IT kids: exposure to computers and adolescents’ neck posture and pain

L. Strakera, P. O’Sullivana, G. Kendallb,c, N. Sloanb, C. Pollockd, A. Smitha and

M. Perrya
a
School of Physiotherapy, Curtin University of Technology, Bentley 6845, Australia
b
Telethon Institute for Child Health Research, West Perth, 6005, Australia
c
School of Nursing, Curtin University of Technology, Bentley 6845, Australia
d
School of Psychology, Curtin University of Technology, Bentley 6845, Australia

Abstract

Musculoskeletal disorders such as neck pain have been related to computer use in adults and an association
between computer use, neck posture and neck pain has been suggested. Computer use in increasing in children and
thus the potential for related neck pain and postural changes is increasing. This study evaluated the neck pain, neck
posture and computer use of 884 adolescents. Over one third (38%) of adolescents reported using computers for > 7
hours per week, with 4.5% reporting > 21 hours per week. Nearly one half (46.7%) reported ever having
neck/shoulder pain, with 7.7% reporting chronic neck/shoulder pain. Computer use was related to neck/shoulder pain
and to neck/shoulder postures. Adolescents who reported no use of computers or high use of computers were about
twice as likely to report neck/shoulder pain as those who reported moderate use of computers (Odds Ratio = 1.79 and
2.51 respectively). Increasing computer use was related to increased head, neck and thorax flexion during usual
sitting (rho=0.069, 0.067 and 0.129, p<.001 respectively). The results demonstrate neck/shoulder pain is a significant
problem in adolescence and the potential impact of computer use needs exploring with longitudinal studies.

Keywords: Neck pain, neck posture, adolescents, computer use

1. Background now spending in excess of 60 minutes a day with a

computer [4].
Children start using computers at an early age. Concerns have been raised that the increased use
We recently reported that over half of Western of computers may be influencing the development of
Australian children used a computer by 5 years of age adolescent musculoskeletal systems [5,6]. In children,
[1]. In earlier reports, 99% of Australian children departures from normal sitting postures have been
between the ages of 11 and 14 had used a computer [2]. observed with computer use [7,8]. These findings are
Not only are the majority of children in affluent supported by adult studies showing that computer
countries using computers, they experience substantial display position influences head and neck posture
exposure to computer use by the end of adolescence. In during computer use [9]. These temporary postural
a meta-analysis of studies mainly from Europe and changes may extend to changes in habitual postures,
North America, Marshal et al. [3] found the mean daily though this issue has yet to be examined.
exposure to computers to be 34 minutes. More recent There has been little work linking specific
data suggests this is rising rapidly, with USA children cervical postures with neck pain in children. Hertzberg
[12] noted an association between neck pain and 2. Method
“postural deviations” but these were not specified.
Adolescents have been reported to perceive posture as 2.1. Design
the major contributor to neck pain [13] but this may
simply reflect lay beliefs. Although fixed sitting The study was a cross sectional survey involving
postures have been associated with neck pain in 11-14 questionnaires on computer use and neck/shoulder pain
year olds [14], no such association was found in a and photographic assessment of usual sitting posture.
study of 8 year olds [15]. However, neck and shoulder
pain has been associated with certain neck postures in 2.2. Participants
adults [16,17,18] and there is minimal conflicting
evidence [19,20]. It is believed that certain postures 884 adolescents with a mean (sd) age of 14.01
may invoke pain through higher neck muscle forces (0.24) years were included in the study. The
[21] or neck extensor muscle activity [22]. adolescents were part of a longitudinal cohort (the
There have also been concerns raised that the Raine Study) of 2,000 children, followed since 18
increasing use of computers may put children at higher weeks gestation. 476 (53.8%) of the participants were
risk of neck/shoulder problems – such as those male. This cohort is described in detail by Newnham et
commonly seen in adult computer users [6,23]. al. (1993). The mean height was 1.64 (0.08)m and
Computer use may have a direct link to increased risk mean weight was 56.95 (12.41)kg.
for neck/shoulder problems, or an indirect link via
changes in habitual postures. 2.3. Variables
Niemi et al. [24] observed that activities
involving static loading of the upper extremities, such Exposure to computers was measured in a
as computer use, were associated with neck pain in questionnaire completed by each participant using the
children, and Ramos et al. [25] demonstrated a positive following question: On average, how many hours a
link between neck pain and the amount of computer use week do you usually use a computer, e.g. play video or
at school. Moreover, Hakala et al. [26] argued that the computer games, use the Internet or chat on line
increase in adolescent neck prevalence rates between (including school days and weekends)? Possible
1991 and 2001 was due to the increased use of answers were: “none at all”, “up to 7 hours a week”,
computers. However, Van Gent et al. [27] and Burke “7-14 hours per week”, “14-21 hours per week”, or “21
and Peper [28] found no association between computer or more hours per week”.
use and neck pain in children, and so further work is The questionnaire also gathered information on
required in this area. the prevalence and nature of neck/shoulder pain using
Neck pain is surprisingly common in yes/no responses to the following questions:
adolescents, with a lifetime prevalence of around 13% 1. Have you ever had neck and shoulder pain?
at 13 years of age [29]. Annual prevalences around 2. Is your neck and shoulder painful today?
18% [24,30] and month prevalences ranging from 8.8% 3. Has your neck and shoulder been painful in the
[31] to 53% [18] have been reported for 10 to 18 year last month?
olds. No data on point prevalences of adolescent 4. Did your neck and shoulder pain last for more
neck/shoulder pain have been reported. In general, the than 3 months?
prevalence in adolescence approaches reported adult Possible answers were “yes” or “no” for
values (for example annual adult prevalences range question 1 and “yes”, “no” and “never had back/neck
from 16% [32] to 34% [33]. pain” for the other questions.
The aim of this study was to determine whether Usual sitting posture was assessed by placing
the computer exposure of 14 year olds was related to retro-reflective markers on the right outer canthus, right
poorer usual sitting head and neck postures and to external auditory meatus (EAM), C7 spinous process,
reports of neck/shoulder pain. right acromion process, T12 spinous process. Lateral
photographs were taken with each child sitting on a
stool (adjusted to their popliteal height) and looking
straight ahead and looking down at their lap. Marker
points were digitised using PEAK motion analysis
system and head/neck/thorax angles calculated. Angles
are defined in Table 1.
Table 1
Definitions of Postural Angles

