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The Effect of Backpacks on the Lumbar Spine in Children A Standing Magnetic Resonance Imaging Study

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This study is a repeated measures design to measure the lumbar spine response to typical school backpack loads in healthy children. The lumbar spine in this setting was measured for the first time by an upright magnetic resonance imaging (MRI) scanner. The purpose of this study is to measure the lumbar spine response to typical school backpack loads in healthy children. We hypothesize that backpack loads significantly increase disc compression and lumbar curvature. Children commonly carry school backpacks of 10% to 22% bodyweight. Despite growing concern among parents about safety, there are no imaging studies which describe the effect of backpack loads on the spine in children. Three boys and 5 girls, age 11 +/- 2 years (mean +/- SD) underwent T2 weighted sagittal and coronal MRI scans of the lumbar spine while standing. Scans were repeated with 4, 8, and 12 kg backpack loads, which represented approximately 10%, 20%, and 30% body weight for our sample. Main outcome measures were disc compression, defined as post- minus preloading disc height, and lumbar asymmetry, defined as the coronal Cobb angle between the superior endplates of S1 and L1. Increasing backpack loads significantly compressed lumbar disc heights measured in the midline sagittal plane (P < 0.05, repeated-measures analysis of variance [ANOVA]). Lumbar asymmetry was: 2.23 degrees +/- 1.07 degrees standing, 5.46 degrees +/- 2.50 degrees with 4 kg, 9.18 degrees +/- 2.25 degrees with 8 kg, and 5.68 degrees +/- 1.76 degrees with 12 kg (mean +/- SE). Backpack loads significantly increased lumbar asymmetry (P < 0.03, one-way ANOVA). Four of the 8 subjects had Cobb angles greater than 10 degrees during 8-kg backpack loads. Using a visual-analogue scale to rate their pain (0-no pain, 10-worst pain imaginable), subjects reported significant increases in back pain associated with backpack loads of 4, 8, and 12 kg (P < 0.001, 1-way ANOVA). Backpack loads are responsible for a significant amount of back pain in children, which in part, may be due to changes in lumbar disc height or curvature. This is the first upright MRI study to document reduced disc height and greater lumbar asymmetry for common backpack loads in children.
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SPINE Volume 35, Number 1, pp 83–88
©2009, Lippincott Williams & Wilkins
The Effect of Backpacks on the Lumbar Spine in Children
A Standing Magnetic Resonance Imaging Study
Timothy B. Neuschwander, MD,* John Cutrone, MD,† Brandon R. Macias, BA,*
Samantha Cutrone,† Gita Murthy, PhD,* Henry Chambers, MD,‡ and Alan R. Hargens, MD*
Study Design. This study is a repeated measures de-
sign to measure the lumbar spine response to typical
school backpack loads in healthy children. The lumbar
spine in this setting was measured for the first time by an
upright magnetic resonance imaging (MRI) scanner.
Objective. The purpose of this study is to measure the
lumbar spine response to typical school backpack loads in
healthy children. We hypothesize that backpack loads sig-
nificantly increase disc compression and lumbar curvature.
Summary of Background Data. Children commonly
carry school backpacks of 10% to 22% bodyweight. De-
spite growing concern among parents about safety, there
are no imaging studies which describe the effect of back-
pack loads on the spine in children.
Methods. Three boys and 5 girls, age 11 2 years
(mean SD) underwent T2 weighted sagittal and coronal
MRI scans of the lumbar spine while standing. Scans
were repeated with 4, 8, and 12 kg backpack loads, which
represented approximately 10%, 20%, and 30% body
weight for our sample. Main outcome measures were
disc compression, defined as post- minus preloading disc
height, and lumbar asymmetry, defined as the coronal
Cobb angle between the superior endplates of S1 and L1.
Results. Increasing backpack loads significantly com-
pressed lumbar disc heights measured in the midline
sagittal plane (P0.05, repeated-measures analysis of
variance [ANOVA]). Lumbar asymmetry was: 2.23°
1.07° standing, 5.46° 2.50° with 4 kg, 9.18° 2.25° with
8 kg, and 5.68° 1.76° with 12 kg (mean SE). Backpack
loads significantly increased lumbar asymmetry (P
0.03, one-way ANOVA). Four of the 8 subjects had Cobb
angles greater than 10° during 8-kg backpack loads. Using
a visual-analogue scale to rate their pain (0-no pain, 10-
worst pain imaginable), subjects reported significant in-
creases in back pain associated with backpack loads of 4,
8, and 12 kg (P0.001, 1-way ANOVA).
Conclusion. Backpack loads are responsible for a sig-
nificant amount of back pain in children, which in part,
may be due to changes in lumbar disc height or curva-
ture. This is the first upright MRI study to document re-
duced disc height and greater lumbar asymmetry for
common backpack loads in children.
Key words: backpacks, children, disc compression,
spinal asymmetry. Spine 2010;35:83– 88
Over 92% of children in the United States carry back-
packs that are typically loaded with 10% to 22% body
weight.
1,2
Thirty-seven percent of children aged 11 to 14
years report back pain, the majority of whom attribute
their pain to wearing a school backpack.
3
Previous stud-
ies in children with 10%, 20%, and 30% body weight
loads indicate that these loads generate very high contact
pressures under backpack straps as well as significant
pain.
