Abstract
BACKGROUND:
Students increasingly rely on digital devices, leading to text neck syndrome, a common overuse syndrome caused by repetitive forward neck flexion.
OBJECTIVE:
This study aimed to determine the prevalence of text neck syndrome among medical students and the resulting neck dysfunction and to investigate the possible associated factors.
METHODS:
This cross-sectional study used an online self-developed questionnaire among medical students. Students’ characteristics and data about smartphone usage were evaluated for diagnosis. Individuals with at least 3 of the 6 text neck syndrome symptoms and a history of more than four hours a day spent on a smartphone were diagnosed with text neck syndrome. Neck dysfunction was measured using the neck disability index. Descriptive statistics and the chi-square test were used. P values < 0.05 were considered statistically significant.
RESULTS:
The study found that 31.7% of students with text neck syndrome have mild neck disabilities, with a higher proportion of females (40%). The characteristics that have a significant relation to text neck syndrome include being female (p < 0.0001), overweight (p = 0.025), being right-handed (p = 0.001), using four digital devices or more (p = 0.002), having low levels of physical activity (P = 0.018), and spending more than three hours a day sitting down (P = 0.027).
CONCLUSION:
More than a quarter of medical students had text neck syndrome, and most of them had a mild neck disability. Text Neck Syndrome was linked to an increased number of gadgets used, low exercise, and more time spent in a sitting position.
Keywords: Exercise, medical students, neck, overuse syndrome, sitting position, smartphone
1. Introduction
Neck pain is a concerning and rising health problem that leads to a significant economic burden, disability, and discomfort among different age groups [1]. It is the fourth most common health disorder causing humans to live with a disability [2] and the second most common musculoskeletal disease following lower back pain [3].
The sedentary and inactive lifestyle of the 21st century and the long time people spend in head flexion staring at their digital devices either at work or in their leisure time are two factors that contribute to the onset of neck pain [4]. In addition, in the era of advanced technology, with more updates and developments on smartphones and other digital devices such as tablets and laptops, people spend more than half of their time using these devices, [5, 6] leading to the development of a cluster of clinical symptoms collectively known as Text Neck Syndrome (TNS). The term TNS describes an overuse syndrome while flexing a head person in a forward position and tilting down to look at his digital device for prolonged periods. Clinically, TNS manifests with many symptoms, including headaches, neck discomfort, shoulder pain, arm pain, and back pain [7]. Disc compression, disc herniation, cervical radiculopathy, and irreversible nerve or muscle injury are just a few of the dire effects that might result [8, 9].
TNS is a widespread health issue that is now often reported, with varying prevalence among various age groups. It is more prevalent in adolescents as well as in students who use their smartphones more frequently [10–13]. Previous studies on the prevalence of TNS among students have been conducted in several nations. In 2021, a study was conducted in India, 46% of students reported neck pain during prolonged smartphone use [14]. In 2018, another study was conducted among physiotherapy students, TNS had a prevalence of 32% [15]. A higher prevalence was reported among medical students in 2019 : 43.6% of Pakistani medical students, [9] 64.5% of Iraqi medical students in 2015, [16] and 68.1% of Saudi Arabia in 2022 [8].
Some studies have investigated the correlation between many risk factors while using digital devices and neck pain. A study conducted in 2022 found that sitting and resting on a chair’s backrest provided the optimal head and neck tilt angles, and the forward head posture was the most undesirable while seated on a chair without a backrest [17]. According to a study conducted in 2021, there was a substantial correlation between smartphone usage duration and NDI ratings. Furthermore, 69.9% of students who used their phones for 5 hours or more and 77% of students who used them for 4–5 hours had a neck problem [13]. In 2018, another study focused on the prevalence of various TNS causes among medical undergraduates and concluded that the majority of students had neck discomfort that was made worse by using a smartphone or other digital devices and when they did not warm up before using a device [18].
Other studies conducted in 2017 and 2021, established an association between the Smartphone Addiction Scale (SAS) and Neck Disability Index (NDI), having a higher SAS score, which indicates excessive smartphone use, has been associated with a significantly higher risk of experiencing other musculoskeletal symptoms, such as neck/shoulder discomfort, upper back discomfort, arm discomfort, and wrist/hand discomfort [19, 20].
Given the significance of TNS and its associated impact, there is a scarcity of research on its associated factors. The present study is the first in Jordan to investigate the prevalence of TNS among smartphone users in medical students and the impact of TNS on neck dysfunction and the first to determine the correlation between TNS and many postural- and ergonomic-associated factors. Furthermore, the correlation between TNS and other categorical factors was examined, such as demographics, digital device usage patterns, degree of physical activity, sitting duration, and neck tilting.
