1

Influence of backpack weight on school girls'

balance and musculoskeletal pain

A Thesis Submitted in Partial Fulfillment of the Requirements for the

Master Degree in Physical Therapy

Department of Health Rehabilitation Sciences

College of Applied Medical Sciences

King Saud University

Submitted by
Fadelah Fadel Al Qallaf
1432-2011
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Supervisor
Dr. Amal Hassan Mohammed Ibrahim
Associate Professor of Physical Therapy

Department of Health Rehabilitation Sciences

College of Applied Medical Sciences

King Saud University

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ABSTRACT

BACKGROUND: School age children are in critical stage of their

development. They might be carrying heavy backpacks and they are unable

to voice their concern and problems. That leaves them more exposed to

postural deviations, musculoskeletal problems and balance instability.

OBJECTIVES: The aims of this study were to measure the backpack

weight carried by Saudi school girls, to determine the influences of

backpack loads on ear and shoulder posture level. determine the different

influences of backpack weight on musculoskeletal pain and investigate the

effectiveness of daily load of backpack on dynamic balance and postural

stability. METHODS: A sample of 175 Saudi school girls age between

12-15 years recruited from random five public schools in Riyadh city. A

questionnaire was used to evaluate musculoskeletal problems. Postural

mirror was used to measure the level of the ears and the level of the

shoulders. The balance master machine was used to measure the dynamic

balance in three tests (limits of stability, Step /quick turn, Step up/over).

RESULTS: The questionnaire showed significant number of girls

complain of shoulder (43.43%), neck (32.6%) and back pain (40%), and

majority of girls (87.4%) carried their backpack using a single strap

backpack, who reported that their backpacks were heavy. The results
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revealed that most of the students spend more than 4 hours watching

television and using computer. There is a significant difference in shoulder

level (P<0.000). A significant difference in the balance master variables

with carrying and without backpack was reported. CONCLUSION: The

results of this study concluded that carrying backpack that is 10.08% of

body weight caused girls complain of shoulder, neck and back pain,

induced postural changes and affected their dynamic balance. The

backpack weight percentile is recommended to be reduced to 5% body

weight.

KEY WORDS: Backpack, Musculoskeletal problems, Posture, Dynamic

balance.
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ACKNOWLEDGEMENTS

At the onset I offer my obeisance to ALLAH, the almighty for

all the blessings showered on me, which enabled me to complete this study.

It has been an honor to work under Dr: Amal Hassan

Mohammed Ibrahim, Associate professor, Department of Health

rehabilitation sciences, College of Applied Medical Sciences, King Saud

University. As my guide, supervisor and mentor her dedication, enthusiasm

and constant support contributed in a large measure into completing this

project. No words are enough to convey my gratefulness to her.

I am thankful to my mother, whose silent support during this

period made things that much easier.

I will take this opportunity to emphasis the role played by my

husband. He encourages me to continue my education and his support

during this period both in the course and in the study, psychologically and

academically, help to increase myself believe. This in no small measure

was the defining factor, for which I cannot thank him enough.

My children Ahamad, Lujain, Jury, and Amir deserve a

special mention. This study would not have been completed on time if not

for the sacrifice on their part.

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I thank the Ministry of Education for having given me the

opportunity to conduct the study.

Last but not the least I wish to thank all the children who

participated in the study, their parents and the school authorities for having

cooperated with me during this endeavor.

To the faculty in the department of health rehabilitation

sciences who have been patient and always ready to help.

I will be failing in my duties if I do not thank my friends and

colleagues who stood by me and helped me in various ways during this

period.

Fadelah AlQallaf
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TABLE OF CONTENTS

ABSTRACT II
ACKNOWLEDGENTS IV
TABLE OF CONTENTS VI
LISTS OF TABLES XI
LIST OF FIGUERS XIII
LIST OF ABBREVIATIONS XV

CHAPTER I

1. INTRODUCTION 2
1.1. INTRODUCTION ............................................................................ 2

1.2. STATEMENT OF PROBLEM ......................................................... 4

1.3. PUROSES OF THE STUDY ............................................................ 5

1.4. SIGNIFICANCE OF THE STUDY .................................................. 6

1.5. HYPOTHESIS ................................................................................. 8

1.6. VARIABLES ................................................................................... 9

CHAPTER II

2. REVIEW OF LITERATURES 10
2.1. BACKPACK LOAD ...................................................................... 10

2.2. BACKPACK LOAD AND MUSCULOSKELETAL PROBLEMS 17

2.2.1. BACKPACK LOAD AND BACKPAIN .................................. 18

2.2.2. BACKPACK LOAD AND SHOULDER PAIN ....................... 25

2.2.3. BACKPACK LOAD AND OTHER MUSCULOSKELETAL

INJURIES ............................................................................................ 28

2.2.4. BACKPACK TYPE AND MUSCULOSKELETAL INJURIES30

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2.2.5. BACKPACK WAY OF CARRYING AND

MUSCULOSKELETAL INJURIES .................................................... 33

2.2.6. BACKPACK POSITION AND MUSCULOSKELETAL

INJURIES ............................................................................................ 36
2.3. BACKPACK LOAD AND POSTURE 37

2.3.1. BACKPACK LAOD AND SHOULDER POSTURE .............. 40

2.3.2. STUDIES USED EMG TO TEST POSTURE ......................... 43

2.3.3. BACKPACK LOAD AND PRESSURE UNDERNEATH

SHOULDER STRAPS ......................................................................... 45

2.3.4. BACKPACK LOAD EFFECT ON STATIC AND DYNAMIC

POSTURE ........................................................................................... 46

2.4. BACKPACK LOAD AND PHYSIOLOGICAL CHANGES ............ 53

2.5. BACKPACK LOAD AND MUSCLES FATIGUE ........................... 57

2.6. BACKPACK LOAD AND BALANCE ............................................ 59

2.6.1. BACKPACK LOAD, FATIGUE AND BALANCE ............... 66

2.6.2. BACKPACK LOAD , GAIT AND BALANCE...................... 67

CHAPTER III

3. MATERIAL AND METHOD 75

3.1. SUBJECTS ..................................................................................... 75

3.2. ETHICAL APPROVAL ................................................................. 77

3.3. PROCEDURES .............................................................................. 78

3.3.1. STUDY DESIGN ...................................................................... 78

3.3.2. INSTRUMENTS ....................................................................... 78

3.4. PROCEDURE OF DATA COLLECTION ..................................... 93

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3.4.1. PILOT STUDY ........................................................................ 93

