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Epidemiology and Health System Journal
© 2023 The Author(s); Published by Shahrekord University of Medical Sciences. This is an open-access article distributed under the terms
of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
2023 Spring;10(2):63-68doi:10.34172/ehsj.2023.11
Postural Habits and Related Joint and Muscle Pain Among
School-age Students: A Cross-sectional Study
Sajad Bagherian1*
ID
, Khodayar Ghasempoor2
ID
, Julien S. Baker3
ID
1Department of Sport Sciences, Shahrekord University, Shahrekord, Iran
2Department of Physical Education and Sport Sciences, Technical and Vocational University, Tehran, Iran
3Centre for Health and Exercise Science Research, Department of Sport, Physical Education and Health, Hong Kong Baptist
University, Kowloon Tong, Hong Kong
http://ehsj.skums.ac.ir
Original Article
Abstract
Background and aims: Current lifestyles, with the growing use of contemporary technologies, have
resulted in changes in people
’
s behavior, causing them to become increasingly sedentary and develop
unhealthy body habits. Posture is an essential variable determining an individual
’
s physical and
emotional well-being. The purpose of this study was to investigate postural habits and any related joint
and muscle pain among school-aged students.
Methods: An online questionnaire was utilized to measure participants
’
postural habits and related
joint and muscle pain. The questionnaire was completed by 43 660 school-aged students (15 532
boys and 28 128 girls in the age range of 8-17 years) by a non-randomized convenient sampling
method through Google Forms via social media on the schools
’
platform in Chaharmahal and Bakhtiari
province, Iran, in the middle of 2022. The questionnaire inquired about body postural patterns and any
associated joint or muscle pain.
Results: The majority of participants (77%) reported spending most of their time in the sitting position.
Overall, 57% of the students reported that they did not maintain the correct posture during their daily
activities. The majority of respondents (54%) reported feeling some joint or muscle pain. The greatest
pain was reported in the neck (28%), upper back (14%), and lower back (13%).
Conclusion: The findings indicated that schools and the medical profession may need to screen
students for health risks such as poor postural status. Further, information related to bad posture should
be provided to children, their families, and healthcare professionals to take care of them.
Keywords: Musculoskeletal pain, Sitting position, Public health, Injury prevention, Corrective exercises
*Corresponding Author:
Sajad Bagherian,
Email: s.bagherian@sku.ac.ir
Received: October 29, 2022
Accepted:
February
25, 2023
ePublished:
April 18, 2023
Introduction
Sedentary people spend most of their days sitting or lying
down, reading, talking, watching television, or taking
virtual classes on their phone or computer.1,2 Individuals
find it challenging to be physically active and maintain
good posture as a result of the rising use of electronics
and associated keyboard activity.3 According to studies,
there is an increasing need to treat postural difficulties
and musculoskeletal disorders caused by excessive use of
technology.3,4
Individual posture is an essential aspect influencing
human physical and mental health throughout the life
span.5 Some factors influence human posture, including
genetics, anatomical structural deficits, postural habits,
and occupation.6 Posture is the position taken by the body
with support during muscular activity or as a result of a
coordinated action by a set of muscles working together
to preserve stability.6 The way people present themselves
in a stance is referred to as
“
static posture”. The ability
to maintain posture while completing functional tasks is
referred to as
“
dynamic posture”.6 The postural deviation
is defined as any deviation from the ideal posture.7 When a
person has good posture, the body
’
s alignment is balanced,
resulting in less stress on anatomical body parts.8,9 When a
person
’
s posture is poor, body alignment suffers, causing
excessive strain on various body parts.8 These postural
deviations and forms can be found in all categories of life,
and statistics show that the prevalence of poor posture
is increasing.7 Even at low levels of bad posture, the
continuous stress generates anatomical modifications over
time.5 The ability to work and perform correct movement
patterns pain-free is impacted by these changes.8,10
Healthcare professionals frequently examine both static
and dynamic postures in order to guide treatment (e.g., by
providing a baseline assessment of movement quality and/
or musculoskeletal dysfunction).8,11
Strong evidence exists to support the necessity of
improving and monitoring the quality of children
’
s
