a systematic review of posture and psychosocial factors as contributors to upper quadrant...

Physiotherapy Theory and Practice, 24(4):221–242, 2008

Copyright r Informa Healthcare

ISSN: 0959-3985 print/1532-5040 online

DOI: 10.1080/09593980701704089

A systematic review of posture and psychosocial factors

as contributors to upper quadrant musculoskeletal pain

in children and adolescents

Yolandi Prins, BSc, MSc (Physiotherapy),1 Lynette Crous, BSc,MSc,2 and Prof QA Louw, BSc, MSc (Physiotherapy), PhD

(Adelaide Australia)31Enrolled PhD student, Paarl, South Africa

2Head and Senior Lecturer, Division of Physiotherapy, Department of Interdisciplinary Health Sciences,

Tygerberg, South Africa3Professor and Senior Lecturer, Division of Physiotherapy, Department of Interdisciplinary Health Sciences,

Tygerberg, South Africa

Musculoskeletal pain has become a major symptomatic complaint among children and adolescentsand is increasingly occurring at a younger age. This systematic review was done to evaluate the evidencefor the contribution of posture and psychosocial factors to the development of upper quadrant mus-culoskeletal pain in children and adolescents. The review describes the measurement tools used to assessmusculoskeletal pain, sitting posture, and psychosocial factors. Two independent reviewers searchedseven databases for observational studies that included prospective and cross-sectional study designs.Ten studies were extracted and assessed by two reviewers using the Critical Appraisal Form-Quanti-tative Studies (Law et al, 1998). The studies measured upper quadrant musculoskeletal pain as anoutcome measure. Five studies evaluated sitting posture and found an association between the durationof static sitting and upper quadrant musculoskeletal pain. Six studies measured psychosocial factors ofwhich depression, stress, and psychosomatic symptoms were the factors most commonly found toinfluence the development of upper quadrant musculoskeletal pain. The eligible studies used differentpain measurement tools and different measurement tools to assess sitting posture and psychosocialfactors. This review concludes that the duration of sitting posture and psychosocial factors mayinfluence the experience of musculoskeletal pain among children and adolescents.

Introduction

Musculoskeletal pain experienced duringchildhood and adolescence may develop intochronic musculoskeletal pain syndromes thatpersist into adulthood (Brattberg, 2004; Siivola

et al, 2004). Studies have shown that the pre-valence of musculoskeletal pain increases withage, ranging from 21.3% to 34% in childhoodand from 44% to 47% in adolescence (Brattberg,2004; Sunblad, Saartok, and Engstrom, 2007;Wedderkopp et al, 2001). In the literature, both

Accepted for publication 18 September 2007.

Address correspondence to Yolandi Prins, BSc, PO Box 2101, Windmeul 7630 Paarl, South Africa. E-mail: yolandi@

physiopaarl.co.za

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preadolescent and adolescent girls reportedgreater musculoskeletal pain rates than theirmale counterparts (Bakoula et al, 2006; Siivolaet al, 2004; Sunblad, Saartok, and Engstrom,2007). The result of high pain prevalence andpersisting musculoskeletal pain among childrenand adolescents is the development of chronicpain symptoms in adults and the consequenthigh economic cost of treating these symptoms.The prevention of upper quadrant musculoske-letal pain is aimed at modifying the potentialrisk factors to prevent the occurrence of symp-toms in an asymptomatic population (Staal,De Bie, and Hendriks, 2007). However, the pre-vention of upper quadrant musculoskeletal painamong children and adolescents is poorly repor-ted because of a lack of understanding of thecausality of this pain.

The most common associative factors forupper quadrant musculoskeletal pain amongchildren and adolescents are reported to be age,gender, psychosocial factors, and posture(Bakoula et al, 2006; Briggs, Straker, and Grieg,2004; Egger, Costello, Erkanli, and Angold,1999; Grieg, Straker, and Briggs, 2005; Hakalaet al, 2002; Jacobs and Baker, 2002; Mikkelssonet al, 1999; Siivola et al, 2004; Wedderkopp et al,2001). This review investigates static sittingposture because children and adolescents mimicthe poor static sitting postural alignment seen inthe adult population (Briggs, Straker, and Grieg,2004; Grieg, Straker, and Briggs, 2005; Harrisand Straker, 2000). Ariens, Van Mechelen,and Bongers (2000) and Ariens, Bongers, andHoogendoorn (2001) have confirmed that neckflexion, arm position, and the duration of sittinghave a positive association with the occurrenceof neck pain in the adult population. Schoollearners are becoming more exposed to differentinformation technologies from a young age andsubsequently are exposed more to prolongedpoor sitting posture (Briggs, Straker, and Grieg,2004; Grieg, Straker, and Briggs, 2005; Ramos,James, and Bear-Lehman, 2005; Storr-Paulsenand Aagaard-Hensen, 1994). Studies havereported on the positive relationship betweentime spent sitting in front of a computer and theprevalence of musculoskeletal pain experiencedby children (Harris and Straker, 2000; Jacobsand Baker, 2002). Several studies have evaluatedsitting posture using a variety of postural mea-surement tools, from administering self-report

questionnaires to measuring postural anglesthree-dimensionally via video analysis systems(Murphy, Buckle, and Stubbs, 2002; Vieira andKumar, 2004). The quantitative biomechanicalmeasures were found to be more precise andreliable than the self-report questionnaires(Vieira and Kumar, 2004). Postural rehabilita-tion is an important component of physiother-apy treatment in preventing and managingupper quadrant musculoskeletal pain. Steele,Dawson, and Hiller (2006) recommended intheir review of school-based spinal interventionsthat future interventions should be evidencebased to ensure that children and adolescentsbenefit from these interventions.

The impact of psychosocial factors on theexperience of musculoskeletal pain in children andadolescents is prominent in the current literature,with depression, anxiety, and psychosomaticsymptoms being the most common associativepsychosocial factors that influence the prevalenceof musculoskeletal pain in children and adolescents(Brattberg, 2004; Diepenmaat, Van der Wal, andDe Vet 2006; Egger, Costello, Erkanli, and Angold,1999; Mikkelsson et al, 1999). Psychosomaticsymptoms, such as headache and abdominal pain,form part of a child or adolescent’s psycholo-gical profile, and depression has a strong associa-tion with these psychosomatic symptoms (Egger,Costello, Erkanli, and Angold, 1999; Mikkelssonet al, 1999). Most studies have used well-validatedand reliable measurement tools for assessing psy-chosocial factors (Sen and Christie, 2006). Themanagement of upper quadrant musculoskeletalpain comprises a multidisciplinary rehabilitationapproach, especially where psychosocial factors arethe more prominent risk factors, because they falloutside the management scope of physiotherapyand need to be addressed by the appropriate healthprofessional (Sen and Christie, 2006).

