Musculoskeletal pain among medical students at two Jordanian universities

Abstract

BACKGROUND:

Musculoskeletal (MSK) pain is a debilitating multi-perceptual condition afflicting many individuals, especially individuals in the medical profession.

OBJECTIVE:

To analyze and evaluate the prevalence of musculoskeletal pain among medical students at Jordanian universities during the complete virtual learning process.

METHODS:

A cross-sectional study of 593 medical students at two Jordanian universities was conducted. A modified Nordic questionnaire was used to assess musculoskeletal pain in three body regions.

RESULTS:

Five hundred ninety-three students at the two Jordanian universities participated in this study. The prevalence of having MSK pain during the past week in the neck, shoulder, and lower back was 34.6%, 27%, and 41%, respectively; during the past 12 months, it was 61.2%, 45.5%, and 63.1%, respectively. Overall prevalence of having MSK pain was 58.9% in the last week and 78.1% in the past 12 months. 66.8% of students who had psychosomatic symptoms and 62.3% of those with depressive symptoms in the past week had MSK pain. Students who studied 8 hours per day had higher percentages of MSK pain (68.4%) (OR 1.12, 95% CI 0.965–1.312). The average number of hours using a computer per day was significantly associated with MSK pain ( $p=$ 0.032). MSK pain during the last week was significantly associated with psychosomatic symptoms (OR 1.842, 95% CI 1.272–2.668, $p=$ 0.001). Family history of MSK pain was significantly related to the presence of the problem in participants (OR 1.732, 95% CI 1.182–2.538, $p=$ 0.005). Gender, depressive symptoms, average hours of computer use per day, and average hours of study at home per day did not show significant relationships with MSK pain over the year.

CONCLUSIONS:

High prevalence of MSK pain was observed among medical students. Measures to balance in-person and virtual learning should be considered in medical schools to minimize the risk of MSK pain.

Keywords

Musculoskeletal pain neck shoulder low back pain Jordan

1. Introduction

Musculoskeletal (MSK) pain is a debilitating multi-perceptual condition afflicting many individuals, especially individuals in the medical profession. The application and training process for medical school is challenging, and many medical students face significant physical and emotional stress. Academic, ethical, and economic demands have all contributed to a high frequency of psychological illnesses, such as burnout and depression [1, 2, 3, 4, 5]. Even in young people, psychological stress can appear as MSK symptoms [6, 7, 8, 9, 10, 11]. During the coronavirus outbreak and under the lockdown regulations, a lot of universities adapted to a new teaching model depending on virtual or distance learning methods. These changes reduced daily life activities and increased the sedentary life pattern, contributing to the prevalence of musculoskeletal pain in university students [12]. This musculoskeletal overload has been attributed to spending a long time sitting while studying and inappropriate use of chairs [12]. Previous research has found that medical students had a high rate of musculoskeletal pain. In one study conducted at a Malaysian medical college, 65% of the students had experienced musculoskeletal pain in the previous year, with clinical years, computer use, and a prior history of trauma being associated [13]. Lower back discomfort was shown to be prevalent in 53% of medical students in an Austrian medical school survey [14]. These common complaints in different societies alerted the authors to study the prevalence of MSK pain in Jordanian medical students and compare it to what has been published previously.

2. Objective

In this study, an online survey was conducted to evaluate the impact of e-learning on musculoskeletal complaints in two Jordanian universities’ medical students and to assess any negative health outcomes among them.

3. Methods

3.1 Study design and participants

In this cross-sectional study, 6495 medical students from two Jordanian universities (Yarmouk University and University of Jordan) were enrolled through an online questionnaire survey. Medical school in Jordan lasts for 6 years. The first 3 years (preclinical years) are for basic sciences, where the students spend their time in the school of medicine, and the last 3 years are clinical years, where the students have their training completely in hospitals. The English-language adapted form of the Nordic musculoskeletal questionnaire (NMQ) [13, 15] was used to conduct a survey between May and August 2021.

3.2 Sampling and sample size

The study was carried out with convenience sampling. The sample size was calculated based on the Cochrane formula for a small population size [16].

$\displaystyle\textit{Sample Size}=\frac{\frac{Z^{2}pq}{e^{2}}}{1+\frac{\frac{Z% ^{2}pq}{e^{2}}}{N}}$

Where $Z$ is the $Z$ score at a confidence level of 95% (standard value of 1.96), $p$ is the population proportion, $q$ is 1- $p$ , $e$ is the level of precision (sampling error, set to 0.5%), $N$ is the population size (equal to 6495 students).