4
Despite growing parental concern regarding heavy
backpack loads in schoolchildren and their association
with childhood back pain, there are no known radio-
graphic studies of the pediatric spine response to back-
pack loads.
5
Radiation risk to normal subjects from de-
tailed roentgenographic or computed tomography
analysis has precluded such studies, and the current data
set is limited to estimates made with anatomic mark-
ers.
5,6
Only a biplane radiographic vertebral analysis can
appropriately describe changes in disc height, lumbar
lordosis, and spinal asymmetry. There are several radio-
graphic studies describing the effects of axial loading in
the adult
7,8
and pediatric spine.
9
These studies compare
supine and simulated upright lumbar spine loading but
do not describe the increased loads caused by typical
school backpack loads in children. A new standing mag-
netic resonance imaging (MRI) imaging device permits
detailed radiographic analysis of the lumbar spine re-
sponse to backpack loads without risk of radiation.
The purpose of this study is to measure lumbar disc
compressibility and lumbar spine curvature in response
to school backpack loads in children. We hypothesize
that typical school backpack loads significantly decrease
lumbar disc height and increase lumbar curvature.
Materials and Methods
This study is a repeated measures design to measure the lumbar
spine response to typical school backpack loads in healthy chil-
dren. The lumbar spine in this setting was imaged for the first
time by an upright MRI scanner (FONAR Upright MRI,
Melville, NY). Three boys and 5 girls, aged 11 2 years
(mean SD) were recruited by flyer distribution at local
schools. Inclusion criteria were healthy children aged 9 to 14
with no history of back pain, scoliosis, or spine surgery. Writ-
From the *Department of Orthopaedic Surgery, University of Califor-
nia, San Diego, CA; †TrueMRI, San Diego, CA; and ‡Rady Children’s
Hospital, San Diego, CA.
Acknowledgment date: March 4, 2009. Revision date: May 8, 2009.
Acceptance date: May 11, 2009.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
Other funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Written child assent and parental informed consent were obtained per
UCSD IRB guidelines.
TrueMRI is a local imaging center that donated use of their upright
MRI. Fonar provided subject reimbursement.
Address correspondence and reprint requests to Timothy Neuschwan-
der, MD, Department of Orthopaedic Surgery, University of Califor-
nia, San Diego, 350 Dickinson St, Suite 121, Mail Code 8894, San
Diego, CA 92103; E-mail: tneuschwander@ucsd.edu
83
ten child assent and parental informed consent were obtained
per UCSD IRB guidelines. Subjects weighed 44 9 kg (mean
SD) and were all between age-adjusted 25th and 75th percen-
tiles for height and weight.
After resting for 30 minutes supine, subjects underwent sag-
ittal T2 scans of the lumbar spine first supine, then standing. A
Jansport backpack (San Leandro, CA) loaded with 4 kg of
ceramic tiles was then placed on the subject’s shoulders in the
standard, 2-strap condition, and sagittal T2 scans were re-
peated. The subject then repeated the measurements with 8 kg
and 12 kg backpack loads. These loads represented approxi-
mately 10%, 20%, and 30% body weight for our sample pop-
ulation. The empty backpack weighed approximately 500 g.
Lumbar disc height on midline sagittal T2 images was de-
fined as the average of anterior and posterior disc heights.
10
Data are presented in terms of compressibility, defined as post-
loading disc height minus supine disc height.
7
Lumbar lordosis
was defined as the sagittal Cobb angle between the superior
endplates of S1 and L1.
7
Lumbar asymmetry was defined as the
coronal Cobb angle between the superior endplates of S1 and
L1. Distances and angles were measured twice by a radiologist,
and the 2 results were averaged. There was never a difference
between the 2 results of 10%.
To compare loading among all 6 lumbar discs under study,
a64 (6 discs 4 loading conditions) repeated measures
analysis of variance (ANOVA) was performed, and significance
was set at P0.05. A 1 4 one-way ANOVA was performed
for lordosis and asymmetry data and significance was set at P
0.05. Recumbent data for compressibility, lordosis, asymme-
try, and pain were not included in ANOVA analysis in order to
isolate the effects of load on disc height and spinal curvature.
All pairwise comparisons were adjusted for multiple compari-
sons using the Sidak test and a P-value of P0.05. A priori and
post hoc power calculations were performed with G*Power
11
and all other statistical analyses were performed with SPSS
software (SPSS, Chigago, IL).
Results
Disc Height Compression
Increasing backpack loads significantly compressed the
T12–L1, L1–L2, L2–L3, L3–L4, L4–L5, and L5–S1 disc
heights (Figure 1, P0.05, repeated measures
ANOVA). In addition, the caudal lumbar discs were
more compressible, with the L5–S1 disc about twice as
compressible as the T12–L1 disc (Figure 1, P0.05,
repeated measures ANOVA). Interaction between disc
and load was nonsignificant, indicating that each disc
responded to increasing loads similarly (P0.05, inter-
action between disc and load).