postural habits.3,12 When muscle length is altered as
a result of misalignment (i.e., poor posture), tension
development is reduced, and the muscle is unable to
deliver enough force to provide effective and efficient
Epidemiology and Health System Journal, Volume 10, Issue 2, 2023 64
Bagherian et al
movement.6 In children and adolescents, a systematic
review represented a link between sitting posture and
upper quadrant musculoskeletal pain.13 In addition, there
are many different habits used in the home in addition to
sitting posture that could eventually affect the spine and
contribute to bad posture.7 The assumed position may place
parts of the body at the very end of its range of motion and
may cause some muscle imbalances and postural changes.7
Identifying if these modifiable household habits are linked
to postural deviation could aid in the development of
preventative methods14; early adulthood is crucial in the
development of appropriate body behaviors and postural
habits, which will help reduce postural problems and their
repercussions later in life.12
The pubertal growth spurt is a critical stage in the
process of postural genesis.15 Growing children often
experience postural deformities as a result of poor postural
habits that have developed over time.16 Although most of
these postural abnormalities occur gradually, they can be
identified after a few years.17 These defects may progress
into structural deformities (i.e., idiopathic scoliosis) if
left untreated, which could have an impact on a child
’
s
mental health and acceptance of one
’
s own body image.15
In light of the available knowledge, there seems to be no
doubt that children with postural defects should receive
comprehensive care.3 However, there is little knowledge
about the poor postural habits of developing children,
despite the possibility that risk factor identification may
facilitate their elimination.16,18 To design a preventative
and educative program, it is crucial to identify postural
abnormalities and musculoskeletal risk factors early.
Therefore, the goal of this study was to look into students of
school age
’
s habitual postural positions and any associated
joint and muscle pain.
Materials and Methods
The study comprised a cross-sectional online
questionnaire distributed on May 20, 2022, and ended on
June 5, 2022. Iranian school-aged students of both genders
in Chaharmahal and Bakhtiari Province were invited to
participate in the study. The questionnaire was sent out
anonymously and electronically using Iran School
’
s
“
Shad”
social media platform. This study received ethical approval
from the Iranian Ministry of Education
’
s Department
of Physical Education and Health. All participants were
informed about the study
’
s goals and provided electronic
consent for inclusion. All participants were under the age
of 18. A written informed consent form was attached to
the screening questionnaire to obtain parental consent in
advance of data collection. The exclusion criteria were any
history of injury or trauma that caused joint or muscle
pain. In this study,
“
school-aged students” refer to students
who are in school and have not finished high school yet
(ages 7-18).
The target population was recruited by a non-
randomized, convenient sampling method and was
representative of students available on social media
platforms. The study also demonstrated the beneficial
use of social media as a method of data collection. This
manuscript was written in accordance with Strengthening
the Reporting of Observational Studies in Epidemiology
guidelines.19
Questionnaire
The research team developed a questionnaire based on
the primary study questions to learn more about postural
habits and related joint and muscle pain among school-
age students. The questionnaire
’
s content and face validity
were approved by 10 specialists and professors who
were familiar with the research topic. Cronbach
’
s alpha
coefficient was also used to determine the tool
’
s reliability,
which was found to be 0.82. Demographics (age, gender,
weight, height, and grade) and seven additional questions
were included in the questionnaire, including kinds of
body posture, sitting positions, lying positions, feeling
joint or muscle pain, and the part of the body experiencing
pain (Supplementary File 1).
The participants received the questionnaire as Google
Forms via social media on the school
’
s platform. For fifteen
days, they had access to the information provided by the
questionnaire via the provided link. With a mix of open-
ended and closed-ended questions, the questionnaire was
of a semi-structured type (including multiple-choice and
ranking questions). To guarantee optimum participation,
reminders were sent out to potential participants. Once the
information was returned from participants, appropriate
statistical analysis procedures were employed to analyze
the data.