3.4.2. SELECTION AND PREPARATION OF SCHOOLS .............. 94

3.4.3. COLLECTION OF SAMPLE .................................................. 94

3.4.4. PROCEDURE OF DATA COLLECTION ............................... 95

3.4.4.1. QUESTIONNAIRE DATA COLLECTION ..................... 96

3.4.4.2. DEMOGRAPHIC DATA COLLECTION ........................ 96

3.4.4.3. POSTURAL MIRROR DATA COLLECTION ................ 98

3.4.4.4. BALANCE MASTER DATA COLLECTION ............... 101

3.5. DATA ANALYSIS ...................................................................... 106

CHAPTER IV

4. RESULTS 108

CHAPTER V

5. DISCUSSION 134
5.1. BACKPACK LOAD .................................................................... 134

5.1.1. WEIGHT OF THE BACKPACK ........................................... 134

5.1.2. BACKPACK WEIGHT AS A PERCENTAGE OF BODY

WEIGHT ........................................................................................... 137

5.2. WAY OF CARRYING ................................................................. 141

5.3. BACKPACK DESIGN ................................................................. 142

5.4. BACKPACK LOAD AND MUSCULOSKELETAL PROBLEMS143

5.4.1. LOCATION OF PAI N .......................................................... 145

5.4.2. PAIN WHILE CARRYING BACKPACK ............................. 147

5.4.3. FREQUENCY OF PAIN ........................................................ 148

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5.4.4. INTENSITY OF PAIN ........................................................... 149

5.4.5. WAY OF CARRYING AND USE OF BACKPACK ............. 149

5.4.6. DIFFICULT ACTIVITIES ..................................................... 150

5.4.7. PERCEPTION OF BACKPACK ........................................... 150

5.4.8. TIME CARRYING BACKPACK .......................................... 152

5.4.6. PHYSICAL ACTIVITY ......................................................... 155

5.5. POSTURE .................................................................................... 158

5.5.1. BACKPACK WEIGHT AND LEVEL OF EAR .................... 159

5.5.2. BACKPACK WEIGHT AND LEVEL OF SHOULDERS ..... 159

5.6. BALANCE .................................................................................... 165

5.6.1. LIMITS OF STABILITY ....................................................... 165

5.6.2. STEP/QUICK TURN ............................................................. 173

5.6.3. STEP UP/OVER .................................................................... 177

CHAPTER VI

6. SUMMERY, CONCLUSION AND RECOMMENDATION 185

6.1. SUMMERY.................................................................................. 185

6.2. CONCLUSION ............................................................................ 187

6.3. RECOMMENDATIONS .............................................................. 188

6.4. RECOMMENDATIONS FOR FURTHER STUDIES ................. 202

6.5. LIMITATIONS OF THE STUDY ................................................ 203

REFERNCES 205
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APPENDICES

APPENDIX I. CONSENT FORM ........................................................ 229

APPENDIX II. INFORMATIONS SHEET .......................................... 231

APPENDIX III. QUESTIONNAIRE .................................................... 233

APPENDIX II. ASSESSMENT SHEET .............................................. 240

ARABIC SUMMERY .......................................................................... 241

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LIST OF TABLES

Table 1 Recruitment of the sample 76

Table 2 The descriptive statistics of the demographic variables 108

Table 3 Frequency distribution of subjects regarding the 110

grade, age, way of carrying and period variables
Table 4 One way AOVA test of backpack load regarding the 111
age, grade, and way of carrying
Table 5 Least significant differences in mean (Post Hoc) test 112
of assessing the differences in mean backpack weight
and age
Table 6 Least significant differences test of assessing the 113
differences in mean way of carrying and body weight
Table 7 Pearson correlation coefficients backpack load and 113
other variables
Table 8 Questions about back, neck and shoulder pain location. 115

Table 9 Questions about back, neck and shoulder pain 117

intensity, duration, and frequency.

Table 10 Questions about the frequency of backpack use, 119

perception and way of carrying

Table 11 Questions about difficult activities during carrying 120

backpack

Table 12 Questions about the frequency of backpack use, and 121

use of additional bag
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Table 13 The frequency of time spent in watching television or 122

using computer

Table 14 Paired t-test for the mean difference of the right and 123
left level of ear and shoulder

Table 15 Limit of stability test of girls without and with carrying 124
different backpack percentile.
Table 16 Paired Samples t-Test of limit of stability without and 125
with carrying backpack
Table 17 Step/quick turn of girls without and with carrying 128
different backpack percentile.
Table 18 Paired Samples Test of step/ quick turn test. 129

Table 19 Step up /over of girls without and with carrying 132

different backpack percentile.
Table 20 Paired Samples Test for Step up/ over test without and 133
with carrying backpack.
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LIST OF FIGUERS

Figure 1 Visual analog scale and happy face-sad face pain 79

scale

Figure 2 Body Diagram 80

Figure 3 Postural Mirror 81

Figure 4 Digital weighting scale 82

Figure 5 Balance Master Machine 83

Figure 6 The electronic walkway 84

Figure 7 The monitor 84

Figure 8 Limits of stability results 87

Figure 9 Step quick turn results 89

Figure 10 Step up over result 92

Figure 11 Body mass index (BMI) calculations 98

Figure 12 Standing in front of mirror 99

Figure 13 Measurement of Shoulder Level 100

Figure 14 Measurement of Ear Level 100

Figure 15 Dynamic balance tests. 102

Figure 16 Placement of the step on the force plate 105

Figure 17 The backpack percentile according to the girls 111

age.
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Figure 18 The reaction time and maximum velocity without 126

and with backpack.

