Neck, Shoulder and Low Back Musculoskeletal Pain in Greek Physical Education University Students: A Series of Three Cross-Sectional Studies

Musculoskeletal pain (MSP) is a highly prevalent and disabling condition that affects people of all ages, gender and socio-demographic characteristics, with subsequent increased health care utilization ^{1, 2}. In spite of the different social and cultural substrate of the studied populations, the MSP prevalence in the general population rises approximately to 30% (range 13.5–47%) ¹. Epidemiological surveys document a worrying MSP prevalence in young populations and underline the need for early prevention and detection ³. The MSP development in university students is of particular interest as it may affect their daily life ⁴ and academic success ⁵. The MSP may also have a significant impact on their future musculoskeletal health ⁶. Pain tends to persist ^{7, 8} and predisposes to a higher risk of future MSP ^{8, 9}.

In university students, the MSP is usually associated with the physical load that they must sustain to meet the demands of their learning compulsory activities ¹⁰. The studies on university students examine either a variety of disciplines ^{4, 11} or distinct disciplines as dental hygiene ¹², medicine ¹³, nursing ¹⁴, physiotherapy ¹⁵ and, physical education teacher ^{6, 17}. The physical education teacher (PET) students constitute a distinct university discipline because of the inherent injury risk associated to the physical load of the compulsory sports participation required by their study curriculum. Cross-sectional studies examined the injury prevalence in PET students a long time ago ¹⁸, with an ongoing research interest ^{19, 20, 21}. However, to the best of our knowledge, only two outdated studies appear to examine the MSP prevalence in PET students ^{16, 17}, indicating the lack of research during the last decade. In particular, Brennan et al. ¹⁶ reported a 30% prevalence of low back pain, using a past 12-month retrospective questionnaire to examine a single only site of pain. Fliciński ¹⁷ examined a variety of pain sites and reported an almost 50% prevalence in their PET students, who claimed as most frequent the knee, shoulder, and ankle pain. In the study of Fliciński ¹⁷, sports injuries were the most critical risk factor for MSP (42.4% and 50.5% of women and men, respectively reported a total of 1065 casualties) with participation in specific sports identified as the primary injury risk factor.

The pain prevalence in PET students is of particular interest due to the physical load and injury susceptibility associated not only to their academic but also to their future working life as Physical Education (PE) teachers ^{22, 23}. In fact, the PE teachers claim their rather high prevalence of musculoskeletal disorders as a limiting factor of their working capacity ^{22, 23, 24}. The prospective studies about multiple MSP in university students ^{7, 8, 11} conclude that the average sites of pain appear to be settled by age 20, and little variation occurs thereafter ⁸. Thus, PET students with multisite pain will most probably enter their working life as PE teachers already suffering from multiple MSP. However, there appear no prospective data regarding the MSP prevalence in PET students. The lack of prospective or serial cross-sectional research on MSP prevalence in PET students highlights the necessity for more and up to date studies. Such studies may contribute to MSP prevention and management during their physically demanding academic years. Thus, this study aimed to explore the prevalence of neck, shoulder and low back pain in a series of academic years in Greek PET students.

The characteristics of the 479 students (Men: 48%, Women: 52%) who completed the questionnaire along the three years are presented in Table 1. Across all three years, 67.6% of the students reported MSP symptoms, with 25.7% of them reporting more than one pain site (Table 2). The gender association to the neck and low back pain was significant (Figure 1), with women demonstrating a significantly higher pain prevalence in almost all three years (p ≤ 0.05), whereas the gender association to shoulder pain was not significant (p > 0.05). Association of the other demographics to pain (age, body mass index, coursework hours, computer use, and spine disorders) was not examined as their distribution was predominantly in a single category.

†Scoliosis (14%), Kyphosis (4.8%), Lordosis (1.3%), multiple spine disorders (2.7%).

Figure 1.Gender association to pain prevalence in neck, shoulder and low back. *significant gender difference at p ≤ 0.05.

The study aimed to examine the neck, shoulder, and low back prevalence of MSP in Greek PET students across three academic years. The 67.6% overall MSP prevalence is higher than the prevalence of 32% and 50%, respectively, reported for PET students by Brennan et al. ¹⁶ and Fliciński ¹⁷. However, it must be noted that Brennan et al. ¹⁶ examined only the low back pain. Furthermore, despite their variety of pain sites (shoulder, elbow, wrist, hand, hip, knee, ankle, and foot), Fliciński ¹⁷ did not include the neck and low back in their study. Sports injuries appear as the most critical risk factors for MSP ¹⁷ with an ongoing research interest regarding interventions that could prevent the injury incidences in PET students ^{19, 20, 21, 22}. When compared with other disciplines, the overall pain prevalence in the present study was within the range reported in studies including the neck, the shoulder, and the low back to examine the past 12-month pain. In specific, the overall pain prevalence was 64.3% for dental students ¹², 75.8-89.3% for medical students ¹³, 64% for nursing students ¹⁴ and, 63% for physiotherapy students ¹⁵. When a variety of disciplines was included in the same study, the MSP prevalence ranged from 34% ¹¹ up to 92.7% ⁴.

