after online distance learning.

Before Online During Online After Online

Learning Learning Learning p-Value
Mean ± SD Mean ± SD Mean ± SD
LBP severity 2.85 ± 2.16 4.79 ± 2.6 4.76 ± 2.69 P1 = 0.000 *
P2 = 0.000 *
Abbreviations: LBP, Low Back Pain; p, Probability value (according to paired t-test); P1, refers to the difference in
LBP severity before to during online learning; P2, refers to the difference in LBP severity before and after online
learning; *, statistically significant difference.

The most-reported pain was stiffness (40.5%), while the lowest-reported was burning
pain (4.8%). Approximately 65.5% of participants reported that low back pain was not
hindering their movement; at the same time, 76.2% of participants reported that they did
not take any pain relief medications (see Table 3). In total, 65.5% of participants reported
that they have been infected with COVID-19, where a 40% reported the continuation of
low back pain after getting COVID-19 infection; most of the participants 40% reported that
their pain level remained the same (see Table 3).

3.4. Sleep and Psychological Stress during Online Distance Learning

We categorized sleep hours into two groups: less than 8 h and more than 8 h. We
found that most of participants (61.9%) spent less than 8 h of sleep during the period of
online learning. Furthermore, 76.2% of participants reported an experience of psychological
stress during online distance learning (see Table 5). Table 6 present the association between
the occurrence of LBP and some of the demographics characteristics of the participants.

Table 5. Sleep hours and psychological stress after online distance learning.

n (%)
Sleep hours’ number
<8 52 (61.9%)
>8 32 (38.1%)
Psychological stress
Yes 64 (76.2%)
No 20 (23.8%)

Table 6. Association between low back pain and demographics.

Low Back Pain No Low Back Pain OR (95% CI) p-Value

n (%) n (%)
Gender
Female 19 (52.8%) 27 (56.2%) 1ˆ
Male 17 (47.2%) 21 (43.8%) 1.15 [0.43–2.74] 0.752
Educational level
High School 1 (2.8%) 4 (8.33%) 1ˆ
Diploma 1 (2.8%) 3 (6.25%) 1.33 [0.057–31.121] 0.858
Undergraduate BSc 33 (91.6%) 40 (83.33%) 3.30 [0.352–30.9] 0.296
Graduate 1 (2.8%) 1(2.09%) 4.00 [0.117–136.957] 0.442
BMI level
Underweight 3 (8.3%) 2 (4.2%) 1ˆ
Healthy weight 14 (38.8%) 29 (60.4%) 0.322 [0.048–2.151] 0.242
Overweight 14 (38.8%) 14 (29.2%) 0.667 [0.096–4.62] 0.682
Obese 5 (13.8%) 3 (6.3%) 1.11 [0.112–10.98] 0.928
Age groups
18–22 28 (8.3%) 39 (8.3%) 1ˆ
23–28 4 (38.8%) 8 (38.8%) 0.696 [0.191–2.542] 0.584
>28 4 (38.8%) 1 (38.8%) 5.57 [0.096–52.567] 0.134
Abbreviations: OR Odds Ratio; CI, Confidence Interval; p, Probability value (according to logistic regression); ˆ,
reference category.
Int. J. Environ. Res. Public Health 2023, 20, 342 6 of 10

3.5. Posture during Online Distance Learning

We found that most participants did not use the proper posture to attend lectures.
Only 36.9% used desks to attend online lectures, while the remaining participants reported
lying on a bed 32.1%, sitting on a couch 17.9%, or using an Arabic mattress 13.1% (see
Table 7).

Table 7. Association between low back pain and physical parameters.