Figure 19 The mean of endpoint excursion, maximum 127

excursion, and directional control without and with
carrying backpack.

Figure 20 The mean of Turn time (left foot) without and 130
with carrying backpack

Figure 21 The mean of Turn time (right foot) without and 130
with carrying backpack

Figure 22 The mean of Turn sway (right foot) without and 131
with carrying backpack
Figure 23 Way of carrying 143

Figure 24 Changing in the level of shoulders 162

Figure 25 Carrying backpack 198

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LIST OF ABBERVIATIONS

AAOS American Academy of Orthopedic Surgeon

ACA American Chiropractic Association

AIS Adolescent Idiopathic Scoliosis

AOTA American occupational Therapy Association

AP Antro-Posterior

APTA American Physical Therapy Association

BMI Body Mass Index

BOS Base of Support

BP Back Pack

BW Body Weight

CCA Cranio-Cervical Angle

CD Compact Desk

CD ROM Compact Desk Read Only Memory

CHA Cranio-Horizontal Angle

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CNS Central Nervous System

Cm Centimeters

COG Center Of Gravity

COM Center Of Mass

COP Center Of Pressure

CP Cervical Pain

CVA Cranio Vertebral Angle

DCL Directional Control

DP Dorsal Pain (Thoracic)

Ear L Ear Level

EMG Electromyography

EPE End Point Excursion

FEF Forced Expiratory Flow

FEV Forced Expiratory Volume

FVC Forced Vital Capacity

HNA Head on Neck Angle

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HNTA Head and Neck on Trunk Angle

HR Heat Rate

HT Trunk Angle

ICC Interclass Correlation Coefficient

ICPA International Chiropractic Pediatric Association

II Impact Index

Kg Kilogram

L Level

L3, L5 Lumber 3, Lumber 5

LBP Low Back Pain

LLT Lower Limb Angle

LOS Limit Of Stability

LT Lower Trapezius

LUI Lift Up Index

M Meter

Max. Maximum
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Min. Minutes

Mini. Minimum

MT Movement Time

MVL Movement Velocity

MXE Maximum Excursion

NASN The National Association of School Nurse

PEF Peak Expiratory Flow Rate

R Right

RA Rectus Abdominis

RR Respiratory Rate

RT Reaction Time

S1 Sacral 1

SD Standard Deviation

Shou. L Shoulder Level

Sig. Significant

SPSS Statistical Package for Social Sciences

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SQT Step/Quick Turn

SSP Sagittal Shoulder Posture

SUO Step Up/Over

t Paired t Test

T7 Thoracic 7

TT Turn Time

TS Turn Sway

TV Television

UT Upper Trapezius

VAS Visual Analogue Pain Scale

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CHAPTER I

INTRODUCTION
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INTRODUCTION

1.1. INTRODUCTION

Backpacks have become the common mode of transporting books

and school supplies for school aged children from kindergarten to the

college. Each school year millions of children walk to, from and around

school carrying backpacks filled with books and materials. Using a

backpack allows a person to carry more items than would be possible by

the arms and hands alone. The risk, however, is overload, which can strain

the back, neck or shoulders (Barbara et al. 2008; Brent et al. 2003; Triano

2000).

Recently there has been growing concern among health care

professionals, parents, and educators regarding the weight of children's

school bags and the negative consequences of such loads on the developing

spine. There is particular attention for the junior students in secondary

schools, as spine is at a critical stage of development in children between

12-14 years of age. This also the stage at which the bag weight to BW ratio

is likely to be high as some students are still quite small but carry loads

similar to larger and older children (Dockrell et al. 2006). Since the use of

backpack begin at a very young age and continue until adulthood, the high
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loads carried over a number of years may have an effect on the growing

body (Palumbo et al. 2001).

Despite the lack of scientific evidence on the short or long term

effects of backpacks on adolescents, guidelines to limits the weight of the

backpack have been proposed by many associations and organizations,

Recommended weight limits of 5-20% of the bodyweight (BW) including

the American Academy of Orthopedic Surgeons (AAOS) which state that

backpack could cause a clinical problem when the contents weigh 20%

more than the child's BW (American Academy of Orthopedic Surgeons

Bulletin 1999; Wiersema et al. 2003).

Human upright posture is inherently unstable and is maintained by

continuous response to integrate sensory information from the visual,

proprioceptive and vestibular systems (Peterka & Loughlin 2004). Factors

which have an impact on any of these sensory systems or the feedback

mechanism may affect stance stability and balance (Yamada et al. 1984). It

is very important to diagnose postural deviations between the age of seven

and fourteen years, not only because the child is susceptible to

modifications of the bone system but also because poor posture and poor

bone formation are more easily corrected at this stage of life. It has been

reported that postural deviations adopted by children at home and at school

cause body musculature imbalance and postural abnormalities which may

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last throughout their life and cause painful symptoms if it not corrected

(Chansirinukor et al. 2001; Pascoe et al. 1997).

