DOI: 10.1542/peds.2004-2766 2006;117;412Pediatrics

A.C.M. Diepenmaat, M.F. van der Wal, H.C.W. de Vet and R.A. HirasingActivity, Stress, and Depression Among Dutch Adolescents

Neck/Shoulder, Low Back, and Arm Pain in Relation to Computer Use, Physical  

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ARTICLE

Neck/Shoulder, Low Back, and Arm Pain in Relationto Computer Use, Physical Activity, Stress, andDepression Among Dutch AdolescentsA.C.M. Diepenmaat, MSCa, M.F. van der Wal, PhDa, H.C.W. de Vet, PhDb, R.A. Hirasing, PhDb,c

aDepartment of Epidemiology and Health Promotion, Municipal Health Service, Amsterdam, Netherlands; bInstitute for Research in Extramural Medicine, cDepartment ofPublic and Occupational Health, VU University Medical Center, Amsterdam, Netherlands

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT

OBJECTIVE. To examine among adolescents (1) the prevalence of neck/shoulder, lowback, and arm pain within different sociodemographic groups and (2) the associ-ation of neck/shoulder, low back, and arm pain with computer use, physicalactivity, depression, and stress.

METHODS.A school-based questionnaire survey in 2002 and 2003 of neck/shoulder,low back, and arm pain, computer use, physical activity, depression, and stress.The survey was given to 3485 adolescents aged 12 to 16 years who attendedsecondary schools in Amsterdam, Netherlands.

RESULTS. The overall prevalence of neck/shoulder, low back, and arm pain was11.5%, 7.5%, and 3.9%, respectively. The prevalence of neck/shoulder pain washigher among girls and adolescents not living with both parents. The prevalence oflow back pain also was higher among girls. Depressive symptoms were associatedwith neck/shoulder pain, low back pain, and arm pain. The stress experienced wasassociated with neck/shoulder pain and with low back pain.

CONCLUSIONS. This study strengthens the findings that musculoskeletal pain is com-mon among adolescents and is associated with depression and stress but not withcomputer use and physical activity.

www.pediatrics.org/cgi/doi/10.1542/peds.2004-2766

doi:10.1542/peds.2004-2766

KeyWordsneck pain, shoulder pain, arm pain,computer use, physical activity, depression

AbbreviationsMET—metabolic rateCES-D—Center for Epidemiologic StudiesDepression ScaleOR—odds ratioCI—confidence interval

Accepted for publication Apr 21, 2005

Address correspondence to A.C.M.Diepenmaat, MSC, Municipal Health ServiceAmsterdam, Department of Epidemiology andHealth Promotion, PO Box 2200, 1000 CEAmsterdam, Netherlands. E-mail:adiepenmaat@ggd.amsterdam.nl

PEDIATRICS (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Copyright © 2006 by theAmerican Academy of Pediatrics

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IN THE NETHERLANDS, as in other industrialized Westerncountries, back and neck/shoulder pain is one of the

leading causes of inability to work and sick leave.1,2 Backor neck/shoulder pain already occurs in adolescence.3–5

Adolescents with such complaints are at risk of display-ing similar symptoms in later life.6,7 The risk and protec-tive factors of these pains can be divided into physicaland psychosocial factors.8,9 For example, neck/shoulderpain is related to exercise3 but also to psychosomaticproblems and depression.3,10,11

In the past decades there has been an increase in lowback and neck/shoulder pain among adolescents.4,5 Littleis known about what is causing this increase, but Vikatet al3 suggest that it might be the rise in psychosocialproblems. Increased computer use among children12

might be another explanation. Two epidemiologic re-views concluded that in adults there is a relation be-tween working at visual display units and having upperextremity musculoskeletal disorders.13,14 There is littleinformation about the relation between computer useand musculoskeletal pain among children and adoles-cents.

In the current study we assessed the prevalence ofneck/shoulder, low back, and arm pain among differentsociodemographic groups. We furthermore investigatedif neck/shoulder, low back, and arm pain were associ-ated with computer use, physical activity and inactivity,depression, and stress among groups of schoolchildren.

