Relationship of smartphone use time with cervical range of motion,shoulder-girdle muscle strength, posture, and neck pain in university students

Authors

Abstract

AimThis study aimed to examine the relationship between smartphone (SP) use time and cervical range of motion, shoulder-girdle muscle strength, posture, and neck pain in university students.
Methods100 volunteers were divided into 4 groups according to their duration of use. Postural analysis, goniometric measurements, and manual muscle tests were performed.
ResultsWhen the difference between the groups in terms of neck pain was examined with the VAS-activity results, it was found that the difference was significant (p<0.05). The presence of scoliosis, passive and active neck extension, and neck range of motion (ROM) of passive rotation were found to be significantly different between the groups (p<0.05).
ConclusionLong-term use of SP by young people could trigger neck pain, limit ROM, and cause postural impairments. Therefore, it is important to increase the awareness of individuals to minimize damage to the musculoskeletal system and maintain correct use and posture during SP usage.

Keywords

Introduction

Technology is developing rapidly to make life easier and meet the needs of the growing global population. One of the most groundbreaking sectors of technology is mobile telephones. Previously, phones only allowed us to hear another person’s voice, but now they can be used as a computer, music and video player, camera, navigator, and for fast internet access.¹ For these reasons, smartphones (SP), which meet many needs and are small, are actively and continuously used by many people and have become a basic everyday item. The age of SP start-up usage is declining, and the incidence of SP usage reached more than 5.19 billion users worldwide in 2020, with an increase of approximately 124 million (2.4%) each year compared with the previous year (available at: https://datareportal.com/reports/digital-2020-global-digital-overview). Consequently, this widespread use lays the groundwork for some health problems. Excessive SP use causes various musculoskeletal and physical health problems, such as blurred vision and pain in the wrists and neck.^2,3 A previous study reported that impaired hand function caused pain in the thumb and decreased finger grip strength.⁴ Prolonged and continuous SP usage causes postural changes in the cervical and lumbar vertebrae, and proprioception deficiencies in the cervical region.⁵ Upper crossed syndrome develops in individuals who work continuously in a head-forward posture, and after the posture begins to deteriorate, an imbalance between the muscles causes pain. The young onset of SP usage also lays the groundwork for the development of upper crossed syndrome.⁶
While the person is looking at an SP, the head is in a sustained flexion position for a long period and a spasm develops in the neck muscles. Therefore, if no precautions are taken, current conditions can lead to muscular and bone deformities. If populations are not warned about this, staying in a poor sustained posture becomes a habit, and the pathological disorders of cumulative neck pain negatively affect the activities of daily living (ADL) and reduce the quality of life (QoL).^5,6
According to previous research, various etiological, psychosocial, and personal factors play a role in neck pain. Unfortunately, in some cases, the cause cannot be determined. Tasks performed by repeatedly raising the upper limbs and bending the neck forward have been associated with neck pain.⁷ Because of neck pain, QoL deteriorates and work efficiency decreases. Considering that increasing numbers of patients create a burden on the healthcare system, neck pain causes both personal and governmental economic burdens. Moreover, neck pain seriously affects the psychology of the individual negatively.⁸ Among people using an SP, the neck is constantly flexed; however, the elbows are not supported. This can cause an excessive static load on the neck and shoulder areas. In addition, SPs are often held with one hand and controlled with one finger. These repetitive movements cause microtraumas in the musculoskeletal system, resulting in chronic pain, paresthesia, and weakness in the neck and upper extremities over time.⁹ In a study conducted with students, SP use and the relationship with the musculoskeletal system were examined, and almost half of the participants reported shoulder pain.¹⁰
In this respect, recent studies of SP usage have examined psychological well-being and the social and psychosocial dimensions of the individual, such as the level of loneliness. However, although there are very few scientific studies in the literature that examine the relationship between SP usage time and the musculoskeletal system, there are no studies addressing shoulder-girdle muscle strength in university students.¹¹ Therefore, this study aimed to examine the relationship between SP usage time and normal range of motion, shoulder-girdle muscle strength, posture, and neck pain in university students.