A review of epidemiological literature regard-ing the association between upper quadrantmusculoskeletal pain and workplace factors,including psychosocial factors, presented strongevidence to support a relationship between staticposture, psychosocial factors, and neck orshoulder pain in the adult population (NationalInstitute for Occupational Safety and Health,1997). However, there is no systematic reviewthat presents a comprehensive view of the con-tribution of posture and psychosocial factors tothe experience of upper quadrant musculoskeletal

222 Prins et al. /Physiotherapy Theory and Practice 24 (2008) 221–242

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pain among children and adolescents. The aim ofthis review was to ascertain the evidence for theassociation of posture and psychosocial factorswith upper quadrant musculoskeletal pain inchildren and adolescents. This review addressesthe following questions:

1. What measurement tools are used to evaluatemusculoskeletal pain, posture, and psychoso-cial factors in children and adolescents?

2. Is sitting posture (alignment, frequency, andduration) associated with the experience ofupper quadrant musculoskeletal pain inchildren and adolescents?

3. Are psychosocial factors associated with theexperience of upper quadrant musculoskele-tal pain in children and adolescents?

The following definitions apply to this review:

1. Musculoskeletal pain: Symptoms of soreness,tingling, burning and numbness pertaining tothe skeleton and muscles (Cho, Hwang, andChen, 2003).

2. Upper quadrant: The upper quadrant con-sists of the occiput, cervical spine and theupper extremities, including the clavicles andthe scapulae (Donatelli, 1987).

3. Static sitting posture: Maintaining the align-ment of the body and its segments in a sittingposition (Norkin and Levangie, 2005).

4. Psychosocial factors: Involving aspects ofsocial (relating to human society and its modesof organization) and psychological (relatingto the mind or emotions) behavior (http://www.thefreedictionary.com/psychosocial).

Review method

Prior to commencing this study, seven elec-tronic databases (CINAHL, BIOMED CEN-TRAL, PEDRO, PROQUEST, PUBMED,PsycINFO, and SCIENCE DIRECT) weresearched to verify that there is no publishedsystematic review that describes the relationshipbetween sitting posture, psychosocial factors,and upper quadrant musculoskeletal painamong children and adolescents.

Inclusion criteria for selection ofstudies

This systematic review sought epidemiologi-cal studies that included descriptive or analyticalobservational studies using a prospective orcross-sectional time frame (Portney and Watkins,2000). A language restraint was set, and onlypapers published in English and presented in full-text format were accepted. No limit was set onthe publication date. The participants includedmale and female children aged 6–12 years andadolescents aged 13–18 years.

Articles that reported on static sitting postureand/or psychosocial factors were eligible forinclusion in this review. Static sitting posturecould be evaluated either by direct measurementof postural angles, by observing frequency andduration of sitting, or by a descriptive assessmentof school-based and recreational seated activitiesvia a questionnaire or interview. Psychosocialfactors could be assessed via a questionnaire orinterview. Articles in which psychosocial factorswere appropriately defined by the authors asaspects of social and psychological behavior wereeligible for this review.

Articles were included if the outcome of thestudy measured and reported on upper quadrantmusculoskeletal pain in terms of the onset, area,frequency, intensity, or duration of pain. Themeasurement tool, either an interview or ques-tionnaire, had to measure one or more of theabove-mentioned aspects of pain.

Exclusion criteria for selection ofstudies

Articles were excluded 1) if only headache wasmeasured, because headache is regarded as apsychosomatic symptom rather than a muscu-loskeletal symptom (Harma, Kaltiala-Heino,Rimpela, and Rantanen, 2002; Mikkelsson et al,1999; Vikat et al, 2000); 2) if musculoskeletal painwas due to a systemic condition (e.g., juvenilearthritis, chronic fatigue syndrome, or fibro-myalgia; 3) if musculoskeletal pain and psycho-somatic pain were grouped and measuredtogether; 4) if the results of upper quadrantmusculoskeletal pain were not reported on sepa-rately to the results of lower limb or lower backmusculoskeletal pain; 5) if only psychosomatic

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symptoms and no other aspects of psychosocialfactors were measured; and 6) if a study samplewas within the age limit at baseline measures butexceeded this age limit when follow-up measureswere taken.

Search strategies

Two independent reviewers searched sevenelectronic databases that were available at theStellenbosch University Library. The databaseswere BioMed Central, CINAHL, PEDRO,PROQUEST, PUBMED, PsycINFO, and SCI-ENCE DIRECT. All the databases were sear-ched up to April 2007. No restriction was set onthe publication date. The search was limited tofull-text articles published in English. MESHterms were used only in PUBMED and whenapplicable. The following keywords were used:pain, neck and/or shoulder pain, musculoskele-tal pain, upper limb pain, upper extremity pain,posture, sitting posture, children, adolescents,learner, student, and psychosocial factors. Thelimits child, adolescence, human, and Englishwere used in the CINAHL, PsycINFO, andPUBMED databases. In addition, secondarysearching (pearling) was performed on thereference list of retrieved articles. Experts in thisfield of research were contacted to ensure that alleligible articles were retrieved for this review.

For including articles for this review, tworeviewers selected the eligible articles by firstscreening all the possible hits, second reading theabstract, and finally reading the full-text article.A list of all the most successful hits from the sevendatabases appears in Appendix A (Figure 1).

Methodological quality appraisal

The full-text version of the selected articleswas obtained and assessed by two reviewersaccording to the Critical Appraisal Form-Quantitative Studies (Law et al, 1998). The formconsists of 16 questions and allowed for a totalscore of 16. The questions appear in Appendix B.All the yes answers scored 1 and the noanswers scored 0, except for questions 3 and 4,where a no answer scored 1 and a yes answerscored 0.

Results

Search results

Two independent reviewers searched thedatabases presented in Table 1. Fifteen articleswere considered eligible for this review. Seven ofthe 15 articles were duplicates and thereforeexcluded. An additional two articles (Harrisand Straker, 2000; Ramos, James, and Bear-Lehman, 2005) were obtained after screening thereference lists of the eight eligible articles. Noarticles were included after experts in this fieldof research had been contacted. Ten articlestherefore were finally included in this review.

