Back Pain : Effects of Backpack Carrying in Children
Back pain is epidemic in the adult population with >60% of adults reporting having experienced back pain.1-3 Back symptoms are the second leading symptomatic reason expressed by patients in the United States for consulting physicians.4 The occurrence of back pain in children and adolescents varies from 8% to 84.1%.5-15 The reported occurrence depends on the population under study and the definition used.16 The majority of low-back pain is mild.17 There is growing concern among educators, health-care professionals, parents, and legislators that back pain is becoming a serious health issue in school-aged children due to the increased use of heavy backpacks.18
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The carrying of heavy backpacks is common in the school-age population.2 Young children sometimes carry as much as 30% to 40% of their body weight.2 The association of back pain with backpack use is controversial within the scientific literature with some studies finding no association and some finding an association. This review article studies the impact of backpack carrying on children and reviews the available scientific literature.
Back Pain : Effects of Backpack Carrying in Children
Prevalence and Risk Factors for Back Pain
The prevalence of nonspecific back pain increases dramatically during adolescence from <10% in preteens to 50% in 15- to 16-year olds.11,19 The most frequent increase in prevalence of reported back pain occurs in girls aged 12-13 years and in boys aged 13-14 years.20 Viry et al15 noted that this period corresponds to the time of puberty and maximum linear growth. It is known that back pain at a young age is an important factor in the risk of experiencing back pain as an adult.7,21
Most authors have reported the following associations with back pain: gender (higher prevalence in females),11,13,15,22-24 poor general health,11 a family history of back pain,6,13,15 psychological profile,6,16,22,25-28 time spent sitting or watching television,11,13,23,29 heavy backpack weights,11,14 exposure to backpack loads (time spent carrying loads),11,23,30 increased back flexor strength,9 high growth rate,26 tight hamstrings,26 tight quadriceps femoris,26 previous back injury,13,14 low physiologic maximum lumbar spine mobility,31 increased body mass index,24,32 and age (more back pain at older age).8,9,12,13,17,19,23,29 Although one study suggested that low levels of physical activity are associated with back pain in adolescents,33 other studies have found that high levels of physical activity9,13,14 and participation in competitive sports5,13,17,19,23,24,29,34 are associated with back pain in adolescents.
In a systematic literature review of 56 journal articles reporting on 65 epidemiologic studies about body weight and low-back pain, Leboeuf-Yde et al20,35 concluded that if body weight should be considered a possible weak risk indicator, insufficient data exists to assess whether it is a true cause of low back pain. In a systematic literature review of 41 journal articles reporting on 47 epidemiologic studies about smoking and low-back pain, Leboeuf-Yde36 concluded that smoking should be considered a weak risk indicator and not a cause of low back pain.
Back Pain : Effects of Backpack Carrying in Children
Backpack and Gait Analysis/Cost of Locomotion
Walking with a heavy load changes posture: patients carrying a heavy load lean forward and raise their heads.2 Chansirinukor et al37 revealed that both backpack weight and time carried influenced cervical and shoulder posture. Forward head posture increased when carrying a backpack, especially one with a heavy load. Carrying a backpack representing 15% of body weight appeared to be too heavy to maintain standing posture for adolescents.
Cottalorda et al38 analyzed the effect of different backpack carrying methods on gait kinetics in children. Forty-one children, mean age 12 years, participated in this study. The mean weight was 40 kg. The 3 trials consisted of walking on a treadmill at 3.5 km/h, first without a backpack and then carrying a 10-kg backpack, on one shoulder and both shoulders. When carrying a backpack on one shoulder and then on both shoulders the children walked with longer strides (time between two consecutive heel-on contacts), stance (portion of the gait cycle during which the foot is in contact with the ground), and double stance (time during which both feet are in contact with the ground) compared to walking without a backpack. These results were supported by Hong and Brueggemann39 and Kinoshita40 who noted that the double-support period lengthened significantly as the load increased. This can be attributed to the need for stability when carrying loads.2,38
Cottalorda et al38 found that carrying a 10-kg backpack on one shoulder brought about an imbalance and, after the swing, children needed a greater propulsive force to regain balance. Carrying a 10-kg one-strap backpack also induced an asymmetric gait for braking and propulsive fore-aft forces. It is interesting to note that this asymmetric gait was not apparent with a two-strap backpack. Cottalorda et al38 concluded that carrying a 10-kg schoolbag makes a difference to gait kinetics and that children should carry their backpacks on both shoulders rather than use a one-strap backpack.
