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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 31  |  Issue : 2  |  Page : 119-126

Prevalence and patterns of musculoskeletal pain among school students in Puducherry and its association with sociodemographic and contextual factors


1 Department of Epidemiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Centre for Chronic Disease Control, New Delhi, India
3 Surveillance Medical Officer, World Health Organization, India
4 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication6-Sep-2017

Correspondence Address:
Anindo Majumdar
Centre for Chronic Disease Control, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon - 122 002, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_26_17

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  Abstract 

Background: Limited data exist in India regarding burden of musculoskeletal pain (MSP) in school children. Objectives: The objective of this study is to determine the prevalence and patterns of MSP, to find out the association of sociodemographic and contextual factors with MSP, and to report the association of MSP-related characteristics and bag weight with school attendance. Material and Methods: It was a cross-sectional study conducted among 7th and 8th grade students of a private school in urban Puducherry. Students who could ambulate independently and stand on the weighing scale were included in this study. Previously diagnosed self-reported pathological causes of MSP were excluded from the study. A self-administered questionnaire was used for data collection. Height and weight were measured along with weight of student's backpack. Results: A total of 327 students were enrolled, majority (67%) being boys. Mean age of participants was 12.7 (standard deviation ±0.7) years. About 86% (282 out of 327) participants had experienced MSP in the preceding 2 weeks. Shoulders, neck, and knees were the parts reported to have maximum pain, i.e., in 43.6%, 39%, and 34.8% of the participants, respectively. A high proportion, i.e., 96% of the school bags weighed more than 10% of body weight. Significant association of MSP was found with participants' grade of study (P = 0.04), perception of bag weight (P = 0.01), comfort level of carrying bag (P < 0.01), and duration of carrying bag (P < 0.01). Factors such as pain affecting daily activities (P < 0.01) and number of health-care consultations (P < 0.01) were significantly associated with school attendance (P < 0.05). Conclusion: The prevalence of MSP in school children was high. Associated sociodemographic and contextual factors should be addressed urgently.

Keywords: Factors, India, musculoskeletal pain, prevalence, school students


How to cite this article:
Parthibane S, Majumdar A, Kalidoss VK, Roy G. Prevalence and patterns of musculoskeletal pain among school students in Puducherry and its association with sociodemographic and contextual factors. Indian J Pain 2017;31:119-26

How to cite this URL:
Parthibane S, Majumdar A, Kalidoss VK, Roy G. Prevalence and patterns of musculoskeletal pain among school students in Puducherry and its association with sociodemographic and contextual factors. Indian J Pain [serial online] 2017 [cited 2019 Sep 20];31:119-26. Available from: http://www.indianjpain.org/text.asp?2017/31/2/119/214117


  Introduction Top


The World Health Organization (WHO), after realizing the potential of musculoskeletal disorders to impair the health of societies at large, declared the years 2000–2010 as a bone and joint decade.[1] Musculoskeletal complaints including musculoskeletal pain (MSP) were largely neglected till recent times owing to their nonfatal nature. In recent times, studies have shown that rheumatic musculoskeletal symptoms are the most common morbidities among the Indian communities with prevalence ranging from 7.08% to 33.09%.[2],[3],[4],[5]

There are 132 million children going to school in India.[6] Studies among Indian school going children have reported the prevalence of MSP to range between 55% and 86%.[7],[8],[9],[10] MSP among school going children has become a new area of concern, due to its direct and indirect effects on health. This is because it is this particular age when vertebral column continues to grow and any kind of unbearable stress on the musculoskeletal system can have detrimental consequences in child's later life.

In recent years too, the issue of schoolchildren carrying heavy school bags has been raised in both India and abroad. Following this, several countries and states have put forth recommended levels of schoolbag weight carriage, for schoolchildren. It recommends for bags to weigh <10% and could be up to 15% of the child's body weight.[11] According to Children Schoolbags Act in India, schoolchildren should not carry bags weighing more than 10% of their body weight.[12] However, several studies and reports have revealed that 30%–50% of school going children carry bags that are more than the recommended bag weight levels.[13],[14],[15],[16] In India, 54%–91% of schoolchildren carry bags that are above the recommended bag weight carriage levels.[10],[17],[18] Earlier studies have reported that private school students carry heavier bags compared to government school students.[19] Significant relationships have also been observed between heavy school bag, and educational failure, school absenteeism, lack of motivation and learning among the school going children.[20]

Limited literature exists in India regarding the burden of MSP and its associated factors among school children. A good understanding of this issue is a prerequisite for taking decisions on policy change, prevention, early diagnosis, and treatment of musculoskeletal problems. Therefore, this study was set with the primary objective of determining the prevalence and patterns of MSP among school students carrying school bags. The secondary objectives were to find out the association between demographic and contextual factors with MSP and to report the association of MSP-related characteristics and bag weight with school attendance among the students.