Our hypothesis might state a difference in the risk of developing TNS between sex, BMI, handedness, the preferred hand used to hold/type on the smartphone, number of used digital devices, time spent using a smartphone (hour/day), taking breaks while using a smartphone (hour), level of physical activity, length of sitting, neck tilting, and ergonomics.
2. Methods
2.1. Study design and participants
Participants were recruited from six public universities in Jordan. This cross-sectional study was carried out from November to December 2022. The study inclusion criteria focused on interns, residents, and undergraduate medical students between the ages of 17 and 31, being a smartphone user for a year or more, and using a smartphone minimally one hour per day.
Exclusion criteria for the study included anyone with a condition that causes neck or upper limb pain, such as traumatic injuries, surgeries, congenital deformities, or any neurological, rheumatic, musculoskeletal, or cardiorespiratory diseases.
Students were invited to participate in an online survey, and a self-administered questionnaire was distributed on Google Forms via social media and official student groups. Participation was voluntary, and participants were asked in the questionnaire if they agreed to participate and filled out the survey as their consent. The local ethics committee at the Faculty of Medicine approved this study on Oct 22, 2022.
2.2. Questionnaire and scale for assessment
A semi-structured self-developed questionnaire that was in English with a combination of short-answer and multiple-choice questions consisting of six sections. In Section One are the study’s objectives, inclusion and exclusion criteria, and a brief explanation of the research. Participants’ sex, height, weight, handedness, and preferred hand for holding/typing on the smartphone were all included in section two. Sections three and four measured behavioral patterns in digital device usage such as daily hours spent on smartphones, having break time while using it, the level of physical activity, daily time spent sitting, degree of neck tilt while using a smartphone, and ergonomic measures. Physical activities were categorized into vigorous physical activity (such as lifting heavy objects, cycling, or running), moderate physical activity (such as carrying light weights or riding a stationary bike at a regular pace), and low physical activity (such as free body exercises with or without the use of tools, for example, elastic bands or dumbbells, in addition to separate exercises and treadmills). The categories of physical activity were centered on intensity rather than energy expenditure because this study was primarily concerned with qualitative measures. Ergonomic measures included chairs with back and arm supports and digital device holders. Section five included two questions to determine if the participant had TNS. According to the literature, the subjects who used to spend more than four hours/day using a smartphone and had at least 3 out of 6 TNS symptoms, including neck pain, upper back pain, shoulder pain, headache, insomnia, and tingling or numbness in hands, were vulnerable to having TNS [21, 22]. Section six measured the effects of neck pain and symptoms during a range of functional activities using the NDI. This index is the most often used for evaluating patients’ self-rated disability due to neck pain and the most thoroughly validated tool, where concurrent validity on 30 subjects showed moderately high correlations (0.69–0.70), with a high degree of reliability (Pearson’s r = 0.89) [23]. It involves ten items, the maximum score for the test is 50, and it is scored in raw form. Greater neck disability is indicated by a higher NDI score. The questionnaire was validated by content; it was reviewed by two experts in medical health, in addition, it was sent to 60 students (as a pilot study) for identification errors and misunderstood questions.
2.3. Sample size estimation
The minimal sample size was estimated before the study using an online sample size calculator (https://www.calculator.net/sample-size). Based on the population of 24000 (medical students, interns, and resident doctors), a 50% population proportion, a 5% margin of error, and a 95% confidence level. Using this calculator, a minimum sample size of 379 subjects was considered representative enough for this study, and using the equation of adjusted sample size, calculated sample size/(1 – dropout rate), a target of 421 subjects was set to compensate for a dropout rate of 10%.
2.4. Statistical analysis
SPSS version 22 (Statistical Package for Social Sciences 22.0) was used for data analysis. Pearson’s chi-square test and Fisher’s exact test were used to investigate correlations between the associated factors influencing TNS. P values less than 0.05 were considered statistically significant.
3. Results
3.1. Participants’ characteristics
Five hundred and fifty medical students and doctors from all six medical colleges around the kingdom participated in this study. Participants who did not meet the study criteria and those who provided incomplete responses were excluded, leaving 463 responses in the final analysis. The participants’ mean age was 21.02±2.04, with 302 (65.2%) females and 161 (34.8%) males and a male-to-female ratio of 1 : 1.9. Most of the participants were medical students from BAU (47.9%), while the rest were from University of Jordan (JU), the Hashemite University (HU), Jordan University of Science and Technology (JUST), Yarmouk University (YU), and Mutah University (MU). Almost half of the participating students were at the basic level (50.5%), while 49.5% were at the clinical, intern, and residency levels. The majority of the participants had healthy weight (61.1%), were right-handed (84.7%), used their dominant hand to hold a smartphone (54.6%), and used two or three digital devices (81.6%). The data are summarized in Table 1.