Low Back Pain No Low Back Pain

n% n% OR (95% CI) p-Value

Exercise before
online learning
Yes 22 (61.1%) 40 (83.3%) 1ˆ
No 14 (38.9%) 8 (16.7%) 0.314 [0.114–0.865] 0.025 *
Exercise during
online learning
Yes 22 (61.1%) 32 (66.6%) 1ˆ
No 14 (38.9%) 16 (33.4%) 0.786 [0.320–1.932] 0.599
Hours of using
electronic devices
<6 16 (44.4%) 25 (52.08%) 1ˆ
>6 20 (55.6%) 23 (47.92%) 1.359 [0.571–3.23] 0.488
Posture during
online lectures
Lying on Bed 13 (36.1%) 14 (29.2%) 1ˆ
Sitting at the desk 13 (36.1%) 18 (37.5%) 0.778 [0.275–2.19] 0.635
Sofa-couch sitting 5 (13.8%) 10 (20.1%) 0.538 [0.145–2.00] 0.355
Arabic mattress 0.880
sitting 5 (13.8%) 6 (12.5%) 0.897 [0.220–3.66]

COVID-19 infection
Yes 24 (66.7%) 31 (64.6%) 1ˆ
No 12 (33.3%) 17 (35.4%) 1.097 [0.441–2.728] 0.842
Psychological stress
Yes 29 (80.5%) 35 (72.9%) 1ˆ
No 7 (19.5%) 13 (27.1%) 1.53 [0.543–4.364] 0.418
Hours of sleep
<8 20 (55.6%) 32 (66.7%) 1ˆ
>8 16 (44.4%) 16 (33.3%) 1.6 [0.657–3.89] 0.301
Abbreviations: OR Odds Ratio; CI, Confidence Interval; p, Probability value (according to logistic regression); *,
statistically significant difference; ˆ, reference category.

3.6. Association between Low Back Pain and Demographics and Other Parameters
Gender, educational level, and BMI were not significantly associated with low back
pain. There was no significant association between low back pain and the time using
electronic devices, exercising during online learning, number of sleep hours, and pos-
ture during online lectures. However, exercising before online learning (OR = 0.314,
95% CI [0.114–0.865], p = 0.025) was independently associated with a low prevalence of
LBP at the time of the study (see Table 7).

4. Discussion
4.1. Online Learning and Incidence of LBP
This study aimed to estimate the prevalence of low back pain among university
students attending virtual classes during the COVID-19 pandemic. Some demographic and
lifestyle-related factors were assessed in this study using a content validated questionnaire.
The results showed that the prevalence and the intensity of LBP increased during distance
learning throughout COVID-19 pandemic. This is supported by the literature, where the
percentage of people who suffered from LBP increased significantly during COVID-19
and pain intensity also increased among people who underwent distance learning [22]. In
addition, most of the participants in this study reported stiffness. This might be related
to the fact that most of the participants did not use a proper posture and did not use the
Int. J. Environ. Res. Public Health 2023, 20, 342 7 of 10

ergonomic chairs and desk during online learning. This may increase tension in the back
muscles and cause stiffness.
Although one-third of the participants were infected with COVID-19, this study
showed that there was no correlation between having COVID-19 and the incidence of LBP.
This is supported in the literature. For instance, the WHO shows that aches and pains are
less-common symptoms among people with COVID-19 [23]. Additionally, Murat et al.
showed that only 28% of the participants who suffered from COVID-19 reported back
pain [24]. Furthermore, the literature supports that during online learning, as a result of
COVID-19, students spent more time using the laptops, computers and smart devices,
which increased the incidence and intensity of musculoskeletal pain, including LBP [25–27].
The results of this study showed that the average sleeping hours and average hours of
using electronic devices did not significantly affect LBP, which is supported by Basri et al.’s
study, where they found no correlation between LBP with sleeping and smartphone usage
per day [28]. Lastly, there was no significant difference in the prevalence of LBP in relation
to gender, which is consistent with other studies [22,29].

4.2. Posture/Physical Activity and LBP

Prolonged sitting during online learning may worsen LBP [30], as it may decrease
low back muscle activation; this leads to a reconditioning of the muscles and increasing
the load at intervertebral and ligaments [31]. Furthermore, a prolonged static posture may
increase physical stress, which in turn can injure soft tissues and cause musculoskeletal
pain and LBP [27,32,33]. The participants in this study used different ways of sitting,
such as a comfortable position, to reduce tension on the low back area, and this is why
posture during online learning was not a significant factor of LBP. This is supported in the
literature, where sitting hours and awkward posture were not correlated with LBP [28].
However, one study showed that people who adhered to ergonomic recommendations had
significantly less pain [22], and other studies have reported that prolonged sitting on a chair
may cause joint pain [34–36]. A lack of physical activity has an important role in increasing
the intensity of LBP [37]. During online learning, students need to spend more time in
a sitting position, and this may reduce physical activity [26]. However, the majority of
participants in the current study kept performing exercise during online learning. This may
explain why physical activity did not significantly affect LBP. A study conducted in 2022
among undergraduate students showed that self-perceived exercise was not significantly
correlated with LBP [38], and another study showed that not performing sports activities
during the COVID-19 pandemic was not associated with LBP [28].