Name Angle definition

Head flexion Line of canthus to EAM with vertical
(measured from vertical above intersect)
Neck flexion Line of EAM to C7 with vertical
(measured from vertical above intersect)
Craniocervical angle Line of canthus to EAM with line of EAM
to C7 (measured anterior to intersect)
Cervicothoracic Line of EAM to C7 with line of C7 to T12
angle (measured anterior to intersect)
Thoracic flexion Line of C7 to T12 with vertical (measured
from vertical above intersect)

2.4. Analyses

SPSSv13 was used to calculate descriptive

statistics and examine relationships using spearman,
chi-square, logistic regression and unpaired t tests.

2.5. Ethics Fig. 2: Association of neck pain ever with weekly use of
computers
The study was approved by the ethics
committees of Curtin University of Technology and thoracic angle of 134.8° (9.2) and thoracic flexion of
Princess Margaret Hospital for Children. 24.2 (11.3).

3.3. Neck pain

3. Results
Nearly half (46.7%) of these adolescents
3.1. Computer use reported ever having neck/shoulder pain; 28.0%
reported pain in the last month, 4.7 reported pain today
Thirty-eight percent of adolescents reported and 7.7% reported chronic neck/shoulder pain (lasted
using a computer for more than 7 hours/week (~>1 >3 months). Only around 1% of the adolescents had
hour/day on average), with 4.5 % reporting more than missing data for these variables.
21 hours/week (~>3 hours/day) (See Fig. 1).
3.4. Computer use – Pain Relationship
3.2. Posture
Computer use was related to reports of ever
When adolescents were sitting looking straight having neck/shoulder pain (Chi square = 12.6, p =
ahead they had a mean (sd) head flexion of 71.9° (9.3) , .002) as shown in Figure 2. Adolescents who did not
neck flexion of 51.9° (8.6), cranio-cervical angle of use a computer had significantly increased probability
160.1° (11.7), cervico-thoracic angle of 149.7° (8.0) of developing neck pain as compared to those subjects
and thoracic flexion of 22.1 (10.9). When adolescents who used a computer for 1-21 hours/week (p = 0.015,
were looking down at their hands in their lap they had a (Odds Ratio) = 1.79, 95%CI: 1.12-2.85). Similarly,
head flexion of 106.4° (13.0) , neck flexion of 68.9°
(10.9), cranio-cervical angle of 142.6° (11.3), cervico-
Figure 1 Weekly use of computers.
 Fig. 4: Exaggerated illustration of the reduced head flexion
Fig. 3: Association of thoracic flexion with weekly use of
and thoracic flexion postures of adolescents with pain (dotted
computers
line) compared with adolescents with no pain (solid line)
adolescents who used a computer more than 21
A large proportion of the adolescents reported
hours/week had significantly increased probability of
considerable weekly exposures to computers (>7
developing neck pain as compared to those who used a
hours/week), in line with international estimates [3,4].
computer for 1-21 days per week (p = 0.008, Exp(β)
Computer use is clearly a significant activity for
(Odds Ratio) = 2.51, 95%CI: 1.27-4.96).
adolescents in affluent countries and thus its impact on
health and development needs to be understood.
3.5. Computer use – Posture Relationship
One in twenty adolescents had neck/shoulder
Computer use was also related to greater head pain on the day of assessment, and nearly half had
flexion (rho=0.069, p=.043), neck flexion (rho=0.067, experienced this pain at some time. The high
p=.049), cervico-thoracic angle (rho=0.102, p=.003) prevalence of neck/shoulder pain in young people is
