The Impact of E-learning During COVID-19 Pandemic on Body Aches Among Students in a Palestinian University


 Background: Musculoskeletal system pain is a major concern in our life due to its negative effects on our ability to perform our daily functions. During the COVID-19 pandemic several countries around the world switched their teaching programs into e-learning programs, where students spend long hour using desktop/ laptop or tablet devices. The use of these devices was associated with several complains among the students like neck, shoulder and back pain. The aim of this study is to evaluate the degree of different body aches associated with e-learning on university students and to find a link between the most common body posture, the duration of usage of desktop/ laptop or tablet devices with the negative health outcome on these students. Methods: The subjects of this study were students from An-Najah university in Palestine. 385 questionnaires were filled using Google forms as a web-based questionnaire and all the subjects were using e-learning approach due to COVID-19 pandemic. Upon completion of the study, descriptive statistics, correlation statistics with Pearson coefficient and Chi square analysis were used to study the sample.Results: Our study showed that a large percentage of participants used the desktop/ laptop or tablet devices for e-learning during the pandemic. The Duration of these devices use was correlated with the duration and degree of pain among the participants, and also associated with the difficulty in their ability to perform several daily activities. In addition, most of the students used the sitting position with the supine bent forward during the device usage. When comparing the pain level and duration associated with desktop/ laptop or tablet device usage in both genders, female tend to have higher duration and more severe pain compared to male. Conclusion: The university students that participated in this study had an increase in body aches during the e-learning process, and the aches duration and severity increases if the duration of desktop/laptop or tablet usage increase.


Introduction
Around 20% of adults worldwide suffers from musculoskeletal system pain (1). The impact of musculoskeletal disorders is particularly highlighted in the workplace setting, where they contribute substantially to annual illness and injury costs and reduced productivity (2).
Several studies have been performed to evaluate the possible harmful effects of certain o ce work on general health. The results of these studies showed that neck (3) and lower extremity pain (4) may be associated with sitting for long periods at work, and upper extremity problems (5) may be associated with computer use. Moreover, prolonged sitting can aggravate lower back pain when combined with improper postures (e.g., sitting while leaning forward instead of upright) (6). Based on the previous studied, the most common musculoskeletal complaints among desk-based workers are neck pain, shoulder pain and lower back pain (7). However, the cause effect relationship is not well established and requires more investigation.
Since the current advance in technology, the use of mobile phones is becoming more common among the populations worldwide. Many studies have been conducted to study the correlation between using mobile phones for texting and both, neck and shoulder pain (8). In addition, even application of other physical activities, prolonged neck exion is linked to neck, shoulder, and upper extremity pain (9). Several studies explained the effect by the static muscular load and prolonged neck exion along with the lack of support to the arms and the repetitive movement of the ngers, especially when using one hand only (9,10).Furthermore, the position that a person takes during mobile phone utilization can be linked to physical pain associated with mobile use for texting. It is documented that the best position is the sitting position with a straight neck and supporting the forearms with holding the mobile phone with both hands and to use both thumbs (11,12).
During the COVID-19 pandemic, several countries have tried to coop with social isolation and the general lockdown for all educational institution by switching to other forms of learning. And thus, the E-learning methods have been implicated widely all over the world for all generations.
The switch to e-learning was a big challenge to most of the countries, although some countries have already implicated programs before the beginning of COVID-19 pandemic. Several programs and courses in several universities were already tough from a distance using several e-learning methods. However, during the pandemic all the courses were switched to e-learning methods with the students of different ages spending long hours over their laptops, computers, and smart devices. This change in learning methods was associated with several complains among the students like neck, shoulder and back pain.
In this study we aimed to evaluate the degree of different body aches associated with e-learning on university students and nd a link between the most common body posture that are associated with the high negative health outcome on these students.