In agreement with the majority of previous studies in university students ^{11, 13, 17} as well as in general population ^{1, 26} women had a higher MSP prevalence than men. The strong association of gender to MSP prevalence is broadly supported ^{1, 26, 27, 28}. The purpose of this study was not to determine the factors of the gender related MSP differences. However, in general, the explanations for gender differences in MSP are categorized in three groups, in terms that women rather than men: (A) are more willing to report pain, (B) are more vulnerable to develop MSP because of gender-linked factors (hormones, physiology, pain sensitivity), and (C) may possibly sustain a greater accumulative exposure to MSP risk factors when one considers both the working (studying in the case of university students) and typical household-related activities (cleaning, laundry, etc.) ^{26, 27, 28}. Some studies do not succeed in revealing any specific risk factors that could explain the higher prevalence of chronic musculoskeletal complaints in women than men ²⁶. As concluded by Andorsen et al. ²⁶ in their 13-year prospective study, unmeasured factors may also be contributing substantially to the MSP gender differences, which warrants further research focused on such factors.

The increasing trend of MSP highlights a documented worldwide growing health problem that appears to affect people of all ages, gender and socio-demographic characteristics ^{1, 2}. In our study, the MSP prevalence did not reveal a significant year trend for the neck and the shoulder pain. However, it showed a decreasing year trend in the low back past 12-month pain, the recurrent pain, and the shoulder previous injury/accident. The pain and time loss duration did not show a specific year trend profile for the three pain sites, with both significantly increases and decreases in Y3 compared to the other years. The comparison to earlier data is not feasible due to the scarcity of previous serial cross-sectional or prospective studies on university students. To the best of our knowledge, the single MSP prospective study in university students is the nationwide study of Oksanen et al. ¹¹. Oksanen et al. ¹¹, using the previous week rather than the past 12-month symptoms, report an increasing trend of MSP from 2000 to 2012 in Finnish university students. Over a 6.5 year period, there was an increase in the number of pain sites in men but not in women young technical students entering their working life ⁷, indicating a gender specificity regarding the MSP risk factors. So far, a variety of psychosocial and lifestyle factors have been proposed for the increasing MSP in adolescents (sedentary activities and sleeping, physical activity level, body mass index, alcohol consumption, smoking, and emotional and behavioral factors) ²⁹. However, the reasons for increasing MSP in young adults are not known, and there is still much uncertainty about the factors leading to pain.

In university students, the MSP is associated with the physical load that they need sustain during their compulsory learning activities ^{12, 13, 14, 15, 16, 17}. Oksanen et al. ¹¹ suggest that broad ergonomic information targeted to young people, together with the increase and widening of the preventive health care could lower the future MSP prevalence in university students. Ergonomic information may also regard the use of computers in university students as their daily hours of computer use are associated with musculoskeletal discomfort ¹⁰. However, in our study, the vast majority (95.1%) of PET students reported their computer use to be less than 10 hours per day, allowing us to disregard computer use as a factor for their MSP based on the data provided by Noack-Cooper et al. ¹⁰. It should not be ignored that, in university students, health complaints are also associated with perceived stress ^{5, 30}. More specifically, Ekpenyong et al. ⁵ suggest to particularly consider certain factors (i.e., demographics, reaction to stress) when developing interventions for stress-induced MSP among university students.

Regardless of the reasons for their MSP development, the comparison of our PET students with previous PET students is limited to the somewhat outdated cross-sectional studies of Brennan et al. ¹⁶ and Fliciński ¹⁷ which both used a past-12 month questionnaire. Brennan et al. ¹⁶ examined only the low back pain and report a higher (40.1%) than the present (30%) pain prevalence. Fliciński ¹⁷ reported the shoulder prevalence about 30% (Men: 28%, Women: 29%) similar to the 30.1% pain prevalence of the present study; however, they did not include the neck and the low back in their study. In the survey of Fliciński ¹⁷, sports injuries were the most critical risk factors for MSP (42.4% and 50.5% of women and men, respectively reported a total of 1065 incidences) with participation in specific sports identified as the primary injury risk factor. The recurrent pain in our study is also worrying; more than one-third of the students reported their pain as a recurrent one (32.4%, 33.6% and 44.1% for the neck, shoulder, and low back, respectively). Besides the discomfort itself, pain, and particularly the recurrent one, may limit students’ daily and leisure time ^{4, 14} and increase the psychical stress ³⁰. Above all, MSP symptoms may impair study success ⁵ and affect the students’ future musculoskeletal health ⁶.

