Introduction
The coronavirus disease-2019 (COVID-19), which emerged in Wuhan, China in December 2019, was declared as a pandemic by the World Health Organization on March 11, 2020. The governments began to take various quarantine preventions in order to slow the spread of the virus. Among the preventive measures taken in Turkey, along with the curfews, education on online platforms was at the forefront. In March 2020, face-to-face education was suspended and online education has become an important part of the lives of all students, including university. This major change in the learning environment brought about a significant increase in the time that students spent with technological devices in various forms such as laptops, computers, mobile phones, or tablets. The uncertainty in the education system, whether each student has his/her own study room or computer, and the conditions of the home environment during online education increased anxiety and depressive symptoms (1). In addition to all these, curfews also caused students to remain inactive.
It is known that certain positions like prolonged standing or sitting (2), long hours of computer use (3), lack of physical activity (4), and depression (5) are triggers for musculoskeletal pain (MSP). In studies evaluating MSP among medical school students before the pandemic has reported that at least 65.1% of medical students complained of pain in at least one body region within a year (6). To the best of our knowledge, there is no study evaluating MSP and related factors during online education among medical students. The primary aim of this study is to determine the prevalence of MSP and to explore associated factors among Ankara University Faculty of Medicine students during online education in the COVID-19 pandemic. The secondary aim is to determine the impact of MSP on the students’ quality of life.
Materials and Methods
This cross-sectional study was conducted between April-July 2021 in line with the principles of the Declaration of Helsinki. It was approved by the Ankara University Faculty of Medicine Students Ethics Committee (date: 25/03/2021, number: 79366). It was carried out as a web-based assessment via an online form. Ankara University Faculty of Medicine students aged 18 and over who volunteered to participate were involved in the study. Those with a history of musculoskeletal operation, a disease affecting the musculoskeletal system, with a diagnosis of depressive disorder, and who were 6th year of medical school were excluded.
Demographic and clinical characteristics of participants such as age, sex, body mass index (BMI), residence status before and after the pandemic, time spent on technology-based activities for education, was recorded.
Alterations of MSP among students were assessed with the standardized Turkish version of the Nordic Musculoskeletal Questionnaire (NMQ) (7). The NMQ is designed to assess the presence of musculoskeletal alterations covering nine different parts of the body: neck, shoulders, upper back, elbows, wrists/hands, lower back, hips/thighs, knees, and ankles/feet. All items are dichotomous and answered as “yes/no”.
Physical activity was evaluated using the Turkish version of the International Physical Activity Questionnaire-Short Form (IPAQ-SF), which contains 7 questions (8). The questionnaire referred to the last 7 days and asked about walking, moderate-intensity activities, vigorous-intensity activities, and sitting time. Physical activity was estimated by multiplying the metabolic equivalent (MET) score of each activity by the total amount of minutes spent per week. It was reported as a continuous measure and expressed as MET minutes per week (MET-min/week). Classified as physically inactive (<600 MET-min/week), low physical activity level (600-3000 MET-min/week), and adequate physical activity level (>3000 MET-min/week).
The rates of self-reported depression were assessed using the Beck Depression Inventory (BDI) (9). This questionnaire consists of 21 items, and each assesses a symptom related to depression during the past 2 weeks. Each item is scored on a 4-point scale from 0 to 3, with higher scores indicating severe symptoms. The total score is the sum of scores of all items and is calculated from 63 (10). A total score of 0 to 9 indicates minimum, 10 to 16 mild, 17 to 29 moderate, and 30 to 63 severe depression.
The health status of the students was evaluated with the Short Form-36 Health Survey Questionnaire (SF-36) consisting of eight scales: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health (10,11). Higher scores were related to good health status.
Statistical Analysis
Data were summarized as the mean ± standard deviation and median (minimum-maximum) for continuous variables and frequencies (percentiles) for the categorical variables. The Student’s t-test or Mann-Whitney U test was used for two group comparisons, depending on the distributional properties of the data. Categorical variables were compared using the chi-square or Fisher’s exact test as appropriate. The data was analyzed using the SPSS 11.5 for Windows (SPSS Inc., Chicago, IL, USA).
Results
A total of 233 students with an average age of 20.1±1.5 years responded to our survey. There were 153 (65.7%) females and most of the participants were year 2 students. Seventy-four percent of the participants stated that they attended more than half of the online training. The time spent on technology-based devices was found to be 3.8±2.3 hours. The participants rate the comfort level of the environment in which they participated in online education 5.7±2.07 out of 10 and 49% of them stated that they preferred face-to-face education. 83% of students had severe depression according to BDI and 41% of them were physically inactive (Table 1).
By individual body side, the most commonly affected body regions within one year were upper back (79,4%), neck (71.7%), lower back (69.5%), and shoulders (60.1%) respectively. The 7-day period prevalence was also similar (Table 2). Statistically significant differences in 12-month MSP prevalence were noted in female students at the neck (p=0.01) and upper back (p=0.001). BMI, smoking, and time spent on technology-based devices were not related to MSP prevalence.
BDI scores were found to be significantly higher in those with neck, upper back, lower back, and shoulder pain in the 7-day-period, compared to those without (Table 3). While physical activity levels were similar in those with and without neck, and shoulder pain, physical activity level was significantly lower in those with upper back and low back pain (p=0.043 and p=0.006 respectively). The SF-36 scores of those with MSP were found to be significantly lower than those without (Table 3).