METHODSIn the school year 2002/2003, school nurses from theAmsterdam Municipal Health Service’s Child HealthCare department invited all secondary schools in Am-sterdam, Netherlands, to participate in the study. Dataon neck/shoulder, low back, and arm pain, computeruse, physical activity and inactivity, depression, per-ceived stress, and sociodemographic factors were col-lected by means of self-report questionnaires. The ques-tionnaires were distributed to second-year pupils (aged12–16 years) and completed in the classroom. Prior per-mission was asked of the children’s parents.

Neck/shoulder, low back, and arm pain were gaugedby using 3 preshaded manikin pictures showing (1) theneck/shoulder, (2) the low back (back pain caused bymenstruation was excluded from this study), and (3) thearm area. The question posed was: “In the past monthhave you experienced pain lasting a day or longer in theindicated shaded area?” (yes/no). If the response wasaffirmative, the second question was: “How long, interms of days, did you experience pain in this areaduring the past month?” To meet our neck/shoulder,low back, or arm pain criteria, participants had to expe-rience pain for �4 days per month in the neck/shoulder,low back, or arm area.

The following physical factors were measured: com-puter use, physical activity, and physical inactivity.

Computer use was measured by asking 2 questions: “Onaverage, how much time per day do you spend workingor chatting on the computer?” and “On average howmuch time per day do you spend playing the PlaySta-tion, Nintendo, or other computer games?” The totaltime (hours and minutes) was calculated (0–0.5, 0.51–1.5, 1.51–3.00, or �3 hours). Physical activity levelswere assessed by using open-ended questions to deter-mine the type, frequency, and duration of sporting ac-tivities during a normal week in the previous month.The total number of types of sporting activities was thencalculated and transformed into a metabolic rate(MET).15 According to Dutch guidelines for healthy ex-ercise, children and adolescents should have a moderatelevel of physical activity for at least 1 hour a day.16

Moderately intensive activities for children such as bik-ing, swimming, and running have a MET of 21 to 33.6kJ/kg per hour.15 The time spent on physical activitieswith a MET of �5 (0–0.5, 0.51–1.0, or �1 hour) wasused in the analysis. Physical inactivity was measured byposing the question: “On average, how much time perday do you spend watching television or video?” (inhours and minutes) (0–1.50/1.51–2.50/2.51–4/�4hours). Data relating to computer use and physical in-activity were divided into 4 groups of approximately thesame size.

Depressive symptoms were measured by using theCenter for Epidemiologic Studies Depression Scale (CES-D).17 The CES-D is a 20-item self-report scale that wasdesigned to measure depressive symptoms in the generalpopulation. The total score ranges from 0 to 60 and iscalculated by summing all items. The CES-D has beenvalidated previously in adolescents.18 Adolescents whoscored �16 were classified as being depressed. Perceivedstress was measured by asking the question: “Have youexperienced stress in the past week” (no � never/some-times; yes � often/always).

Sociodemographic information included gender, fam-ily structure (whether the child was living with both ofhis or her natural/adoptive parents), and education level(low � [specific] prevocational education; intermediate� junior [intermediate] general secondary education;high � senior [higher] general secondary education).Ethnic origin was defined according to the mother andfather’s country of birth: Netherlands, Surinam/Antilles,Morocco, Turkey, or other countries. A child was classi-fied as non-Dutch if 1 or both parents were foreign-born.The questionnaire was pilot tested on a few studentswith different ethnic backgrounds and education levelsfor comprehension and applicability. Logistic-regressionanalyses were used to examine univariate associationsbetween neck/shoulder, low back, and arm pain, andsociodemographic characteristics (gender, ethnicity,family structure, and education level), computer use,physical activity, physical inactivity, depressive symp-toms, and perceived stress. By means of forward step-

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wise logistic regression, multivariate analyses were per-formed. At each step, we included variables with a 5%level of significance.

RESULTSIn total, 4515 (92.2%) of 4898 eligible schoolchildrentook part in the survey. Two reasons for nonparticipa-tion were that some children were not given permissionby their parents to take part in the survey (54 [1.2%])and some children (241 [5.3%]) were ill and thereforeabsent on the day of the survey. The questions werecompleted fully by 3485 schoolchildren (71.2%). Thefollowing analysis is based on their answers.