Subjects:
The subjects of this study were students from An-Najah university in Palestine. The data collection was from 10/11/2020 to 10/2/2021. During this period,385 questionnaires were lled using Google forms as a web-based questionnaire (Supplement 1 File). Questionnaires were distributed to students by posting it on their groups on social networks like Facebook. Students from almost all faculties at the university were included. All the subjects were using e-learning teaching approach due to COVID-19 pandemic.
Questionnaire design: At the beginning of the questionnaire, general demographics data including age, gender, and faculty were studied. Later, the general conditions for usage of desktop/laptop or tablet devices including handedness, frequency of use, duration, causality of usage and position during use were studied. Students' experience of neck, back and shoulder pain associated with e learning use of the previously mentioned devices, including the severity of the pain using the NRS-11 was evaluated; students were asked to rate their pain on a scale from 0 to 10, where zero represents "no pain at all" and 10 represents "the worst pain they have ever experienced," using whole numbers. At last, the frequency, duration and timing of pain and how bad the pain affected their daily activities were also studied.
Ethical approval: Ethical approval for our study entitled " E-learning and body aches among students in Palestinian university " was obtained from An-Najah National University IRB committee on 27 th of October 2020 (OTH 10/2020/21).
An informed consent was obtained in the rst page of the study's questionnaire, and it was written in Arabic, which is the o cial language in Palestine, it explained the aims of the study and emphasized the con dentiality of the lled information. Participants were able to withdraw from the questionnaire at any point. No identifying information were obtained through the questionnaire, and all collected data were solely used for statistical analysis.
Statistical analysis: SPSS (version 21.0, Chicago, USA) was used in analysis of the data. Descriptive statistics were used to study the sample. Correlation statistics with Pearson coe cient was used to assess the correlation between duration of use, and both pain duration and severity, and for the assessment of the correlation between gender and duration and severity of the pain. Chi square analysis was also used to test the null hypothesis in some factors. A p value of 0.01 was adopted as a threshold for signi cance.

Characteristics of the subjects:
In an attempt to understand the different pain levels caused by e-learning, the questionnaires were distributed to several faculties at AN-Najah national university. A total of 385 students were included in the study, the mean age for study participants was 19.91 (SD = 9.8). The sample included 148 men (38.4%) and 237 women (61.6%) (table S1). Most of the participating students were from the faculty of medicine and health sciences (29.6 %), followed by faculty of engineering and information technology (28.3%), faculty of educational sciences and teacher training (20%), faculty of Islamic law (6.8%), faculty of economic and nancial sciences (5.5%), faculty of science (4.9%). The participation of students from faculties other than the mentioned were minimum (Table 1). Concerning the handedness of the subjects, around 90.6% of the subjects were right handedness, while 4.2% had left handedness and 5.2% can use both of their hands (Table S2). When questioning the pattern of laptop and tablet usage, our analysis showed that (1.3%) of the participants never using desktop / laptop, 46.8% of the participants used the desktop/laptop daily, 48.8% of them used the computer from (4-6 days), while 3.1% of them used it from 1-3 days (table S3).
In addition, the average daily usage of laptop and tablets was about 8.2+-4.2hours, from theses hours around 5.9 +-3.5 were for e-learning use (table S4). Detailed analysis showed that the main purpose of using the desktop / laptop or tablet device was in favor of multiple usage with percent of (42.3%), then for the studying with percent of (35.1%), followed by for watching videos with percent of (8.6%) and for following social media with percent of (7.8%), and for working with percent of (3.4%) and just for gaming with percent of (1.8%) and nally for texting with percent of (1%). Chi2 value = 469.855 and its signi cant at level of < 0.001 and the variance was in favor of multiple purposes (table 2). Upon analysis of the most common sitting position during desktop/laptop usage, 49.9 % of the participants that they were Sitting on the chair with the Spine slopping forward. However, 17.1 % of the participants said that they usually sit on the chair with straight spine, and 14.3% of the participants said that they usually sit with supine position. In addition, 12.7%, 3.6%, and 2.3% of the participants said that they sit on the ground with supine sloping forward, Spine sloping back, and straight supine, respectively. Chi2 = (346.268 and its signi cant at level of < 0.001 and the variance was in favor of sitting position on the chair with back slopping forward (table 3).   On the other hand, analysis of the pain severity was assessed using a 10-degree scale. Chi2 value con rms that there is a variance between the pain's severity among the participants and the degrees were ranged between 0 to 10 but the most pains severity was from degree (2 -8), while (9 -10) degrees were less than other degrees ( To evaluate the effect of the pain associated with desktop/laptop use on the daily activity of the participants, we asked them to assess their ability to perform several daily functions. Our results showed that the mean of di culties found in case of neck and back is 1.79 / 4.00 +-0.65 which is equivalent to low level di culty on a scale of no, low, moderate, and severe di culty. However, walk for several miles was ranked rst with the mean of 2.02 +-0.99 and it is of a moderate level on the di culty scale. In addition, standing up for 20 to 30 minutes ranked second with mean of 1.92 +-0.94 and it is of low level on the di culty scale. On the other hand, walking for short distances was ranked last with mean of 1.41+-0.67 which is also equivalent to low level on the di culty scale (  Table 9. The level of di culties nds in descending order. Pain experience during e-learning Upon analyzing predictors for pain severity, we found that the duration of desktop/laptop usage for elearning was signi cantly associated with pain duration (p <0.01) with Pearson correlation of 0.146 for duration of use (Fig 1).
In addition, our results showed a signi cant correlation between the duration of desktop/laptop use for elearning and the severity of the pain among participants (p<0.001) with Pearson correlation of 0.199 for duration of use ( g 2).
When comparing the duration of desktop/ laptop or tablet use with gender, there was a signi cant correlation between both factors (p<0.001) with Person correlation of 0.197 ( g. 4A). Moreover, a signi cant correlation was also detected between the gender of the participants and the severity of the pain (p<0.001) with Person correlation of 0.267 ( g. 4B).