Statistics
The Shapiro-Wilk test was applied to verify the normality
of the data (P < 0.05). The Chi-square goodness-of-fit test
was used to determine the differences in the distribution
of the participant responses (i.e., categorical variables such
as not at all, very little, relatively high, and very much).
The Kruskal-Wallis test was also applied to investigate
differences in the characteristics of the school-age
children of each gender. In addition, the Mann-Whitney
U test was calculated for comparing boys and girls in each
characteristic.
All the Google forms received were screened by
the research team, and inappropriate and incomplete
responses were discarded from the analysis. Close-
ended data were automatically analyzed using a Google
Spreadsheet, and descriptive statistics were developed
using percentages and frequency distribution. The data
were analyzed using the Statistical Package for Social
Sciences, version 26 (IBM Inc., Chicago, IL, USA), and a
P value of ˂0.05 was considered statistically significant.
Microsoft Excel was utilized for data entry, editing, and
sorting. Continuous and categorical data were presented
as the mean and standard deviation (SD), as well as
frequency and percentages, respectively.
Epidemiology and Health System Journal, Volume 10, Issue 2, 2023 65
Joint and Muscle Pain Among School-aged Students
Results
In Chaharmahal and Bakhtiari province, 43 660 students,
including 15 532 boys (36%) and 28 128 girls (64%),
completed the questionnaire. Table 1 provides the
characteristics of school-aged children in full detail. A
chi-square goodness-of-fit test demonstrated significant
differences between the boys
’
and girls
’
responses to
questions related to body posture (χ2 = 40250.7, P = 0.001),
different sitting positions (χ2 = 8142.7, P = 0.001), place
of sitting (χ2 = 2234.4, P = 0.001), different lying positions
(χ2 = 2523.1, P = 0.001), place of lying (χ2 = 3225.2,
P = 0.001), joint or muscle pain (χ2 = 52832.2, P = 0.001),
and joint or muscle pain in various parts of the body
(χ2 = 41643.9, P = 0.001). The details of school-aged
students
’
responses to questions are presented in
Figures 1 and 2.
Based on data in Figure 1, the majority of participants
(77%) reported sitting most of the time during the day, while
Table 1. Characteristics of School-Age Children
Gender Boys Girls
School Stage Elementary
(n = 5017)
Secondary
(n = 6180)
High
(n = 4335)
Elementary
(n = 10355)
Secondary
(n = 10640)
High
(n = 7133)
Weight (kg) 46.1 ± 17.6ab 52.7 ± 17.9 58.1 ± 12.8b43.6 ± 10.6a49.4 ± 10.1 53.4 ± 7.8
Height (cm) 139.1 ± 14.4a161.1 ± 10.5 167.8 ± 9.4 137.8 ± 13.6a159.2 ± 10.1 165.2 ± 9.8
BMI (kg/m2)24.4 ± 10.8a20.5 ± 7.3b20.8 ± 5.1b23.3 ± 5.9a21.2 ± 3.9 20.6 ± 2.9
Sitting position n = 4324ab
(86%)
n = 4624b
(75%)
n = 3094b
(71%)
n = 8748a
(84%)
n = 7807
(73%)
n = 4976
(70%)
Standing position n = 52ab
(1%)
n = 54b
(1%)
n = 42b
(1%)
n = 73a
(1%)
n = 99
(1%)
n = 78
(1%)
Lying position n = 641ab
(13%)
n = 1502b
(24%)
n = 1199b
(28%)
n = 1534a
(15%)
n = 2734
(26%)
n = 2079
(29%)
Neck pain n = 1330ab n = 1724bn = 1339bn = 2865an = 2889 n = 2244
Shoulder pain n = 464ab n = 645bn = 520bn = 998an = 1086 n = 805
Upper back pain n = 562ab n = 837bn = 695bn = 1115an = 1482 n = 1116
Low back pain n = 455ab n = 851bn = 682bn = 993an = 1425 n = 1174
No pain n = 2206ab n = 2123bn = 1099bn = 4384an = 3758 n = 1794
Note. BMI: Body mass index.
a Differences within characteristics of school-age children in each gender (P ≤ .05); b indicates differences between boys and girls in terms of each characteristic
(P ≤ 0.05).