As the back will compensate for any load applied to it for an

extended period of time. A heavy weight carried in backpacks can cause a

person to lean forward, reducing balance and making it easier to fall, distort

the natural curves in the middle and lower backs, causing muscle strain and

irritation to the spine joints and the rib cage and cause rounding of the

shoulders. This type of muscle imbalance can cause muscle spasm and

back pain in the short term and speed the development of back problems

later in life if not corrected. The weight can also pull on the neck muscles,

contributing to headache, neck pain and arm pain. Change in posture

caused disturbance of the center of gravity (COG) (Brent et al. 2003; Karp

2000; Pascoe et al. 1997; Triano 2000). In addition to injuries from the

trauma associated with falls that may be related to backpack use, the added

load will contribute to, and can result in, changes in posture. These changes

in posture can be associated with muscle activity patterns and forces not

found when one stands without a backpack. Muscle activation may increase

in amplitude in the spinal and extremity muscles resulting in altered

recruitment patterns, the expenditure of additional energy to meet a higher

metabolic need and greater compressive forces on the joint surfaces (Goh et

al. 1998).
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As an alteration in the center of gravity will result in an

accompanying change in the relationship of the center of gravity to the base

of support, it has the potential to change postural stability. Students

carrying their books and supplies in their backpacks encounter stairs on

buses or in school walk on multiple may have to lift the loaded bag into a

locker and often bend over to pick up fallen objects with the backpack on.

Performing these activities with an altered center of gravity or one that may

suddenly change as items in the backpack shift may result in slips or falls

(Hong & Li 2005).

In fact not only the load of backpack caused problems but the

combined effects of heavy loads, position of the load on the body, size and

shape of the load, load distribution, time spent carrying, physical

characteristics and physical condition of the individual were associated

with these problems (Haisman 1988).

1.2. STATEMENTS OF THE PROBLEM

1- What are the different backpack weights carried by the Saudi

schoolgirls aged 12 to 15 years?

2- What are the different effects of backpack weight on ear and

shoulder level posture of Saudi schoolgirls aged 12-15 years?

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3- What are the different influences of backpack weight on

musculoskeletal pain of Saudi schoolgirls aged 12-15 years?

4- What are the different effects of backpack weight on dynamic

balance and postural stability of Saudi schoolgirls aged 12-15 years?

1.3. PURPOSES OF THE STUDY

The goals of this study are to:

1- Measure the backpack weight carried by Saudi schoolgirls aged 12-

15 years.

2- Determine the different influences of backpack loads on ear and

shoulder level posture of Saudi schoolgirls aged 12-15 years.

3- Determine the different influences of backpack weight on

musculoskeletal pain of Saudi schoolgirls aged 12-15 years?

4- Investigate the effectiveness of daily load of backpack used by

Saudi schoolgirls aged 12-15 years on dynamic balance and postural

stability.
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1.4. SIGNIFICANCE OF THE STUDY

Backpack used by school children is considered as an appropriate

way for carrying books and other school materials. Several studies have

investigated the weight of school backpack and showed that the average

loads vary greatly between studies either the variation is due to region, day

of the week or curriculum (Grimmer & Williams 1999; Negrini &

Carabalona 2002; Whittfield et al. 2001). The importance of establishing

safe load carriage limits is to find preventive measures to reduce the

injuries associated with backpack load.

Postural abnormalities are often found in children. At the pre-

pubertal phase and puberty stage of life, the posture undergoes many

adjustments and adaptations due to changes in the body proportions. These

changes may be due to differences in bone and muscle tissue growth rate

(Penha et al. 2009). Repeated carrying, lifting and manipulating a heavy

backpack might alter the children's normal posture in a wide spectrum

starting with simple muscles strain of their necks, shoulders and backs,

extended to the other extreme of posture deviations like kyphosis, lordosis

or scoliosis (Whittfield et al. 2005). Factors that influence these alterations,

such as the effect of the type, weight, position of the backpack and the way

of carrying must be investigated to determine if concern for potential

adverse health effects from backpack weight is warranted.

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The human body in the upright posture is not normally stable. Small

deviations from a perfect upright body position result in a gravity induced

torque acting on the body, causing it to accelerate further away from

upright position. As the child carries the backpack, the weight of the

backpack will force the child to lean forward and this alters the standing

posture which eventually disturbs the standing (static) balance and when

the child walks, he/she needs more effort to carry the backpack and to

maintain the (dynamic) balance in the same time, from this prospective

increase in the weight of the backpack will increase the demand to maintain

the posture and therefore the balance during standing still or walking

(Peterka & Loughlin 2004).

The growth peak of school children and adolescents who experience

a cease of the appendicular skeletal system is around the 16 years of age for

females and 18 years for males (lanes et al. 1995; Ibrahim & Abd el Azeem

2002). Their spinal structures are markedly different from those of adults,

as growth of spinal structures extends over a longer period of time than the

other skeletal tissues (Mohan et al. 2007). Consequently posture in

adolescents can be affected by both internal and external influences, which

may make adolescent more susceptible to musculoskeletal injury.

Although the health professionals represent the carriage load of the

backpack by school children could be a problem that cause disturbance in

the static and dynamic balance. This alteration in balance could be

 30

contribute to misalignment of the trunk, head and shoulders and might

eventually cause spinal deformities. Till now the scientific health

community is still having a little knowledge about the consequences of

postural stability, balance alteration and musculoskeletal problems resulted

from backpack carriage.

In addition; A lot of Saudi families drive their children to school so

children's does not need to walk long distance with their school backpacks

but most of the schools are multi stores build and children need to carry

their backpacks to move from place to place and up and down stairs, from

this fact the dynamic balance will be tested for up and down stair.

Therefore; we have to justify and highlight these problems working

together with Ministry of Education, principles, teachers and parents trying

to find suitable and applicable solutions. Help to create preventive

programs to reduce the risk of postural instability, postural changes, and

musculoskeletal injuries in schoolgirls who used backpack inappropriately.

1.5. HYPOTHESES

It was hypothezed that:

1- That the load of the backpack will be within the recommended range

of 10% BW.
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2- The load of the backpack has no effect on the ear or shoulder levels

in Saudi schoolgirls aged 12-15 years.

3- The load of the backpack has no effect on the musculoskeletal pain of

Saudi schoolgirls aged 12-15 years.

4- The load of the backpack has no effect on the dynamic balance or

postural stability of Saudi schoolgirls aged 12-15 years.

1.6. VARIABLES

The load of the backpack.

The level of ear and shoulder posture.

The musculoskeletal pain or discomfort in different body areas.

Dynamic balance and postural stability.

