do schoolbags cause back pain in children and adolescents? a systematic review

Objective to investigate whether the characteristic of children and adolescents using schoolbags is a risk factor for back pain.
As of April 2016, e-search of data sources for MEDLINE, EMBASE and CINAHL databases.
Qualification criteria for selected studies prospective cohort studies, cross-cutting
Segmented and randomized controlled trials were conducted for children or adolescents.
The main result is back pain, and the secondary result is seeking care and missing classes due to back pain.
We add warrants from longitudinal researchsectional.
A modified version of the quality of the prognostic research tool was used to assess the risk of bias in longitudinal studies.
As a result, we included 69 studies (n=72u2009627)
5 of them are forward-looking and vertical, and 64 are cross-cutting
Segment or review.
We found from five prospective studies that bag features such as weight, design and carrying methods do not increase the risk of back pain in children and adolescents.
The included studies had moderate to high risk of bias.
Evidence of Cross
Segmented research consistent with longitudinal research (
That is, there is no consistent correlation mode between bag use or type and back pain).
Due to different variables and inconsistent results, we are unable to pool the results.
Summary/conclusion there is no convincing evidence that all aspects of bag use increase the risk of back pain in children and adolescents.
Objective to investigate whether the characteristic of children and adolescents using schoolbags is a risk factor for back pain.
As of April 2016, e-search of data sources for MEDLINE, EMBASE and CINAHL databases.
Qualification criteria for selected studies prospective cohort studies, cross-cutting
Segmented and randomized controlled trials were conducted for children or adolescents.
The main result is back pain, and the secondary result is seeking care and missing classes due to back pain.
We add warrants from longitudinal researchsectional.
A modified version of the quality of the prognostic research tool was used to assess the risk of bias in longitudinal studies.
As a result, we included 69 studies (n=72u2009627)
5 of them are forward-looking and vertical, and 64 are cross-cutting
Segment or review.
We found from five prospective studies that bag features such as weight, design and carrying methods do not increase the risk of back pain in children and adolescents.
The included studies had moderate to high risk of bias.
Evidence of Cross
Segmented research consistent with longitudinal research (
That is, there is no consistent correlation mode between bag use or type and back pain).
Due to different variables and inconsistent results, we are unable to pool the results.
Summary/conclusion there is no convincing evidence that all aspects of bag use increase the risk of back pain in children and adolescents.
Back pain is known for its frequency and global burden.
1 average incidence of lower back pain (LBP)
Adults are estimated to be 18 years old. 3% and 1-
The annual prevalence was 38% per cent, while 1-
Universal rate of the year
The range of back pain ranges from 15% to 35%.
2 epidemiology data show that back pain is not only a health problem for adults, but is often reported by children and adolescents.
3 4 back pain reported by children and adolescents is common in many parts of the world, between 5 and adolescence, and the incidence increases rapidly with age.
According to a recent large multinational study,
It is reported that the prevalence of back pain among children aged 11, 13 and 15 is 27%, 37% and 47%, respectively.
Seven other studies found that 11%-71% of people experienced back pain at least once at the age of 14-17.
9 The cause of back pain in children and adolescents is unknown.
Studies investigating risk factors for back pain in children and adolescents are mostly unclear.
4. Some evidence shows that psychological and social factors (eg, distress)
Female sex and smoking may increase the risk of back pain in the population.
Evidence of human body measurement factors (
Height, weight, for example)
The factors of posture and lifestyle are mixed and the quality is generally poor.
While load or biomechanical factors are often considered to be the cause of back pain in children and adolescents, the evidence is inconsistent.
4 10 schoolbags are characterized as a biomechanical factor in back pain in children and adolescents.
Despite the lack of convincing evidence, schoolbags have traditionally been linked to back pain in children and adolescents.
High public awareness of the issue means that clinicians are often asked to advise on the preferred bag and/or how to carry it to reduce the risk of back pain.
More specifically, attention has been increasing to the load on children and adolescents going to and from school.
So far, there have been different suggestions for children and teenagers carrying schoolbags.
13 The Safety load guide is mostly within 10%-15% of the weight (BW)
Range, but include values as low as 5% 14 and as high as 20%.
A number of biomechanical studies have shown that a 10%-weight schoolbag may be sufficient to cause changes in exercise, body posture, and muscle strain.