  Material and Methods Top


The present study was a cross-sectional study conducted among the 7th and 8th grade high school students of a private higher secondary school located in urban Puducherry, using an anonymous self-administered questionnaire. The study duration was from November 2015 to April 2016. The school was selected as per the convenience of the research team. The assumption for selecting a private school from urban area was that students of private schools are often under great academic pressure, leading to the students carrying heavy bags, which in turn leads to MSP and other health ailments.

We included 7th and 8th grade students of the school. Each grade had five batches, and three batches were selected randomly under each grade. A sample size of 325 was arrived using an assumed prevalence of 24.4%,[21] absolute prevalence of 5%, and an additional 10% for nonresponse or refusal to consent for the study. The criteria for including students were being in 7th or 8th grade, student's consent, ability to ambulate independently, and able to stand on weighing scale with schoolbag. Those having previously diagnosed self-reported pathological causes of MSP were excluded from the study.

The data collection was done in March 2016 on randomly selected days in a week. The data was collected in batches during the morning hours. Prior permission for the study was obtained from the school authorities. A pretested semi-structured questionnaire developed in English was used by the research team. The questionnaire administered had two parts. The first part sought demographic, personal, and school-related characteristics of the study participants and the second part sought the students' pain-related characteristics. The study assessed the presence of MSP using a direct dichotomous question (did you experience any bodily pain during last 2 weeks?). Only those who answered “Yes” were asked to attend the second part of the questionnaire. A body chart indicating the names of body parts was used to assess the distribution of bodily pain. Participants were asked to make tick mark against one or more body parts having pain. They were also asked to mention “Max” against a body part to indicate the body part having maximum pain. The body chart used was divided into two regions. “Upper body parts” included neck, shoulders, upper back, elbows, and “lower body parts” included lower back, wrist/hands, hips/thighs/buttocks, knees, and ankles/feet. A numerical rating scale was used to measure the intensity of pain experienced by the students. Participants were asked to circle a number between 0 and 10 that best fit their intensity of pain.

In each batch, the study investigators initially explained to the students about the study's objectives, rational and requirement of consent to participate in the study. Informed assent was taken from parents and children. Those from whom assent could be obtained were administered the study questionnaire. The investigators then provided instructions for filling the questionnaire, and then guided the students through the questionnaire. Understanding of each question was checked by asking the students to repeat the meaning. During the filling of questionnaires, the investigators helped the students throughout and helped simplifying the meaning of each question, clarifying doubts as and when they arose, and checking for completeness of filling up the questionnaire. The investigator had to translate few questions orally into the local language for clear understanding by the students.

After the filled up questionnaires were collected, students were instructed to go for anthropometric measurements, and weight of their bags was also measured. Height and weight were measured using standard guidelines. The height and weight of the students were measured using a digital weighing scale and a stadiometer. The weighing scale was placed at one corner of the classroom and calibrated to zero. Weight was measured as students in school dress with their shoes removed. Each students weight was measured while wearing and not wearing schoolbag and the difference between the two weights was recorded as the weight of the school bag. The measured bag weight was converted into percentage of child's body weight (relative bag weight) to allow comparisons with recommended bag weight guidelines. The weighing scale was recalibrated after each measurement. Body mass index (BMI) was calculated as the ratio of weight (kg) to the height (m) squared and was transformed into BMI categories using WHO's BMI-for-age (boys and girls separately) reference scales.

Data were entered in EpiData software version 3.1 (The EpiData Association, Odense, Denmark) and analysis was done using Statistical Package for Social Sciences version 22 (IBM Corp., Armonk, NY, USA). The continuous variables and categorical variables were summarized using mean (standard deviation) and proportions, respectively. Chi-square test was used to test the association between categorical variables. P < 0.05 was taken as statistically significant.