Critical appraisal of methodologicalquality

The methodological quality of the eligiblearticles was considered good because the averagescore was 12 out of a possible 16 (76%). Thearticles adhered to the criteria for questions 1, 2,5, 8, 12, 13, and 15, 16. A discrepancy betweenthe scores of the two reviewers was found forcriterion 6 for the article by Diepenmaat, Vander Wal, and De Vet (2006) and was discusseduntil consensus was reached. Four articlesscored 81% (Cho, Hwang, and Chen, 2003;Diepenmaat, Van der Wal, and De Vet, 2006;Murphy, Buckle, and Stubbs, 2004; Niemi et al,1996), four articles scored 75% (Harris andStraker, 2000; Murphy, Buckle, and Stubbs,2007; Niemi et al, 1997; Vikat et al, 2000), andtwo articles scored 68% (Feldman, Shrier,Rossignol, and Abenhaim, 2002; Ramos, James,and Bear-Lehman, 2005). The two articles(Feldman, Shrier, Rossignol, and Abenhaim,2002; Ramos, James, and Bear-Lehman, 2005)that scored less than the required 70% were notexcluded because of the low number of articlesretrieved that were eligible for review (Walker,2000). There were sample biases (criterion 3) infive articles, either due to non-randomization ofthe selected schools (Feldman, Shrier, Rossignol,and Abenhaim, 2002; Harris and Straker,2000; Ramos, James, and Bear-Lehman, 2005)or to an opportunistic sample chosen on the dayof the study (Murphy, Buckle, and Stubbs,2004), or to a low response rate of 20% forthe participating schools (Murphy, Buckle, and


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Stubbs, 2007). Measurement biases (criterion 4)were detected in four articles, mainly due to thepain recall period being 6 and 12 monthly (Cho,Hwang, and Chen, 2003; Feldman, Shrier,Rossignol, and Abenhaim, 2002; Niemi et al,1997; Vikat et al, 2000). In none of the articleswas a sample size calculation (criterion 7) doneto justify the sample size, although all theauthors described the sample and samplingmethod in detail (criterion 6) except for Murphy,Buckle, and Stubbs (2004) and Diepenmaat, Vander Wal, and De Vet (2006). Harris and Straker

(2000) and Ramos, James, and Bear-Lehman(2005) failed to describe their method of outcomemeasurement (criterion 9) sufficiently.

Only two articles reported on both the relia-bility and validity of all the measurement toolsused in the study (Cho, Hwang, and Chen, 2003;Murphy, Buckle, and Stubbs, 2004). Threearticles explained the validity (criterion 11) butnot the reliability (criterion 10) of the measure-ment tools (Diepenmaat, Van der Wal, and DeVet, 2006; Harris and Straker, 2000; Ramos,James, and Bear-Lehman, 2005). The remaining

Electronic databases searched by using combinations ofkeywordsBioMed Central (n = 338) CINAHL (n = 605) PEDRO (n = 0) Proquest (n = 253) PsycInfo (n = 652) PUBMED (n = 550) Science Direct (n = 3252) TOTAL = 5650

Abstracts screened by reviewers

Apply inclusion criteria on the title and exclude articles N = 5525

Apply inclusion criteria on the abstracts and exclude articlesN = 18

Apply inclusion criteria on the full text article and exclude articles N = 31

Exclude duplicate articles from other databases N = 7

Exclusion on account of obviously

not conforming to answering the

review questions or not published

in English

Excluded if the sample population

not aged between 6 and 18 years

and assessment of upper quadrant

musculoskeletal pain not the

outcome of the study

Excluded if assessment of upper

quadrant musculoskeletal pain not

the outcome of the study and

sitting posture or psychosocial

factors not described in relation to

pain

Exclude duplicate articles within one database N = 61

Full text articles reviewed and verified by reviewersN = 8

Pearling of the reference list of selected articles N = 2

Total articles selected for this review N = 10

Figure 1. Flowchart to demonstrate the selection of studies.


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five articles did not report on either the validityor reliability of the measurement tools.

Two articles did not discuss the impact and therelevance of their findings on clinical practice(criterion 14) (Cho, Hwang, and Chen, 2003;Ramos, James, and Bear-Lehman, 2005). Figure 2presents a summary of the responses to themethodological criteria.

Study design and sample description

The studies, as summarized in Table 2, wereconducted from 1996 to 2006, and 6 of the 10studies were done in Western Europe. One studywas conducted in Australia, Canada, the United

States, and Taiwan. An analytical observationalstudy design using a cross-sectional time framewas used in nine studies, except for that byFeldman, Shrier, Rossignol, and Abenhaim(2002), who used an analytical observationalprospective design.

The participants were either elementary and/or high school students and within the age rangethat defines preadolescents (6–12 years old) andadolescents (13–18 years old). The sample sizevaried, ranging from 66 to 10,302, as describedin Table 2. The response rate of four of thestudies, namely, those by Vikat et al. (2000)Feldman, Shrier, Rossignol, and Abenhaim(2002) Ramos, James, and Bear-Lehman (2005)and Diepenmaat, Van derWal, and De Vet (2006),

Table 1. The selection of studies from different databases.

Database HitsExcludetitle

Exclude duplicateswithin database

Excludeabstract

Excludearticle

Studiesremaining

Duplicates inother databases

CINAHL 605 573 15 4 7 3 1BIOMED

CENTRAL338 334 3 0 1 0 0

PEDRO 0 0 0 0 0 0 0PROQUEST 253 251 1 0 1 0 0PsycINFO 652 621 17 2 8 1 0PUBMED 550 521 14 5 2 2 6SCIENCE

DIRECT3252 3225 11 7 7 2 0

TOTAL 5650 5525 61 18 31 8 7

0

1

2

3

4

5

6

7

8

9

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Methodological criteria

Nu

mb

ero

fart

icle

s

YES

N0

Figure 2. Summary of the methodological critical appraisal.


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Table

2.Summary

ofthestudyaim

sandthemusculoskeletalpain

outcomemeasurementtools.