4.3. Psychological Issues

The majority of participants reported psychological issues. Mattioli et al. reported
that quarantine increased psychological distress among people, which pushed people to
adopt unhealthy lifestyles and worsen LBP [39]. Online learning was shown to result in
academic stress, as it increases the workload and is not suitable for courses that require
hands-on skills [40]. This may affect the mental status of students. Many studies show
that psychological distress may increase the intensity of pain among people suffering from
LBP [41–44]. Sagat et al. (2020) showed that stress increased the intensity of LBP among
Saudi people during COVID-19 quarantine [22]. However, the results of this study showed
that psychological stress was not a significant factor in LBP, and might instead be related to
the fact that most of the participants kept doing exercises during online learning.

4.4. Future Consideration

This study assessed many factors that could affect LBP. However, none of the studied
variables significantly contributed to the incidence or the severity of LBP among Jordanian
students. The next step is to study participants’ behavior during online learning and assess
the long-run impact of distance learning among high-school and undergraduate students
in order to target significant variables and improve health status among students.
Int. J. Environ. Res. Public Health 2023, 20, 342 8 of 10

4.5. Limitations
There were some limitations in this study that need to be noted. The number of the
participants in this study was not high; only 84 students participated. Therefore, the results
of this study cannot be generalized to all students in Jordan. Additionally, there were some
variables that were not assessed in the study, such as pre-exercise and sedentary levels and
psychological distress before COVID-19.

5. Conclusions
We concluded that the majority of the students spent the same number of hours using
electronic devices—an average of 7.7 h daily—during online distance learning, and most
of them (51.2%) reported that they spent more than 6 h a day using electronic devices.
However, we found that the pain scores before online learning were lower than during and
after online distance learning. The results showed that the prevalence and intensity of LBP
increased during distance learning throughout the COVID-19 pandemic. The next step is
to study participants’ behavior during online learning and assess the long-term impact of
distance learning among high-school and undergraduate students in order to target the
significant variables and improve health status among students.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/10

.3390/ijerph20010342/s1.
Author Contributions: M.H., T.A.A. and A.S. formulated the conceptualization and methodology;
R.A.G. and S.M.O. performed the statistical analysis. S.A., S.M.A.-N. and Z.N. performed writing
up original draft preparation. O.E., M.A. and U.M.A. performed writing, review and editing for
the final version of the manuscript. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki. The study protocol was approved by the institutional review board at The Hashemite
University. All participants volunteered and no identifications were made, in line with ethical
standards. All tests were part of physical examinations, no invasive intervention was performed.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Not applicable.
Acknowledgments: The researcher team would like to thank AbdAlMalik Ali Bilal Tobolat, Ab-
dalqader Talal Badawi, Abanoub Elkes Athanasius, and Mahmoud Qaddora, Makaryous Gadelrab
Fekry Abdelshahid, and Hani Salah for their assistant in distribution the research questionnaire.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Woolf, A.D.; Pfleger, B. Burden of major musculoskeletal conditions. Bull. World Health Organ. 2003, 81, 646–656. [PubMed]
2. Hartvigsen, J.; Hancock, M.J.; Kongsted, A.; Louw, Q.; Ferreira, M.L.; Genevay, S.; Hoy, D.; Karppinen, J.; Pransky, G.; Sieper, J.;
et al. What low back pain is and why we need to pay attention. Lancet 2018, 391, 2356–2367. [CrossRef] [PubMed]
3. Chinna, K.; Sundarasen, S.; Khoshaim, H.B.; Kamaludin, K.; Nurunnabi, M.; Baloch, G.M.; Hossain, S.F.A.; Sukayt, A.; Dalina, N.;
Rajagopalan, U.; et al. Psychological impact of COVID-19 and lock down measures: An online cross-sectional multicounty study
on Asian university students. PLoS ONE 2021, 16, e0253059. [CrossRef] [PubMed]
4. Huang, C.; Wang, Y.; Li, X.; Ren, L.; Zhao, J.; Hu, Y.; Zhang, L.; Fan, G.; Xu, J.; Gu, X.; et al. Clinical features of patients infected
with 2019 novel coronavirus in Wuhan, China. Lancet 2020, 395, 497–506. [CrossRef] [PubMed]
5. Smedley, J.O. Modelling the impact of knowledge management using technology. OR Insight 2010, 23, 233–250. [CrossRef]
6. Ayyildiz, E.; Gumus, A.T. A novel distance learning ergonomics checklist and risk evaluation methodology: A case of Covid-19
pandemic. Hum. Factors Ergon. Manuf. 2021, 31, 397–411. [CrossRef]
7. Young, J.R. Rethinking the Role of the Professor in an Age of High-Tech Tools. Chron. High. Educ. 1997, 44, A26–A28.
8. Can, S.; Karaca, A. Determination of musculoskeletal system pain, physical activity intensity, and prolonged sitting of university
students using smartphone. Biomed. Hum. Kinet. 2019, 11, 28–35. [CrossRef]
Int. J. Environ. Res. Public Health 2023, 20, 342 9 of 10