Based on this equation, a sample size of 364 was set to be representative. The data used for this study are valid and reliable, with Cronbach’s alpha of 0.806. The NMQ tool was developed to evaluate musculoskeletal problems by Kuorinka et al. in 1987 [15]. In this tool, the participants are asked if they have had pain in specific areas of their bodies in the past week and 12 months. If they have had pain, then they elaborate on whether or not that pain prevented them from carrying out their usual work. This modified questionnaire includes a body diagram that divides the body into three areas (neck, shoulder and lower back) and includes three parts. The first part asks about sociodemographic data, the second focuses on the risk factors associated with the pain complaints, and the third part asks about pain in specific areas in the preceding week and 12 months [13]. This questionnaire was transformed into Google Forms and sent to all medical students on their online classes’ lists in both universities. No exclusion criteria were set.

3.3 Statistical analysis

The data were analyzed using PASW statistics 18 (IBM Corp., Armonk, NY, USA). The Mann-Whitney U test and $t$ -test were used for continuous variables and Chi-square for categorical variables. Binary logistic regression was used to compare variables that showed significant differences in the primary analysis.

Table 1
Demographic characteristics of participants

	Count	Column $N$ %	Mean	Standard deviation
University	Yarmouk University	298	50.3%
	University of Jordan	295	49.7%
Gender	Male	224	37.8%
	Female	369	62.2%
Academic year	1	184	31.0%
	2	78	13.2%
	3	75	12.6%
	4	85	14.3%
	5	90	15.2%
	6	81	13.7%
Age in years			20.89	2.13

3.4 Ethics

This study was performed according to the Declaration of Helsinki. Ethical approval to conduct this study was obtained from the institutional review board (IRB) of Jordan University Hospital (JUH), with approval number 10/2021/9413. All the students participated in this study voluntarily and informed consent was obtained at the beginning of the questionnaire once they had agreed to answer and be enrolled in the study.

4. Results

Five hundred and ninety-three undergraduate students at the two Jordanian universities participated in this study: 298 (50.3%) from Yarmouk University and 295 (49.7%) from the University of Jordan. The mean age of the participants was 20.89 (SD 2.13) years. Most of them were female (369, 62.2%; see Table 1).

The overall prevalence of having MSK pain at any site of the studied body areas was 58.9% in the last week and 78.1% in the past 12 months. The prevalence of lower back pain was the highest in the last week and in the last year (41.0%, and 63.1% respectively) compared to the other body regions (Table 2). Four hundred twenty-four medical students had a family history of musculoskeletal pain, of whom 270 (63.7%) had MSK pain in the past week. 66.8% of students who had psychosomatic symptoms and 62.3% of those with depressive symptoms during the past week had MSK pain (Table 3).

Table 2
Prevalence rate of MSK pain

		Count	%
Last week neck trouble	No	388	65.4%
	Yes	205	34.6%
Last year neck trouble	No	230	38.8%
	Yes	363	61.2%
Last week lower back trouble	No	350	59.0%
	Yes	243	41.0%
Last year lower back trouble	No	219	36.9%
	Yes	374	63.1%
Last week any shoulder trouble	No	433	73.0%
	Yes	160	27.0%
Last year any shoulder trouble	No	323	54.5%
	Yes	270	45.5%

Table 3

Prevalence of MSK pain at any site of the studied body areas last week

		MSK pain at any site last week
		No count %		Yes count %		$p$ -value
University	Yarmouk University	123	41.3%	175	58.7%	0.949
	University of Jordan	121	41.0%	174	59.0%
Gender	Male	109	48.7%	115	51.3%	0.004
	Female	135	36.6%	234	63.4%
Family history of neck, shoulder, or low back pain?	No	90	53.3%	79	46.7%	$<$ 0.001
	Yes	154	36.3%	270	63.7%
Smoking	No	217	42.2%	297	57.8%	0.176
	Yes	27	34.2%	52	65.8%
Psychosomatic symptoms during medical studies	No	127	52.7%	114	47.3%	$<$ 0.001
(numbness, tingling, weakness)	Yes	117	33.2%	235	66.8%
Depressive symptoms during medical studies	No	76	51.7%	71	48.3%	0.003
	Yes	168	37.7%	278	62.3%

MSK, musculoskeletal.