Author

Age

Sample

size

Response

rate

(%)

Aim

sMeasurementtool

forpain

Pain

recall

period

Pain

definition

Niemiet

al,

1996

15–18

714

87

dTodescribethe

prevalence

ofneckand

shoulder

pain

among

highschoolstudents

Nordic

Musculoskeletal

Questionnaire

Weekly

and

monthly

Accordingto

the

frequency

of

pain

dTodescribethe

relationship

between

pain

andstaticversus

dynamic

loadingofneck

andshoulder

muscles

duringleisure

time

activities

Group1¼no

symptoms

Group2¼1–2

times

orless

per

month

Group3¼once

or

more

per

week

Niemi,

Levoska,

Rekola,and

Keinanen-

Kiukaan-

niemi,1997

Adolescents

714

87

dTodescribethe

prevalence

ofneckand

shoulder

symptoms

amonghighschool

students

dTodeterminethe

relationship

between

neckandshoulder

pain

andpsychosocialfactors

such

asstress,self-

efficacy,anddepressive

symptoms

Nordic

Musculoskeletal

Questionnaire

12months

Accordingto

the

frequency

of

pain

Symptom

group¼pain

more

thanonce

aweek

Vikatet

al,

2000

14–18

10302

77

dTodeterminethe

prevalence

and

determinants

ofself-

reported

neckor

shoulder

pain

andlow

back

pain

among

adolescents

AdolescentHealth

andLifestyle

Survey

of

Finland

6months

Accordingto

the

frequency

of

pain

Group

1¼seldom

or

notatall;group

(Continued)


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Table

2.Summary

ofthestudyaim


outcomemeasurementtools(C

ontinued).

Author

Age

Sample

size

Response

rate

(%)

Aim

sMeasurementtool

forpain

Pain

recall

period

Pain

definition

2¼aboutonce

amonth;

group3¼once

aweek;

group

4¼alm

ost

daily

Feldman,

Shrier,

Rossignol,

and

Abenhaim

,2002

Adolescents

502

62

dTodeterminethe

incidence

ofneckand

upper

limbpain

ina

cohort

ofadolescents

dTodeterminewhether

poormentalhealthand

certain

activitiesare

risk

factors

fordeveloping

neckorupper

limbpain

Self-designed

questionnaire

6months

Accordingto

the

frequency

of

pain

Pain

occurring

once

aweek

Cho,Hwang,

andChen,

2003

16

471

86

dTodeterminethe

prevalence

of

musculoskeletal

symptomsduring6

months

dToidentify

the

contributingfactors

associatedwiththese

symptoms

dTodescribethe

relationship

between

psychologicaldistress

andmusculoskeletal

pain

amongChinese

adolescen

ts

Musculoskeletal

Symptom

Questionnaire

(Nordic

Musculoskeletal

Questionnaire)

12months

Accordingto

the

frequency

of

pain

(1)symptom—

tingling,

numbness,

soreness,

burning

(2)frequency—

seldom,

sometim

es,

always

(3)intensity—

mild,moderate,

severe

Diepenmaat,

Vander

Wal,

12–16

3485

71.2

dToexaminethe

prevalence

ofneckand

shoulder,low

back,and

Self-designed

questionnaire

1month

Accordingto

the

durationofpain

Pain

thatlasts


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andDeVet,

2006

arm

pain

within

different

sociodem

ographic

groups

forlonger

than4

daysper

month

dToexaminethe

associationofpain

with

computeruse,physical

activity,depression,and

stress

Murphy,

Buckle,and

Stubbs,2007

11–14

679

97

dToreport

theratesof

musculoskeletalpain

dToidentify

possible

physicaland

psychologicalfactors

inschools

dToevaluate

the

relationship

between

pain

andphysicaland/or

psychologicalfactors

Nordic

Musculoskeletal

Questionnaire

Weekly

and

monthly

Accordingto

the

frequency

of

pain

(1)pain

present

inthelast

week

ormonth?

(2)intensity

on

3-pointscale

(3)durationin

term

sofhours/

days

Harrisand

Straker,2000

10–17

314

N/A

dToinvestigate

postures

adaptedforlaptopuse

andthelength

oftime

laptopsare

used

Self-designed

questionnaire

None

Notmentioned

inarticle

dTodetermineif

musculoskeletalpain

isassociatedwiththe

above

Murphy,

Buckle,and

Stubbs,2004

11–14

66

N/A

dTorecord

postural

behaviorduringstatic

sitting

dToidentify

theextentof

neckpain,upper

back

pain,andlow

back

pain

dToestablish

arelationship

between

sittingposture

andpain

Nordic

Musculoskeletal

Questionnaire

Weekly

and

monthly

Accordingto

the

frequency

of

pain

(1)pain

present

inthelast

week

ormonth?

(2)intensity

on

3-pointscale

(3)durationin

(Continued)


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Table

2.Summary

ofthestudyaim


outcomemeasurementtools(C

ontinued).

Author

Age

Sample

size

Response

rate

(%)

Aim

sMeasurementtool

forpain

Pain

recall

period

Pain

definition

term

sofhours/

days

Ramos,James,

andBear-

Lehman,

2005

6–14

479

68.6

dTodeterminethe

averagetimechildren

spendoncomputers

either

workingor

playingelectronic

games

dTodescribehowchildren

use

computers

or

electronic

games

dTodescribethe

discomfort

childrenmay

experience

whileusing

computers

orplaying

electronic

games

Self-designed

questionnaire

None

Accordingto

the

intensity

ofpain

(1)just

aches

(2)enoughto

makemistakes

(3)enoughto

takeabreak

(4)enoughto

stop


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was 77%, 62%, 68.6% and 71.2%, respectively.The remaining studies had a response rate greaterthan the required 80% (Liddle, Williamson, andIrwig, 1996).

Study aims

The 10 eligible studies measured upperquadrant musculoskeletal pain when exposed toeither poor sitting posture or psychosocial fac-tors. The aims of seven studies (Cho, Hwang,and Chen, 2003; Diepenmaat, Van der Wal, andDe Vet, 2006; Feldman, Shrier, Rossignol, andAbenhaim, 2002; Murphy, Buckle, and Stubbs,2007; Niemi et al, 1996, 1997; Vikat et al, 2000)were similar in ascertaining the prevalence orincidence of upper quadrant musculoskeletalpain and associated factors. The remaining threestudies (Harris and Straker, 2000; Murphy,Buckle, and Stubbs, 2004; Ramos, James, andBear-Lehman, 2005) had a different aim which ispresented in Table 2.