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CHAPTER II

REVIEW OF LITRATURE
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2. REVIEW OF LITERATURES

Every school day, children are carrying their belongings in backpack

to, from, and around the school from very young age and continue until

adulthood. This means that these young children are subjected to long

period of time to backpack load which may lead to musculoskeletal

problems. Students, parents, teachers, school administrators, and health

care specialists are highly concerned about childrens health and safety

with their backpack load.

2.1. BACKPACK LOAD

Various professional associations have looked at this phenomenon

and established guideline weight limits for backpacks as a percentage of a

childs BW. These guidelines fall in the range of 5% to 20% of BW.

According to American Chiropractic Association (ACA) (2004), the weight

of a backpack should be limited between 5 - 10% of BW. American

Physical Therapy Association (APTA) (2009) guideline suggests that the

backpack should not exceed 10 to 15% of child BW. According to the

American occupational Therapy Association (AOTA) (2009) and the

International Chiropractic Pediatric Association (ICPA) (2008) the weight

 34

of backpack should not exceed 15% of a child's BW. The National

Association of School Nurse (NASN) (2006) has also developed guideline

suggested that no more than 20% of BW be carried by school children.

Some researchers found that the load of the backpacks was below or

within the recommended limit and others found the backpack weight

exceed this limits. Forjuoh et al. (2003), conducted a cross sectional study

in three elementary schools in central Texas on 745 students. They quantify

the weight of backpacks and percentage of BW. They found that for all

schools, the mean backpack weight was 2.6 kg but the weight increased

significantly with increasing grade level from 6.2% among those in

kindergarten to 12.0% among fifth graders, varied significantly by

race/ethnicity, by schools and by type of backpack carried. Although, girls

carried heavier backpacks than boys, overall, the backpack loads

represented an average of 8.2% of student BWs, 26% of the students

carried a backpack that weighed at least 10% of their BWs, including 2.4%

who carried a backpack that weighed at least 20% of their BWs.

A Study investigated the weight of schoolbags and the effects of

schoolbag carriage on first year secondary school students with mean age

of 13.1 years. They found that schoolbag weight ranged from 1.6 - 11.3kg

over the 5 days, and weekly mean equal to 6.2kg. The mean schoolbag

weight as a percentage of mean BW carried by the students was 12% and

ranged from 3%-30% BW. The boys carried heavier schoolbags than girls.
 35

The majority of the schoolbags (68%) weighing more than the proposed

approximate guideline of 10% BW (Dockrell et al. 2006).

Goodgold et al. (2002) assessed school bag use, way of carrying, and

students perceptions of bag weight and comfort while wearing the bag and

past history of back pain of 345 students aged 11-14 years. They found that

more than half of the students 57.1% perceived their bag to be of medium

or medium-heavy weight, and the remainder of students 37.1% responded

that their bag were heavy, 55% of all subjects carried a load greater than

15% of their BW. Younger children carried proportionally greater

backpack loads.

Forjuoh et al. (2004) studied the demographic and other correlates of

carrying backpacks that weigh at least 10% BW in 713 elementary students

from three schools in central Texas, and found that 26% of students used a

heavy backpack that weighed at least 10% of their BW, with a mean weight

of 4.9 kg .These heavy backpacks represented an average of 14.4% of

student BW. Backpack weights of the remaining 525 students represented

an average of 5.9% of student BW. Heavy backpack use was significantly

associated with age as the older students carry heavier backpacks. Students

with wheeled backpacks were 14 times more likely to carry heavy loads

than those who used backpacks without wheels. And no association was

found between heavy backpack use and race, gender or BMI.

 36

Research data gathered by numerous researchers suggest that

children are wearing backpack loads that may be too heavy. Korovessis et

al. (2005) examined 1263 students from seven schools and found that the

weight of backpacks represented 10.6 3.5% of the students BW.

Whitfield et al. (2005) reported that the mean of schoolbag weight was

11.7% BW, and mean weight of 6.6kg. They found that the third grade

carry heavier schoolbag than sixth grader students. Limon et al. (2004)

studied 10,000 children in elementary schools, using a questionnaire. They

found that more than half of the students (54%) in the lower grades and

nearly one third (30%) of those in the upper grades were carrying backpack

more than 15% of their BW.

The weight of the backpack and the percentage to the BW were

measured by Cavallo et al. (2003) for 39 fourth graders students' age

between 9 and 10 years old participated in the study. They found that the

students carry mean backpack weight of 3.90 Kg, and the backpack weight

percentage to BW was more than 10% BW. The average load and the

maximum load of the backpack were calculated over a period of 3 weeks

for 237 Italian students aged 11.6 years old. The result showed that the

average load carried daily by schoolchildren was 9.3 Kg (22.0%), and

34.8% of the pupils carried more than 30% of their BW at least once during

the week (Negrini et al. 1999). Ren et al. (2005) found that 44% of the
 37

student were carrying backpack weigh greater than 15% of their BW, and

found that the 7th grade carried over 15% of their BW than 6th grade.

The results obtained from Mohan et al. (2007) revealed that most of

Indian children in the group age of 10-15 years carried school bag

weighing between 10%-18% of their BW. The mean value of weight of the

school bag carried by children was 6.1Kg (17.5% of their BW). With a

sample of 61 students Pascoe et al. (1997), found that the students routinely

transport book in bags weighted 1.8-10.9 Kg with mean of 7.7 Kg,

equivalent to17% of their BW. Negrini and Negrini (2007) found that most

of the 12 year old schoolchildren in their study population carried average

school bags weight 22% of their BW. The average of the week load was

ranged between 21.8% and 27.3% of the BW.

The mean bag weight measured by Murphy et al. was just over 3

kg and the maximum was 9.35 kg. The bag weight expressed as percentage

of bodyweight ranged from 7% to 21% of BW (Murphy et al. 2007).