16 17 the evidence to investigate the relationship between bag weight or other bag features and the risk of back pain is uncertain and does not help to determine any restrictions or suggested options regarding the bag.
Have more understanding of the schoolbag
Risk factors associated with back pain are important in determining appropriate preventive measures for children and adolescents.
18 The purpose of this study is to investigate the features of bag use (
For example, weight, time of use, bag design, bag lifting method, perceived weight)
It is a risk factor for back pain in children and adolescents.
Methods the programme of this review is proactively registered in the register of international forward-looking systematic reviews (42016037689 CRD.
This system review is based on Meta-
Observation Study analysis in the epidemiology checklist.
Starting from MEDLINE, EMBASE and CINAHL, 19 search system searches were conducted from November 2017.
Search strategies include terms for spinal pain, terms related to children and adolescents, and terms related to school bags;
The search strategy was based on previous Cochrane comments on the number of times of care related to seeking back pain and missing classes due to back pain (
Secondary results);
Weight of bag (
Absolute weight or percentage expressed as child weight);
Other features of bag use (
For example, duration of use, bag design, bag lifting method, perceived weight);
Statistical metrics for quantitative associations (
Relative risk, or HR)and 95% CI.
The risk of bias assessment in longitudinal studies is assessed by modified versions of the quality of Prognostic Studies (QUIPS)
The tools recommended by the Cochrane prognostic method group.
A playful remark was improved to judge the bias associated with risk factors, rather than the concern of the original tool for prognostic factors.
The following six areas were considered :(1)
Learning participation ,(2)
Learning loss ,(3)
Measurement of risk factors ,(4)
Measurement and Control of mixed variables ,(5)
Measurement of results and (6)
Analysis and Reporting.
Each area is assessed as biased with high, medium or low risk.
The overall risk of bias was also assessed.
We believe that a study is of high quality, when the risk of bias in at least four of the six areas is rated as low and low in research loss and research mix.
The two reviewers independently assessed the risk of bias in the study and, if necessary, resolved the differences through consensus and the third author helped to reach a consensus.
We plan to incorporate the risk of bias ratings into the interpretation of the results of the study by comparing the results of the low risk bias study with the results of the total number of studies included.
Vertical and horizontal data synthesis
The segmented design was evaluated separately.
In order to analyze whether features using schoolbags are a risk factor for back pain, if a sufficient number of longitudinal studies were identified to examine similar risk factors, the relationship between schoolbags features and back pain was explored and summarized. For the cross-
In the segmented study, we performed a descriptive analysis to report the factors associated with back pain.
We made prior decisions, mainly based on the results of longitudinal studies, as they provide a more robust design for causal inference.
The decision on whether to pool research is based on clinical and methodological consistency;
This includes subjective decisions based on the author\'s consensus.
Key elements of this decision include the measurement of exposure and results, the timing of data collection, and the analysis report.
A systematic search was conducted from MEDLINE, EMBASE and CINAHL until November 2017.
Search strategies include terms for spinal pain, terms related to children and adolescents, and terms related to school bags;
The search strategy was based on previous Cochrane comments on the number of times of care related to seeking back pain and missing classes due to back pain (
Secondary results);
Weight of bag (
Absolute weight or percentage expressed as child weight);
Other features of bag use (
For example, duration of use, bag design, bag lifting method, perceived weight);
Statistical metrics for quantitative associations (
Relative risk, or HR)and 95% CI.
The risk of bias assessment in longitudinal studies is assessed by modified versions of the quality of Prognostic Studies (QUIPS)
The tools recommended by the Cochrane prognostic method group.
A playful remark was improved to judge the bias associated with risk factors, rather than the concern of the original tool for prognostic factors.
The following six areas were considered :(1)
Learning participation ,(2)
Learning loss ,(3)
Measurement of risk factors ,(4)
Measurement and Control of mixed variables ,(5)
Measurement of results and (6)
Analysis and Reporting.
Each area is assessed as biased with high, medium or low risk.
The overall risk of bias was also assessed.
We believe that a study is of high quality, when the risk of bias in at least four of the six areas is rated as low and low in research loss and research mix.
The two reviewers independently assessed the risk of bias in the study and, if necessary, resolved the differences through consensus and the third author helped to reach a consensus.