With pairwise comparisons among discs, only 2 disc
levels were significantly different, with L2–L3 signifi-
cantly more compressible than L1–L2 (P0.05). With
pairwise comparisons among loads, 4, 8, and 12 kg loads
each caused significantly more disc compression than
standing without a backpack load (P0.05), but differ-
ences among compression caused by each load were not
significant. With pairwise comparisons between loads by
disc, L4–L5 and L5–S1 demonstrated significant differ-
ences between standing and 4 kg loads, while L3–L4,
L4–L5, and L5–S1 demonstrated significant differences
between standing and 8 kg loads, and T12–L1, L3–L4,
L4–L5, and L5–S1 demonstrated significant differences
between standing and 12 kg loads. Disc level L3–L4
demonstrated a significant difference in compressibility
between 4 kg and 12 kg loads.
As demonstrated in Table 1, backpack load correlated
linearly with disc compressibility at each disc level, with
r
2
ranging from 0.10 at T12–L1 and steadily increasing
to 0.23 at L5–S1.
Lumbar Lordosis
Changes in lumbar lordosis were quite variable as chil-
dren adjusted their posture to higher backpack loads
(Figure 2). No significant changes in lumbar lordosis
were seen in response to load (P0.767, 1-way
ANOVA, post hoc power analysis 0.35).
Figure 1. Lumbar disc compress-
ibility during backpack loading.
Backpack loads of 4, 8, and 12 kg
significantly compressed each
disc (P0.05). Disc compress-
ibility increased in the caudal
lumbar discs (P0.05). Changes
in compressibility (mm) are re-
lated to the control condition of
supine posture.
Table 1. Linear Regression Between Disc Compression
and Backpack Load
Level r
2
P
T12–L1 0.10 P0.045
L1–L2 0.12 P0.03
L2–L3 0.11 P0.036
L3–L4 0.15 P0.017
L4–L5 0.22 P0.004
L5–S1 0.23 P0.003
Backpack loads of 4, 8, and 12 kg significantly increased back pain (P0.001,
one-way ANOVA).
Subjects rated their pain using a visual-analogue scale (0-no pain, 10-worst
pain imaginable).
84 Spine Volume 35 Number 1 2010
Spinal Asymmetry
Backpack loads caused lumbar spinal asymmetry (Figure
3). The coronal Cobb angle from the superior endplates
of S1 and L1 was measured during all loading condi-
tions. Backpack loads of 4, 8, and 12 kg significantly
increased lumbar asymmetry (P0.03, 1-way
ANOVA). Four of the 8 subjects had Cobb angles greater
than 10° during loading, and 1 subject had a Cobb angle
of 21.1° (Figure 4) during the 8 kg load. Five subjects had
a lumbar curve to the right, and 3 subjects had a lumbar
curve to the left. All subjects maintained the same direc-
tion of curvature throughout the loading conditions. Al-
though the correlation coefficient was small, lumbar
asymmetry correlated linearly with backpack load (r
2
0.124, P0.015).
Pain
Pain was associated with backpack loading (Figure 5).
Using a visual-analogue scale to rate their pain (0-no
pain, 10-worst pain imaginable), subjects associated
Figure 2. Lumbar lordosis during backpack loading. The sagittal Cobb angle from the superior endplates of S1 and L1 was measured during
all loading conditions. Backpack loads of 4, 8, and 12 kg did not significantly increase lumbar lordosis (P0.767, 1-way ANOVA). Lumbar
lordosis was quite variable as children adjusted posture during each load.
Figure 3. Lumbar spinal asymmetry during backpack loading. Lumbar spinal asymmetry was assessed by coronal Cobb angle from the
superior endplates of S1 and L1 during all loading conditions. Backpack loads of 4, 8, and 12 kg significantly increased lumbar asymmetry
(P0.03, 1-way ANOVA).
85Spine Loading in Children Neuschwander et al
backpack loads of 4, 8, and 12 kg with significant in-
creases in back pain (P0.001, 1-way ANOVA). Pain
was positively correlated with backpack load (r
2
0.711, P0.001).
Discussion
To our knowledge, this is the first upright MRI study to
demonstrate decreases in lumbar disc height and in-
creases in lumbar asymmetry due to typical school back-
pack loads in children.
Disc Compression
Kimura et al found decreases in L4–L5 disc height with a
50% body weight axial load, intended to mimic upright
posture.
7
These investigators found disc height changes
in the order of about 1 mm in the L4–L5 disc in young
Figure 4. Example of lumbar asymmetry. Coronal T2 images demonstrating our most exaggerated example of backpack-induced lumbar
asymmetry in a 9-year-old boy. A, Shows a child standing with no load. B, Shows a child standing with an 8-kg backpack load in the
standard, 2-strap position. The Cobb angle from the superior endplate of S1 to the superior endplate of L1 in Ais 0°. After loading (B),
the Cobb angle increased to 21.1°.
Figure 5. Pain during backpack loading. Backpack loads of 4, 8, and 12 kg significantly increased back pain (P0.001, 1-way ANOVA).
Subjects rated their pain using a visual-analogue scale (0-no pain, 10-worst pain imaginable).
86 Spine Volume 35 Number 1 2010
adult subjects. Our results for L4–L5 disc compressibil-
ity from supine to upright posture in children are similar
(Figure 1). Macias et al found decreases in lumbar height
with supine axial loading, but individual disc heights did
not approach significance.
8
In a roentgenographic study
of normal adolescent spines, Reuben and associates were
unable to demonstrate a difference between standing and
supine intervertebral disc heights.
9
These authors mea-
sured the central vertebral disc height rather than the
commonly used Dabbs and Dabbs method.