9. In, T.-S.; Jung, J.-H.; Jung, K.-S.; Cho, H.-Y. Spinal and Pelvic Alignment of Sitting Posture Associated with Smartphone Use in
Adolescents with Low Back Pain. Int. J. Environ. Res. Public Health 2021, 18, 8369. [CrossRef]
10. Yamamoto, Y.; Miyatake, N.; Owari, Y.; Kataoka, H.; Katayama, A. Influence of Smartphone Usage on Low Back Pain and/or
Shoulder Pain in College Students in a Judo Therapist Training Course: A pilot study. J. Allied Health Sci. 2019, 10, 1–9. [CrossRef]
11. Kim, H.-J.; Kim, J.-S. The relationship between smartphone use and subjective musculoskeletal symptoms and university students.
J. Phys. Ther. Sci. 2015, 27, 575–579. [CrossRef] [PubMed]
12. Xie, Y.; Szeto, G.; Dai, J. Prevalence and risk factors associated with musculoskeletal complaints among users of mobile handheld
devices: A systematic review. Appl. Ergon. 2017, 59, 132–142. [CrossRef] [PubMed]
13. Beach, T.A.; Parkinson, R.J.; Stothart, J.P.; Callaghan, J.P. Effects of prolonged sitting on the passive flexion stiffness of the in vivo
lumbar spine. Spine J. 2005, 5, 145–154. [CrossRef] [PubMed]
14. Jung, K.-S.; Jung, J.-H.; In, T.-S.; Cho, H.-Y. Effects of Prolonged Sitting with Slumped Posture on Trunk Muscular Fatigue in
Adolescents with and without Chronic Lower Back Pain. Medicina 2021, 57, 3. [CrossRef]
15. Kim, Y.; Kang, H.-W.; Kim, S.-H.; Park, K.-N. Prolonged sitting-induced back pain influences abdominal muscle thickness in a
sitting but not a supine position. Sci. Rep. 2021, 11, 16369. [CrossRef]
16. Roggio, F.; Trovato, B.; Ravalli, S.; Di Rosa, M.; Maugeri, G.; Bianco, A.; Palma, A.; Musumeci, G. One Year of COVID-19 Pandemic
in Italy: Effect of Sedentary Behavior on Physical Activity Levels and Musculoskeletal Pain among University Students. Int. J.
Environ. Res. Public Health 2021, 18, 8680. [CrossRef]
17. Haroon, H.; Mehmood, S.; Imtiaz, F.; Ali, S.A.; Sarfraz, M. Musculoskeletal pain and its associated risk factors among medical
students of a public sector University in Karachi, Pakistan. J. Pak. Med. Assoc. 2018, 68, 682–688.
18. Pereira, A.S.; Gomes, R.M.; Marques, D.R.; Walker, S.L. Psychometric Properties of the European Portuguese Version of the
Distance Education Learning Environments Survey (DELES). Curr. Psychol. 2021, 40, 367–378. [CrossRef]
19. Kim, H.J.; Boo, S.; Meeker, T.J. Pain Prevalence, Management and Interference Among University Students in South Korea: An
Exploratory Cross-Sectional Study. J. Pain Res. 2021, 14, 2423–2431. [CrossRef]
20. Hoy, D.; March, L.; Brooks, P.; Blyth, F.; Woolf, A.; Bain, C.; Williams, G.; Smith, E.; Vos, T.; Barendregt, J.; et al. The global burden
of low back pain: Estimates from the Global Burden of Disease 2010 study. Ann. Rheum. Dis. 2014, 73, 968–974. [CrossRef]
21. Abbas, J.; Hamoud, K.; Jubran, R.; Daher, A. Has the COVID-19 outbreak altered the prevalence of low back pain among
physiotherapy students? J. Am. Coll. Health 2021, 1–6. [CrossRef] [PubMed]