Table 1.
Participants’ characteristics
| Participants | n = 463 |
| Sex | n (%) |
| Female | 302 (65.2) |
| Male | 161 (34.8) |
| BMI level | |
| Underweight | 39 (8.4) |
| Healthy weight | 283 (61.1) |
| Overweight | 101 (21.8) |
| Obese | 40 (8.6) |
| Handedness | |
| Right-handed | 392 (84.7) |
| Left-handed | 71 (15.3) |
| The preferred hand used to hold/type on the smartphone | |
| Dominant hand | 253 (54.6) |
| Both hands | 210 (45.4) |
| Number of used digital devices | |
| 1 | 62 (13.4) |
| 2–3 | 378 (81.6) |
| ≥4 | 23 (4.9) |
3.2. Behavioral patterns during the usage of digital devices
The majority of users (80.4%) spent more than 4 hours each day on their digital devices, and a maximum of 35.2% of students took a break every 2 hours or more while using their digital devices (Table 2).
Table 2.
Participants’ behavioral patterns in digital device usage, level of physical activity, and ergonomic measures
| Variables | n (%) | |
| Time spent on digital devices (hour/day) | ||
| <4 | 91 (19.7) | |
| ≥4 | 372 (80.4) | |
| a break time during smartphone usage (hour) | ||
| <2 | 300 (64.8) | |
| ≥2 | 163 (35.2) | |
| Level of physical activity | ||
| Low | 259 (55.9) | |
| Moderate and Vigorous | 204 (44.1) | |
| Time spent in a sitting position (hour/day) | ||
| <3 | 51 (11) | |
| ≥3 | 412 (89) | |
| Degree of neck tilting during the usage of a smartphone | ||
| No tilting | 11 (2.4) | |
| Moderate tilting | 288 (62.2) | |
| Heavy tilting | 164 (35.4) | |
| Ergonomics | Yes | No |
| Use a chair with an armrest | 267 (57.7) | 196 (42.3) |
| Use a chair with a backrest | 152 (32.8) | 311 (67.2) |
| Use a smartphone or tablet holder | 116 (25.1) | 347 (74.9) |
3.3. Level of physical activity, time spent sitting, and neck tilting
Regarding physical activity, more than half of the participants (55.9%) reported a low level of physical activity, 89% spent more than 3 hours sitting, and 62.2% used a moderate tilt of their necks (Table 2).
3.4. Ergonomic measures
Of all participants, 57.7% used a chair with an armrest, and 32.8% used a chair with a backrest. In addition, only 25.1% used smartphones or tablet holders, and the results are shown in Table 2.
3.5. Prevalence of text neck syndrome
The total number of students who had TNS was 147 (31.7%). Out of all, 121(40.1%) were females and 26 (16.1%) were males (Table 3).
Table 3.