10
Lordosis
Kimura et al found increases in lumbar lordosis at L3–L4
and L5–S1 with a 50% body weight axial load, which
was intended to mimic upright posture.
7
Macias et al
also found that axial loading in a supine MRI caused
increases in lumbar lordosis, measured from T12–L1 to
L5–S1.
8
Chow et al found decreases in lumbar lordosis
and increases in thoracic kyphosis with increasing load
due to backpack weight while standing.
5
Although our
comparable data are not significant, the trend is similar
to published data. We postulate that lordosis is de-
creased in supine posture and that lordosis increases with
standing and other axial loads. A backpack load is not an
axial load, however, and for the load to stay balanced
over the subject’s center of mass, thoracic kyphosis must
increase. This causes a lever-arm effect as flexion occurs
at the lumbar spine and lumbar lordosis decreases. Since
many of our subjects moved frequently to change the
load center of mass between image acquisitions, this may
have introduced variability in our data.
Asymmetry
Most children will carry their backpacks with both
straps,
3
but occasionally will carry their backpacks using
only 1 shoulder strap.
12
It has been established that
asymmetric load carrying in children due to using only 1
backpack strap likely contributes to low back pain.
6
Ne-
grini and Negrini found that the postural response to a
1-strap asymmetric backpack load was to elevate the
loaded shoulder and laterally deviate the trunk away
from the load so as to reposition the load over the sub-
ject’s center of mass.
13
They did not find lumbar asym-
metry with subjects wearing a pack in a 2-strap condi-
tion; however, anatomic markers were placed on the skin
overlying every other spinous process. Pascoe et al also
reported significantly increased lumbar asymmetry,
about 17° with a 1-strap condition, but no lumbar asym-
metry with a 2-strap condition.
12
Both studies used an-
atomic markers on the skin to quantify coronal asymme-
try. Chow et al found that increasing backpack load was
associated with increasing pelvic obliquity and rotation
in normal children and children with adolescent idio-
pathic scoliosis, but these investigators did not measure
the lumbar spine itself since their anatomic skin markers
that did not include the lumbar spine.
14
Studies with
anatomic skin markers are unable to measure true Cobb
angles and thus may not be able to detect lumbar spine
asymmetry. A recent study found asymmetric load dis-
tribution in children wearing backpacks with both straps
adjusted to equal length, with children tending to load
the right shoulder significantly more than the left.
15
Asymmetric loading was not associated with handed-
ness; this latter study had a small sample size.
Our study found that asymmetry increased with
weight up to the 8 kg load, but subsequently decreased
with the 12 kg load. Subjectively, we noted that our
subjects could tolerate the 8 kg load with minimal pos-
tural adjustment. With the 12 kg load, however, most
subjects attempted to readjust both posture and load be-
fore imaging. As with all loading conditions, subjects
carried the load in the standard, 2-strap condition.
Pain
Correlating back pain with load was not a principal hy-
pothesis of our study, and as such, we did not randomize
loads. Thus, the linear correlation between pain and
backpack load (r
2
0.711, P0.001) in this study may
be a result of subjects’ awareness of increasing load.
However, the correlation between back pain and back-
pack load is well-documented in the literature. A cross-
sectional study of children from the metropolitan Los
Angeles area found that heavier school backpack loads
correlated with back pain.
3
In a recent review on school
backpacks, Mackenzie et al summarized the following as
risk factors for low back pain in schoolchildren: female
gender, poorer general health, high levels of physical ac-
tivity (including sports competition), time spent sitting,
heavier backpack loads, greater time spent carrying a
backpack, low physiologic maximum lumbar spine mo-
bility, and a family history of back pain.
16
It is suggested
that psychological factors play a role in low back pain
occurrence in children.
17
Individuals with low back pain
during childhood and family history of back pain have
an 88% chance of developing low back pain as adults.
18
Limitations
Our study has some limitations. A lumbar coil was used
to image the lumbar spine. Because the entire spine was
not imaged, coronal measurements did not accurately
reflect a true scoliosis measurement, since the apex and
endpoints of the curve were not identified. The coronal
Cobb angles measured in this study likely underestimate
the true coronal curvature of the spine under load. In
addition, our study did not control for time of day, since
the spinal column shortens throughout the day.
19
Each
of our subjects had been ambulatory for at least an hour
before the required 30-minute of supine rest. Since most
of the daily disc height decrease occurs during the first
hour after rising, the required supine rest period likely
imposed some uniformity on the disc heights.
20
It would
have been difficult to impose a longer period of rest on
our sample population. The amount of time our subjects
experienced load may underestimate the amount of time
per day that children typically wear backpacks. Packs
were worn for approximately 10 minutes at each load for
a total of about 30 minutes, whereas children typically
carry backpacks for between 30 and 60 minutes per
87Spine Loading in Children Neuschwander et al
day.
21
However, our loading times were contiguous
whereas children typically wear their backpacks inter-
mittently throughout the day. Since backpack loading
induced coronal asymmetry, midline sagittal disc heights
may have been oriented obliquely to the perpendicular
axis. It is possible that we overestimated postloading disc
height and therefore underestimated disc compression.
Finally, our pain data were not specific to low back pain
and likely captured shoulder, thoracic, and lumbar pain
caused by the pack.