Outcome measurement tools forassessing pain

A modified version of the Nordic Musculo-skeletal Pain Questionnaire was used in five of thestudies (Cho, Hwang, and Chen, 2003; Murphy,Buckle, and Stubbs, 2004, 2007; Niemi et al, 1996,1997). In four studies, the researchers used self-designed pain questionnaires (Diepenmaat, Vander Wal, and De Vet, 2006; Feldman, Shrier,Rossignol, and Abenhaim, 2002; Harris andStraker, 2000; Ramos, James, and Bear-Lehman,2005). Vikat et al. (2000) used a modified versionof Finland’s health and lifestyle survey for ado-lescence. All the studies used the frequency of painto classify symptomatic groups of children oradolescents, except for those by Ramos, James,and Bear-Lehman (2005) and Diepenmaat, Vander Wal, and De Vet (2006), which used theduration of pain and the intensity of pain,respectively. Participants had frequent pain ifsymptoms occurred more than once a week.However, Cho, Hwang, and Chen (2003) useddescriptive words (i.e., seldom, sometimes, andalways to describe the frequency of pain).

The duration of pain was addressed in onlythree studies (Diepenmaat, Van der Wal, and DeVet, 2006; Murphy, Buckle, and Stubbs, 2004,

2007) and was determined either in terms of painpersisting for a certain number of hours or days.The intensity of pain was assessed in five studies,using either descriptive words (Cho, Hwang, andChen, 2003; Ramos, James, and Bear-Lehman,2005), a point-scoring scale (Murphy, Buckle,and Stubbs, 2004, 2007) or weekly reports of pain(Diepenmaat, Van der Wal, and De Vet, 2006).

The pain recall period of this age group varied,from 1 week to 12 months. Two studies (Cho,Hwang, and Chen, 2003; Niemi et al, 1997)required the students to recall pain symptoms forthe preceding 12 months. Two studies (Feldman,Shrier, Rossignol, and Abenhaim, 2002; Vikatet al, 2000) asked questions about pain for thepreceding 6 months. Four studies (Diepenmaat,Van der Wal, and De Vet, 2006; Murphy, Buckle,and Stubbs, 2004, 2007; Niemi et al, 1996) usedmonthly and weekly reports of pain. Harris andStraker (2000) and Ramos, James, and Bear-Lehman (2005) did not set a certain time framewithin which the students should recall their painsymptoms. The different pain measurement tools,pain recall periods, and definitions of pain aresummarized in Table 2.

The Nordic Musculoskeletal Pain Ques-tionnaire was not retested for validity andreliability, but it is assumed by the researchers tohave good validity and reliability because of itsfrequent use in published reports on painassessment. Three other studies that used self-designed pain questionnaires (Diepenmaat, Vander Wal, and De Vet, 2006; Harris and Straker,2000; Ramos, James, and Bear-Lehman, 2005)tested for validity by means of conducting pilotstudies or determined concurrent validity. Noneof the 10 eligible studies reported on the relia-bility of the pain measurement tool.

Postural measurement tools

Sitting posture was evaluated in five of theeligible studies, and these studies conducted theevaluation in either a classroom or home setting(Cho, Hwang, and Chen, 2003; Harris andStraker, 2000; Murphy, Buckle, and Stubbs,2004; Niemi et al, 1996; Ramos, James, andBear-Lehman, 2005). These five studies aimedto determine the relationship between staticsitting posture and musculoskeletal pain. Themeasurement tools to measure posture varied ineach of the five studies. Niemi et al. (1996) used


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a self-designed questionnaire to assess the type,frequency, and intensity of leisure time activitiesthat involve the static use of the upper extremity(e.g., needlework and computer). However, theydid not report the validity and reliability of theposture evaluation questionnaire. Harris andStraker (2000) used a self-designed questionnairefor measuring posture and also conducted directobservation of the sitting posture. These toolswere used to evaluate the different postureswhen laptops were used (sitting, lying prone,sitting on the floor) and at different locations(school, home, boarding house). The time spentper session and the frequency of laptop use athome or at school were also recorded. Directobservation of laptop use served as cross-validation of the questionnaire. Cho, Hwang,and Chen (2003) used a checklist that allowedthe participants to indicate whether posture wasa contributing factor for musculoskeletal pain.This checklist was not validated.

One study (Murphy, Buckle, and Stubbs,2004) assessed the sitting posture of school-children by using the Portable ErgonomicObservation (PEO) method, which allows fordirect observation of postures in real time in theclassroom setting. The PEO measures neck flex-ion/rotation, trunk flexion/rotation, supported orunsupported sitting and working at a desk. Thepostures were recorded in relation to uprightsitting (e.g., trunk flexion of more than 201 wasrecorded when the subject’s torso was at an angleof 201 or more from the vertical. This measure-ment tool had been validated (Murphy, Buckle,and Stubbs, 2002). Ramos, James, and Bear-Lehman (2005) used a 23-item self-designedquestionnaire to assess the duration of static sit-ting while using a computer or electronic game.The questionnaire was piloted by using fourchildren aged 6–11 years to assess whether theconstruction of the sentences was clear.

Psychosocial measurement tools

Six studies measured psychosocial factors andused a variety of different measurement tools.Three studies used commonly used tools, includingthe five-item MOS-36 Short Form Health Survey(Feldman, Shrier, Rossignol, and Abenhaim,2002); the 20-item Centre of EpidemiologyDepression Scale (Diepenmaat, Van der Wal, andDe Vet, 2006); and the Strengths and Difficulties

Questionnaire (Murphy, Buckle, and Stubbs,2007). Vikat et al. (2000) conducted their study inFinland and used the Adolescent Health andLifestyle Survey of Finland. Cho, Hwang, andChen (2003) used the 12-item Chinese HealthQuestionnaire in a Chinese population. A self-designed questionnaire was used in one of thestudies (Niemi et al, 1997). Depression, stress, andpsychosomatic symptoms were the most com-monly measured variables to determine if adoles-cents were experiencing psychosocial issues andwhether these issues influenced the experienceof upper quadrant musculoskeletal pain (Cho,Hwang, and Chen, 2003; Diepenmaat, Vander Wal, and De Vet, 2006; Feldman, Shrier,Rossignol, and Abenhaim, 2002; Murphy, Buckle,and Stubbs, 2007; Niemi et al, 1997; Vikat et al,2000). The other psychosocial aspects measuredincluded family and social factors (Murphy,Buckle, and Stubbs, 2007; Vikat et al, 2000),health behaviors (Feldman, Shrier, Rossignol, andAbenhaim, 2002; Murphy, Buckle, and Stubbs,2007; Vikat et al, 2000) and academic performanceat school (Vikat et al, 2000).