Materials and Methods

Participants
The study included 100 university students between the ages of 18 and 26 years, who were using SP. To determine the relationship between SP usage and neck pain, subjects with any neck pathology were excluded. All participants gave written informed consent before participation after receiving information about the study protocol, which conformed to the standards for human experiments set by the Declaration of Helsinki.
Measurements
To determine the use time of SP in a day, and the duration and severity of neck pain at the end of the day, face-to-face interviews and assessments were performed. Demographic information was recorded for each subject.
The study participants were separated into four groups according to SP use time. The visual analog scale (VAS), manual muscle test, postural analysis, and ROM assessments were performed in a sequence. VAS was used to determine the severity of pain during rest, activities, and SP usage.¹² The muscles in the neck and shoulder girdle were evaluated manually.¹³ Posture analysis was performed using a plumb line and observation from the anterior, lateral, and posterior sides to determine the postural changes, especially in the spine, head, shoulders, and chest region.¹⁴ To evaluate ROM, flexion-extension, right-left lateral flexion, and rotation movements of the cervical region were measured using a universal goniometer.¹⁵
Ethical Approval
This study was approved by the Ethics Committee of Hatay Mustafa Kemal University Non-Interventional Clinical Research Ethics Committee (Date: 23.12.2014, Decision No: 241).
Statistical Analysis
The statistical package SPSS 21.00 for Windows (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Descriptive statistics were used to describe the characteristics of the participants. All continuous variables were evaluated for normality using the Kolmogorov-Smirnov test. To determine the differences between the four groups, an ANOVA test was used. Correlation analysis was performed using the Spearman correlation analysis method. The level of correlation was classified as very weak (rho = 0-0.19), weak (rho = 0.2-0.39), moderate (rho = 0.40-0.59), strong (rho = 0.6-0.79), and very strong (rho = 0.8-1). In the analyses, p<0.05 was accepted as statistically significant.

Results

The demographic characteristics of the groups were also similar (p>0.05, Table 1). It was seen that VAS scores in activity were higher than those in rest. Interestingly, VAS scores were higher in the 61-90 min SP users’ group, both in rest (1.62 ± 1.96) and activity (4.19 ± 1.83), than the other groups.
While there was a statistically significant difference between the groups for the neck pain severity in activities, because of the higher scores in the 61-90 min SP users’ group (p<0.05), the neck pain at rest was so low and not different between the groups (p>0.05, Table 2).
When the groups were compared with respect to posture, muscle strength, and ROM, statistically significant differences were determined in the more than 90 min SP users’ group with respect to the presence of scoliosis (p<0.05), passive and active ROM of neck extension (p≤0.001), and passive ROM of neck rotation (p<0.05) (Table 2 and Table 3).