Prevalence of Text Neck Syndrome and the factors associated with
| Variables | No TNS, n = 316, n (%) | Having TNS, n = 147, n (%) | Total, n (100%) | Sig. | Adjusted p-value |
| Sex | |||||
| Female | 181 (59.9) | 121 (40.1) | 302 | < 0.0001** | 0.000 |
| Male | 135 (83.9) | 26 (16.1) | 161 | 0.000 | |
| BMI | |||||
| Underweight | 29 (74.4) | 10 (25.6) | 39 | 0.025* | 1.000 |
| Normal weight | 199 (70.3) | 84 (29.7) | 283 | 1.000 | |
| Overweight | 57 (56.4) | 44 (43.6) | 101 | 1.000 | |
| Obese | 31 (77.5) | 9 (22.5) | 40 | 1.000 | |
| Handedness | |||||
| Right-handed | 256 (65.3) | 136 (34.7) | 392 | 0.001** | |
| Left-handed | 60 (84.5) | 11 (15.5) | 71 | ||
| The preferred hand used to hold/type on the smartphone | |||||
| Dominant hand | 172 (68) | 81 (32) | 253 | 0.893 | |
| Both hands | 144 (68.6) | 66 (31.4) | 210 | ||
| Number of used digital devices | |||||
| 1 | 42 (67.7) | 20 (32.3) | 62 | 0.002** | |
| 2–3 | 266 (70.4) | 112 (29.6) | 378 | ||
| ≥4 | 8 (34.8) | 15 (65.2) | 23 | ||
| Time spent using a smartphone (hour/day) | |||||
| <4 | 68 (75.6) | 22 (24.4) | 90 | 0.097 | |
| ≥4 | 248 (66.5) | 125 (33.5) | 373 | ||
| Taking breaks while using a smartphone (hour) | |||||
| <2 | 208 (69.3) | 92 (30.7) | 300 | 0.497 | |
| ≥2 | 108 (66.3) | 55 (33.7) | 163 | ||
| Level of physical activity | |||||
| Low | 165 (63.7) | 94 (36.3) | 259 | 0.018* | |
| Moderate and Vigorous | 151 (74) | 53 (26) | 204 | ||
| Time spent in a sitting position (hour/day) | |||||
| <3 | 41 (82) | 9 (18) | 50 | 0.027* | |
| ≥3 | 275 (66.6) | 138 (33.4) | 413 | ||
| Degree of neck tilting during the usage of a smartphone | |||||
| No tilting | 9 (81.8) | 2 (18.2) | 11 | 0.131 | |
| Moderate tilting | 204 (70.8) | 84 (29.2) | 288 | ||
| Heavy tilting | 103 (62.8) | 61 (37.2) | 164 | ||
| Ergonomics | |||||
| Use a chair with an armrest | |||||
| Yes | 179 (67) | 88 (33) | 267 | 0.579 | |
| No | 137 (69.9) | 59 (30.1) | 196 | ||
| Use a chair with a backrest | |||||
| Yes | 96 (63.2) | 56 (36.8) | 152 | 0.1 | |
| No | 220 (70.7) | 91 (29.3) | 311 | ||
| Use a smartphone or tablet holder | |||||
| Yes | 85 (73.3) | 31 (26.7) | 116 | 0.179 | |
| No | 231 (66.6) | 116 (33.4) | 347 |
*Indicates p < 0.05; **indicates p < 0.01.
3.6. Impact of text neck syndrome on neck disability
Out of 147 participants who had TNS, 135 (91.8%) had neck disability, 114 (77.6%) were females and 21 (14.2%) were males. On the other hand, only 12 (8.2%) had no neck disability, 7(4.8%) were females and 5 (3.4%) were males (Table 4).
Table 4.
Neck Disability Index among Students with Text Neck Syndrome
| TNS | ||||
| NDI | Female, n (%) | Male, n (%) | Total, n = 147 | Sig. |
| No Disability | 7 (4.8) | 5 (3.4) | 12 (8.2) | 0.038* |
| Having Disability | 114 (77.6) | 21 (14.2) | 135 (91.8) | |
| Degree of Disability | ||||
| Mild Disability | 85 (70.2) | 15 (57.7) | 100 (68) | |
| Moderate Disability | 26 (21.5) | 6 (23.1) | 32 (21.8) | |
| Severe disability | 3 (2.5) | 0 | 3 (2) | |
| Complete disability | 0 | 0 | 0 | |
*Indicates p < 0.05.
As illustrated in Table 4 participants’ scales of the NDI showed varying degrees of neck disability; most of them had a mild disability (68%), a lower proportion had moderate disability (21%), and only 2% had a severe disability. In contrast, no one had a complete disability. Using Fisher’s exact test, NDI was associated with sex (P = 0.039), where females had a higher proportion than males (Table 4).
3.7. Factors associated with text neck syndrome
Very significant associations were found between sex and TNS (p < 0.0001). Furthermore, BMI level (p = 0.025), handedness (p = 0.001), the number of digital devices used (p = 0.002), level of physical activity (p = 0.018), and time spent sitting (p = 0.027) were significantly correlated with TNS. Contrary to the preferred hand to use the smartphone (p = 0.893), it was not significantly associated with TNS. Additionally, no significant associations were found between the time participants spent using digital devices, break time taken while using a smartphone, neck tilting, or ergonomics (P > 0.05), as shown in Table 3.
