Lockdown is an effective way to prevent the spread of the COVID-19 virus [10].Yet the shift in academic studies from on-campus studies to online learning exerted negative effects on students. The COVID-19 lockdown had an adverse impact on NP among college students. The current study reported NP at four time points—lifetime, last year, last six months, and current—on a scale ranging from never/seldom to almost every day. The mean NP score increased gradually and significantly during the lockdown period. To the best of our knowledge, the current study is the first to assess NP at four time points among college students, particularly during the COVID-19 lockdown.
In addition, current reports of NP were highly associated with VAS scores, as well as with the scores on the NDI. Furthermore, the results indicate that about a third (35.6%) of the college students reported at least a moderate degree of neck-related disability, while about two thirds of them (64.4%) reported no significant disability.
Similar results emerged in recent a previous study [2], showing that 38.2% of female medical students experience at least moderate neck and shoulder pain, whereas about 60% of them reported mild or no symptoms. Even though the previous study [2] was conducted before the coronavirus pandemic, both studies exhibited same prevalence of moderate NP among students. Furthermore, the current study assessed NP severity and disability according to the NDI questionnaire, whereas the previous study [2] used one question from the Computer Vision Syndrome Questionnaire to assess the severity of neck and shoulder symptoms as mild, moderate or severe.
Other studies conducted before the COVID-19 pandemic also reported a prevalence of NP symptoms among academic students; NP was reported in 69% of students in Italy [25], 24% of medical students in Egypt [26], and 75.1% of students at the University of Jamaica [27], and 22.3% of students at a university in Thailand [28]. Since musculoskeletal pain in the neck and shoulder region depends on exposure to risk factors, such as stress, incorrect posture, number of hours sitting per day and electronic device use, the range is diverse.
Majumdar et al. [3] reported no adverse effects of the COVID-19 pandemic on NP. Another study conducted in Turkey found that during the three-month lockdown when workers stayed home, the number of complaints of NP in workers was lower compared to the pre-lockdown period [29]. The results of the current study are inconsistent with those of these two previous studies. The main reason for this difference lies in the fact that two different populations were examined. In both previous studies the participants were workers, while in the current study the participants were students.
A possible explanation for these findings is that most people who stayed at home spent less time working or did not work at all. Hence, their work hours and exposure to work-related physical stress may have been reduced [29].Indeed, the reduction in the rate of NP and musculoskeletal complaints may be attributed to a decrease in work hours [29]. In contrast, the study population in the current study consisted of students. During the lockdown, students spent more time sitting in front of screens and may therefore have been more exposed to physical stress and excessive use of electronic devices.
Furthermore, our results indicate that sitting more than three hours a day is associated with a higher risk of experiencing at least moderate neck-related disability. The lockdown increased students’ reliance on electronic devices to connect online, resulting in increased screen time as well as sitting time. In a recent systematic review, working in sustained awkward positions was determined to be a risk factor associated with the development of NP [6].
During the COVID-19 lockdown, our student participants reported a moderate level of perceived stress. Moreover, about 60% of them reported study-related stress. Furthermore, higher levels of stress and study-related stress were also associated with higher odds for experiencing at least a moderate degree of neck-related disability.
According to the WHO, the pandemic crisis is generating stress throughout the population that can have a negative impact on physical and mental well-being [7]. Zhang et al [17] revealed that undergraduate students who are confined to their homes suffer from chronic stress. The literature about COVID-19 and psycho-emotional distress reports similar findings [30, 31]. As in these studies, the current study found that psycho-emotional distress has a greater impact on students. According to Marelli et al [30], the lockdown in Italy had a significant impact both on sleep and on psycho-emotional well-being and this impact was greater among students than among administrative staff workers and greater among women than among men. Similarly, Li et al [31] found that 16.3% students at Wuhan universities and colleges had posttraumatic syndrome four months after the COVID-19 pandemic.
Our finding concerning the high prevalence of study-related stress among students provides further support for the results of a previous cross-sectional study, which demonstrated that NP is related to academic pressure [17].
Moreover, NP has been found to be associated with psychosocial and mental stress [3]; stress was found to be one of the strongest predictors of neck/shoulder pain [32]. Similarly, a high degree of mental stress is considered a risk factor for musculoskeletal disorders in the neck [33].
The results of the current study indicate that sitting more than three hours a day is associated with a greater risk of experiencing at least a moderate level of neck-related disability. The lockdown increased people’s reliance on electronic devices to connect online, which in turn resulted in more time in front of the screen time as well as more time sitting.. A recent systematic review determined that working in sustained awkward positions is a risk factor associated with the development of NP [6].
One surprising result of the current study is that leisure time physical activity was not found to be associated with NP-related disability. This finding is inconsistent with previous studies, which found that physical activity reduced NP [34, 35] and served as a protective factor against NP [6]. However, most risk factors found for neck pain were related to psychosocial characteristics rather than to physical characteristics [6]. We believe that the psychosocial condition expressed by the stress students experienced during the pandemic period is the dominant cause of pain, rather than leisure time physical activity.
Our results also indicate that older age and smoking among students were not related to NP and disability during the lockdown period. The results of our study are consistent with those of a recent systematic review suggesting that age and smoking status, were not risk factors for developing NP [6].
Several potential sources of bias may be identified. First, potential participants may have chosen not to respond to the online questionnaire. Their characteristics compared to those of students who completed the questionnaire are unknown, constituting a limitation of the study. Second, the online protocol required that participants complete the questionnaire in full so as to avoid missing data. Third, social desirability may have biased the respondents’ answers. For that reason, the data were collected anonymously. Fourth, the study design is cross-sectional, and retrospective questions were asked. Reporting may have been affected by current emotions or cognitions, constituting another limitation of the study. Finally, a larger sample size is needed in order to be able to generalize the conclusions of the current study.