Discussion

This study examined the relationship between SP use duration and cervical ROM, shoulder-girdle muscle strength, posture, and neck pain in university students. As a result, it was determined that as the duration of SP use increased, the severity of neck pain during activity, presence of scoliosis in posture, neck passive and active extension, and passive rotation ROM were significantly different between the groups, especially in the more than 90 min SP users’ group.
SPs are used in all areas of life and have become a basic need. Although there are undeniable benefits of mobile phones, long-term usage can cause several health problems. SP overuse can lead to pain in the neck and shoulders, reduced proprioception, postural problems, reduced normal joint movement, increased musculoskeletal system problems, anxiety and depression, and headache.^2,3,5
Xie et al. (2015) compared the use of one or both hands when messaging on a telephone and observed high muscle activity in the upper trapezius and cervical erector spinae muscles in young subjects with neck and shoulder pain.¹⁶ In a study of 292 subjects, SP use duration, screen size, pain, purpose, and position of use were examined. Pain developed most in the neck, eyes, and shoulders, and as screen size increased, complaints in the lower back and legs also increased. Complaints were higher when the telephone was used in a sitting or supine position, and for internet searches and chatting, whereas <2 h users had the fewest complaints.¹⁷ In the current study, when subjects were questioned about neck pain during activity, a significant difference was determined between the groups with respect to VAS activity scores. Pain likely increased because of muscle fatigue formed by staying in the same position for a long time. Muscle fatigue and increased activity of some muscles are well-known reasons for pain in the neck and shoulders. In general, the cervical flexion angle during SP use causes muscle fatigue in the upper trapezius muscle and pain.¹⁸
Factors that increase scoliosis include prolonged sitting, incorrect posture, working at a desk, pelvis asymmetry, and lower extremity inequality.¹⁰ In this study, while neck muscle strength results were similar between the groups, the presence of scoliosis was different, in favor of the 61-90 min SP users’ group (18.8%). People generally do not pay attention to their posture while using SPs. Postural impairments should be prevented from early ages. In a previous study, changes in cervical spine posture were compared in two groups of young adults with and without mild neck pain when using an SP. Kim et al. (2015) stated that the flexion angle of the cervical spine was significantly higher in the group with mild neck pain during SP use than in the group with no pain.¹¹
There is no general concept of posture for SP users; different postures could be seen, with the head held in front, and incorrect postures such as rounded shoulders or oblique posture are the most frequently seen.¹⁰ It is very difficult to maintain proper posture while looking at the SP screen for a long time. Continuous and static repetitive movements in the same position reduce blood circulation and prevent nutrients from being delivered to the muscles. Ultimately, this causes fatigue, pain, and musculoskeletal disorders.¹⁷ Neck pain causes postural deformity around the cervical vertebra, and most people with neck pain experience biomechanical changes in the cervical vertebrae due to abnormal posture. Head-forward posture is a common condition that occurs when sitting at a desk for a long time. The head-anterior posture causes excessive extension of the cervical spine, defined as upper cervical extension and lower cervical flexion.¹⁹ This posture shortens the sternocleidomastoid, levator scapula, upper trapezius, and posterior cervical extension muscles, while weakening the anterior cervical vertebra muscles.²⁰ Research has reported that more than 90% of university students adopt a neck flexion posture with protracted shoulders and non-neutral wrist postures on the side where they use pocket devices.²¹
Our study was conducted on young adults, in whom these problems are not normally observed. While the presence of head anterior tilt (39.3%) was higher in the more than 90 min SP daily users’ group, the difference was not significant between the groups. The absence of muscle weakness for now suggests that accumulated stress could damage the musculoskeletal system and affect muscle strength in the future. Postural defects may not yet have formed, as the study sample consisted of young university students who were highly active with dynamic and good muscle strength. However, the manifestation of scoliosis indicates the onset of postural problems that could become major issues in the future. To take precautions, it is important to reduce SP daily use from younger ages and to adopt correct posture. As the anterior tilt of the head increases, the load on the cervical region also increases. In the neutral position of the head, the cervical area carries an average of 4.5-5.5 kg of the head’s own weight. This load reaches 13.61 kg at 30 degrees. Children are at greater risk because their head weight is higher relative to their body.²²
Samir et al. (2019) reported a significant difference between volunteers using SP for less than 4 h/day and those using SP for more than 4 h/day with respect to neck extension, lateral flexion, and rotation movements.²³ In our study, a significant difference was recorded between the groups with respect to ROM of neck rotation and extension. This could be due to keeping the neck in flexion and rotation to one side in long-term SP use, limiting extension and rotation to the other side. Students using SP performed an anterior head tilt of 30 degrees on average, whereas it was at most 20 degrees when not using the phone and engaged in other activities.²⁰ This could be the main cause of limited ROM during extension and rotation. Starting to use mobile telephones at a young age often lays the ground for upper crossed syndrome. Previous studies have shown that the flexion angle of the neck is increased in a normal stance.^6,19 For this reason, governmental and public health issues should be addressed urgently to increase awareness of proper position and daily usage time of SP.
This study was conducted before the COVID-19 pandemic lockdowns, during which education methods shifted to distance and online teaching. As a result, most students had to use SP for extremely long periods. Future studies should focus on musculoskeletal, pain, and postural problems associated with increased daily SP use following the COVID-19 pandemic. In addition, it is important to prevent problems that may arise with prolonged and long-term use by regulating the duration of use.

Limitations

Our study sample number was higher than the samples in the literature; however, it has limitations in grouping the same number of participants in groups and including the participants with higher daily use duration. In future studies, different body regions and more bio-psycho-social parameters could be handled with longer daily use durations and long-term follow-ups.

Conclusion

In conclusion, prolonged daily SP use by young people can trigger neck pain, and cause postural impairments and limitation in normal range of movements. Using SP for longer durations causes restricted movement in the neck over time, which could lead to muscle strength imbalance in the future and make these individuals vulnerable to neck and musculoskeletal pathologies. Although the users are young and healthy, awareness of the negative effects of SP usage with longer durations and incorrect postures as well as preventive methods should be increased with governmental, public health, and community-based rehabilitation approaches.

Declarations

References

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About This Article

Received:

February 9, 2024

Accepted:

April 9, 2024

Published Online:

June 4, 2024

Printed:

July 1, 2024