Can we ignore it any longer?
Back pain and other musculoskeletal conditions account for a quarter of all UK sickness absence, that’s 31 million working days lost every year. The costs to the economy are more than hosting the 2012 Olympics EVERY YEAR. Back pain has huge social and emotional costs too.
Perhaps due to the immense economic costs, intervention and prevention tend to focus on adults. However, recent research shows that increasing numbers of children are experiencing back and neck pain.
Studies show 72% of primary and 64% of secondary children reported experiencing back and/or neck pain at school, with the majority of cases unreported (Webb 2013).
There are 8.3 million children attending UK schools (Department for Education, 2015), all of whom should be given every opportunity to achieve their full potential. Back pain in children has implications for the future workforce as many young adults are entering the workplace with back and neck pain already present (Murphy et al 2007). It also has substantial economic and public health implications when considering children’s young age and the recurrence potential of the condition throughout adulthood (Trevelyan and Legg 2011). Given that the NHS has 1.4 million employees as the 5th World’s biggest employer, the number of children potentially at risk is enormous.
Non-specific spinal pain in children and young people is multi-factorial in cause but is now a well-established phenomenon and amongst health, education and ergonomics professionals is considered to be on the rise. Predisposing factors for school-aged children include: high body mass index, low physical activity, prolonged sitting, ergonomic risks in the current classroom environment carrying school bags, and >3hours high level sport a week. It must also be noted that back pain in children and young people can also have other biopsychosocial elements (Murphy et al 2007).
It cases absence from education, conservative and pharmacological health interventions, reduced participation in physical activity and the potential to develop long term chronic pain (Hill & Ketaing 2010, Jakes et al 2015). A high proportion of children affected by pain (69% girls and 51% boys) will go on to have a lifetime prevalence of back pain, placing enormous stain on both health and social resources (Jones 2009).
In addition, and fundamental to education, musculo-skeletal pain causes a distraction from learning and can have a detrimental effect on a young persons’ life chances.
One study (Triguerio et al 2013) states that the probability of back pain is increased 4.4 times when school furniture was reported uncomfortable and that children with back pain were 4 times more likely to report sleeping difficulties – this will affect concentration at school due to tiredness and pain. Sleeping difficulties may come first due to anxiety or back pain however. Emotional wellbeing is therefore essential for children. Preventative strategies should focus on reducing physical risk factors in addition to psychological factors to be most successful.
Children spend approximately 30% of their waking hours in school, mostly in a seated position (Webb 2013). This can amount to 800 hours sitting each year in furniture designed for short term use. There are no regulations to keep posture and back health in check for children, despite the known benefits to health, wellbeing and productivity it brings adults in the workplace. It is also important to consider that the formation of habits begins in childhood so the necessity to instil healthy movement patterns, postures and sound ergonomic advice is particularly important early on for the future prevention of potential pain and disability (Syazwan et al 2011).
We know seating at work is important for both adult employees and employers in terms of comfort, concentration and productivity. The Health and Safety Executive Seating at Work Guidance for adults states “Unsuitable seating can cause people to adopt awkward postures which can lead to discomfort, back pain and upper limb disorders. This may prove costly to employers in the form of staff absences, potential civil claims and lost production. Individuals bear some of the costs in the form of lost income”.
For children where their “workplace” is their educational setting, there is no legal duty to protect them. Ofsted 2015 state their goal is “to achieve excellence in education and skills for learners of all ages, and in the care of children and young people” – However, with schools using an increasing amount of technology on a daily basis with minimal or no ergonomics training and limited understanding of the workplace environment, maybe a review of their policies is needed to enable a more holistic and appropriate approach to pupil health and well-being for today’s students?
For every child to be safe, healthy and reach their full potential, greater emphasis needs to be placed on the school learning environment together with awareness of ergonomics and healthy posture, especially when using technology – this may not only have health benefits but could it also improve behaviour and attainment too?
A poll conducted by YouGov for Ofsted in 2014 reported that some pupils could be losing up to an hour of learning each day due to low-level classroom disruption. Inspectors warned that low-level, persistent disruptive behaviour in UK schools is affecting pupils’ learning and damaging their life chances. Reasons for low-level disruption, cited by teachers include:
- swinging on chairs (11%) and
- fidgeting (23%), both of which typically occur as children try to readjust their position because they are uncomfortable or have been sitting for too long.