22. Šagát, P.; Bartík, P.; Prieto González, P.; Tohănean, D.I.; Knjaz, D. Impact of COVID-19Quarantine on Low Back Pain Intensity,
Prevalence, and Associated Risk Factors among Adult Citizens Residing in Riyadh (Saudi Arabia): A Cross-Sectional Study. Int. J.
Environ. Res. Public Health 2020, 17, 7302. [CrossRef]
23. World Health Organization (WHO). Coronavirus Disease (COVID-19); WHO: Geneva, Switzerland, 2020; Available online:
https://www.who.int/health-topics/coronavirus (accessed on 20 November 2022).
24. Murat, S.; Karatekin, B.D.; Icagasioglu, A.; Ulasoglu, C.; Içten, S.; Incealtin, O. Clinical presentations of pain in patients with
COVID-19 infection. Ir. J. Med. Sci. 2021, 190, 913–917. [CrossRef] [PubMed]
25. Harun, Z.; Hamzah, F.M.; Abidin, Z.Z.; Wan Zamri, W.F.H.; Hashim, H. Basic Needs in Online Learning During Covid-19: A
Malaysian Students’ Survey. Asian J. Teach. Learn. High. Educ. 2021, 13, 136.
26. Leirós-Rodríguez, R.; Rodríguez-Nogueira, Ó.; Pinto-Carral, A.; Álvarez-Álvarez, M.J.; Galán-Martín, M.Á.; Montero-Cuadrado,
F.; Benítez-Andrades, J.A. Musculoskeletal Pain and Non-Classroom Teaching in Times of the COVID-19 Pandemic: Analysis of
the Impact on Students from Two Spanish Universities. J. Clin. Med. 2020, 9, 4053. [CrossRef] [PubMed]
27. Yaseen, Q.B.; Salah, H. The impact of e-learning during COVID-19 pandemic on students’ body aches in Palestine. Sci. Rep. 2021,
11, 22379. [CrossRef]
28. Basri, N.F.; Masuri, M.G.; Danis, A.; Isa, S.N.I.; Abd Aziz, N.A.; Isa, K.A.M. Prevalence of low back pain with its associated risk
factors among health science students. In Healthscope: The Official Research Book of Faculty of Health Sciences; UiTM: Shah Alam,
Maleysia, 2021; Volume 4, pp. 51–59.
29. Ferguson, S.A.; Merryweather, A.; Thiese, M.S.; Hegmann, K.T.; Lu, M.-L.; Kapellusch, J.M.; Marras, W.S. Prevalence of low back
pain, seeking medical care, and lost time due to low back pain among manual material handling workers in the United States.
BMC Musculoskelet. Disord. 2019, 20, 243. [CrossRef]
30. Şimşek, Ş.; Yağcı, N.; Şenol, H. Prevalence of and risk factors for low back pain among healthcare workers in Denizli. Agri 2017,
29, 71–78.
31. Mörl, F.; Bradl, I. Lumbar posture and muscular activity while sitting during office work. J. Electromyogr. Kinesiol. 2013, 23, 362–368.
[CrossRef]
32. Argus, M.; Pääsuke, M. Musculoskeletal disorders and associated factors among office workers in an activity-based work
environment. Int. J. Occup. Saf. Ergon. 2022, 28, 2419–2425. [CrossRef]
33. Ekpenyong, C.E.; Daniel, N.E.; Aribo, E.O. Associations Between Academic Stressors, Reaction to Stress, Coping Strategies and
Musculoskeletal Disorders Among College Students. Ethiop. J. Health Sci. 2013, 23, 98–112. [PubMed]
34. Sirajudeen, M.S.; Muthusamy, H.; Alqahtani, M.; Waly, M.; Jilani, A.K. Computer-related health problems among university
students in Majmaah region, Saudi Arabia. Biomed. Res. 2018, 29, 2405–2415. [CrossRef]
Int. J. Environ. Res. Public Health 2023, 20, 342 10 of 10