The prevalence of neck/shoulder, low back, and armpain in this study was 11.5%, 7.5%, and 3.9%, respec-tively. Table 1 shows that the prevalence of neck/shoul-der pain was higher among girls (odds ratio [OR]: 1.4;95% confidence interval [CI]: 1.2–1.8) and adolescentswho do not live with both of their parents (OR: 1.4; 95%

CI: 1.1–1.8) than among boys and adolescents who dolive with both parents. Adolescents coming from “othercountries” reported more neck/shoulder pain (OR afterunivariate logistic regression: 1.5; 95% CI: 1.1–2.1) than“Dutch” adolescents. However, this association was notsignificant after correction for other variables.

The prevalence of low back pain was higher amonggirls (OR: 1.5; 95% CI: 1.1–1.9). There was no associa-tion between arm pain and the sociodemographic char-acteristics. Adolescents who spent 1.5 to 2.5 hours perday watching television reported less low back pain (OR:0.6; 95% CI: 0.4–0.9) than adolescents who watchedless television. This association was not significant aftercorrection for other variables. Computer use and phys-ical activity were not associated with neck/shoulder, lowback, or arm pain.

Depressive symptoms were associated with neck/shoulder pain (OR: 1.9; 95% CI: 1.5–2.5) as well as lowback (OR: 2.5; 95% CI: 1.8–3.4) and arm (OR: 2.1; 95%

TABLE 1 Sociodemographic Factors, Computer Use, Physical Activity, Depressive Symptoms, Stress, and Risk of Neck/Shoulder, Low Back, andArm Pain in Second-Year Adolescents (n � 3485)

N %WithNSP

OR 1 (95%CI)

OR 2 (95%CI)

%WithLBP

OR 1 (95%CI)

OR 2 (95%CI)

%WithAP

OR 1 (95%CI)

OR 2 (95%CI)

GenderMale 1726 8.7 1 1 5.6 1 1 4.2 1 NSFemale 1759 14.2 1.7 (1.4–2.1) 1.4 (1.2–1.8) 9.5 1.8 (1.4–2.3) 1.5 (1.1–1.9) 3.6 0.9 (0.6–1.2)

EthnicityNetherlands 1435 10.2 1 NS 6.8 1 NS 3.5 1 NSSurinam 434 12.2 1.2 (0.9–1.7) 8.3 1.2 (0.8–1.8) 4.8 1.4 (0.8–2.4)Turkey 415 12.8 1.3 (0.9–1.8) 8.4 1.3 (0.8–1.9) 5.3 1.6 (0.9–2.6)Morocco 698 10.3 1.0 (0.7–1.4) 7.4 1.1 (0.8–1.6) 3.0 0.9 (0.5–1.4)Other countries 503 14.9 1.5 (1.1–2.1) 8.3 1.2 (0.9–1.8) 4.2 1.2 (0.7–2.0)

Family structureBoth parents 2476 10.1 1 1 7.3 1 NS 3.5 1 NSAlternative 1009 14.8 1.5 (1.2–1.9) 1.4 (1.1–1.8) 8.2 1.1 (0.9–1.5) 4.9 1.4 (1.0–2.0)

Education levelHigh 1648 11.6 1 NS 7.6 1 NS 3.2 1 NSIntermediate 758 13.5 1.2 (0.9–1.5) 8.3 1.1 (0.8–1.5) 4.7 1.5 (1.0–2.3)Low 1079 9.9 0.8 (0.7–1.1) 6.9 0.9 (0.7–1.2) 4.3 1.3 (0.9–2.0)

Computer use per day, h0–0.5 852 11.5 1 NS 8.2 1 NS 3.9 1 NS0.51–1.5 967 9.9 0.8 (0.6–1.1) 6.9 0.8 (0.6–1.2) 3.0 0.8 (0.5–1.3)1.51–3.0 865 12.0 1.0 (0.8–1.4) 7.6 0.9 (0.7–1.3) 4.2 1.0 (0.7–1.7)�3.01 801 13.2 1.2 (0.8–1.6) 7.4 0.9 (0.6–1.3) 4.7 1.2 (0.7–2.1)