Interestingly, South Rise Primary School, Inner London previously one of the poorest performing schools in the country moved to joint 12th nationally last year after the transformation of their school environment. It is now in the top 10% for progress (KS1-KS2) Executive Headteacher Sophie Powell states “it had a powerful effect which rippled success from the moment you stepped inside the school to the back of each classroom”. The accelerated growth, achieved within a few weeks raised expectations of stakeholders and improved the working and learning environment for staff and pupils. Ms Powell injected a new ethos throughout the wider community which promoted excellence, respect and higher standards. Momentum is gaining amongst educationalists that the school environment is the silent teacher.
A small, two class study carried out in 2014 to identify any benefits of improved sitting posture and learning environment for children aged 4-6 years at Nunnery First School, Somerset produced very favourable feedback from teaching staff after sitting wedge cushions were introduced for pupils:
- Better quality learning can take place without the distraction from “off task” movement,
- Better focus and concentration while sitting continues in a habit of more effective learning behaviours in other situations.
- Children are developing an awareness of other important factors affecting their ability to learn effectively and need fewer prompts for improving learning behaviour.
After these positive results and with the increase in back and neck pain in teenagers, I wished to further explore back health issues affecting secondary students and to see if sitting posture has an effect on concentration, learning and back pain (as perceived by students themselves).
Two groups of Year 10 students (aged 14-15 years) from St John Houghton Catholic Voluntary Academy, Derbyshire completed a pre-intervention questionnaire whilst using their current classroom chair. The Max II chair, assessed and chosen for it’s improved ergonomic and non tip-back design, it’s flexibility to allow some movement, together with it’s affordability for schools, was used as the intervention by students for 3 weeks, after which a post intervention questionnaire was completed. The pre and post questionnaires were the same. Results of the 36 pupils sample showed:
- 86% of students (96% girls and 67% of boys) had experienced back and/or neck pain within the past year. 53% had experienced pain with the past 7 days.
Top 3 most uncomfortable school-based activities as reported by students:
- 1st Carrying my school bag 67%
- 2nd Sitting on school chairs 47%
- 3rd Working at the computer 28%
“Other” activities primarily included using science stools without backrests and using low science lab tables.
Top 3 most uncomfortable home-based activities:
- 1st Working at my desk 19%
- 2nd Working at my computer 19%
- 3rd Working on tablet devices 6% (It should be noted that tablet devices are not used within the school taking part).
The majority of students (72%) rated their pre-intervention classroom chair as uncomfortable (5 or less out of 10 in a 10 point scoring system).
Comments included “They hurt when you lean back on the chair”. “They squeak a lot and lean to one side as they are mostly broken”. “It’s uncomfortable because they are really hard to sit on”. “Very hard and the back rest is very straight up and doesn’t support my back”. “Sitting on them for a long time gets annoying”. “The shape hurts your spine and the plastic is uncomfortable”. “They’re nearly all broken and bend right back. Dig into spine and itchy on back of legs when hot”.
Of the pre-intervention group who had pain in the last 7 days, 75% rated their chair uncomfortable, compared to 62% who reported carrying school bags as uncomfortable. This highlights a higher correlation to chair discomfort and pain in the last 7 days than carrying school bags and pain experienced. However, this does not explain the reasons why.
89% of pupils’ surveyed pre-intervention reported that their concentration had been affected because of being uncomfortable sitting on their school chair. 25% replied “yes- often”.
The majority of students rated their post intervention Max II chair as comfortable 61% (6 or more out of 10). Comments included: “I find the Max II more comfortable than the usual chairs. I would generally find myself sitting straighter rather than slouching over like the previous chairs. It also helps keep me awake during the lesson”. “The arch on the chair supports my back and helps me with posture”. “The new one’s shaped really well”. “Nice back rest, however they are still too hard”. “Comfortable –keeps back straight, less back pain”. “I like them, posture is much better and you sit up straighter. I like them because it does not make me want to slouch which makes me concentrate more”. “It sounds strange but I actually think I’ve learnt quicker”.