The co-occurring MSP is also of particular interest. In the present study, about 36% of our PET students reported multiple pains. This percentage is almost triple than the 12.5% reported by Oksanen et al. ¹¹ in a variety of university students regarding four pain sites (neck-shoulder, low back, limb/joint, temporomandibular). The lower prevalence of multiple pains in Oksanen et al. ¹¹ may be attributed to the student population specificity, as PET students are exposed to a higher physical workload than general student population. However, our 36% multiple pain prevalence is lower than the multiple pain reported for Greek workers ³¹, young technical school students ⁷, and the general population ⁸. In specific, Solidaki et al. ³¹ in their cross-sectional study, report a 67% multiple pain prevalence for a total of 6 body sites (neck, shoulder, elbow, wrist-hand, low back, and knee). Hanvold et al. ⁷, in their 6.5-year prospective study, report the baseline multiple pain at 69% for a total of 4 pain sites (neck-shoulder, low back, arm-hand-wrist, hip-knee-leg). Kamaleri et al. ⁸, in their 14-year prospective site on general population, report the baseline multiple pain at 75% for a total of 10 pain sites (head, neck, shoulder, elbow, hand/wrist, upper back, lower back, hip, knee, and ankle/foot). The pattern of multiple pains has been found to be relatively stable over the years ^{7, 8, 11} as the average sites of pain appears to be settled by age 20 and little variation occurs after that ⁸. Furthermore, the pattern of multiple pain sites is more strongly related to work disability ³² and long-term sickness absence ³³. Thus, even though the multiple pain prevalence in our Greek PET students is lower than in previous studies ^{7, 8, 31}, it should not be overlooked; multisite pain may persist or reoccur, meaning that those students who report multisite pain will most probably continue to do so during their working life ⁸. Studies in European and worldwide populations suggest that it is vital to widen the preventive health care ^{3, 11} and to identify the factors predicting the number of pain sites already at an early age ⁶. Furthermore, it is essential to provide the young population of students with specific preventive and informative programs including ergonomic, physiological, and psychosocial and lifestyle aspects ^{4, 5, 11, 17, 21, 30}.

In the perspective of the physical load and musculoskeletal disorders associated to the upcoming working life of the PET students ^{22, 23, 24, 34}, the pain prevalence is of particular interest as it may limit their future working ability ²⁴. All over the world, PE teachers face similar essential duties demanding a rather high physical workload ^{22, 23, 34}. The musculoskeletal risk due to their work duties justifies the consideration whether it is possible, or even reasonable, to work as a PE teacher after the age of 60 ²⁴. Thus, it is of utmost importance to develop strategies that will allow PET students to enter their working life with the healthiest possible musculoskeletal system. Such strategies aim to prevent the risk factors associated with the study curriculum ²¹.

When interpreting the results of the present study, one should consider the possible bias as the data was collected through questionnaires. Self-reports may be influenced by, for example, personality dimensions such as negative affectivity (common method bias) ³⁵. Also, self-administered questionnaires tend to be answered primarily by those who perceive the questions to be relevant ³⁶. The population of the study does not reflect a 'general' population due to the mean age and narrow age range limited to the academic years as well as the discipline specificities of the PET population. Furthermore, the physical workload induced by the study curriculum of the Greek PET students may be different than PET students from other countries. Thus, the results from this study cannot be generalized to all PET students. As stated in our introduction, the study was conducted to explore the prevalence of MSP among the Greek PET students rather than to study the risk factors. Nevertheless, the results are alarming, and careful attention should be given by school authorities to increase students’ awareness of MSP prevention and management.

In conclusion, our series of three cross-sectional studies in Greek PET students is in agreement with previous studies among university disciplines when students must sustain a significant physical load as part of their compulsory learning activities (i.e., dental, medical, nursing, and physiotherapy students). Although an increasing trend was not revealed across the three academic years of 2011-2012, 2015-2016 and 2017-2018, the overall pain prevalence in our PET students (67.6%) could be considered somewhat high compared to the general population (30%, ranging from 13.5 to 47%) ¹. The reduction of MSP during their academic life is of critical importance, as in their future working life as PE teachers, the PET students will also be susceptible to increased physical load and injury risk due to their distinct work demands. Thus entering their working life with a healthy musculoskeletal system is of critical importance and underlines the need for PE university authorities to take initiatives (i.e., changes of physical curriculum load) for the reduction of MSP.

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