We plan to incorporate the risk of bias ratings into the interpretation of the results of the study by comparing the results of the low risk bias study with the results of the total number of studies included.
Vertical and horizontal data synthesis
The segmented design was evaluated separately.
In order to analyze whether features using schoolbags are a risk factor for back pain, if a sufficient number of longitudinal studies were identified to examine similar risk factors, the relationship between schoolbags features and back pain was explored and summarized. For the cross-
In the segmented study, we performed a descriptive analysis to report the factors associated with back pain.
We made prior decisions, mainly based on the results of longitudinal studies, as they provide a more robust design for causal inference.
The decision on whether to pool research is based on clinical and methodological consistency;
This includes subjective decisions based on the author\'s consensus.
Key elements of this decision include the measurement of exposure and results, the timing of data collection, and the analysis report.
Results 6597 studies were retrieved.
After deleting duplicates and filtering the title and summary, we included 160 full studies
Text assessment;
We can\'t access the full-
Neither the text of six of the studies nor the attempt to contact the author was successful.
A total of 69 studies met our inclusion criteria and were included in this review (
Total number of participants n = 72 ÷ 627).
We include four longitudinal cohort studies (n=1743), one RCT (n=108), 63 cross-
Segmentation Research (n=70u2009720)
And a case-control with retrospective data (n=56)(figure 1).
Features of prospective studies (
Longitudinal Cohort and randomized controlled trials)
Cross features are described in table 1
Segmentation and case-control studies are described in Online Supplementary Appendix 1.
Data cannot be pooled due to the heterogeneity of exposure (backpack)and outcome (back pain)measures.
Supplementary information [SP1. docx]
Download figureOpen in the flow chart of Figure 1 of the new tabDownload powerpoint for the research included in this review.
View this table: View inline View pop-up table 1 features of the study included prospective study five prospective studies are considered to be moderate to high risk deviations in most of QUIPS bias risk domains (table 2).
Two studies 21 22 were assessed as high risk of bias and three23-25 as moderate risk of bias.
\"Research attributes\", \"prognostic factor measurements\" and \"research findings\" are the areas that describe the worst.
The area of \"measurement of results\" is the best description.
Due to the high heterogeneity between the included studies, we describe the results.
View this table: View bias risk assessment for prospective studies in inline View pop-up table 2 (
A vertical cohort23 and an RCT22)
Evaluate the correlation between the weight of the bag (% BW)
The risk of developing medlar;
No report is related.
Based on QUIPS ratings from both studies, weighted by sample size, we believe there is no medium-quality evidence of a relationship between backpack weight and back pain.
Two longitudinal studies assessed the risk of \"perception of bag weight\" and medlar.
A study 21 found that children with back pain reported difficulty carrying schoolbags and increased risk of developing persistent Medlar (RR 2. 1, 95%u2009CI 1. 1 to 4. 0).
Another study 25 also reported the perception of bag weight and medlar (OR 2. 2, 95%u2009CI 1. 0 to 4. 8).
Based on QUIPS ratings from both studies, we believe that low quality evidence of the relationship between backpack weight perception and back pain.
Another longitudinal study 24 did not investigate bag weight or perception of weight;
However, for the problem of \"situations causing pain\", none of the participants mentioned that carrying a bag would cause pain.
None of the prospective longitudinal studies reported data on the duration of using schoolbags, the number of times back pain care was sought, or the number of missed classes caused by back pain.
Table 3 summarizes the results of the longitudinal study.
View this table: View the inline View pop-up table 3 results for longitudinal studies included in the comments. Cross-
Segmentation and case
Control Research report-
Eight studies investigated the weight of the bag (% BW)
Weighing ranging from 5% to 19%, 29 studies investigated loads ranging from 2 to 10 kilograms.
14 studies investigated the use period of the schoolbag (
Carrying time)
20 to 85 minutes a day.
According to 22 studies, most students use backpacks or backpacks (around 90%)
Carry the bag on two shouldersaround 75%)
, A small number of students use satchels or shoulder bags carried by one shoulder or hand. Twenty-nine cross-
Segmentation studies did not find the association between bag features and medlar United.
26-54 four studies reported a positive association between children\'s perception of backpack weight and back pain.
55-58 three studies reported an association between the duration of carrying a backpack (
Long time)and back pain.