Pascoe et al41 investigated the impact of backpacks on 10 children aged 11-13 years using measurement of static posture and gait kinematics. The children participated in tests under four conditions: no backpack, one-strap backpack, two-strap backpack, and one-strap athletic bag. Pascoe et al41 also noted that carrying one-strap bags caused a shoulder elevation and a curvature of the spine away from the weight of the backpack. In their study, shoulder elevation from a horizontal position and lateral spinal deviation was not significantly different between two-strap back packs and no backpack. However, one-strap athletic bags promoted lateral spinal bending and shoulder elevation, while the two-strap backpack significantly reduced the stresses of carrying backpacks. Pascoe et al41 concluded that the daily physical stresses associated with carrying athletic bags on one shoulder significantly alter the posture and gait of young people. These alterations of the spine may be responsible for the perceived back pain (51%) reported in their study.41
Backpack Weight, Back Pain, & Structural Spinal Deformity
Does low back pain in childhood predict low-back pain in adulthood? Few longitudinal data are available. Harreby et al7 used a questionnaire to collect data from a cohort of 578 adults aged 38 years who had participated in a study of schoolchildren conducted 25 years earlier. In patients with a history of low-back pain in childhood, the odds ratio (OR) for low-back pain in adulthood was 2.23 (confidence interval: 1.00-4.97). Mirovsky et al3 had similar findings: 62% of the children in their prospective study reported pain after maturity.
Orthopedics surgeons should pay careful attention to the identification and management of risk factors for low-back pain. Postural changes in the spine occur when heavy backpacks are carried.2 This raises concerns in the lay population that scoliosis and kyphosis may be caused or aggravated by backpack use.2 Although adolescents with back pain stand a greater risk of experiencing back pain as adults, there is no evidence that structural spinal deformity can result from backpack use.2,18
Backpack weight is a major problem. Research has not yet identified a critical backpack weight per child above which that child risks back pain.2 Backpack loads >10% of body weight have been shown to increase energy consumption,42 increase trunk forward lean,39,41 and result in decreased lung volumes.43
Hong and Brueggemann39 examined the gait pattern, heart rate, and blood pressure in 10-year-old boys carrying backpacks of 0% (as control), 10%, 15%, and 20% of their own body weight while walking on a treadmill. No significant difference was found in the measured parameters between the 10% and 0% load conditions, however a significant difference was found between the 0% and 15% or 20% load conditions with a significant increase of forward trunk bending. Hong and Brueggemann39 concluded that backpack weight should not exceed 10% of body weight in 10-year-old boys. These results are in agreement with the previous findings reported by Malhotra and Sen Gupta.44
The mean backpack weight in United States was 7.7 kg, which represented 17% of the student's mean body weight.36,41 Hong Kong students carried backpacks weighing approximately 20% of their body weight.39 The recommended backpack load limit for physically fit adults is 30%.28 Of Italian schoolchildren, 34.8% regularly exceeded this load limit.45 In the study by Viry et al,15 the mean backpack weight was 9.6 kg, which corresponded to 19.2% of the mean child's weight, and 49% of children were carrying backpacks that weighed >20% of their body weight. Viry et al15 reported that carrying a backpack weighing >20% of the bearer's body weight was significantly associated with back pain within the previous year and with back pain requiring a physician visit (adjusted OR, 3.1 [P<.05] and 5.2 [P<.01], respectively).
In a cross-sectional study of 1126 children, aged 12-18 years, Sheir-Neiss et al11 reported that the use of backpacks during the school day and backpack weight are independently associated with back pain. However, in this study adolescents with back pain were more likely to carry a heavier backpack and to use their backpack more during the school day. Adolescents without back pain were more likely to attend schools that banned carrying backpacks between classes.
Negrini and Carabalona30 found an association between back pain and time spent carrying backpacks, but not between back pain and backpack weight. Viry et al15 found an association between back pain and walking to and from school, only if the relative backpack weight was >20% of body weight. Wall et al18 found that only 0.3% of children requiring specialty evaluation for back pain attribute their pain to backpack use, and only a few children felt that a backpack worsened their pain.
Backpack Design, Load Carriage, and Prevention
The way the backpack is carried may be of influence in the occurrence of back pain.13 Backpacks worn on one side or poorly positioned could weaken or damage posture.46 In the study by Viry et al,15 back pain leading to absence from school or sporting activities was reported in 50% of the patients who carried their backpack by hand versus 11.5% of those who carried it by the shoulder harness. Children often carry their backpack with only one strap: 76 % in the study by Cottalorda et al38 and 73% in the study by Pascoe et al.41 However, in the study by Sheir-Neiss et al,11 most of the students (87.6%) carried their backpacks using both shoulder straps. Sheir-Neiss et al11 found no significant difference in the reporting of back pain between those who used one strap and those who used two straps. Carrying the bag on two shoulders is the best way ergonomically.13,38,41,44
Conclusion
Although the results of the literature review were not always homogeneous (according to different backpack weights, carrying, or methodology in the studies), common conclusions exist. Improper backpack use can result in changes of posture and gait. There is no evidence that structural spinal deformity can result from backpack use. Some authors reported that carrying a backpack weighing .20% of the bearer's body weight was significantly associated with back pain. Many studies concluded that backpack weight should not exceed 10% of body weight. Children should be advised to carry backpacks with two straps rather than one.
Authors
From the Exercise and Disability Physiology and Pathophysiology Laboratory, University School of Medicine, Saint-Etienne, France.
The authors have no industry relationships to declare.
Reprint requests: Pr. Jérôme Cottalorda, Service de chirurgie infantile, Hôpital Nord, 42055 Saint-Etienne Cedex 2, France.
Back Pain : Effects of Backpack Carrying in Children
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