Predictors of neck disability among undergraduate students: A cross-sectional study

1 Introduction

Neck pain is one of the most common musculoskeletal disorders worldwide. It is considered the fourth leading cause of years lived with disability [1], with tremendous direct and indirect health-related costs [2–4]. The point prevalence of neck pain worldwide ranges from 5.9% to 22.2% [5, 6]. The reported prevalence and incidence of neck pain varied in literature, which could be attributed to the differences in defining the neck pain and the heterogeneity of the used assessment tools. Neck pain is subjective and, in most instances, may require no intervention. However, when the neck pain starts to compromise function, this could be described as a significant medical condition requiring intervention [2]. Therefore, neck disability results from neck pain is a clinically meaningful description and precisely related to the quality of life [7]. Whereas incidental neck pain is treatable, significant neck pain can become recurrent and can lead to chronic neck pain and disability [8].

Multifactorial etiology of neck disability is well known and might be associated with diverse factors such as gender, body mass index, presence of other musculoskeletal disorders, lifestyle factors (smoking and physical activity), psychosocial factors (stress, anxiety, depression, marital status, economic status, and job satisfaction), and work-related factors (physical requirement of the work, inadequate posture, and performance of repetitive activity) [9, 10]. Further, the prevalence of neck pain and resultant disability has been shown to vary in different age groups [6, 10]. Therefore, there is value in identifying specific neck disability predictive factors according to specific age groups in the population [11–13].

Students who develop neck pain during school years have three times the risk of developing serious neck pain or neck disability when they join the workforce following graduation [14]. There are limited studies that have investigated predictors of neck pain among undergraduate university students. A study that examined neck pain in undergraduate students reported that ergonomics associated with computer use (keyboard position) and year of study were the only associated factors with onset and persistence of neck pain [15]. The investigators, however, did not find mental health indicators to be a significant predictor of neck pain. Besides, the study only included computer use as an academic factor and did not include other possible academic factors like the academic program of study, rigor of the academic program, satisfaction associated with the program of study, and academic achievement. Further, the researchers did not collect data for stress, depression, and anxiety which have been shown to predict multiple musculoskeletal disorders [16]. Recently, Almhdawi et al. [16] surveyed the allied health students and concluded that stress, as measured by depression, anxiety, and stress score (DASS), was the only predictor of 12-month reported neck pain. The study used the Nordic scale to assess the incidence of neck pain and found that 67.1% of participants complained of 12-months neck pain incidences, and 38.2% of the participants reported functional limitations due to neck pain. However, the study was limited to allied health students and did not use a specific measure for neck pain-related disability. These findings imply that the allied health students may experience different level of academic and training demands that predisposes them to neck pain, which may differ from other undergraduate students.

Mental health indicators such as anxiety, depression, and stress are prevalent among undergraduate students [13, 17]. Many studies have indicated that mental health indicators are significantly correlated with musculoskeletal pain, including neck pain [16, 19]. However, limited studies have investigated mental health indicators among undergraduate students across different academic programs. Besides, recent studies have also indicated that sleep quality is associated with pain at multiple body sites [20] and may predict absence from work due to neck and shoulder pain [7], Despite this knowledge, sleep quality indicators have not been studied as a predictor of neck disability among undergraduate students.

Lifestyle factors such as general health status, diet, smoking, smartphone use, and associated quality of life (QoL) could be predictors of musculoskeletal pain in general and neck pain in particular [21]. Neck pain is one of the most common musculoskeletal complaints due to smartphone use in university students [22, 23]. Quality of life varies according to undergraduate majors, and undergraduate students may experience differences in quality of life compared to other cohorts in the population [24].

There are limited studies investigated the prevalence and predictors of neck disability among undergraduate students of various academic majors. Also, there are specific factors related to university students which might contribute to the development of neck disability. Therefore, this study aimed to examine the prevalence of neck disability among undergraduate university students and the role of diverse personal, lifestyle, academic, and mental health factors in neck pain and disability.

2 Methods

3 Results

The questionnaire was sent to 1650 students, and 1472 (89.2%) students responded to the survey. Participants were excluded from the analysis if they self-reported psychological disorder (n = 20), physical disorder other than neck pain(n = 140), and both medical and psychological disorder diagnoses (n = 20). Thus, a total of 1292 participants (78.3%) were deemed eligible for inclusion in the final analysis.