Two studies tested for the validity of the psy-chosocial measurement tools (Cho, Hwang, andChen, 2003; Diepenmaat, Van der Wal, and DeVet, 2006). Niemi et al (1997) used a self-designedquestionnaire without verifying its validity andreliability in detecting psychosocial factors. Vikatet al (2000) used a modified version of Finland’shealth and lifestyle survey for adolescents and didnot retest its validity and reliability. Feldman,Shrier, Rossignol, and Abenhaim (2002) used afive-item questionnaire derived from the MOS-36Short Form Health Survey but did not reportwhether the modified version was valid and reli-able. Murphy, Buckle, and Stubbs (2007) usedthe well-known Strengths and Difficulties Ques-tionnaire but did not report on its validity andreliability in the particular population included intheir study. Cho, Hwang, and Chen (2003) werethe only authors to report on the reliability of thepsychosocial measurement tool used.

Risk factors for upper quadrantmusculoskeletal pain

This review identified the six most commonfactors associated with the development of upperquadrant musculoskeletal pain among children


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and adolescents. Static postures, depression,stress, psychosomatic symptoms, gender, and agemay be associated with the prevalence of mus-culoskeletal pain.

The association between static sitting postureand upper quadrant musculoskeletal pain amongchildren and adolescents was reported by five ofthe studies reviewed (Cho, Hwang, and Chen,2003; Harris and Straker, 2000; Murphy, Buckle,and Stubbs, 2004; Niemi et al, 1996; Ramos,James, and Bear-Lehman, 2005). A study byNiemi et al (1996) found that reports of weeklyneck and shoulder pain were significantly asso-ciated with static sitting posture that involvedstatic loading of the upper extremities during lei-sure time activities among girls (p<0.001), but notamong boys. Harris and Straker (2000) found asignificant association between the maximum timeon task for static sitting while using a laptopcomputer and neck or shoulder discomfort(w2¼ 16.51, p¼ 0.0024). Students reported thatthey considered posture to be the most importantcontributing factor for neck (43%) and shoulder(15.1%) pain on the checklist administered byCho, Hwang, and Chen (2003). Murphy, Buckle,and Stubbs (2004) conducted a study in which lesstrunk flexion movement, between 201 and 451observed with the Portable Ergonomic Observa-tion method, was significantly associated with self-reported upper back pain in the previous month(p¼ 0.006) and week (p¼ 0.033), as well as withself-reported neck pain in the previous week(p¼ 0.047). Ramos, James, and Bear-Lehman(2005) demonstrated an association between theduration of sitting in front of a computer and theprevalence of discomfort. An increase from 1 hourto more than 4 hours on the computer equaled anincrease of 43% to 71% in discomfort experiencedin the neck and shoulders. Neck discomfort wasstatistically significant for time on the computer atschool (p¼ 0.001) and at home (p¼ 0.008).

Niemi et al (1997) found that both adolescentboys and girls with neck and shoulder pain alsoexhibited relatively higher stress and depressivescores than asymptomatic adolescents. Themean difference in the stress score was 1.87(95% CI 1.33–2.4) for girls and 0.89 (95% CI0.13–1.65) for boys. The stress scores were thussignificantly associated with pain in both sexes.However, depression had an association withpain only among girls (mean difference: 0.63;95% CI 1.4–0.85) and was less obvious among

boys (mean difference: 0.22; 95% CI 0.14–0.57).Diepenmaat, Van der Wal, and De Vet (2006)found that high levels of depression and stresswere associated with the prevalence of neck,shoulder, and arm pain. A depression score of 16or more was considered to classify a depressedadolescent. Depression in adolescents was sig-nificantly associated with the prevalence ofneck, shoulder, and arm pain. Adolescents withregular or daily stress had a greater chance ofexperiencing upper musculoskeletal pain thanadolescents who never experienced stress(Diepenmaat, Van der Wal, and De Vet, 2006).Diepenmaat, Van der Wal, and De Vet (2006)also observed that students not living with boththeir parents had a greater chance of experien-cing neck and shoulder pain (OR 1.4; 95%CI 1.1–1.8). Cho, Hwang, and Chen (2003)found that students with high psychologicaldistress had significantly more neck symptoms(w2¼ 9.0355, p¼ 0.003) than those with lowpsychological distress scores. Feldman, Shrier,Rossignol, and Abenhaim (2002) found thatlower levels of mental health had a signifi-cant influence on the prevalence of upperquadrant musculoskeletal pain. However, afterexploring the possible interaction of mentalhealth and working status of the adolescent, itwas found that lower mental health was onlysignificantly associated with pain for the ado-lescents with part-time employment comparedwith those without part-time employment (OR1.64; 95% CI 1.29–2.10). The odds ratios forneck, shoulder, and arm pain with perceiveddepression and stress are presented in Table 3.

Vikat et al (2000) reported that the presenceof psychosomatic symptoms (e.g., headache,recurrent abdominal pain, and tiredness) weresignificantly associated with neck and shoulderpain. Their findings indicate that adolescentsexperiencing three or more psychosomaticcomplaints have a greater chance of having neckand shoulder pain simultaneously. Murphy,Buckle, and Stubbs (2007) showed that psycho-somatic symptoms experienced at least twice permonth were positively associated with neck painand upper back pain. The odds ratios for neckand shoulder pain with perceived psychosomaticcomplaints are presented in Table 3.

More girls reported neck and shoulder painthan boys (Diepenmaat, Van der Wal, and De Vet,2006; Niemi et al, 1996, 1997; Vikat et al, 2000).


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The findings of five of the studies reviewed illus-trate that pain prevalence increases with age(Harris and Straker, 2000; Niemi et al, 1996, 1997;Ramos, James, and Bear-Lehman, 2005; Vikatet al, 2000).

Discussion

This systematic review illustrates that theremay be an association between posture andpsychosocial factors and the development ofupper quadrant musculoskeletal pain in childrenand adolescents. Only 10 eligible studies con-cerned with children and adolescents that hadbeen conducted in this field of research could beretrieved for this review. The inclusion criteriawere applied strictly, especially the criterionconcerning the age of the children and adoles-cents and the outcome measure of upper quad-rant musculoskeletal pain.