Navuluri and Navuluri (2006) found about 37% of the boys and 34% of

the girls were carrying backpacks that relatively weighed equal or more

than 15% of their BW. However, 7.4% of the boys and 15.6% of the girls

in the study were carrying backpacks weighing equal or more than 25% of

their BW.
 38

Watson et al. (2003) recorded the average load of five days bag

weight diary of 1446 students with age between 11 to 14 years was 4.5 kg.

The individual five day average loads ranged from 1.2 kg to 18 kg with

almost three quarters of students carried loads between 2 and 6 kg.

Negrini and Carabalona (2002) found the average loads in the three schools

they studied were 8.57, 9.17, and 9.46 kg, respectively. Within the three

schools, statistically significant differences were found in the average loads

between classes and between days of the week. Within each class,

statistically significant differences were found between the average loads

carried by the pupils on different days of the school week.

In Saudi Arabia, the extent of this problem is not yet investigated

except two papers, a study by Ibrahim (in press) conducted in an

international private school on 254 Egyptian schoolgirls, age between 6 to

14 years. The subjects divided into two groups, group A age (6- 10years)

and group B age (11-14 years). The result revealed that the percentage of

backpack weight to the student's BW ranged from 13% to 50% for group A

and from 6.6% to 41.7% for group B. Which is significantly high for both

groups, both groups exceed the recommended limit of 10%. Another study

by (Al Hazzaa 2006), who studied how much load do Saudi school boys

carry on their shoulders and to identify the methods of carrying book bags

by elementary school in Riyadh city, this study was conducted on 702 boys

aged 6-14 years, chosen from five schools randomly. The full School bag
 39

with the daily load of books and school supplies was weighed. The result

revealed that the maximal weight recorded for school bag was 7.5 kg, with

average BP percentage of 10.7% and maximum of 28.7% BW. Nearly half

of students (49%) were carrying bags weighting more than 10% BW, while

18% of the students carried bags weighting more than 15% of their BW.

Mohan et al. (2007) suggested that carrying school bag weighing 10%

of BW would be too heavy for students aged 10-14 years to be able to

maintain their normal postural alignment. In other words carrying a load of

less than 10% of BW school bag is recommended to maintain good

postural alignment. While Hong et al. (2008) suggested that backpack loads

for children should be restricted to no more than 15% BW.

From the previous studies we can say that there is no evidence for

backpack weight limitations. A variety of factors have led to heavier

backpack loads, for example, a schools in the United States strive to raise

academic performance, children are assigned more homework. Also, to

allocate greater time for academic studies at school, and many schools have

decreased time between classes, which in turn affects locker use.

Overcrowding may also affect locker availability, and some schools have

banned locker use as a violence prevention strategy. In addition, textbooks

are often hardcover and in many cases heavier than they were a decade ago.

Furthermore, children participating in after-school activities, such as sports

 40

and music, carry additional equipment, clothing, and instruments. This

translates into children carrying greater loads of books and school supplies

(Goodgold et al. 2002). Some researchers found that the weight of the

backpack varies greatly according to the region, classes and day of the

week (Singh and Koh 2009). Adding to these; the researchers reported that

they cannot know exactly which students carry heavy backpacks;

backpacks weight in excess of 10% of BW are considered the least safe

(Grimmer et al. 1999; Grimmer et al. 2002).

2.2. BACKPACK LOAD AND MUSCULOSKELETAL

PROBLEMS

Weight of the backpack is one of numerous contributing factors

related to musculoskeletal discomfort among school age students. In

additional to the weight of the backpack, duration and frequency of

carriage and the manner in which the weight is carried all affect the

demands on the musculoskeletal system and may affect the incidence of

musculoskeletal pain or discomfort. Currently, school aged children are

reporting lower back, shoulder and neck pain (Lockhart et al. 2004; Mackie

et al. 2003).
 41

2.2.1. BACKPACK LOAD AND BACK PAIN

Back pain is a widespread musculoskeletal condition in the adult

population. This problem has stretched into the younger age groups and

become a condition often experienced by adolescents (Brackley and

Stevenson 2004). Back problems are usually caused by cumulative trauma,

which results from continues postures or repetitive tasks, such as lifting or

sitting. Many back injuries are occupational in nature and are associated

with repetitive bending and lifting. These positions slowly weaken and

stiffen structures of the spine, which can cause injury in the future (Cavallo

et al. 2003).

Back pain is the most frequent musculoskeletal problem found in the

review of the literature among school students. Goodgold et al. (2002)

found that one third of subjects 32.5% reported a history of back pain, as

indicated by answering yes to having had to miss school, abstain from

play or sports, or see a physician for back pain. Korovessis et al. (2004)

reported that (21%) of participants had low back pain (LBP) and (21.4%)

dorsal pain (DP) during backpack carrying. Girls reported significantly

more LBP than boys. Sixteen percent of the boys and 46.7% of the girls

reported LBP during backpack carrying and, 62.6% of the girls and 23.8%

of the boys reported DP. While Students age, height, and BW as well as
 42

magnitude of kyphosis, lordosis, and scoliosis did not correlate with either

LBP or DP. Girls reported significantly more LBP than boys.

The rates of musculoskeletal disorders among 679 students

recruited from 12 schools, age range between 11 to 14 years was reported

by Murphy et al. (2007). They used self-report questionnaire sought

information on demographic characteristics, back pain history, school and

leisure activities, school bag and furniture, common childhood complaints

and psychological factors. A body map question used to indicate if they

experienced pain in each region of the body during the last month. They

asked respondents how long the pain lasted and the intensity of the pain

using visual analogue pain scale VAS. The result revealed that 27 % of

children reported having neck pain, 18% reported having upper back pain,

and 22% reported having low back pain. Twenty two percent of the

younger children had experienced low back pain ever and 32% of the

older children had experienced low back pain ever. Upper back pain

was associated with school bag weight (3.44.45 kg), school furniture

features, emotional problems and previous treatment for musculoskeletal

disorders. Low back pain was associated with school furniture features,

emotional problems, family history and previous injury or accident.