57 59 60 four studies reported an association between bag weights (heavier)
And back pain, 60-63 and three other studies found a correlation between the methods of carrying a bag (
One shoulder or asymmetrical)with back pain.
42 64 65 for a retrospective case-control study, there was no data on the weight or features of the bag, but 75% of chronic non-
It is reported that carrying a bag has aggravated their pain.
It is reported that there have been nursing incidents seeking back pain at 14 intersections
Segmentation research.
27 30 35 37 38 42-44 61 64 66-69 the prevalence of seeking care ranged from 1. 6% to 35% (median 18. 5, IQR 8. 6–23. 3).
However, none of the studies investigated the association between bag use and seeking back pain care.
It is reported that six intersections are missing classes due to back pain
In the segmented study, 27 30 38 41 55 61 with a median prevalence of 7.
8% absence from work for 1 day or more (IQR 1. 8–20. 5).
However, none of the studies investigated the association between using schoolbags and missing classes due to back pain.
Because we expect different definitions of back pain episodes, we plan to conduct a sensitivity analysis to explore the impact of the onset definition on risk.
However, the definitions are very similar for prospective studies, so we did not do this analysis.
Prospective studies five prospective studies are considered to be moderate to high bias risk in most areas of risk of bias (table 2).
Two studies 21 22 were assessed as high risk of bias and three23-25 as moderate risk of bias.
\"Research attributes\", \"prognostic factor measurements\" and \"research findings\" are the areas that describe the worst.
The area of \"measurement of results\" is the best description.
Due to the high heterogeneity between the included studies, we describe the results.
View this table: View bias risk assessment for prospective studies in inline View pop-up table 2 (
A vertical cohort23 and an RCT22)
Evaluate the correlation between the weight of the bag (% BW)
The risk of developing medlar;
No report is related.
Based on QUIPS ratings from both studies, weighted by sample size, we believe there is no medium-quality evidence of a relationship between backpack weight and back pain.
Two longitudinal studies assessed the risk of \"perception of bag weight\" and medlar.
A study 21 found that children with back pain reported difficulty carrying schoolbags and increased risk of developing persistent Medlar (RR 2. 1, 95%u2009CI 1. 1 to 4. 0).
Another study 25 also reported the perception of bag weight and medlar (OR 2. 2, 95%u2009CI 1. 0 to 4. 8).
Based on QUIPS ratings from both studies, we believe that low quality evidence of the relationship between backpack weight perception and back pain.
Another longitudinal study 24 did not investigate bag weight or perception of weight;
However, for the problem of \"situations causing pain\", none of the participants mentioned that carrying a bag would cause pain.
None of the prospective longitudinal studies reported data on the duration of using schoolbags, the number of times back pain care was sought, or the number of missed classes caused by back pain.
Table 3 summarizes the results of the longitudinal study.
View this table: View the inline View pop-up table 3 results for longitudinal studies included in the comments. Cross-
Segmentation and case
Control Research report-
Eight studies investigated the weight of the bag (% BW)
Weighing ranging from 5% to 19%, 29 studies investigated loads ranging from 2 to 10 kilograms.
14 studies investigated the use period of the schoolbag (
Carrying time)
20 to 85 minutes a day.
According to 22 studies, most students use backpacks or backpacks (around 90%)
Carry the bag on two shouldersaround 75%)
, A small number of students use satchels or shoulder bags carried by one shoulder or hand. Twenty-nine cross-
Segmentation studies did not find the association between bag features and medlar United.
26-54 four studies reported a positive association between children\'s perception of backpack weight and back pain.
55-58 three studies reported an association between the duration of carrying a backpack (
Long time)and back pain.
57 59 60 four studies reported an association between bag weights (heavier)
And back pain, 60-63 and three other studies found a correlation between the methods of carrying a bag (
One shoulder or asymmetrical)with back pain.
42 64 65 for a retrospective case-control study, there was no data on the weight or features of the bag, but 75% of chronic non-
It is reported that carrying a bag has aggravated their pain.
It is reported that there have been nursing incidents seeking back pain at 14 intersections
Segmentation research.
27 30 35 37 38 42-44 61 64 66-69 the prevalence of seeking care ranged from 1. 6% to 35% (median 18. 5, IQR 8. 6–23. 3).
However, none of the studies investigated the association between bag use and seeking back pain care.