4. Discussion
This study aimed to identify the prevalence of TNS among medical students, which was found to be 31.7%. This is consistent with the results of a study conducted in Navi Mumbai, India 2020 (32%) [24]. In contrast, studies from different countries, such as Haryana, India 2021 (46.9%), Iraq 2022 (64.5%), and Saudi Arabia 2021 (68.1%), have reported higher prevalence rates [14, 16, 13]. Our prevalence of TNS is still in the range obtained from a recent systematic study conducted in 2021 in Hong Kong, which found that using a smartphone frequently was associated with a significant prevalence of musculoskeletal issues, ranging from 3% to 67.8% for neck problems [25]. Studies carried out in 2020 and 2021 confirmed the hypothesis that the rising reliance of educational institutions on electronic devices for a variety of functions is the direct cause of the high prevalence of TNS [24, 25]. Another study in central India conducted in 2020 believes that medical students are more susceptible to TNS because of the high levels of stress they face [26]. Another study conducted in 2021 found that several risk factors for developing musculoskeletal neck pain have been identified as contributing to the development of the condition. One of these is bending the head, neck, and shoulders during the usage of mobile and other portable devices, which could lead to distorted neck positions while studying and sitting and, as a result, can cause great cervical spine stress [27].
In our study, most of the students who experienced TNS reported mild neck disability (68%), which aligns with the results of many previous studies that also reported the highest prevalence of mild neck disability but with different proportions. A previous study revealed a prevalence of 49.5% of mild neck disability [13], which is equal to the prevalence reported in a similar study conducted in Iraq [16]. However, a study in Pakistan reported a much lower prevalence (30%) of mild disabilities [9].
This study demonstrated a significant relationship between sex and TNS, suggesting that females were more vulnerable to TNS than their male counterparts, and females had a significantly higher proportion of developing neck disability than males. Our findings were consistent with several studies that showed an association between sex and NDI [10, 15], these findings can be explained by the finding of another study, which showed that females use their phones more frequently compared with males [28].
Neck pain has a multifactorial origin, and one of the factors that can influence it is BMI, and that a statistically significant association was found in our study, participants with an overweight BMI were significantly more likely to develop TNS. Our findings were consistent with a study conducted among Iranian adults in 2017, where they found that BMI ≥25 was considered a risk factor for developing chronic neck pain [29].
The level of physical activity significantly affected the likelihood of developing TNS. This finding is consistent with a previous study demonstrating that regular exercise lowers the risk of developing neck discomfort [30]. On the other hand, individuals who had a sedentary lifestyle were found to be more vulnerable to neck pain, highlighting the potential advantage of physical activity in preventing neck disorders [31].
When correlating smartphone usage time and having TNS, our study has shown results similar to a study by Hae-Jung Lee, with no significant correlation [32]. In contrast, a study by Alsiwed found that the heavy use of smartphones was significantly correlated with TNS [13]. Furthermore, our study showed no statistically significant association between break time taken while using a smartphone and TNS.
The degree of neck tilt using digital devices is one of the most well-established factors associated with TNS. Nevertheless, in our study, the association between the degree of neck tilt and the likelihood of developing TNS was not significant. Our findings differ from earlier studies, including a systematic review in which a flexed cervical spine during sitting has been proven to place a mechanical demand on neck muscles 3–5 times that of a neutral neck posture [26]. In contrast, a study conducted in Rio de Janeiro found no correlation between neck posture and neck discomfort when it was assessed by physiotherapists or by self-report, which could be because the sample of their study was inadequate. The confidence interval was too wide to make any inference [33].
The current study revealed new significant findings among students with TNS; most of them used 4 digital devices or more, were right-handed, and spent more than 3 hours using their digital devices. More gadgets used means more time spent sitting, and the more hours students spent sitting, the more unaware they were of their posture, suggesting that they might have poor posture in sitting, which in turn had a profoundly negative effect on the musculoskeletal system. More studies are needed to support these new findings and to be applied to a more generalized population.
4.1. Limitations
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•
The sample of this study was medical students from different colleges, it would be better to include other college students in the study for greater generalizability.
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Since this is a questionnaire-based study, there was no TNS investigation conducted on the study subjects, and underreporting of TNS cases is a possibility.
5. Conclusion
To the best of the author’s knowledge, this study will be the first to shed light on the prevalence of TNS among medical students in Jordan. Our findings suggest that most students with TNS developed mild neck dysfunction. Furthermore, this study found many factors associated with TNS, such as the number of digital devices used, level of physical activity, and time spent sitting.
Acknowledgments
We would like to extend our sincere gratitude to Rama T. Alzu’bi and Abeer B. Suleiman for their invaluable assistance in the data collection process.
Ethical approval
Name of the institute: Al-Balqa Applied University, Approval date: Oct 22, 2022, Approval #: NA
Informed consent
At the beginning of the questionnaire, participants were asked if they agreed to participate and filled out the survey as their consent.
Conflict of interest
The authors declare that they have no conflict of interest.
Funding
The authors report no funding
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