Overall prevalence of MSK pain in the past week was higher among students in the pre-clinical years compared to those in the clinical years, without statistical significance ( $p=$ 0.106), while it was nearly the same in the past 12 months ( $p=$ 0.558).

Table 4

Factors associated with MSK pain at any site of the studied body areas last week

		MSK pain at any site of the studied body areas last week
		No		Yes		$p$
		Count	Row $N$ %	Count	Row $N$ %
Academic year	1	73	39.7%	111	60.3%
	2	22	28.2%	56	71.8%
	3	32	42.7%	43	57.3%	0.106
	4	36	42.4%	49	57.6%
	5	40	44.4%	50	55.6%
	6	41	50.6%	40	49.4%
Average hours of computer use per day	1 – $<$ 2	27	52.9%	24	47.1%
	2 – $<$ 4	48	48.0%	52	52.0%
	4 – $<$ 6	65	44.8%	80	55.2%
	6 – $<$ 8	47	36.7%	81	63.3%	0.032
	$>$ 8	57	33.7%	112	66.3%
Average hours of study at home per day	1 – $<$ 2	27	50.0%	27	50.0%
	2 – $<$ 4	70	48.6%	74	51.4%
	4 – $<$ 6	70	44.0%	89	56.0%	0.012
	6 – $<$ 8	41	33.6%	81	66.4%
	$>$ 8	36	31.6%	78	68.4%
Place of study	Bed	29	53.7%	25	46.3%
	Study table	139	45.0%	170	55.0%	0.003
	Both	76	33.0%	154	67.0%
Exercise	Not at all	47	37.6%	78	62.4%
	Not regularly	147	40.3%	218	59.7%	0.213
	Regularly	50	48.5%	53	51.5%
Drinking coffee	Not at all	109	48.7%	115	51.3%
	$<$ 3 cups/week	57	42.2%	78	57.8%	0.004
	$>$ 3 cups/week	78	33.3%	156	66.7%

MSK, musculoskeletal.

Table 4 shows the relationships between study routines, using computers, and drinking coffee with neck pain in the past week. The most prevalent association was between the place of study and troubles in the studied body regions ( $p=$ 0.003). Students who used both a desk and a bed for studying had the highest percentage of MSK pain. This was followed by a significant relationship with drinking coffee ( $p=$ 0.004). Students who drank more than three cups of coffee per week were likelier to have MSK pain (66.7%).

Hours spent studying had a significant relationship with MSK pain ( $p=$ 0.012): higher percentages of students had pain as the hours spent studying increased. Students who studied 8 hours per day had a higher rate of MSK pain compared to other categories (68.4%). Average hours using a computer per day also showed a significant difference ( $p=$ 0.032): it can be observed that students who spent 8 hours or more had a higher rate of problems (66.3%) (Table 4).

Binary logistic regression was performed on demographics, personal factors, daily practices, and studying behaviors, which showed statistical significance with psychosomatic symptoms (OR 1.842, 95% CI 1.272–2.668, $p=$ 0.001). A family history of neck, shoulder, and low back pain was significantly related to the presence of the problem in participants (OR 1.732, 95% CI 1.182–2.538, $p=$ 0.005). Students who drank more than three cups of coffee a week were 1.332 times more likely to present with MSK pain than those who didn’t drink coffee. Also, the place of the study had a direct significant effect (OR 1.502, 95% CI 1.134–1.990, $p=$ 0.005) (Table 5). Other variables did not show significant relationships with MSK pain.

Table 5

Binary logistic regression for factors associated with MSK pain last week

	$p$ -value	Odds ratio	95% confidence interval
			Lower – upper
Gender	0.183	1.282	0.889–1.848
Family history	0.005	1.732	1.182–2.538
Psychosomatic symptoms	0.001	1.842	1.272–2.668
Depressive symptoms	0.461	1.172	0.769–1.788
Average hours of computer use per day	0.137	1.118	0.965–1.296
Average hours of study at home per day	0.159	1.120	0.965–1.312
Usual place of study (both bed and study table vs. bed only)	0.005	1.502	1.134–1.990
Drinking coffee $>$ 3 cups/day vs. not at all	0.005	1.332	1.090–1.627

MSK, musculoskeletal.