This study is the first radiographic analysis to describe
the lumbar spine in children wearing backpacks. Lumbar
asymmetry induced by backpack loading is a new and
unexpected finding. Low back pain in children may be
worsened by discogenic or postural changes. Future
studies should be directed at upright MRI analyses of
spine loading in children with idiopathic low back pain
and compared with the present study of normal children.
Key Points
Typical school backpack loads significantly com-
pressed lumbar disc heights in children.
Typical school backpack loads significantly in-
creased lumbar asymmetry.
Children reported significant increases in back
pain associated with backpack loads.
References
1. Watson KD, Papageorgiou AC, Jones GT, et al. Low back pain in school-
children: occurrence and characteristics. Pain 2002;97:87–92.
2. Negrini S, Carabalona R, Sibilla P. Backpack as a daily load for schoolchil-
dren. Lancet 1999;354:1974.
3. Skaggs DL, Early SD, D’Ambra P, et al. Back pain and backpacks in school
children. J Pediatr Orthop 2006;26:35863.
4. Macias BR, Murthy G, Chambers H, et al. High contact pressure beneath
backpack straps of children contributes to pain. Arch Pediatr Adolesc Med
2005;159:1186–7.
5. Chow DH, Leung KT, Holmes AD. Changes in spinal curvature and propri-
oception of schoolboys carrying different weights of backpack. Ergonomics
2007;50:2148–56.
6. Korovessis P, Koureas G, Zacharatos S, et al. Backpacks, back pain, sagittal
spinal curves and trunk alignment in adolescents: a logistic and multinomial
logistic analysis. Spine 2005;30:247–55.
7. Kimura S, Steinbach GC, Watenpaugh DE, et al. Lumbar spine disc height
and curvature responses to an axial load generated by a compression device
compatible with magnetic resonance imaging. Spine 2001;26:2596600.
8. Macias BR, Cao P, Watenpaugh DE, et al. LBNP treadmill exercise main-
tains spine function and muscle strength in identical twins during 28-day
simulated microgravity. J Appl Physiol 2007;102:22748.
9. Reuben JD, Brown RH, Nash CL Jr, et al. In vivo effects of axial loading on
healthy, adolescent spines. Clin Orthop Relat Res 1979;139:17–27.
10. Dabbs VM, Dabbs LG. Correlation between disc height narrowing and low-
back pain. Spine 1990;15:1366–9.
11. Faul F, Erdfelder E, Lang AG, et al. G*Power 3: a flexible statistical power
analysis program for the social, behavioral, and biomedical sciences. Behav
Res Methods 2007;39:175–91.
12. Pascoe DD, Pascoe DE, Wang YT, et al. Influence of carrying book bags on
gait cycle and posture of youths. Ergonomics 1997;40:631–41.
13. Negrini S, Negrini A. Postural effects of symmetrical and asymmetrical loads
on the spines of schoolchildren. Scoliosis 2007;2:8.
14. Chow DH, Kwok ML, Cheng JC, et al. The effect of backpack weight on the
standing posture and balance of schoolgirls with adolescent idiopathic sco-
liosis and normal controls. Gait Posture 2006;24:173–81.
15. Macias BR, Murthy G, Chambers H, et al. Asymmetric loads and pain
associated with backpack carrying by children. J Pediatr Orthop 2008;28:
512–7.
16. Mackenzie WG, Sampath JS, Kruse RW, et al. Backpacks in children. Clin
Orthop Relat Res 2003;409:7884.
17. Watson KD, Papageorgiou AC, Jones GT, et al. Low back pain in school-
children: the role of mechanical and psychosocial factors. Arch Dis Child
2003;88:12–7.
18. Harreby M, Neergaard K, Hesselsøe G, et al. Are radiologic changes in the
thoracic and lumbar spine of adolescents risk factors for low back pain in
adults? A 25-year prospective cohort study of 640 school children. Spine
1995;20:2298–302.
19. Tyrrell AR, Reilly T, Troup JD. Circadian variation in stature and the effects
of spinal loading. Spine 1985;10:161–4.
20. Styf JR, Ballard RE, Fechner K, et al. Height increase, neuromuscular func-
tion, and back pain during 6 degrees head-down tilt with traction. Aviat
Space Environ Med 1997;68:24–9.
21. Balague´ F, Skovron ML, Nordin M, et al. Low back pain in schoolchildren.
A study of familial and psychological factors. Spine 1995;20:1265–70.
88 Spine Volume 35 Number 1 2010
... Students reporting back pain declared that their backpack was heavy more often than their counterparts who did not report back pain (Kędra and Czaprowski 2013). Subjects reported significant increases in back pain associated with backpack loads of 4, 8 and 12 kg (Neuschwander et al. 2010). Schoolchildren carrying the heaviest backpacks had a higher risk of back pain and a higher risk of back pathology, although this last result was not statistically significant (Rodríguez-Oviedo et al. 2012). ...
... Furthermore, Kistner (2011) revealed statistically significant differences in postural angles and increased complaints of pain after walking with increased backpack loads. Increasing backpack loads significantly compressed lumbar disc heights measured in the midline sagittal plane and significantly increased lumbar asymmetry (Neuschwander et al. 2010). The added load of a backpack and the changes in spinal posture when carrying a backpack imposed considerable demand on internal tissues and probably results in considerable spinal loads (Suri et al. 2020). ...