  Results Top


The sample size required for the study was 325. The study was therefore restricted among the six batches of totally 327 students of the 6th and 7th grade who consented to participate. Among the participants, a majority (67%) were boys. Mean age of the participants was 12.7 ± 0.7 years (range 11–15 years), with the mean age of boys and girls being 12.8 (±0.7) years and 12.7 (±0.7) years, respectively. The demographic, anthropometric and contextual characteristics of the study participants are shown in [Table 1].
Table 1: Demographic, contextual, and anthropometric characteristics of the study participants

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Nearly 86.2% (282/327) participants (boys - 85.4%, girls - 88%) had experienced MSP in the preceding 2 weeks. Out of those having MSP in the last 2 weeks, 27.3% (77/282) had this pain as a chronic pain (more than 6 months). [Figure 1] shows that shoulders, neck, and knees were reported to be the most common body parts where participants had experienced pain in the preceding 2 weeks, which was present in 43.6% (123/282), 39% (110/282), and 34.8% (98/282) of the participants, respectively. Participants who reported pain in one or more body parts were asked to report the body part where they felt maximum pain out of all parts. Participants reported shoulders, lower back, and knees as the top three body parts having maximum pain in 27% (76/282), 12.4% (35/282), and 11.7% (33/282) of participants, respectively. The mean weight of schoolbags carried by participants was 7.5 kg (range 1.9–16 kg). More than 72.5% (237/327) of children carried schoolbags weighing more than the recommended bag weight of 15% of body weight [Table 1]. When recommended bag weight of 10% of body weight was taken as cutoff, 96% participants carried bags heavier than this value.
Figure 1: Distribution of pain among various parts in participants

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[Table 2] shows the perceptions of participants regarding schoolbag weight and distribution of pain-related characteristics among them. The majority of the participants felt that their bags were very heavy (45%) and slightly heavy (38.8%). Nearly, three-fourth (73.1%) of participants felt that their bags were uncomfortable to carry, and almost 90% participants felt tired while carrying their school bag. About 104 (36.9%) of participants had taken medications for pain. Pain had caused 12.2% of study participants to remain absent from school. Among participants who had MSP in the past 2 weeks, about 31% participants reported experiencing pain all the time. In more than half, i.e., 52.7% of the participants, MSP was present irrespective of wearing the school bag. The majority (90%) had pain in at least one of their upper body parts. The pain score assessment showed a median value of 5.5 (range: 4–8). In more than half (52%) of the participants, pain was affecting their daily activities. Almost 90% of participants had never consulted a health professional for treatment of the pain.
Table 2: Perceptions of bag weight and distribution of pain-related characteristics among the study participants

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Association of demographic and contextual variables with MSP is reported in [Table 3]. The test of association showed a significant association of participant's grade of study, perception of bag weight, level of comfort of carrying school bag, and transport times to and from the school, with MSP in the preceding 2 weeks. [Table 4] shows that variables such as pain affecting daily activities and number of healthcare consultations were significantly associated with school attendance of participants (P< 0.05). Chronic pain (MSP >6 months) almost reached statistical significance.
Table 3: Association of demographic and contextual variables with musculoskeletal pain among the study participants

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Table 4: Association of variables related to pain, perception of bag weight, and actual bag weight with participants' attendance in the school

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  Discussion Top


The present study showed that 86.2% participants had MSP in the preceding 2 weeks. Other studies done among Indian school children also encompassed similar results where MSP ranged between 55% and 86%.[7],[8],[9],[10] A study by George et al. among school children (10–12-year-old) showed that 86% of them had musculoskeletal discomfort.[10] In the present study, shoulders (43.6%), neck (39%), and knees (34.8%) were the mostly commonly reported body parts to have pain. Similar results were found in another study done among Indian school children.[22] Other studies have also reported shoulder as the body part, most commonly having pain.[23],[24] However, various studies that assessed musculoskeletal symptoms among school children in different countries showed back pain as the most common body part to have pain followed by shoulders.[25] However, the present study showed back pain as the sixth most common body part to have pain, as reported by 17% of study participants. This difference could be attributed to the magnitude of the relative bag weight reported the means of transport, the fashion, in which students carry bags and factors concerning distribution of weight, for example, width of the shoulder strips.