Table 6

Prevalence of MSK pain at any site of the studied body areas last year

		Trouble at any site last year
		No count %		Yes count %		$p$ -value
University	Yarmouk University	69	23.2%	229	76.8%	0.466
	University of Jordan	61	20.7%	234	79.3%
Gender	Female	70	19.0%	299	81.0%	0.026
	Male	60	26.8%	164	73.2%
Family history of neck, shoulder, or low back pain?	No	57	33.7%	112	66.3%	$<$ 0.01
	Yes	73	17.2%	351	82.8%
Smoking	No	108	21.0%	406	79.0%	$<$ 0.172
	Yes	22	27.8%	57	72.2%
Psychosomatic symptoms during medical studies	No	78	32.4%	163	67.6%	$<$ 0.01
(numbness, tingling, weakness)	Yes	52	14.8%	300	85.2%
Depressive symptoms during medical studies	No	49	33.3%	98	66.7%	$<$ 0.01
	Yes	81	18.2%	365	81.8%

MSK, musculoskeletal.

Table 6 shows results between certain variables and MSK pain in the past year. The most significant association with MSK pain was having a family history of neck, shoulder, or low back pain ( $p<$ 0.01). Also, psychosomatic symptoms (numbness, tingling, and weakness) and depressive symptoms during medical studies had a significant relationship with MSK pain ( $p<$ 0.01 for both).

Gender was significantly associated with MSK pain ( $p=$ 0.026) – it can be observed that a higher percentage of females had the problem during a year (81.0%) in comparison to males (Table 6).

Table 7

Factors associated with MSK pain at any site of the studied body areas last year

		MSK pain at any site of the studied body areas last year
		No		Yes		$p$
		Count	Row $N$ %	Count	Row $N$ %
Academic year	1	40	21.7%	144	78.3%	0.558
	2	14	17.9%	64	82.1%
	3	20	26.7%	55	73.3%
	4	18	21.2%	67	78.8%
	5	16	17.8%	74	82.2%
	6	22	27.2%	59	72.8%
Average hours of computer use per day	1 – $<$ 2	20	39.2%	31	60.8%	0.009
	2 – $<$ 4	27	27.0%	73	73.0%
	4 – $<$ 6	30	20.7%	115	79.3%
	6 – $<$ 8	23	18.0%	105	82.0%
	$>$ 8	30	17.8%	139	82.2%
Average hours of study at home per day	1 – $<$ 2	21	38.9%	33	61.1%	0.005
	2 – $<$ 4	38	26.4%	106	73.6%
	4 – $<$ 6	31	19.5%	128	80.5%
	6 – $<$ 8	21	17.2%	101	82.8%
	$>$ 8	19	16.7%	95	83.3%
Place of study	Bed	16	29.6%	38	70.4%	0.221
	Study table	70	22.7%	239	77.3%
	Both	44	19.1%	186	80.9%
Exercise	Not at all	26	20.8%	99	79.2%	0.15
	Not regularly	74	20.3%	291	79.7%
	Regularly	30	29.1%	73	70.9%
Drinking coffee	Not at all	60	26.8%	164	73.2%	0.078
	$<$ 3 cups/week	27	20.0%	108	80.0%
	$>$ 3 cups/week	43	18.4%	191	81.6%

MSK, musculoskeletal.

Table 7 shows the relationships of study routines, using computers, and drinking coffee with MSK pain in the past year. The average hours of study at home per day and average hours of computer use per day showed significant differences in causing MSK pain during the last year ( $p=$ 0.005 and $p=$ 0.009, respectively). Students who spent more than 8 hours studying had a higher rate of pain neck (83.3%). Students who used a computer for more than 6 hours per day on average also had a higher likelihood of having the problem (82.2%). Academic year, drinking coffee, place of study, and exercise had no significant relationship with the problem ( $p=$ 0.558, $p=$ 0.078, $p=$ 0.221, and $p=$ 0.15, respectively; Table 7).

Binary logistic regression was also performed on demographics, personal factors, daily practices, and studying behaviors. The model showed statistical significance with psychosomatic symptoms ( $p=$ 0.001), which made students 2.062 times more likely to have MSK problems. Family history of having neck pain was also significantly related to neck pain in participants ( $p=$ 0.001), making them 2.112 times more likely to develop MSK pain.