Discussion
Our study showed that the MSP prevalence was common in the upper back, neck, lower back, and shoulder among Ankara University Medical School students who received online education. While female gender and higher BDI scores were related to MSP prevalence, smoking, BMI, and time spent on technology-based devices were not related. Physical activity level was found to be associated only with lower back and upper back pain. It was found that the quality of life in students with MSP was more negatively affected.
There are different studies evaluating the prevalence of MSP among medical students in different countries. The prevalence of MSP among Australian medical students was high, most commonly involve the neck (52.8%) followed by the lower back (51.6%) and shoulders (46.5%) (12). Among Malaysian medical students, lower back pain was most common, with a 7-day and 12-month prevalence of 27.2% and 46.1%, respectively (6). In Chinese medical students, the 12-month MSP prevalence was found 40.1% in the lower back, followed by the neck and shoulders 33.8%, 21.7% respectively (13). While the prevalence of MSP may differ depending on the selection of different student samples (pre-clinical, clinical, or both), the prevalence of pain in all body regions was found to be higher than the literature in our study. Considering that physical inactivity and depression levels, which are factors contributing to the development of MSP, increase during the pandemic period, this may be attributed to the higher prevalence of depressed and sedentary students in the study population. Also, we detected the highest prevalence of MSP in the upper back and neck. To the best of our knowledge, there is no study evaluating the prevalence of MSP and related factors in distance education in medical students during the COVID-19 pandemic. It is known that computer use increased in this period compared to face-to-face education. Therefore, our results are not surprising considering that neck pain is the most common in computer users, followed by upper back, and shoulder pain (3,14). However, contrary to our expectations, we did not find a relationship between the time spent on technology-based devices and the prevalence of MSP. There are some studies in the literature that are consistent with our results (15,16) in which Rajagopal et al. (15) stated higher MSP prevalence in female than male students but they could not found any correlation with the prevalence of MSP and the hours of computer use per day among Malaysian college students. The authors stated that this may be due to the smaller sample size. In our study, there are possible explanations. Firstly, although 74.2% of the students stated that they attended more than half of the online lectures, the daily time spent in front of technology-based devices seems to be low. In addition, this time was found to be similar in students with and without MSP. Second, correct posture may be effective in the prevalence of MSP as well as time spent in front of the computer. Future studies are needed to evaluate the relationship between posture and MSP.
Many studies reported that outbreaks such as COVID-19 increase symptoms of psychological distress and depression (17,18). In a previous study conducted at Ankara University Faculty of Medicine, depressive symptoms were found in 41% of the students (19). In our study, 83.2% of the students were reported severe depression and 16.8% of them reported moderate depression according to the BDI score. The most important reason for these increased rates is probably due to the pandemic. Since any of the students describe minimal or moderate depression according to BDI scores, the parameters that might have an effect on depression couldn’t be evaluated in this study. However, BDI scores were found to be higher in all students with neck, upper back, lower back, and shoulder pain in the last week compared to those without. Studies examining the relationship between MSP and depression in medical school students generally evaluated the presence or absence of mental stress (20,21). In this sense, our study is valuable in terms of using a standardized scale to measure depression. Although the high BDI scores in patients with MSP are important in terms of showing the relationship between these two factors, it is impossible to know whether these symptoms occurred before or after the onset of pain.
In our study, while low physical activity was related to upper back and lower back pain, not related to neck and shoulder pain. In the literature, there are different results in studies evaluating the relationship between physical activity level and MSP. First of all, the definition of physical activity has varied among many researchers and is not derived from objective data (4,22). In studies in which physical activity levels were questioned by validated questionnaires such as ours, the results differ. In line with our results, Scarabottolo et al. (23) showed that lack of physical activity was associated with lower back and neck pain. Also, Wedderkopp et al. (24) stated that high-level physical activity in childhood seems to protect against lower back pain in early adolescence. However, Balagué et al. (25) reported that adolescents, who were involved in sports programs, had higher chances of the occurrence of lower back pain. In this context, the findings in the literature are not clear.
MSP is a major cause of chronic pain that may affect the quality of life. Our study showed that the quality of life of the students who experienced neck, upper back, lower back, and shoulder pain was significantly lower than the students who did not. In this context, it has been found that low back pain has a significant effect on all aspects of students’ quality of life.
Study Limitations
There are several limitations of this study. First, the number of participants responding to the survey was low and did not reflect the entire student population. While it was aimed to reach a student population of nearly 2000 in total, only 233 students responded to the survey. In addition, since only students who met the inclusion criteria could participate in the online survey, it could not be determined how many students were excluded because they did not meet the inclusion criteria.
Conclusion
In conclusion, the prevalence of MSP was very high among medical students receiving online education during the COVID-19 pandemic. Depressive symptoms were more pronounced in students with MSP and it was evident that the MSP affected the quality of life negatively. Preventive measures should be considered to reduce MSP in this population.
Ethics
Ethics Committee Approval: This study was approved by the Ankara University Faculty of Medicine Students Ethics Committee (date: 25/03/2021, number: 79366).
Informed Consent: All patients provided informed consent and the study was carried out in compliance with the principles of the Declaration of Helsinki.
Peer-review: Externally peer-reviewed.
Authorship Contributions
Concept: S.G., Ş.K., Design: S.G., Data Collection or Processing: B.H.U., E.A., E.M., B.K., B.A.K., Ş.A., M.N., Analysis or Interpretation: S.G., İ.K., Literature Search: S.G., Writing: S.G.
Conflict of Interest: We declare that there is no conflicts of interest associated with this publication.
Financial Disclosure: We declare that we have not received any financial support to perform this study.