Epidemiological studies are imperative tounderstand the etiology of and to recognize thepossible risk factors for a disorder (Goodmanand McGrath, 1991). All eligible studies wereobservational in design, and although the studyby Feldman, Shrier, Rossignol, and Abenhaim(2002) collected measures prospectively, thestudy findings did not provide insight into thecausality of the upper quadrant musculoskeletalpain. There is a dearth of research that long-itudinally establishes the causation of upperquadrant musculoskeletal pain in children andadolescents. It is thus important to focus onconducting well-designed prospective studies toexplore causation of upper quadrant muscu-loskeletal pain. Six of the nine cross-sectionalstudies acknowledged this study design limita-tion. The authors of the reviewed studies alsoemphasized that prospective longitudinal studiesmust be conducted to investigate causation(Diepenmaat, Van der Wal, and De Vet, 2006;

Table 3. Odds ratios for upper quadrant musculoskeletal pain with exposure to depression, stress, and psychosomatic

complaints.

Neck pain Upper back pain Shoulder pain Arm pain

Depressioncrude OR(95%)

1.9 (1.5–2.5)Diepenmaat,Van der Wal,and De Vet

(2006)


(2006)Depression

adjusted OR(95%)

1.8 (1.42–2.31)Feldman, Shrier,Rossignol, andAbenhaim(2002)


1.67 (1.29–2.17)Feldman, Shrier,Rossignol, and

Abenhaim(2002)


Stresscrude OR(95%)


(2006)Psychosomatic

complaintscrude OR(95%)

3.4 (2.05–5.64)Murphy,

Buckle, andStubbs (2007)

5.24 (2.61–10.51)Murphy,

Buckle, andStubbs (2007)

Psychosomaticcomplaintsadjusted OR(95%)

4.4 (CI notprovided)Vikat et al(2000)

4.4 (CI notprovided)Vikat et al(2000)


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Murphy, Buckle, and Stubbs, et al, 2004, 2007;Niemi et al 1996, 1997; Vikat et al, 2000). Theaim of cross-sectional studies is to ascertainassociations between the variables under study(i.e., musculoskeletal pain, psychosocial factors,and sitting posture). It is also notable that noneof the eligible studies investigated the associa-tion between psychosocial factors and sittingposture; further research is warranted.

Measurement tools for musculoskeletalpain

The studies scored high for the appraisal ofmethodological quality, although it was con-cerning to note that many studies did not adhereto the criteria regarding methodological biasesand the validity and reliability of the measure-ment tools. The results of the selected studiesshould therefore be interpreted with caution,especially the pain measurements, because noneof the studies defined the frequency, duration, orintensity of pain in the same manner. This couldcreate either an under- or an overestimation ofthe associations made between risk factors andpain. The studies used self-reported muscu-loskeletal pain measurements, and these couldbe influenced by psychosocial and culturalcomponents (Ming, Narhi, and Siivola, 2004).However, Schierhout and Myers (1996) statedthat subjective measures, or self-reports of pain,have good construct validity, good field utility,and the ability to assimilate a variety of symp-tom patterns when used as an outcome mea-surement tool. The literature states that thevalidity of that measurement will increase ifmore aspects of pain are measured (Goodmanand McGrath, 1991). The recall period forexperiencing musculoskeletal pain also variedfrom weekly to 12-month reports of pain. It isyet unclear what the optimal time frame iswithin which high school students can accura-tely recall musculoskeletal pain, but previousresearch has found a high accuracy of recalledpain intensities over a 1-week time interval forchildren, and this accuracy increases with age(Zonneveld, McGrath, Reid, and Sorbi, 1997).A standardized approach to measuring muscu-loskeletal pain in adolescents is lacking, and thiscompromises the comparability between studies.

Measurement tools for sitting posture

The measurement tools for assessing staticsitting posture varied from direct observation ofsitting posture and direct measurement of pos-tural angles (Harris and Straker, 2000; Murphy,Buckle, and Stubbs, 2004) to self-reported ques-tionnaires (Cho, Hwang, and Chen, 2003; Niemiet al, 1996; Ramos, James, and Bear-Lehman,2005). Vieira and Kumar (2004) reported thatbiomechanical measures were the more preferredmanner to report posture; however, these aremore time-consuming and the sample sizes arevery small. One of the five studies that reportedon sitting posture (Murphy, Buckle, and Stubbs,2004), quantitatively measured the posturalangles of 66 children in the classroom and mightgive a better indication of the association betweenposture and pain. The results of the self-reportedposture questionnaires showed significant asso-ciations between static sitting posture and upperquadrant musculoskeletal pain. Static sittingposture was not adequately assessed in the eligi-ble studies, and it consequently is difficult toconclude if sitting posture is a risk factor forupper quadrant musculoskeletal pain.

Measurement tools for psychosocialfactors

Each study used a different measurement tooland assessed different psychological and socialaspects of behavior. Two studies measured psy-chosomatic symptoms when assessing muscu-loskeletal pain and found a strong associationbetween these two types of pain. Vikat et al(2000) suggested that neck pain could be more ofa psychosomatic complaint than a musculoske-letal symptom. When psychosocial elements areassessed in a population experiencing pain, anysomatic items must be excluded from the ques-tionnaire to avoid subsequent inflated psycho-logical scoring (Pincus, Burton, Vogel, andField, 2002). The opposite might also occurwhen a patient with psychosocial issues soma-tizes and presents as a patient experiencingmusculoskeletal pain or discomfort. Somatiza-tion is a process by which psychological distressis expressed as physical symptoms (http://www.medterms.com/script/main/art).


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Risk factors for upper quadrantmusculoskeletal pain

Three studies found that the duration of staticsitting was associated with upper quadrantmusculoskeletal pain (Harris and Straker, 2000;Murphy, Buckle, and Stubbs, 2004; Ramos,James, and Bear-Lehman, 2005). This has adefinite implication for prevention and man-agement strategies of upper quadrant muscu-loskeletal pain among children and adolescents.The National Institute for Occupational Healthand Safety (1997) found that physical exposure(e.g., lifting, forceful movements, awkwardposture, and static work postures) increases thedevelopment of neck and shoulder symptomsamong the adult population. Some of theseexposures might be present in schools (e.g.,carrying heavy school bags and prolonged staticsitting). This review presented evidence to sup-port that the duration of static sitting increasesupper quadrant musculoskeletal pain amongchildren and adolescents and that this was theonly physical exposure that was similar to thatof the adult population. This review illustratesthat depression, mental distress, and psychoso-matic complaints are the most common psy-chosocial factors influencing the experience ofupper quadrant musculoskeletal pain. High jobdemands, low social support from coworkers,monotonous work, limited job control, andwork-related stress are psychosocial risk factorsfor neck and upper extremity pain among adults(NIOSH, 1997; Van den Heuvel et al, 2005),which is in contrast with the psychosocial factorsfound among children and adolescents. Themeasured psychosocial factors in children andadolescents were related more to emotional andsocial behavior.