Physical activity per day, h0–0.5 1231 13.1 1 NS 7.3 1 NS 3.2 1 NS0.51–1.0 628 10.7 0.8 (0.6–1.1) 8.4 1.2 (0.8–1.7) 3.7 1.1 (0.7–1.9)�1.01 1626 10.6 0.8 (0.6–1.0) 7.4 1.0 (0.8–1.3) 4.4 1.4 (0.9–2.0)

Television-watching per day, h0–1.50 814 12.4 1 NS 9.1 1 NS 3.4 1 NS1.51–2.50 818 9.9 0.8 (0.6–1.1) 5.7 0.6 (0.4–0.9) 3.5 1.0 (0.6–1.8)2.51– 4 943 10.9 0.9 (0.7–1.2) . 7.5 0.8 (0.6–1.1) 3.9 1.1 (0.7–1.9)�4 910 12.6 1.0 (0.8–1.4) 7.8 0.8 (0.6–1.2) 4.5 1.3 (0.8–2.2)

Depressive symptomsCES-D score � 16 2943 9.5 1 1 5.9 1 1 3.3 1 1CES-D score � 16 542 22.3 2.7 (2.2–3.5) 1.9 (1.5–2.5) 16.6 3.2 (2.4–4.2) 2.5 (1.8–3.4) 6.8 2.1 (1.4–3.1) 2.1 (1.4–3.1)

Feeling stressNever/once only 3110 9.9 1 1 6.6 1 1 3.7 1 NSRegularly/always 375 24.8 3.0 (2.3–3.9) 2.0 (1.5–2.7) 15.5 2.6 (1.9–3.5) 1.6 (1.1–2.2) 5.3 1.5 (0.9–2.4)

NSP indicates neck/shoulder pain; LBP, low back pain; AP, arm pain. OR 1 (ORs after univariate logistic regression) and OR 2 (ORs after forward stepwise logistic regression).

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CI: 1.4–3.1) pain. Stress experienced was associatedwith neck/shoulder (OR: 2.0; 95% CI: 1.5–2.7) and back(OR: 1.6; 95% CI: 1.1–2.2) pain.

DISCUSSIONThis study strengthens previous findings that musculo-skeletal pain in adolescence is a common phenome-non.3–5 It is associated with depression and experiencedstress but not with computer use.

In total, 1030 adolescents of the 4515 adolescentswho took part in the survey did not complete the ques-tionnaire fully. It is possible that the prevalence of mus-culoskeletal pain is overestimated because the adoles-cents with pain were more motivated to complete thequestionnaire. However, no significant differences in theprevalence of neck/shoulder, low back, and arm painwere found among the adolescents who did or did notcomplete the questionnaire fully (results not presented).Therefore, and because of the overall good response rateand number of adolescents included, this study can beconsidered representative of the prevalence of neck/shoulder, low back, and arm pain and the associationsfound. It is possible that the prevalences are slightlyhigher, because 241 adolescents called in sick on the dayof the survey, some of whom could have been absentbecause of neck/shoulder, low back, or arm pain com-plaints.

More girls than boys reported having neck/shoulderand low back pain. This result is in accordance withprevious cross-sectional studies that showed a greaterfemale predisposition to musculoskeletal pain.3–5,8–11 Thereasons for this remain speculative. Pain prevalence mayindeed be higher, but it is also possible that it may bemore acceptable for girls to complain about pain thanboys. After univariate analyses, we found that adoles-cents coming from “other countries” had more neck/shoulder pain. After multivariate analyses, this associa-tion was no longer significant. Adolescents in thisethnicity group with neck/shoulder pain were more of-ten stressed and depressed (results not presented). Aportion of these adolescents were (children of) asylumseekers and refugees. A lot of these adolescents had beentraumatized.19 It therefore is conceivable that neck/shoulder pain in these adolescents is more a result of(posttraumatic) stress and depression.