Table 8

Binary logistic regression for factors associated with MSK pain last year

	Sig.	Odds ratio	95% confidence interval
			Lower – upper
Gender	0.380	1.210	0.790–1.854
Family history	0.001	2.112	1.378–3.237
Psychosomatic symptoms	0.001	2.062	1.336–3.182
Depressive symptoms	0.096	1.479	0.932–2.346
Average hours of computer use per day	0.124	1.145	0.964–1.360
Average hours of study at home per day	0.141	1.153	0.954–1.394

Gender, depressive symptoms, average hours of computer use per day, and average hours of study at home per day did not show significant relationships with MSK pain over the year. Table 8 shows the results in detail.

5. Discussion

The objective of this research was to analyze the prevalence of musculoskeletal pain among medical students at Jordanian universities as the online teaching increased and the students became more sedentary. More than 50% of the students reported MSK pain during the study period. The current study results are similar to those presented by Alshagga et al. [13] and Hendi et al. [11]. A study done on Italian students during the COVID-19 outbreak showed a decrease in physical activity during the pandemic and consequently observed onset of musculoskeletal pain [17].

The second-year medical students showed a higher positive response rate of having MSK pain during the studied period (Tables 4 and 7). The second year in the studied medical schools is the first year where the students start to study true medical sciences. They spend a longer time studying to understand the new terminology, and this might be considered a stressful transition in their study. A similar observation was raised by Alturkistani et al. [18].

The overall past year prevalence (78.1%) was higher than in previously reported studies [13, 19].

The gender that experienced more pain was females (Table 3) when reported over a week; however, there was no significant difference between both genders when reported over a year (Table 8). A similar result of higher prevalence of upper body MSK pain in women was reported by Katz et al. [20].

The current study showed that MSK pain was associated with increased computer use during the online teaching process, which the change in medical study during the COVID outbreak necessitated. This coincided with results from research done on medical students at Qassim University; most students had an electronic device addiction, which was directly linked to MSK pain [21]. Contrary to that, Salameh et al. found no significant association between MSK pain and the time spent on digital devices [22]. The results also showed that using both desks and beds to study increased pain over the last week only. This might be attributed to the recall bias, where the students might remember more in their short-term memory. Most students who reported pain also had depressive symptoms and psychosomatic symptoms; these were two of the most prevalent factors. These results correspond to two other studies done on mental pressure: Chinese medical students were 3 times more likely to experience MSP if under mental pressure [19], and Jazan University students were 3 times more likely to experience MSP if they had psychomotor psychological factors such as depression [23].

The strongest association was having a family history of musculoskeletal pain. This was also highlighted in research done on Malaysian medical students, which found a higher prevalence of MSK pain in those with a significant family history of MSP [13].

Data provided about MSK pain in the past week and year did not show significant differences between clinical and preclinical academic years. This might be attributed to the similar conditions of home studying during online learning and the absence of clinical training in hospitals. Alshagga et al. showed that students in clinical years have a higher rate of MSK pain. They attribute that to the probability of spending a longer time standing during different sessions of clinical training [13].

No relationship between MSK pain and participation in regular exercise was confirmed in the current study. A similar observation was made by Alshagga et al. [13]. This might be also related to the different sports activities asked about in the current study. Proper categorization and direct links between specific types of sports and MSK pain could be explored in future research.

The current study has some limitations. It involves self-reported data on pain perception that was not assessed directly by an expert through objective and validated tools. The same also holds for the evaluation of depressive and psychosomatic symptoms. No data were available from before the pandemic period to compare with and assess any changes over that period. It may also be useful in the future to compare the prevalence of pain from before the pandemic to how it is now to develop a bigger picture. Another implication of the previous studies is that the use of a self-reported questionnaire leads to a systematic bias: what people report may differ from the actual situation.

6. Conclusion

High prevalence of MSK pain was observed among medical students during the online teaching period. There was a clinically significant relationship between musculoskeletal pain and many variables, such as hours using the computer, hours spent studying, family history, and psychosomatic symptoms. Measures to balance between in-person and virtual learning should be considered in medical schools to minimize the risk of MSK pain and its relation to psychomotor and depressive symptoms.

Footnotes

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

The authors report no funding.

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Musculoskeletal pain among medical students at two Jordanian universities

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Objective

3. Methods

3.1 Study design and participants

3.2 Sampling and sample size

3.3 Statistical analysis

Table 1 Demographic characteristics of participants

4. Results

Table 2 Prevalence rate of MSK pain

6. Conclusion

Footnotes

Conflict of interest

Funding

References

Table 1
Demographic characteristics of participants

Table 2
Prevalence rate of MSK pain