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... A cross-sectional study conducted in Malta with 4,0 0 0 students aged 8 to 13 years ( Spiteri et al., 2017 ) also reported an association between LBP and backpack weight. Moreover, Neuschwander et al. (2010) evaluated the effects of backpack weight using magnetic resonance and found that it increases lumbar asymmetry and the occurrence of back pain. From the biomechanical point of view, this association can be explained by the fact that carrying more weight than the spine can bear changes the center of gravity and increases lumbar lordosis, overloading the joints, ligaments, and muscles that stabilize the spine, causing LBP ( Adeyemi et al., 2017 ;Macedo et al., 2015 ;Neuschwander et al., 2010 ). ...
... Moreover, Neuschwander et al. (2010) evaluated the effects of backpack weight using magnetic resonance and found that it increases lumbar asymmetry and the occurrence of back pain. From the biomechanical point of view, this association can be explained by the fact that carrying more weight than the spine can bear changes the center of gravity and increases lumbar lordosis, overloading the joints, ligaments, and muscles that stabilize the spine, causing LBP ( Adeyemi et al., 2017 ;Macedo et al., 2015 ;Neuschwander et al., 2010 ). ...
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Background Low back pain (LBP) is highly prevalent in children and adolescents, while psychosocial, anthropometric, developmental, and lifestyle factors have been associated. However, the evidence is inconsistent from a biological point of view, so identifying predictors of LBP in the 6–12 years children through physical examination should be appropriate. Aims To estimate the prevalence of LBP and associated factors in schoolchildren in a Brazilian population. Design Cross-sectional study. Setting Three schools in Botucatu, Brazil. Participants/Subjects 377 students from 6-12 years. Methods Data collection consisted of questions regarding personal history, socioeconomic and anthropometric information, kinesiologic evaluation with anthropometry, lumbar biophotogrammetry, and backpack weight and use. Descriptive analyses were performed, and simple and multiple logistic regression models were used for risk factors. Results The prevalence of LBP was 27.32% (confidence interval [CI] 95% = 23.07-32.03). The mean age was 8.85 years (± 1.83) in the group with LBP and 8 years (± 1.76) in the group without LBP (p = .006). Variables such as backpack weight (odds ratio [OR] = 1.45, CI 95% = 1.018-2.064) and exceeding 3 hours per day in front of the television (OR = 7.97, CI 95% = 1.957-32.515) increased the chance of LBP in these students. Conclusion LBP is prevalent in younger schoolchildren, and the factors associated with this outcome can be effectively addressed through the promotion of health measures. LBP in schoolchildren is a musculoskeletal discomfort that negatively affects the quality of life of these individuals and persists in adulthood.
... However, the use of backpacks with heavy loads may induce several modifications in posture and gait, such as reduced pelvic rotation, increments in the head angle, a forward head position, and trunk flexion [2][3][4][5][6][7][8][9][10][11][12][13]. This may lead to adverse effects, such as increments in compression of intervertebral disks and in spine curvatures [1,[14][15][16][17][18][19][20]. ...
... This becomes even more disturbing when we realize that younger children carry more weight (normalized to BW) than the older ones. Studies showed that 10-year-old students carried more weight than the 15-year-old students [29], or that students from grades 5 to 8 (ages 8-13) carried more relative weight than those from grades 9 to 12 (ages [13][14][15][16][17][18] [34]. These loads used by young children, at least until 9 years old, can increase the risk of modifications of posture [35], potentially risking later back pain and/or other health-related issues. ...
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Backpacks for transporting school loads are heavily utilized by children, and their mechanical advantages have been allowing children to transport heavy loads. These heavy loads may increase ground reaction forces (GRFs), which can have a negative effect on joints and bone health. The aim of this study was to investigate the effect of backpacks on the GRFs generated by children during walking, running, and jumping. Twenty-one children from the fifth (G-5, n = 9) and ninth (G-9, n = 12) grades walked, ran, and jumped over a force plate. When walking, the G-5 had GRF increments in the first (17.3%; p < 0.001) and second (15.4%; p < 0.001) peak magnitude, and in the total integral of the vertical force (20%; p < 0.001), compared to the control condition (i.e., no backpack), and the G-9 had increments of 10.4%, 9%, and 9% (p < 0.001), respectively. The G-9 did not prolong their total stance time (p > 0.05), unlike the G-5 (p = 0.001). When running, total stance time increased 15% (p < 0.001) and 8.5% (p < 0.001) proportionally to the relative load carried, in the G-5 and G-9, respectively. Peak GRF did not increase in any group when running or landing from a jump over an obstacle. It was found that GRF was affected by the backpack load when walking and running. However, when landing from a jump with the backpack, schoolchildren smoothed the landing by prolonging the reception time and thus avoiding GRF peak magnitudes.
... Most of the time, children have to carry the material daily from home to school and back due to the classes and homework activities [1,2]. The literature on the topic has raised concerns about heavy loads carried in backpacks by children [3][4][5], some relating them to health issues [1,6,7]. However, most of the concerns are associated with the effect of the backpack load on posture and gait patterns, such as reduced pelvic rotation [8]; increments on the angle of the head (an adopted forward position) [9][10][11]; excessive trunk flexion [9][10][11]; and an increase in ground reaction forces (GRF) [12][13][14][15]. ...
