The prevalence of text neck syndrome and its association with smartphone use among medical students in Jeddah, Saudi Arabia

INTRODUCTION

In the era of technology, portable devices have become increasingly reliable and useful. The main reason underlying the widespread use of mobile phones is the presence of a device that contains all of the means of communication, entertainment, and more.^[1] Spending much time using electronic devices will result in prolonged neck flexion and leads to text neck syndrome.^[1-4] Fishman D., an American chiropractor, was the first to describe text neck syndrome. It refers to neck pain that is caused by repetitive stress injury or overuse. It results from neck flexion, which happens when the person bends his/her neck in a downward position for a prolonged time, while looking at mobile phones or other digital devices such as tablets and laptops.^[5] An adult head weighs 4.5–5.5 kg (10–12 pounds) in the normal position. Forward head flexion at different angles directly affects the cervical spine. At 15° head flexion, around 12 kg of force is placed on the neck. This force rises to 18 kg at 30°, 22 kg at 45°, and 27 kg at 60°.^[6,7] Because children’s head/body ratio is larger than adults’, they may be more affected by text neck syndrome.^[7] Text neck syndrome is characterized by pain in the cervical spine, upper back, and shoulder regions. Furthermore, it may lead to rounded shoulders, forward head posture, increased vertebral column curvature, and spasms in the surrounding muscles.^[5,8,9] Untreated conditions may lead to permanent damage of the spinal cord, such as flattening of the spinal curvature, early onset of arthritis, spinal cord degeneration, disc compression, and herniation.^[5,8,10,11] Prevention is the first step in managing text neck syndrome.^[12]

A systematic review of 15 articles showed that mobile device users’ most prevalent musculoskeletal complaints were neck related (17.3–67.8%).^[2] Two studies conducted in Pakistan and India reported that the prevalence of text neck syndrome was 43.6% and 42.5%, respectively.^[13,14] Another two studies conducted in Saudi Arabia at Aljouf University and Qassim University among mobile phone users showed that 71.2% and 59.5% complained of cervical pain, respectively.^[10,15] Several studies reported a significant relationship between neck pain and smartphone addiction. The first study, conducted in India, showed a positive correlation between Nomophobia Questionnaire scores and the neck disability index (NDI) (r = 0.36).^[13] The second study conducted at King Saud University, Riyadh, showed a significant relationship between the Smartphone Addiction Scale (SAS) and NDI scores (P < 0.05).^[16] In addition, a study carried out in Australia reported a significant moderate correlation between the time spent on electronic devices and neck pain intensity (P ≤ 0.05).^[17]

These days, text neck syndrome is an alarming problem as more people engage in technology. Due to the worldwide spread of smartphones, more studies exploring the prevalence of text neck syndrome in other countries are needed. Moreover, the association of neck disability with various behaviors during the use of smartphones is still unclear in the literature. Therefore, we aimed to estimate the frequency of such factors and evaluate whether they contribute to text neck.

MATERIALS AND METHODS

This cross-sectional study was approved by Dr. Soliman Fakeeh Hospital Scientific Research Review Committee. It was conducted at six medical colleges (King Abdulaziz University, King Saud bin Abdulaziz University for Health Sciences, Fakeeh College for Medical Sciences, Ibn Sina National College, Batterjee Medical College, and University of Jeddah) in Jeddah, Saudi Arabia, from July 2020 to January 2021 among medical students. According to the Raosoft sample size calculator, the minimum sample size needed for the study with a 95% confidence level, a 5% margin of error, and a 50% response distribution was 370.^[18] Therefore, all undergraduate medical students were invited to participate.

An electronic self-administered questionnaire was distributed online among medical students. Each batch leader of each medical college was contacted through WhatsApp to distribute the link of the questionnaire among the students. The questionnaire consisted of three parts. The first part collected basic demographic data including age, gender, university/college, the amount of daily smartphone use, the purpose of smartphone usage, warming up neck muscles before using a mobile phone, taking breaks while using their cell phone, subjective neck pain, and neck position while using their smartphone. Participants were shown an image of different neck positions (0°, 15°, 30°, 45°, and 60°) and asked to indicate their most frequent position when using their smartphones [Figure 1]. The second part included the SAS-Short Version (SAS-SV). The third part included the NDI.