Discussion
The use of electronic devices like desktop/laptop and tablets have increased widely among students during the COVID-19 pandemic due to global shifting in education to e-learning. Our study showed that using desktop/laptop or tablets among students was associated with increased neck and pain and the longer the duration use the more severe the pain. In addition, the pain could affect the normal activity of the students in certain aspects like sleeping, bending over and walking for long distances. Most of the students usually sit on the chair with supine slopping forward during desktop/laptop or tablets.
In our study, the students' participants were from several faculties at An-Najah national university from both genders. The female participants had greater percentage compared to male in this study. Furthermore, our results showed that females tend to use desktop/laptop or tablets for e-learning for longer duration compared to male, although both of the gender had an almost similar percentage in siting position during desktop/laptop or tablets usage, and the highest percentage sit on the chair with supine slopping forward. However, both pain duration and pain severity were higher in females due to desktop/laptop or tablets usage, this is in accordance to previous studies that showed a higher prevalence of neck pain (13,14) in females compared to males. In addition, even at earlier age like school age, female showed higher percentage of back pain compared to male possibly due to psychological factors, female hormone uctuation, and menstruation (15). Our study also showed that around 50% of the students had an earlier experience of neck, shoulder or back pain, although this pain was worst after e-learning. The frequency and duration of this pain varied among participants, but there was a statistical signi cant in the pain duration range of 1-6 hours per day compared to other groups. Previous studies also showed that during e-learning the student tend to adopt inappropriate postures that can cause pain and musculoskeletal alterations, especially in the upper limbs and spine (19).
The timing of the pain also varied among participants, but the most common time of pain was at night. This is an important nding because pain at night can affect sleep and some early studies suggest that tiredness, di culties in falling asleep, waking up at night and other sleep problems can increase the risk of musculoskeletal pains (20,21), and thus, this factor can increase the pain associated with e-learning.
However, our analysis showed that there was a signi cant correlation between the duration of desktop/laptop or tablet usage for e-learning and the duration and the severity of the physical pain.
These results indicate that the longer the time spent for e-learning the highest the duration and severity of the pain. In accordance with these results, a systematic review aimed at evaluating the prevalence and risk factors for musculoskeletal complaints associated with mobile handheld device use showed that there is a signi cant relationship between the duration of smartphone usage and the musculoskeletal complaints (22).
Finally, our study showed that the duration of desktop/laptop or tablet usage in e-learning signi cantly affected some daily activities of the participants like getting out of bed, sleeping through the night, turning over in bed, standing for 20-30min, bending over and walking for several miles. Increasing the risk of these daily activities by the pain associated with e-learning is a warning sign for this young group of the society as it can negatively affect their general health and even negatively affect their ability to study.

Conclusion
Our study showed that the university students that participated in this study had an increase in pain during the e-learning process, and that this pain duration and severity increases if the duration of desktop/laptop or tablet usage increase. This pain can be severe in some students that it affects their ability to perform some of their normal life activities. Our results indicate that these students need help in explaining the best position and daily practices that can decrease their degree of pain.

Declarations
Ethics approval and consent to participate: Ethical approval for our study entitled " E-learning and body aches among students in Palestinian university " was obtained from An-Najah National University IRB committee on 27th of October 2020 (OTH 10/2020/21).
An informed consent was obtained in the rst page of the study's questionnaire, and it was written in Arabic, which is the o cial language in Palestine, it explained the aims of the study and emphasized the con dentiality of the lled information.
In this study, all methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication:
Not applicable.
Availability of data and material: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The correlation between the duration of desktop/laptop or tablet device usage for e-learning and duration of pain.

Figure 2
The correlation between the duration of desktop/laptop or tablet device usage for e-learning and pain severity.