Article
Background: Backpacks are widely used by children to carry different objects and the literature supports that most backpacks contain excessive weight. To minimize the loading effects (i.e., ground reaction force), modified backpacks have been tested. However, the effects of elastics on shoulders straps are yet to be studied. Thus, the aim of this study was to test and compare the effect on the vertical ground reaction force of a standard backpack with a modified one with elastic straps while walking and running. Methods: 9 children (5 boys and 4 girls) were included in the group G-5 (age: 11.0 ± 0.3 years-old; body mass: 35.3 ± 7.3 kg; height: 1.41 ± 0.1 m) and twelve (7 boys and 5 girls) in G-9 (age: 15.0 ± 0.7 years-old; body mass: 56.7 ± 11.2 kg; height: 1.63 ± 0.1 m). Participants attended a single session and were initially asked to walk and then run over a force plate. The software Ergotest MuscleLab v8.0 (MuscleLab, Ergotest Innovation, Porsgrunn, Norway) was linked to the force platform and was used to collect and export data. The level of statistical significance was set at p ≤ 0.05. Additionally, the effect size of the differences verified on T-Tests was calculated based on Cohen's d. Results: Statistically significant differences between a common backpack and a modified one with straps (p < 0.05) were observed for the variables time and force when walking. Regarding the running condition, the time variable did not differ significantly between the backpacks. However, the force variable changed considerably between backpack types (p < 0.05). The new straps minimized the forces magnitude, resulting in lower stress. Conclusions: The modified backpacks with shoulder elastic straps reduced the ground reaction force and impact when walking and running. The study may encourage other researchers to assess the effects of different movements (such as jumping or rotating) on ground reaction force.
... Since early days, backpack has been regarded as an appropriate way to load the spine closely and 4 symmetrically while maintaining stability. Repeated carrying of heavy backpacks have been reported to place additional stress on the rapidly growing spinal structure of school children (particular, junior secondary school children), making them prone to postural changes and ultimately low back 5,6,7,8,9 problems. ...
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Background: There are varying reports on the detrimental effects of heavy backpacks among school children. The determination of the maximum load that can be lifted during school may contribute to the preventive strategies for back pain in adolescents, which has been reported to be an increasing problem. Objective: This study was designed to determine the response of secondary school students' (SSS) sagittal plane standing posture to variation in backpack weights, using one and two-strap(s) backpacks. Methods: Thirty-eight (38) SSS (22 males and 16 females) with a mean age of 15.30±1.80 years and 14.90±0.90 years for males and females respectively, participated in this study. Participants' upright standing postural response to backpack loads of 7% and 10% body weights, using one�strapped and two-strapped backpacks respectively, was assessed by measuring the craniovertebral angle (CVA) of participants. Results: There was a significant difference between participants' response (CVA) to postural backpack loads of 7% and 10% body weights using two straps in both males (t = 0.045) and females (t = 0.0001) respectively. This was also found between one�strapped and two-strapped backpacks for backpacks weighing 10% of the body weight for males (t = 0.0001) and females (t = 0.0001) respectively. There was no significant difference (p>0.05) between the male and female participants. Conclusion: Two-strapped backpacks of 10% body weight caused a significant shift in CVA in the participants compared to the one-strap backpacks of 7% body weight. A two-strapped backpack weighing less than 10% of the individual's body weight is recommended for secondary school students in Nigeria.
... Other scholars suggested that PT, SS, and LL are affected by different positions and postures, but the constant value of PI should not be affected by any factors. 14,15 But, in contrast, Park et al 4 reported a decrease of PI from standing to supine, which could be explained by more retroverted pelvic bone (higher PT) and more vertically oriented sacral endplate (higher SS). To find the reason for our result, we analyzed the detailed case history of all participants and found that 32% of patients had pain in sacroiliac joint, which indicated sacroiliac joint dysfunction, and thus weightloading in standing might increase the PI by affecting the unstable sacroiliac joint. ...
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Study Design Imaging parameter study. Objective Though lumbar alignment is better evaluated using standing radiograph than supine magnetic resonance imaging (MRI), few studies have researched this. Our study aimed to observe the correlation and difference in alignment between standing radiograph and supine MRI, and assess whether the change of position affects the lumbopelvic parameters. Methods We analyzed 105 patients, measuring lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Inter- and intraparameter analyses were performed to identify any difference between standing radiograph and supine MRI. Statistical differences between the lumbopelvic parameters were compared. Results There was excellent interobserver agreement for each parameter (interclass correlation coefficient > 0.75), and significant differences were observed in each parameter between radiograph and MRI ( P < .05). Strong correlations were noted between the equivalent parameters in radiograph and MRI, both SS and PI were strongly correlated with LL in radiograph and MRI image, both PT and SS were strongly correlated with PI in radiograph and MRI image ( r = −1.0 to −0.5 or 0.5 to 1.0). Conclusion Supine MRI obviously underestimated the measurements of lumbopelvic sagittal alignment parameters in standing radiograph. Therefore, standing lumbar radiographs should be obtained preoperatively in all surgical patients, not only supine MRI. In addition, we observed that PI was not a constant morphological parameter.
... Após descartar os artigos por duplicidade, ou seja, que estavam presentes em mais de uma base de dados, dez artigos compõem esta revisão. discos intervertebrais lombares e sacral (L5-S1) [22][23][24] . ...