and thoracic flexion (rho=0.129, p<.001), though not to poorly recognised by the community and also warrants
cranio-cervical angle (rho=-0.003, p=0.926). Figure 3 close inspection. Early experiences of neck/shoulder
illustrates the increased thoracic flexion with increasing pain are linked to adult pain experience [34] and thus
use of computers. initiatives to understand and prevent episodes in
adolescents are important to reducing the population
3.6. Posture – Pain Relationship burden of neck/shoulder pain.
This is the first study to investigate the links
Adolescents who had ever had neck/shoulder between habitual neck posture and the amount of
pain had less head flexion (pain 71.0° (8.8), no pain computer use in adolescents. Previous research has
72.5° (9.6), tdf=2.38862, p=0.018), a more acute established that computer use has been shown to
cervicothoracic angle (pain 148.8° (7.8), no pain influence instantaneous working posture in both
150.4° (8.1), tdf=2.98859, p=0.003) and less thoracic children [7] and adults [9,10,11]. The positive
flexion (pain 21.3° (10.8), no pain 22.7° (10.9), relationship between weekly computer use and
tdf=1.92859, p=0.055) than those with no experience of increased flexion in usual sitting postures suggests that
neck/shoulder pain (see Figure 4). the postures assumed whilst using computers may
promote the development of more flexed spinal
postures. During adolescence, growth in spinal
4. Discussion structures is especially rapid [35] and thus exposure to
flexed static postures may be of increased significance
Most (90.8%) of the 14 year olds in this study during adolescence. Adolescence is also a time
reported that they used a computer. This is lower than associated with other factors which may cause postural
ABS figures [2] based on 11-14 year olds, probably changes including: increased studying from paper
due to our data being based on average weekly usage, sources, psychosocial issues associated with sexual
rather than having used a computer in the last year. maturity and participation in competitive sports. It has
been suggested that neck flexion may not be as adolescents and the lifetime prevalence of
damaging as extension [9] but findings in adults neck/shoulder pain was high. Computer use was related
suggest that increased neck flexion [16,18,36] or to their experience of neck/shoulder pain and to their
forward head posture [36] are related to neck pain. usual sitting posture.
Our findings are consistent with Ramos et al.
[25] who also found a significant relationship between
computer use and neck/shoulder pain in adolescents. Acknowledgements
However these findings are in contrast to Van Gent et
al. [27] and Burke and Peper [28] who did not find a We would like to acknowledge funding from the
relationship. The conflicting results may be due to Australian National Health and Medical Research
differences in definitions of pain and measurement of Council (project # 323200), the Raine Foundation at
computer use. For example, Burke and Peper [28] only the University of Western Australia, Healthway, the
measured computer use on Saturdays, and neck pain Arthritis Foundation of Australia, and the Arthritis
that was perceived by the subject as being due to Foundation of Western Australia
computer use, thus possibly missing out on other
occurrences of neck pain that might have related to
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