We did not find an association between computer useand musculoskeletal pain. In our study, computer usewas self-reported. Faucett and Rempel20 found that self-reported computer use was overestimated in general.Overestimation, however, was not associated with hav-ing musculoskeletal symptoms. Several studies that wereconducted among adults indicate that computer use canbe a risk factor in the development of upper extremitymusculoskeletal pain.13,14 There is little informationabout the relation between computer use and musculo-skeletal pain among children and adolescents. In a small

sample study, Jacobs and Baker21 found that musculo-skeletal discomfort was associated with the number ofhours spent on the computer. Harreby et al22 found norelation between computer use and low back pain. It ispossible that we did not find an association betweencomputer use and musculoskeletal pain because our def-inition of musculoskeletal pain was stricter than thedefinition that Jacobs and Baker used. It is also probablethat children and adolescents are less prone to muscu-loskeletal pain than adults, because they use computersmostly for fun and therefore do not experience pain, orthey do not consider it as pain but more as a discomfort,as Jacobs and Baker used in their definition. However, itis possible that there is an association between computeruse and musculoskeletal pain. It is likely that adolescentswith pain are using the computer less than they didbefore they experienced pain, possibly because theyknow or think that excessive computer use can be harm-ful.

In line with Ehrmann Feldman et al,23 we did not findan association between physical activity and musculo-skeletal pain. However, Harreby et al22 found that stu-dents who considered themselves to be physically fitexperienced less low back pain. It is conceivable that wedid not find a comparable association in our study be-cause in our study physical activity was assessed moreobjectively by the amount of time that students spent on(�21 kJ/kg per hour MET) activities.

It is surprising that students who spent 1.5 to 2.5hours per day watching television experienced less lowback pain than students who watched less television.After forward stepwise logistic regression, television-watching was no longer significantly associated with lowback pain. Depression, stress, and gender were not con-founding factors. After additional analyses among ado-lescents who were not depressed or stressed, the adoles-cents who watched �1.5 hours of television per dayexperienced more low back pain than adolescents whowatched 1.5 to 2.5 hours of television per day (resultsnot presented). It is possible that adolescents who arenot stressed or depressed and have low back pain aremore often advised to watch less television than stressedor depressed adolescents with low back pain. However,no significant interaction effects between depression andtelevision-watching or stress and television-watchingconcerning low back pain were found.

Depressive symptoms were associated with an in-creased prevalence of neck/shoulder, low back, and armpain. Stress was associated with a higher prevalence ofneck/shoulder and low back pain. These results corre-spond to other cross-sectional findings among youngpopulations.10,11 In view of the cross-sectional nature ofthis study, we are unable to determine whether depres-sive symptoms are consequences or causes of musculo-skeletal pain in schoolchildren or whether they are allcomponents of a more generalized syndrome. Siivola et

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al24 found, however, that psychosocial symptoms in ad-olescence predicted neck/shoulder pain in adulthoodamong those who were symptom-free at baseline. Fur-thermore, in children who were initially free of low backpain, adverse psychosocial factors were predictive of fu-ture low back pain.25 These results suggest that depres-sive symptoms and stress are more likely to be causesrather than consequences of neck/shoulder, low back,and arm pain.

The association between musculoskeletal pain andpsychosocial factors would suggest that psychotherapymight be effective in adolescents with musculoskeletalpain, provided that possible medical grounds are ex-cluded first. In a Dutch randomized, controlled trial,cognitive behavioral therapy proved to be an effectiveform of treatment for adults with medically unexplainedphysical symptoms such as musculoskeletal pain.26 At 6and 12 months of follow-up, those in the interventiongroup reported a significant higher recovery rate and lessphysical symptoms than those in the control group. Ec-cleston et al27 found also physical improvement amongadolescents with chronic pain after cognitive behaviortherapy.

CONCLUSIONSIn Dutch adolescents, especially girls, the prevalence ofneck/shoulder and low back pain lasting for �4 days permonth is high. Neck/shoulder and low back pain areassociated with depression and stress but not with com-puter use, which indicates that improving mental healthcould be a key issue for preventing musculoskeletal pain.Additional study is necessary to assess the effect of psy-chotherapy on musculoskeletal pain in adolescents.

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DOI: 10.1542/peds.2004-2766 2006;117;412Pediatrics

A.C.M. Diepenmaat, M.F. van der Wal, H.C.W. de Vet and R.A. HirasingActivity, Stress, and Depression Among Dutch Adolescents

Neck/Shoulder, Low Back, and Arm Pain in Relation to Computer Use, Physical  

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