According to the NDI cutoff value of 15, 20.8% of the participants had neck pain with disability (see Table 1). Table 1 summarizes the differences in variables between students with or without neck disability and their performance in self-administered questionnaires. Students with neck disability had significantly lower GPA (p = 0.001), spent more hours at the university (p = 0.004), scored higher on stress, anxiety, and depression scores in the DASS questionnaire (p < 0.001), scored lower in the SF-12 total questionnaire score (p < 0.001), and scored higher in the PSQI questionnaire score (p < 0.001).

Table 2 presents a comparison of the sample characteristics based on the presence of neck disability (NDI > 15). The majority of students were females (61.7%), domestic students (73.1%), and living in urban areas (77.9%). Almost half of the students (49.7%) reported that they needed less than half an hour to reach the university. The students that completed the questionnaire were enrolled in medicine (37.7%), dentistry (22.6%), allied health, nursing and pharmacy (18.5%), engineering (14.4%), science and information technology (3.6%), and agriculture and veterinary medicine (3.2%). In addition, there was a significant difference in students with or without disability according to their program of study (p < 0.001), satisfaction (p < 0.001), employment (p = 0.002), diet (p = 0.001), and use of smartphone before sleep (p = 0.003).

Exploratory univariable analysis results (see Table 3) showed that GPA, hours spent at university, program, major satisfaction, employment, diet, health, use of smartphone before sleep, DASS stress score, DASS anxiety score, DASS depression score, SF-12 total score, and PSQI score were all possible predictors (p < 0.01) and were entered to the multivariable logistic regression model.

Multivariable logistic regression model results (see Table 3) showed that satisfaction with academic major (OR 1.46 [95% CI 1.06–2.01]; p = 0.019), DASS anxiety score (OR 1.06 [95% CI 1.03–1.09]; p < 0.001), SF-12 total score (OR 0.89 [95% CI 0.86–0.92]; p < 0.001), and PSQI score (OR 1.21 [95% CI 1.15–1.28]; p < 0.001) were the only significant predictors of neck disability. Negalkerk’s R² was 0.311 and Hosmer-Lemeshow goodness-of-fit test was not significant [χ² (8) = 4.463, p = 0.813], indicating the good fit of the model. The AUC was 0.815 (95% CI, 0.787–0.843).

This study investigated the self-perceived neck disability within a specific age group (approximately 18–22 years) and among a specific cohort of undergraduate university students. The findings of this study identified a relatively high percentage of students with neck disability. In addition, several factors associated with neck disability among college students from diverse programs were identified. Multiple factors were associated with self-perceived neck disability; however, satisfaction with academic major, anxiety, quality of sleep, and life were the only significant predictors of the neck disability.

Undergraduate students usually engage in educational activities throughout a four-years. Daily activities for an undergraduate student such as attending lectures, studying for long periods, using computers to study, and engaging in practical training sessions require prolonged sitting and standing, increasing the risk of neck pain, especially if done in a poor posture ⁶⁰. Prolonged sitting, static forward head posture, and poor positioning during computer use were significantly associated with an increased risk of neck pain among undergraduate students and school teachers [38]. Those practices may explain the high prevalence of neck pain and disability among undergraduate students.

Although the point prevalence of neck disability reported in this study was quite high, it is still comparable to other reports of neck pain among students specifically and adults in general. The point prevalence of neck pain among adults aged 15–74 years is between 5.9% and 22.2% [5, 6]. The point prevalence reported in our study is comparable to the 20.3% prevalence reported in the general population in Brazil [6] and the one-week prevalence reported in Malaysian medical students (24.1%) [39]. Recently, a systematic review concluded that, at any given time, 10–20% of the population has neck pain. Our study showed a relatively high incidence as our group reported neck disability that requires medical intervention, not only neck pain.

Multiple studies have reported that psychological factors play a significant role in musculoskeletal disorders [15, 40]. Mental health symptoms such as stress, psychosomatic symptoms, and depression were reported as significant predictors of neck pain and disability [16, 41]. Our study confirms these findings in undergraduate students enrolled in different programs. Students may experience a different source of psychological stressors than other populations, which may be related to academic life [40]. Studies have reported a high level of emotional and psychological symptoms, including anxiety, among students higher than the general population [42]. An analytical study reported that pain and psychological distress explained 53.5% of the variation in neck disability in patients seen at an outpatient physical therapy clinic [19]. The relationship between anxiety and neck disability could be explained because of its psychosomatic nature rather than nociceptive, or increased anxiety may contribute to increased muscle tension [41]. Therefore, anxiety and its related causes in undergraduate students should be further investigated to design preventive and therapeutic strategies.