A questionnaire was used by Watson et al. (2002) to assess low

back pain prevalence, symptom characteristics, associated disability and

health seeking behavior of school students. The questionnaire completed by

 43

1446 children aged 1114 years in England. An additional self-complete

questionnaire amongst parents sought to validate pain reporting. The result

revealed that the one month period prevalence of low back pain was 24%.

It was higher in girls than boys and increased with age in both sexes and of

those reporting low back pain, 94% experienced some disability. The

activities which gave the most difficulty were carrying a school bag (65%),

sitting at school (53%) and sports activities (50%). Goodgold et al. (2002)

found that one third of students reported a history of back pain, and

percentage of BW carried was not significantly related to history of back

pain. Another report by Pascoe et al. (1997) used a questionnaire answered

by 61 students, aged 11-13 years. They found that the most commonly

reported physical symptoms were muscles soreness (67.2%), followed by

back pain (50.8%), numbness (24.5%) and shoulder pain (14.7%). While

Wall et al. (2003) Found that out of 346 students only one child attributed

back pain to wearing a backpack, and three students stated that their back

pain was made worse by carrying their backpack.

Some studies found that there is no relationship between the back

pack load and the musculoskeletal pain. A short history taken from the

students including anthropometric data, sport activities, mode of

transportation to and from the school, and duration of transport from home

to school and back. All students were additionally asked to answer several

questions regarding current back pain and localization either in the cervical
 44

pain (CP), dorsal pain (DP) or lumbar back pain (LBP) region, pain

intensity while backpack carrying to and from the school, as well as pain in

the holidays. The quantification of pain was made with the use of the

Visual Analogue pain Scale (VAS). The result showed that (16%) students

who went to school on foot and (22%) who went by car reported DP. Eight

percent of the students who went to the school on foot and (13%)

transported by car reported LBP. The time spent with backpacks during

transportation from and to school was 29 to 33 minutes, and there was no

statistically significant correlation between DP, LBP, and percentage of

backpack weight in relation to BW (Korovessis et al. 2005).

A study by Negrini and Carabalona (2002) was conducted on 237

students in 6th grade in Italy from three schools. The school bags were

weighed on six school days over a period of three weeks. A subgroup of

115 schoolchildren were asked to fill a questionnaire includes questions

about transportation, perception about backpack, way of carrying, fatigue

and back pain due to carrying backpack. The result showed that Backpacks

were carried on both shoulders by 94.5% of the children for 5 to 15 minutes

(48.2%) and more (37.3%). School backpacks are felt to be heavy by

79.1% of children, to cause fatigue by 65.7%, and to cause back pain by

46.1%. Fatigue during and time spent carrying backpack, but not the

backpacks weight, are associated with back pain. Back pain was clearly

associated with fatigue during backpack carrying, but not with feeling that
 45

the backpack was heavy, whereas life prevalence of back pain was

associated with the time spent bearing backpacks on the shoulders.

Relationship between low back pain and carrying school bag was

studied by Skoffer (2007) who recruited 546 of ninths grade students

between 14-16 years from 14 public schools. Participants answered a

questionnaire on LBP occurrence during the previous 3 months including

the intensity and duration of LBP and pain coping behavior e.g., reduced

daily activity, disturbed sleep at night, or care seeking. The questionnaire

included questions about furniture used at school and at home and

adjustment potentials; the daily transport of the school bag; physical

activity during school and leisure hours; vocational activity and smoking.

The result showed that one or more episodes of LBP in lifetime were

reported by 64.8%, and 60.3% and 51.3% reported LBP during the

preceding 12 and 3 months, respectively. Nearly one fourth (24.2%)

reported LBP during the preceding 3 months to such a degree, that it had

resulted in reduced level of function, disturbed sleep at night, or care

seeking. Out of 546 respondents, 5.9% had contacted their general

practitioner, 0.7% was referred to an outpatient clinic, and 1.1% had

consulted a medical specialist, 2.7% a physiotherapist, 1.3% a chiropractor,

and 3.7% another type of therapist. Only 0.4% had been hospitalized. The

weight of the school bag was not associated with LBP, but carrying the
 46

school bag on one shoulder was positively associated with LBP and

function-limiting.

While other studies found the back pain was associated with carrying

heavy backpacks, Navuluri and Navuluri (2006) used a questionnaire to

assess backpack use and neck and back pain in seventh and eighth graders.

The questionnaire answered by 61 students, 32 girls and 29 boys. The

result revealed that a higher percentage of girls (62%) compared to boys

(44%) rated their neck and back pains. A higher proportion of both boys

(67%) and girls (65%) reported that their pain lasted less than 24 hours than

those who reported pain lasting 214 days. None in the study reported pain

that lasted more than 14 days. A significant relationship was found between

pain and backpack weight. Skaggs et al. (2006) conducted their study on

1540 children from three middle schools ages 11 to 14 years. They asked to

complete a modified questionnaire and backpack evaluation. The

questionnaire was designed to determine frequency of backpack use,

preferred method of backpack carriage, presence and severity of back pain,

resulting activity limitations, use of pain medication, and whether the child

felt the pain was related to backpack use. They found there were 45

children with a positive school screening for scoliosis. Overall, back pain

was more common in girls, with 43 % of girls reporting back pain

compared with 32% of boys and there was a significant association

 47

between the weight of the backpack and the likelihood of reporting back

pain.

Seventh and eighth grade students aged 11 to 15 years were

participated in a study, to answer a questionnaire identify the prevalence,

chronicity, severity, and frequency of back pain. The result showed that

over 64% of the students reported having back pain at some time, 41.3%

felt this pain when carrying their backpack, and almost all of them reported

feeling relief upon taking off their backpack. Eighty seven percent of

students reported that their pain was bad or very bad by (Siambanes et

al. 2004).