Figure 1. Postural Habits Among School-Aged Students.
Epidemiology and Health System Journal, Volume 10, Issue 2, 2023 66
Bagherian et al
a few respondents reported lying (22%), standing (1%), or
walking postures. For sitting posture, 57% of the students
reported that they did not maintain correct posture while
sitting, and they either leaned forward (28%), backward
(11%), or curved their backs (18%). Regarding students
who reported maintaining lying positions during the day,
half of them indicated lying on their stomachs, while 31%
and 20% of them reported lying on their backs and sides
during the day, respectively. The majority of places where
students sat during the day included sitting on the floor
(58%), and the majority of places where students assumed
a lying position were on the floor. The finding (Figure 2)
revealed that the majority of respondents (54%) reported
feeling some joint or muscle pain. The greatest pain areas
were reported in the neck (28%), upper back (14%), and
lower back (13%), respectively.
Discussion
This study attempted to examine posture positions and
associated joint and muscle pain among school-aged
students. The overall results showed significant differences
between kinds of body posture, different sitting positions,
the place of sitting, different lying positions, the place of
lying, feeling joint or muscle pain, and joint or muscle pain
in various parts of the body. To our knowledge, this is the
first study to assess the impact of posture behaviors and
joint and muscle pain among school-aged students in Iran.
Over the previous decade, postural abnormalities linked
to changes in young people
’
s habits have represented an
increase.7 Bad posture is a modern-day health issue that
affects large numbers of people and has implications for
ill health.12 People
’
s behavior has changed as a result of
their lifestyles, which has resulted in individuals becoming
more sedentary and developing bad physical habits,
including bad posture during work and leisure activities.12
Technological development has provided individuals with
increased comfort and luxury but has also led to a decline
in physical activity that includes increased sedentary
behavior and related postural issues.14 Our results
demonstrated that the majority of participants (77%)
reported sitting postures during most daily activities,
while some others mentioned lying (22%) or standing
(1%) postures. In the sitting posture, 57% of the students
reported incorrect posture. They pointed out leaning
forward (28%), leaning backward (11%), or curving (18%)
during classes. The majority of places where students
sit were on the floor (58%), and the majority of places
where students lie were also on the floor. Regarding lying
positions, half of the students reported lying on their
stomachs, while 31% and 20% of them indicated lying on
their back and side, respectively. Posture acts as a reference
frame for the generation of accurate movement patterns
because it ensures that balance is maintained during the
start, continuation, and completion of any action.5 There
is a link between poor posture and musculoskeletal
disorders in people of all ages, and various variables can
contribute to these changes, including adjustments and
adaptations to body changes, psychosocial pressures, and
ergonomic issues, among others.14 As a result, school-aged
students must be screened by the school when starting in-
person classes, and those who have postural abnormalities
must receive medical or corrective exercise interventions
and information. More research is needed to assess and
compare the postural deviation of school-aged children
before and after the pandemic.
Individuals who maintain long postures or execute
repetitive actions develop tissue adaptations (tissue
impairments).8 Short, stiff, lengthy, overworked, or weak
muscles cause imprecise movement patterns, which can
lead to tissue injury.6 Long periods of sitting, for example,
have been linked to the development of back pain.