35. Shan, Z.; Deng, G.; Li, J.; Li, Y.; Zhang, Y.; Zhao, Q. Correlational Analysis of neck/shoulder Pain and Low Back Pain with the
Use of Digital Products, Physical Activity and Psychological Status among Adolescents in Shanghai. PLoS ONE 2013, 8, e78109.
[CrossRef]
36. Nordin, N.A.M.; Singh, D.K.A.; Kanglun, L. Low back pain and associated risk factors among health science undergraduates.
Sains Malays. 2014, 43, 423–428.
37. Brady, S.R.; Hussain, S.M.; Brown, W.J.; Heritier, S.; Billah, B.; Wang, Y.; Teede, H.; Urquhart, D.M.; Cicuttini, F.M. Relationships
Between Weight, Physical Activity, and Back Pain in Young Adult Women. Medicine 2016, 95, e3368. [CrossRef]
38. Harithasan, D.; Singh, D.K.A.; Razak, N.A.B.A.; Baharom, N.B. Personal, Academic Stressors and Environmental Factors
Contributing to Musculoskeletal Pain among Undergraduates Due to Online Learning: A Mixed Method Study with Data
Integration. Int. J. Environ. Res. Public Health 2022, 19, 14513. [CrossRef] [PubMed]
39. Mattioli, A.V.; Puviani, M.B.; Nasi, M.; Farinetti, A. COVID-19 pandemic: The effects of quarantine on cardiovascular risk. Eur. J.
Clin. Nutr. 2020, 74, 852–855. [CrossRef]
40. Mat, S.; Rantai, V.S.a.; Jieh, I.L.S.; Zulkiply, A.N.B.; Bin Amaluddin, A.N.; Bin Mohamed Yusof, N.A.; Ho, W.S.; Bin Mahdzir,
A.N.K.; Nordin, N.A.M.; Mesbah, N.; et al. Depression, Anxiety, And Stress Related to Online Distance Learning (ODL) Does Not
Influence Academic Performance: Findings from An Online Survey Among Undergraduates in Malaysia. Asian J. Teach. Learn.
High. Educ. 2021, 13, 99–112.
41. Grotle, M.; Vøllestad, N.K.; Brox, J.I. Clinical course and impact of fear-avoidance beliefs in low back pain: Prospective cohort
study of acute and chronic low back pain: II. Spine 2006, 31, 1038–1046. [CrossRef]
42. Beneciuk, J.M.; Bishop, M.; Fritz, J.M.; Robinson, M.E.; Asal, N.R.; Nisenzon, A.N.; George, S.Z. The STarT Back Screening Tool
and Individual Psychological Measures: Evaluation of Prognostic Capabilities for Low Back Pain Clinical Outcomes in Outpatient
Physical Therapy Settings. Phys. Ther. 2013, 93, 321–333. [CrossRef]
43. Rahman, A.; Reed, E.; Underwood, M.; Shipley, M.E.; Omar, R.Z. Factors affecting self-efficacy and pain intensity in patients
with chronic musculoskeletal pain seen in a specialist rheumatology pain clinic. Rheumatology 2008, 47, 1803–1808. [CrossRef]
[PubMed]
44. Peters, M.L.; Vlaeyen, J.; Weber, W.E.J. The joint contribution of physical pathology, pain-related fear and catastrophizing to
chronic back pain disability. Pain 2005, 113, 45–50. [CrossRef] [PubMed]

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