In the univariate analysis, many academic factors were significantly associated with neck disability. GPA, satisfaction, students’ enrolled program, and hours spent at the university significantly correlated with neck disability. Being a student in the faculty of medicine, allied health, or science and arts significantly correlated with neck disability. Only major satisfaction was the significant predictor of neck disability. Major satisfaction is associated with students’ personality, motivation, cognitive ability, and academic achievement [43]. Also, dissatisfaction in academic life is associated with burnout [44]. Academic stress is also reported to be the main source of stress among students and could predispose students to neck and other spine problems [40, 45].

In a population-based study with high sample size, neck pain was weakly correlated with quality of life, and most of the observed correlation was found attributable to comorbidities [46]. In another study, 13.2%, 24.7%, and 11.3% of the participants reported pain in the neck, low back, and shoulder, respectively. Participants also indicated that pain adversely affected their quality of life in the form of frequent absences from school and difficulties in performing their usual daily activities [47]. Our study excluded students with comorbidities, yet quality of life remained a significant predictor of neck pain and disability. The relationship between neck pain and quality of life is bidirectional, and our study showed that poor quality of life predicts more neck disability, which indicates the poor physical and mental quality of life due to neck pain and other possible causes could lead to an increase in the perception of neck disability.

Sleep quality in our study was measured through a standardized questionnaire and was found to be a predictor of neck disability. Previously, sleep was not a predictor of neck pain in allied health students due to the investigator’s use of non-standardized assessment of sleep quality [16]. In a national survey in the USA, the trouble of falling asleep was a predictor of both neck and back pain [10]. Auvinen et al. found that insufficient sleep in adolescents was a predictor of six months’ prevalence of neck pain [48]. A study concluded that sleep difficulty at the age of 15–18 years is a predictor of the development of neck pain after seven years [41]. A significant difference was found between patients with neck pain and controls on all the components of the sleep quality index except the duration of sleep [49]. The increased perception of disability in patients with neck pain may be related to poor sleep. Sleep deprivation may reduce the secretion of endorphin and causes hyperalgesia effects, that counteract the analgesic effects of medications [50]. Another possible mechanism involved in this process is the poor sleep quality alters the immune system [51] and leads to activation of the inflammatory process [52], leading to tissue loss and degeneration. The association can be explained indirectly by insufficient sleep could cause an increase in the other risk factors fora neck disability, such as mental health symptoms [48].

The limitations of the study may be related to the limitations of the cross-sectional study design where the neck disability and possible associated factors were collected simultaneously that limit predictability of the neck disability. However, the study comprehensively evaluated factors related to a neck disability. Future studies should consider using a prospective longitudinal design to measure baseline characteristics and predict neck pain development at multiple follow-up periods (e.g., one-year increments). The longitudinal studies enables researchers to follow first-year students to study potential predictors of neck pain during their education, upon graduation [53]. Follow-ups can also be completed after graduation and before entering their professional careers. Future research may consider the use of standardized physical examinations as predictors of neck pain development, and this approach can be helpful in the development of comprehensive screening tools to prevent neck pain before it happens. Physical examinations may include a comprehensive evaluation of posture during the study, cervical ROM, observation of the thoracolumbar region, and mobile phone use logs. Those potential predictors derived from physical examinations could be used to explain more variation in predictive models of neck disability. It should be noted that our study finding does not imply causation, and the predictive model could mean a bidirectional relationship.

5 Conclusion

The study showed an elevated level of neck disability among undergraduate university students from different faculties and among all years of study. The students who were dissatisfied with their major are more likely to have neck pain than their peers. Additionally, higher stress, anxiety, and/or depression scores increase the probability of having neck disability. Students who have a higher health-related quality of life and sleep quality are less likely to develop neck disability. Healthcare and university administrators are advised to consider these neck disability-associated factors in designing prevention and treatment programs. Future studies can utilize longitudinal studies to follow the progression of neck disability during the study and after graduation.