Article
Investigar se o peso da mochila escolar influencia a marcha de crianças e de adolescentes. Trata-se de um estudo retrospectivo, secundário, categorizado como revisão de literatura desenvolvido em cinco etapas: 1) Definição da pergunta; 2) Busca por evidências científicas; 3) Revisão e seleção dos artigos científicos; 4) Análise da qualidade metodológica dos estudos; 5) Apresentação dos resultados. O período cronológico foi de 2016 a 2010. Os Descritores em Ciências da Saúde foram criança/child; adolescente/adolescente; marcha/gait. A palavra-chave mochila escolar/school backpack, foi associada aos descritores. A estratégia de busca resultou em um total de 77 artigos; 65 destes foram artigos excluídos; 12 artigos foram selecionados; 6 artigos estavam duplicados e, ao final, 6 artigos foram incluídos neste trabalho. Ao considerar 10% do peso corporal ou mais no transporte da mochila escolar, foram encontradas alterações posturais, na biomecânica do tronco e dos membros inferiores na marcha, na aérea de pressão plantar e relatos de dor e desconforto. Todos os trabalhos descreveram alterações corporais. Esta pesquisa torna-se uma ferramenta útil ao atentar para a situação crítica e potencialmente exacerbada que envolve o transporte da mochila escolar com cargas inadequadas.
... Lastly, the current simulations were not based on reallife kinematics, i.e., they were not driven by motion capture data. Especially for the load carrying investigations, it can be assumed that real subjects would have slightly adapted their posture based on the applied load, such as previously observed for regular backpack carrying in healthy young adults (Neuschwander et al., 2010). ...
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The pathomechanisms of curve progression in adolescent idiopathic scoliosis (AIS) remain poorly understood and biomechanical data are limited. A deeper insight into spinal loading could provide valuable information toward the improvement of current treatment strategies. This work therefore aimed at using subject-specific musculoskeletal full-body models of patients with AIS to predict segmental compressive forces around the curve apex and to investigate how these forces are affected by simulated load carrying. Models were created based on spatially calibrated biplanar radiographic images from 24 patients with mild to moderate AIS and validated by comparing predictions of paravertebral muscle activity with reported values from in vivo studies. Spinal compressive forces were predicted during unloaded upright standing as well as standing with external loads of 10, 15, and 20% of body weight (BW) applied to the scapulae to simulate carrying a backpack in the regular way on the back as well as in front of the body and over the shoulder on the concave and convex sides of the scoliotic curve. The predicted muscle activities around the curve apex were higher on the convex side for the erector spinae (ES) and multifidi (MF) muscles, which was comparable to the EMG-based in vivo measurements from the literature. In terms of spinal loading, the implementation of spinal deformity resulted in a 10% increase of compressive force at the curve apex during unloaded upright standing. Apical compressive forces further increased by 50–62% for a simulated 10% BW load and by 77–94% and 103–128% for 15% and 20% BW loads, respectively. Moreover, load-dependent compressive force increases were the lowest in the regular backpack and the highest in the frontpack and convex conditions, with concave side-carrying forces in between. The predictions indicated increased segmental compressive forces during unloaded upright standing, which could be ascribed to the scoliotic deformation. When carrying loads, compressive forces further increased depending on the carrying mode and the weight of the load. These results can be used as a basis for further studies investigating segmental loading in AIS patients during functional activities. Models can thereby be created using the same approach as proposed in this study.
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The possible adverse effects of overloading students' backpacks are a public concern and should be considered by the scientific and educational community. This topic has gained particular importance due to the childhood development process, which can increase the promotion of future disorders ( e.g. , back pain, low back pain, spinal column deviations). In this brief review, we critically analyze the impact of excess load in students' backpacks and attempt to identify solutions that can be useful to minimize the effects of this problem. It is necessary to find a viable alternative to classic backpacks that can contribute to minimizing the effects of backpack loads on children.
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This report was based on a 25-year prospective cohort study and designed as a self-administered questionnaire with low back pain as the main topic. To identify whether radiologic changes in the thoracic and lumbar spine and a history of low back pain in the adolescent period represent risk factors for low back pain in adults. Six-hundred-forty 14-year-old school children were examined with x-rays of the thoracic and lumbar spine and registered by the school doctor regarding a history of low back pain. All of the x-rays and the short journals from the school doctor's registration were reviewed. This primary information was the basis of the investigation 25 years later. Eleven percent of the cohort had a history of low back pain in adolescence, and the results showed an 84% lifetime prevalence of low back pain in these subjects as adults and an increased frequency of low back pain the last month and week before they answered the questionnaire, compared with the rest of the cohort. These problems were associated with increased morbidity and decreased working capacity. Thirteen percent had radiologic abnormalities, mainly Scheuermann changes, in the thoracic and lumbar spine as adolescents, with no positive correlation to low back pain in this period. Unlike other reports, our results did not confirm a positive correlation between x-ray changes in the lower spine in adolescents and a higher prevalence of low back pain in adults. Stepwise logistic regression analyses showed that low back pain in the growth period and familial occurrence of back disease are important risk factors for low back pain later in life, with an observed probability of 88% if both factors are present. This study suggests that low back pain in the growth period is "a real problem," with a trend toward aggravation as time passes. Thus, implementing preventive measures in schools may be very important.