In our study, the average weight of school bags was 7.5 kg (±1.72). This was higher than two other Indian studies which showed 6.75 kg (±0.99)[8] and 4.91 kg (±1.97),[18] respectively. The mean relative bag weight of participants in the present study was 18.2% which was way higher than the recommended safe limit of 10% of child's body weight. Recent studies by Patil and Shagale (11–14-year-old participants) and Balamurugan (6–12-year-old participants) showed that relative bag weights were 15.95%[8] and 16.25%,[18] respectively, which were slightly lesser than our study. Several studies have reported positive association between MSP and a heavy schoolbag.[25] Patil and Shagaleshowed that when the relative schoolbag weight of pupils reached 15% and above, there was a steep rise in reporting of MSP from 57% to 91%.[8] As the mean relative schoolbag weight in this study was higher than previous studies, this could be a possible reason for the observed higher prevalence of MSP in the present study. Studies have shown that carrying schoolbags weighing more than 10% of childrens' body weight makes children difficulty to maintain normal their cervical and shoulder alignment. This predisposes to pain in shoulders, neck, back, and impairment of lung function.

In the present study, 38.8% and 45% participants reported their bags to be as heavy and very heavy, respectively. Similar findings were reported in a study where majority of the participants reported their bag weight as medium (49.9%) and heavyweight (39.8%).[26] In the present study, majority, i.e., 32% and 37% of the participants had to travel 10–20 min and 20–30 min every day, respectively, which led them to report of uncomfortable feeling (73%) and tiredness (88.6%) while carrying school bags. Haselgrove et al. showed that when student had to carry schoolbag for more than 30 min, 51% of them reported fatigue while carrying schoolbag.[27] In the present study, all (100%) pupils reported unavailability of storage facility in their school. A study done among schoolchildren in Uganda showed similar findings where only 19% of children had facilities to store things in schools.[26] An earlier study reported that children reported less back pain with lockers available in their schools (P = 0.016).[28]

The present study showed that around 37% participants had taken medications for their pain during the past 2 weeks. This was higher than a study by Skaggs et al. which reported 14% of children took medicines for back pain.[28] The higher prevalence would be because the later study had assessed the medication taken by school children for back pain alone. In our study, only 11% participants had consulted a health-care professional when they experienced pain. This result was consistent with a study among Ugandan students which showed only 6.9% pupils had ever consulted a doctor for their back pain.[26]

In the present study, various factors such as grade (class) of study participants, participants' perception (comfort, heaviness) of school bag weight and total time spent every day in carrying school bag were significantly associated with MSP. A significant association between total time spent every day while carrying school bag, and MSP was also reported in other studies.[15],[26] Most studies conducted earlier had showed significant association between genders and reporting of pain and discomforts, with females suffering more. This association was not observed in the present study. However, even in this study, pain among females (88%) was higher than males (85.4%). One study by George et al. also showed no association between gender and MSP, similar to our finding.

In the present study, variables such as MSP affecting daily activities and total number of MSP-related consultations were associated with school absenteeism. Nearly 12.2% participants had remained absent from school due to pain during the last 1 month. A study among Ugandan school children showed that 26% students had ever taken leave from school due to pain.[26] The lower percentage of absenteeism observed in our study might be because the present study enquired about absenteeism to school during the last 2 weeks.

One limitation of the present study was that MSP was self-reported and no objective measurement was done for this. Due to cross-sectional nature of the study, reverse causality cannot be ruled out. There is a need to understand the factors associated with MSP through larger longitudinal cohort studies.


  Conclusion Top


In conclusion, 86.2% school children in a private school in Puducherry, belonging to 7th and 8th grade had experienced MSP in the preceding 2 weeks. More than one-fourth of them had this pain as a chronic pain (more than 6 months). Shoulders, neck, and knees were reported to be the most commonly affected body parts. Significant association of MSP was found with participants' grade of study, perception of bag weight, comfort level of carrying bag and duration of carrying bag. Factors such as pain affecting daily activities and number of health-care consultations were significantly associated with school attendance.

Urgent interventions are required from school and government authorities in education sector regarding addressing MSP among school children, especially those studying in private sector. Screening for MSP by school children should be carried out and appropriate referral be made to a consulting physician. MSP should be introduced as a part of school health checkup. Regulation of bag use should be more stringent, and parents and students should be made aware of the consequences of a heavy backpack.

Acknowledgment

We thank Mr. Manoj Kumar MPH, school authorities and staff for helping us in the process of data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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