It is reported that six intersections are missing classes due to back pain
In the segmented study, 27 30 38 41 55 61 with a median prevalence of 7.
8% absence from work for 1 day or more (IQR 1. 8–20. 5).
However, none of the studies investigated the association between using schoolbags and missing classes due to back pain.
Because we expect different definitions of back pain episodes, we plan to conduct a sensitivity analysis to explore the impact of the onset definition on risk.
However, the definitions are very similar for prospective studies, so we did not do this analysis.
Discussion this systematic review provides evidence from prospective studies of moderate to high risk of bias, demonstrating that bag features such as weight, design and carrying methods do not increase the risk of developing back pain in children and adolescents.
Two prospective studies reported that feeling heavy or difficult carrying a bag was associated with back pain and persistent symptoms.
Evidence of Cross
Segmented studies support the results of prospective studies.
Taken together, these results do not indicate a meaningful relationship between backpack use or weight in children and adolescents and back pain.
The advantage of this review is that we focus on data from prospective studies on bag features and risk of back pain, but also include cross-cutting
Collect segmentation and retrospective studies of all possible relevant information on this topic.
Taking into account the data of the latter study, to what extent these data are consistent with the longitudinal study.
If there is a causal relationship between backpack use and back pain, we expect to cross
The segmentation study has been reporting the association between the two variables, but the evidence of this per se is not enough.
So we expect to come from cross-
Segmentation studies can confirm the inference of causal association or lack of causal association in longitudinal data.
In this study, we also conducted a comprehensive search and we registered the program and evaluated the risk of bias for inclusion in the study using a robust approach.
There are limitations in this study.
We found only five prospective studies in this review.
Since these studies investigated different variables and the results were inconsistent, we were unable to pool the results.
Despite these limitations, the number and Association of studies showed no consistent pattern, suggesting that any relationship between backpack use and back pain was at best minimal, research resources aimed at understanding back pain in adolescents are better used elsewhere.
Previous reviews investigated the association between back pain and bag features (
Weight, type, handling method)
Among children and teenagers
9 13 15 70-73 although most of these comments are based on cross-
Their findings are basically consistent with our findings (
That is, there does not seem to be a clear link between the bag features of children and adolescents and back pain).
Most of these comments are narrative reviews, or investigate risk factors without considering longitudinal data.
Our review extends the results of previous studies by providing evidence from five prospective longitudinal studies that show little or no association between bag use and back pain.
The use of schoolbags does not seem to be an important risk factor for back pain in children and adolescents.
However, due to the small number of prospective studies included in this review and the low quality of the methods studied, our findings should be interpreted with caution.
There are very few longitudinal cohort studies of children and adolescents in the literature, and in most cases determining risk factors for back pain is not the primary purpose.
Therefore, the choice of exposure variables, measuring instruments and data collection time is not the best choice for revealing causal relationships.
These questions can explain why there is no strong conclusion in the systematic review in this area.
The findings questioned various guidelines and statements supporting specific weight limits for children and adolescents schoolbags.
13-15 these proposals do not appear to be based on the most reliable evidence on the subject.
These findings also have an impact on a variety of professional institutions and clinicians that recognize or recommend specific backpacks.
It is important that such recognition is made on the basis of solid evidence and no financial conflict.
Based on the evidence of the five longitudinal studies (
N = 1851 children and teenagers)
More than 60 intersections
In the segmented study, there is no convincing evidence that all aspects of bag use increase the risk of back pain.
There is some evidence that heavy feelings are related to back pain.
Acknoknowledge momentum received a doctoral scholarship in CAPES (
Coordination for the improvement of higher education personnel)
Brazil, Ministry of Education.
Research grants for CGM, CMW and SJK are funded by the National Health and Medical Research Council of Australia.
The authors thank Dr. Bruno saragato for his critical revision of the manuscript and data analysis.
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2174/157339607779941624 openurlfootnotescontriators TPY conducted the study as part of her PhD, leading the main writing, screening, data extraction and analysis.
CGM is her supervisor and during her research she contributed to the concept and guidance.
ACT, CMW and SJK contributed to the revision, screening, data extraction and interpretation of the study.
Funding for this study has not been specifically funded from public, commercial or any other funding institutionfor-profit sectors.
No one declared a competitive interest.
Patient consent is not required.
Uncommissioned source and peer review;
External peer review.