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Figure 1:

Illustration of neck positions while using a smartphone at varying degrees.

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The SAS-SV involves 10 items scored using a Likert scale (1 = strongly disagree, 2 = disagree, 3 = weakly disagree, 4 = weakly agree, 5= agree, and 6= strongly agree), with a total score ranging from 10 to 60. The cutoff value was 31 for male and 33 for female students. A score more than the cutoff value indicated a high risk for smartphone addiction. The SAS-SV is a valid and reliable tool for the assessment of smartphone addiction.^[19]

The NDI includes 10 items. Each item is scored from 0 to 5, thus generating a minimum total score of 0 and a maximum total score of 50. The interpretation of the total score is based on five categories of neck disability (0–4 = no disability, 5–14 = mild disability, 15–24 = moderate disability, 25–34 = severe disability, and >34 = complete disability). This index is strongly validated for assessing disability in patients with neck pain.^[20]

RESULTS

A total of 428 medical students from six medical colleges were involved. The majority of the responders were female; 304 (71.02%) and 124 (28.97%) were male. The mean age was 22.11 ± 2.07 years. More students were from the 4^th year (29%). Among participants, 56.3% used their phones for browsing the internet. Only 32 (7.47%) warmed up their neck muscles before using their smartphones, and 261 (60.98%) took frequent breaks when using their smartphones [Tables 1a-c].

We found that the prevalence of text neck syndrome was 68.1%. Among the participants, 49.5% had mild, 16.1% had moderate, and 2.6% had severe neck disability. The majority of the responders were addicted to their smartphones (63.1%). The mean SAS-SV score was 35.29 ± 9.8 and the median value on the NDI was 7 (IQR = 8). There was no statistically significant relationship between gender and NDI or gender and SAS-SV (P = 0.056 and 0.462, respectively) [Figure 2 and Table 2].

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Figure 2:

Neck disability index.

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The majority of students used their smartphones 4–5 and more than 5 h (20.3% and 58.2%, respectively). The duration of smartphone use was significantly related to NDI scores (P = 0.0049). Furthermore, 77% of students who used their phones 4–5 h and 69.9% of students who used their phones for more than 5 h had a neck disability. There was a significant relationship between NDI with neck pain (P < 0.001). Almost half (45.3%) of the responders reported having neck pain, among them, 87.6% had neck disability. Most responders maintained a 30° neck position during their smartphone usage (46.3%).

There was a significant relationship between neck position and NDI (P < 0.001) [Table 3]. On the Kruskal–Wallis test with pairwise comparisons, students using their smartphones with 60° neck position were found to have more neck disability compared with students with 15°, 30°, and 45° neck positions (mean difference ± SE: 6.56 ± 1.29, 5.22 ± 1.20, and 3.80 ± 1.31; P <0.001, <0.001, and = 0.032, respectively).

Moreover, of the 35 students who used their phones at a 60° neck position, only three did not have neck disability while the remaining 32 students had neck disability. Among these 32 students, three used their phones for 3–4 h, four used them for 4–5 h, and the majority (25 students) used them for more than 5 h [Table 4]. Using a Spearman’s correlation, we found a moderate positive correlation between SAS-SV and NDI scores (r = 0.328, P < 0.001).

DISCUSSION

In this study, the prevalence of text neck syndrome among medical students was 68.1%. This result is almost the same as a study carried out in Aljouf University among cell phone users from the medical and dental colleges reported that 71.2% of 282 students complained of cervical pain.^[10] According to a recent study conducted in India, 42.5% of participants had neck disabilities.^[14] Another recent study conducted in India with similar social groups as in our study (82% of females and 17% of males) concluded that the prevalence of text neck syndrome was 32% of a total of 100 physiotherapy students.^[21] There is also a study conducted in Korea among 2353 university students reported that 34.0% had a neck disability.^[3]

In our study, most participants who had text neck syndrome reported experiencing mild neck disability (49.5%). This finding is consistent with other studies in the literature. The study in India that reported text neck syndrome in 42.5% of the participants showed that the prevalence was mostly contributed by those with a mild disability (constituted 31.9%).^[14] Among 34% of students in the Korean study with a neck disability, a vast majority also had mild neck disability (they constituted 32.85% of the total percentage).^[3]

A high prevalence of text neck syndrome among medical students in our study might be explained by the fact that medical students need to study for prolonged periods bending their necks looking toward the screen of smartphones or electronic devices for educational purposes. In addition, the integration of technology into the medical field may increase its usage among such students. Another factor that might have contributed to the problem is the suspension of in-person education due to the COVID-19 outbreak and the transition to online learning in Saudi Arabia on March 8, 2020,^[22] which forced the students to use their electronic devices more excessively.