Negative student comments post intervention, which as a physiotherapist, I found positive, included “I like the old ones. I can’t lean back or slouch on these”. “I can’t rock back on them”. “I can’t get used to it, the chair makes you sit in a really upright position”. These comments suggest how poor sitting postures can become habitual from a young age and perhaps indicate that the earlier the introduction of ergonomically designed furniture throughout a school, the more beneficial it will be to students both in terms of encouraging better sitting posture and promoting comfort throughout the day.
Despite some negative comments and the short intervention time, reported pain in the last 7 days was 3% lower post-intervention. I would like to explore this further, with a bigger sample size.
When asked “How important is the comfort of your school chair to your learning?” (1= not at all important, 10= essential). The average reported was 7 pre-intervention and 8 post-intervention. This demonstrates that teenagers themselves recognise the importance of sitting comfort to their individual learning. Whilst it cannot be assumed attainment will improve, because of their improved sitting comfort, there is growing recognition that if students feel more comfortable, engaged and able to concentrate, they are more ready to learn.
The good news is that some simple ideas, which can be easily implemented, can make a real difference to children’s back health. This is an area, which will hopefully gain further attention at a National level in the near future in terms of health promotion and school intervention.
Here are 10 top tips to recommend to teachers to help keep children’s backs healthy in schools:
1. Think “30:30 sit and stretch”. Limit sitting to 30minutes, stretch and wriggle for 30secs.
2. Limit cross-legged floor sitting to 10minutes. Encourage movement, side sitting to both sides, straight-legged sitting or cross-legged on a seat wedge cushion.
3. Ensure all children have a clear view of the board without twisting. If not, can they turn their chair around or move position?
4. Report eyesight concerns home if children are excessively hunching over their work or a screen.
5. Never use a laptop flat on a desk at home or at school, it should be raised up/on a stand so the top of the screen is at eye level, with a separate mouse and keyboard.
6. Encourage all students to learn to touch type so they are not “hunting and pecking” repetitively looking from screen to keyboard.
7. Recommended safe school bag weight is 10% or less of body weight – Encourage students to repack their bag each night so they only carry what they need. Safe storage areas/lockers are a healthy investment.
8. Physical activity is essential for back health, avoid restricting break and PE times. It’s important to promote adequate hydration too.
9. Fidgeting students and those leaning back using “bucket chairs” are most likely uncomfortable, can they stand up, readjust position and sit back down again? Better still, trial and consider ergonomically designed student chairs as an investment to improve health and the learning environment.
10. Encourage children to view the Healthy Working Move Initiative at www.ergonomics4kids.co.uk – a free e-learning for students of all ages and an accompanying eBook for parents and teachers with advice on how to protect children when using technology in the classroom and at home.
Further information and free resources for school can be found at:
www.jollyback.com or if you’d like to get in touch firstname.lastname@example.org
Webb H Back on Track – development of a school-based back care education programme. 2013 Perspectives in Public Health ISSN 1757-9139 p1-2.
Murphy S, Buckle P & Stubbs A cross-sectional study of self-reported back and neck pain among English schoolchildren and associated physical and psychological risk factors. 2007 Applied Ergonomics 38;6 p797-804
Trevelyan FC & Legg SJ Risk factors associated with back pain in New Zealand schoolchildren. 2011 Ergonomics Mar; 54(3):257-62
Hill J & Ketaing J Risk factors for the first episode of low back pain in children are infrequently validated across samples and conditions: a systematic review. 2010 Journal of Physiotherapy 56(4), 237-244.
Jakes A, Phillips R & Scales M 2015 Teenagers with back pain. BMJ 2015; 350:h1275
Jones G & McFarlane G Predicting low back pain in schoolchildren: a prospective cohort study. 2009 Arthritis Rheum 61:1359-1366
Triguerio MJ, Massada L & Garganta R Back pain in Portuguese schoolchildren: prevalence and risk factors. 2013 European Journal of Public Health 23:3; 499-503
Syazwan A, Mohamad Ashar MN, Anita A, Azizan H, Shaharuddin M, Muhamad Hanafiah J Poor sitting posture and a heavy school bag as contributors to musculoskeletal pain in children: An ergonomic school education intervention program. 2011 Journal of Pain Research; 4:287-96