According to the findings of this study, the majority of
respondents (54%) reported feeling some joint or muscle
pain. The most pain was reported in the neck (28%), upper
back (14%), and lower back (13%). According to research
on the effects of sustained stress, posture positions should
not be maintained for longer than one hour. McGill and
colleagues observed that 20 minutes in a sustained flexion
position might cause creep in the soft tissues, requiring
more than 40 minutes to fully recover.8 The study also
demonstrated how bad posture affects muscles, joints, and
connective tissue over time. Sitting with the head forward
for an extended period of time while reading a book
will elongate the ligaments and muscles in the posterior
Figure 2. Related Joint and Muscle Pain Among School-Aged Students.
Epidemiology and Health System Journal, Volume 10, Issue 2, 2023 67
Joint and Muscle Pain Among School-aged Students
neck and upper back, making it more difficult to regain
appropriate posture.
Poor posture can also weaken the scapular muscles
and put persistent stress on the rotator cuff, leading to
glenohumeral impingement, particularly when using
overhead motions.20 Future research should focus on
interventions to inform people about the effect of postural
habits on their health. Individuals also need to be reminded
of the necessity of engaging in regular physical activity,
and there is strong evidence that physical activity improves
a variety of health outcomes, including posture.21,22 As a
result, more research needs to be conducted on the health
benefits of home-based exercise and the effects of daily
routines on posture. Interventions to improve participation
in home-based activities and reduce associated health risks
need consideration (Figure 3).
This study has some limitations, including no assessment
of postural deviations in person and the inability to
assess the amount of time spent in different postural
positions. The current study used an online self-report
methodology, which may have included biases (e.g., social
desirability and memory recall). Furthermore, this was a
cross-sectional study, thus we could not establish causality
between any of the evaluated variables. Finally, we used
specific general questions designed by the researchers
rather than a standard questionnaire to assess participants
’
physical activity behaviors.
Conclusion
Half of the studied students reported that they did not use
the correct posture. The majority of respondents indicated
feeling some joint or muscle pain, especially in their neck,
upper back, and lower back. The findings of this study
may help guide efforts to protect and promote children
’
s
health. It may be necessary for schools and medical
professions to screen students for health risks such as poor
postural status that may have resulted from online classes.
Examples of good posture practice should also be available
to alleviate pain and discomfort.
Acknowledgments
We appreciate the support of the Iranian Ministry of Education
’
s
Department of Physical Education and Health, as well as all of the
school-aged students who sincerely contributed to this study.
Figure 3. Interrelationships Between Postural Habits, and Related Joint and Muscle Pain Among School-Aged Students.
Epidemiology and Health System Journal, Volume 10, Issue 2, 2023 68
Bagherian et al
Authors
’
Contributions
Conceptualization: Sajad Bagherian.
Data curation: Sajad Bagherian.
Formal analysis: Sajad Bagherian.
Funding acquisition: Sajad Bagherian.
Investigation: Sajad Bagherian, Khodayar Ghasempoor, Julien S.
Baker.
Methodology: Sajad Bagherian, Khodayar Ghasempoor, Julien S.
Baker.
Project administration: Sajad Bagherian, Khodayar Ghasempoor.
Resources: Sajad Bagherian, Khodayar Ghasempoor.
Software: Sajad Bagherian.
Supervision: Sajad Bagherian.
Validation: Sajad Bagherian, Khodayar Ghasempoor, Julien S. Baker.
Visualization: Sajad Bagherian, Khodayar Ghasempoor, Julien S.
Baker.
Writing–original draft: Sajad Bagherian, Khodayar Ghasempoor,
Julien S. Baker.
Writing–review & editing: Sajad Bagherian, Khodayar Ghasempoor,
Julien S. Baker.
Competing Interests
All authors declare that they have no competing interests.
Ethical Approval
The ethics approval was also obtained from the Ethics Committee of
Shahrekord University (IR.SKU.REC.1401.012).
Funding
This work has been financially supported by the Research Deputy of
Shahrekord University. The grant number was GRD34M1636.
Supplementary Files
Supplementary file 1. Questionnaire to Learn More About Postural
Habits and Related Joint and Muscle Pain Among School-age
Students
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