The majority of participants in our study were addicted to smartphone use, with a prevalence of 63.1%. Regarding the amount of daily use, most students use their phones for more than 4 h per day (78.5%). Two studies, one in Korea and one in Brazil, found that 42.1% and 76.6% of participants spent more than 4 h per day on their mobile phones, respectively.^[4,23] The high prevalence of participants using a mobile phone for more than 4 h per day is an alarming problem since the severity of musculoskeletal symptoms in the upper extremities is significantly related to the amount of time spent using smartphones.^[24] In addition, the duration of mobile phone use is not only associated with the severity of neck pain (r = 0.14, P = 0.001) but is also associated with the duration of the pain (r = 0.1, P = 0.036).^[25]

In our study, there is a moderate positive correlation between SAS-SV and NDI scores (r = 0.328, P < 0.001). Two studies support this finding. The first study, conducted in Riyadh, Saudi Arabia, assessed the association between SAS and NDI scores. It revealed a significant Spearman correlation between the two variables (P < 0.05).^[16] The second one was in India, where the Spearman correlation showed a moderately positive significant correlation between SAS and NDI (r = 0.671, P < 0.001).^[26]

However, in the current study, no statistically significant relationship was found between gender and NDI nor gender and SAS-SV (P = 0.056 and 0.462, respectively). This result opposes a study conducted at the University of Jordan that found female students tend to use mobile phones for a longer period compared with their male counterparts (P = 0.005).^[25] Moreover, a study carried out in Korea found that female students’ mean NDI scores were significantly higher than male students’ (P < 0.05).^[3]

Regarding neck position, we found that most students had a 30° neck position during their smartphone use (46.3%). Moreover, students using their smartphones with 60° neck positions had more neck disability compared with the 15°, 30°, and 45° neck positions.

The correlation between neck posture and neck pain has been reported in the literature. A study in Portugal sought to determine the relationship between postural angles and the presence of neck and shoulder pain. They discovered that participants with forward head posture had more neck pain than those who did not have forward head posture (29.8% vs. 8.4%).^[27] This finding is supported by another study conducted in Hong Kong, which revealed that the craniovertebral angle (CV) is negatively correlated with the Northwick Park Neck Pain Questionnaire (r = –0.395, P = 0.002), even after the correlation was adjusted for age (r = –0.3101, P = 0.015). That is, the more forward the head posture (i.e., the smaller the CV angle), the more neck disability occurs.^[28]

This idea is challenged by studies showing that neck posture had no association with neck pain.^[23,29] However, these studies did not consider potential factors such as neck muscle exercise and warm-up, taking frequent breaks, and whether the participants used analgesics to relieve the pain. Participants with more severe neck pain use analgesics more than participants with less severe neck pain (44.6% vs. 12.1%) (P < 0.001). In addition, they are more likely to change their positions during mobile phone use to relieve the pain (64% vs. 50.4%) (P < 0.001).^[25]

Our study shows that only 7.5% of students warmed up their neck muscles before using their smartphones, and 61% took frequent breaks when using smartphones. A study conducted in Pakistan among 500 medical students reported that only 6% warmed up their neck muscles before using mobile phones, and only 12% took breaks while using mobile phones.^[13] Stretching exercises, warming up neck muscles, and taking frequent breaks to relax the neck muscles every 20 min might help to prevent neck injuries caused by prolonged smartphone use.^[5]

Our study has several limitations. First, the study was conducted during the outbreak of COVID-19 and we faced some issues as a result. We had to distribute the questionnaire online and, therefore, we could not measure neck posture during smartphone use objectively. Second, this study was conducted among medical students only. Hence, it may not be representative of the whole population. We recommend further studies on the entire population to generalize the results.

CONCLUSION

We found the prevalence of text neck syndrome to be 68.1% and there was a significant albeit moderate positive correlation between the SAS-SV and the NDI.