The impact of posture and psychosocial fac-tors on the experience of upper quadrant mus-culoskeletal pain also depend on gender and age(Niemi et al, 1997). Niemi et al (1997) found aninteraction between static sitting posture and girlsand between depression and girls. Harris andStraker (2000) and Ramos, James, and Bear-Lehman (2005) found an interaction betweenincreased age and the duration of static sitting.

A recent review by Trevelyan and Legg (2006)regarding the risk factors associated with backpain found similar trends as those seen in thisreview. Trevelyan and Legg (2006) reported that

a prolonged static sitting posture was a commonprovoking factor for low back pain and thatpsychosocial factors, especially depression,loneliness, somatic complaints, anxiety, and anabnormal family structure, increase the pre-valence of musculoskeletal pain among childrenand adolescents. Grimmer, Nyland, and Mila-nese (2006) found that the odds of girls reportinglow back pain five years later was 4.4 (95% CI1.9–10.9) and that gender and age consequentlyalso influence low back pain.

Clinical implications

This review encourages researchers to definepsychosocial factors that have an influence onthe experience of musculoskeletal pain in chil-dren and adolescents and to use measurementtools for psychosocial factors, static sittingposture, and upper quadrant musculoskeletalpain that have adequate validity and reliability.The outcome of this review stresses the multi-disciplinary approach needed to address mus-culoskeletal pain experienced by children andadolescents because of its diverse associationswith postural and psychosocial factors. Themanagement of upper quadrant musculoskeletalpain should include an assessment of psychoso-cial factors (e.g., depression, stress, and psy-chosomatic complaints to refer children andadolescents to the appropriate health profes-sional and to assess the duration of static sittingposture to encourage children and adolescents tominimize the length of static sitting.

Conclusion

It is evident that psychosocial factors, espe-cially depression, mental distress, and psycho-somatic complaints, have an influence on thedevelopment of upper quadrant musculoskeletalpain in children and adolescents. Because oflimited studies on the influence of sitting pos-ture, it was difficult to conclude whether seatedpostural alignment has any effect on upperquadrant musculoskeletal pain, although theduration of static sitting was found to be sig-nificantly associated with musculoskeletal pain.There is a lack of consistency regarding theassessment of upper quadrant musculoskeletal


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pain as an outcome measure and there is a needto further explore the relationship between staticsitting posture and musculoskeletal pain.

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Appendix

A

Most

successfulhitsfrom

theseven

databasessearched.

Databases

Keywords/MESH

HitsLim

its

Excluded

bytitle

Excluded

duplicates

Excluded

by

abstract

Excluded

byarticle

Rem

aining

articles

duplicated

inother

databases

Science

direct

1Sittingposture

andneckor

shoulder

pain

and

(adolescents

orchildren)

981

972

04

32

2Sittingposture

andupper

limbpain

and(adolescents

orchildren)

455

452

30

3Sittingposture

and

musculoskeletalpain

and

(adolescents

orchildren)

200

196

40

4Psychosocialfactors

and

musculoskeletalpain

and

(adolescents

orchildren)

697

691

21

30


and

upper

limbpain

and

(adolescents

orchildren)

445

442

11

10


and

upper

extrem

itypain

and

(adolescents

orchildren)

474

472

11

00

CIN

AHL

1Posture

286

English

280

22

20

2Posture

andpain

59

adolescen

ce56

30

00

3Posture

and(neckorshoulder

pain)

123

6–12years

111

02

63

1


and

musculoskeletalpain

10

91

00

0


and

(neckorshoulder

pain)

127

117

90

10

PsycInfo

1Posture

321

English

314

20

50

2Posture

andpain

10

Human

71

02

0

(Continued)


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Appendix

A.Most

successfulhitsfrom

theseven

databasessearched

(Continued).

Databases

Keywords/M

ESH

Hits

Lim

itsExcluded

bytitle

Excluded

duplicates

Excluded

by

abstract

Excluded

byarticle

Rem

aining

articles

Duplicatedin

other

databses

3Posture

and(neckorshoulder

pain)

24

adolescence

18

30

21


andpain

82

6–12years

73

52

20


and

musculoskeletalpain

38

37

10

00


and(neck

orshoulder

pain)

177

172

50

00

Proquest

1Posture

andpain

226

225

10

00

2Posture

and(adolescents

or

children)andpain

27

26

00

10

Pubmed

1Sittingposture

andMESH

pain

35

adolescence

31

02

00

22

Sittingposture

and[M

ESH

neck

orMESH

shoulder

pain]

3Child

12

00

0

3Sittingposture

and

musculoskeletalpain

4Human

31

00

0

4MESH

posture

and[M

ESH

neckorMESH

shoulder

pain]150

English

141

22

12

2

5MESH

posture

and

musculoskeletalpain

30

27

30

00

6MESH

posture

andMESH

studentandMESH

pain

75

20

00


andMESH

pain

291

287

01

10

2


and[M

ESH

neckorMESH

shoulder

pain]

98

10

00


andupper

limbpain

65

10

00

10

Psychosocialfactors

andupper

extrem

itypain

65

10

00

11

Psychosocialfactors

andMESH

studentandMESH

pain

98

10

00


Phys

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BioMed

1Sittingposture

56

55

00

10

Central

2Posture

andpain

142

141

10

00

3Posture

andmusculoskeletal

pain

78

77

10

00

4Posture

and(neckorshoulder

pain)

62

61

10

00


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Appendix B

Critical appraisal form-quantitative studies (Law et al, 1998).

YES NO

Study purpose1 Was the purpose of the study clearly stated?

Design2 Was the study design appropriate?

Biases3 Were there sample biases detected in the study?4 Were there measurement biases detected in the study?

Sample5 Was the sample size stated?6 Was the sample described in detail?7 Was the sample size justified?

Outcomes8 Were the outcomes clearly stated and relevant to the study?9 Was the method of outcome measurement described

sufficiently?10 Were the outcome measures reliable?11 Were the outcome measures valid?

Results12 Were the results reported in terms of statistical significance?13 Were the analysis methods appropriate?14 Was clinical importance reported?

Dropouts15 Were dropouts reported?

Conclusion and clinicalimplication

16 Were the conclusions relevant and appropriate given themethods and results of the study?


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a systematic review of posture and psychosocial factors as contributors to upper quadrant...

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