Sheir-Neiss et al. (2003) examined the relation between backpack

use and back pain in adolescents. A total of 1126 children, aged 12 to 18

years, completed a questionnaire about backpack use activities and their

health. The result revealed that 74.4% of children were classified as having

back pain, validated by significantly poorer general health, more limited

physical function, and more bodily pain. As compared with no or low use

of backpacks at school, heavy use of backpack was independently

associated with back pain. Female gender and larger body mass index also

were significantly associated with back pain. As compared with

adolescents who had no back pain. Adolescents with back pain carried

significantly heavier backpacks that represented a significant greater

percentage of their BWs.

 48

A self reported questionnaire was completed by 1446 schoolchildren

age between 11 to 14 years. Complete and a five days bag weight diary.

The results revealed that the mechanical factors such as physical activity

and school bag weight were not associated with low back pain and found

strong association with low back pain observed for emotional problems.

The psychological factors rather than mechanical factors are more

important in low back pain occurring in young population and could

possibly be a reflection of distress in school children and have a marked

impact on daily life although it is unlikely to lead them to seek health care

(Watson et al. 2003).

2.2.2. BACKPACK LAOD AND SHOULDER PAIN

Through the literature review the shoulder pain was the second

highest musculoskeletal compliant in children. Orthopedic surgeons report

that 58% of shoulder and back pain in children is caused by heavy

backpacks (American Academy of Orthopaedic Surgeons 1999).

The weight of schoolbags and the prevalence of musculoskeletal

symptoms were investigated among 140 secondary students (third grade

through sixth grade) from five New Zealand schools (Whittfield et al.

2005) They answered a questionnaire about experience of musculoskeletal

symptoms; a body map was used to record the prevalence of

 49

musculoskeletal symptoms. Most of students (77.1%) reported some type

of musculoskeletal symptom during the week preceding data collection,

which may be attributable to schoolbag carriage. The prevalence of

shoulder and upper back pain symptoms were 57.9% and 36.4%

respectively. The third former females recorded the highest prevalence of

musculoskeletal symptoms than males and that the third form students

carry heavier school bags than sixth form. No link was found between the

weight of the bag carried and the incidence of pain.

Chansirinukor and his coworkers investigated the impact of

backpack weighed 15% BW on cervical and shoulder posture compared

with unloaded posture. They recruited six female and seven male high

school students aged between 13 and 16 years. They reported the sagittal

shoulder posture through measuring the angle formed by the intersection of

a horizontal line through C7 and a line between the mid-point of the greater

tuberosity of the humerus and the posterior aspect of the acromion. The

results indicated that the sagittal plane shoulder posture increased under

load of backpack (Chansirinukor et al. 2001). The mean weight of the

schoolbag and the effect of schoolbag carriage on first year secondary

school students with mean age 13.1 years were investigated by Dockrell

and his colleagues. The mean weight of schoolbag was found to be 12%

BW. They found that 59% of both boys and girls reported discomfort. The

number of reports of discomfort increased as the week continued. The

 50

greatest number reported discomfort due to carrying their school bag on

Friday. The majority of discomfort (65%) was reported in the shoulder

region, followed by 30% reported in the back with negligible percentages

reported elsewhere (Dockrell et al. 2006).

In the studies that conducted in Saudi Arabia, Ibrahim (in press)

used a questionnaire to assess musculoskeletal problems on a sample of

254 Egyptian girls, she found that more than one third of the sample

compliant of low back pain and shoulder pain and the intensity of pain

ranged from 3.4 to 8.8, as the students carry backpacks that weighted above

the recommended guidelines. Another study was done by Alhazzaa who

found that the proportion of students who experienced bodily pain due to

backpack carriage was 35.6%. Shoulder pain represented the highest bodily

reported by the students 33.2%. Shoulder pain was also more frequently

experienced by those students carrying their bags on one shoulder and by

older students compared with younger boys. The weight of school bag was

not significantly different between students reporting pain and those not

reporting pain (Alhazzaa 2006).

 51

2.2.3. BACKPACK LOAD AND OTHER MUSCULOSKELETAL

INJURIES

Makela et al. (2006) retrospectively studied the effect of carrying

backpack on causing brachial plexus injuries on 55 finish soldiers with

mean age of 20 years, they found that the different musculoskeletal injuries

like long thoracic nerve was affected in 19, the axillary nerve in 13, the

supra-scapular nerve in seven, and the musculo-cutaneous nerve in six

patients. Four patients had hereditary neuropathy and the typical symptoms

included gradually progressing paresthesias, numbness, and weakness of

the upper extremity during carrying a heavy backpack. A full syndrome

occasionally was preceded by a transient weakness of the upper limb. They

concluded that carrying a heavy backpack exerts compression on shoulders,

with the potential to cause brachial plexopathy, and the vulnerability to this

condition is not easily predicted from body structure in general or from the

level of physical fitness.

Backpack related injury of children between 6 and 18 years old were

studied from one hundred emergency departments and recorded from

19992000 in the National Electronic Injury Surveillance System database.

They separated patient data by age, sex, location of injury, and mechanism

of injury. There were 247 children with backpack injuries. The most

common injury location was the head/face (22%) followed by the hand
 52

(14%), wrist/elbow (13%), shoulder (12%), foot/ankle (12%), and back

(11%). Most of these back injuries, 59% were associated with carrying a

backpack. The most common mechanism for injury was tripping over the

backpack (28%), followed by wearing of backpack (13%), and (13%)

getting hit by the backpack (Wiersema et al. 2003).

The pain caused by carrying heavy backpack has impact on the

activities of child's daily living, (Lockhart et al. 2004); the students filled a

survey on activity participation, indicating the frequency of participation in

specific activities, and whether or not participation in the activities was

influenced by pain from wearing a backpack. The results indicated that

31.0% of the students reported that they having difficulty in participating in

activities as a result of pain. Nearly 25% of students reported they are

having difficulty in carrying their books during school because of pain, and

19% reported they are having difficulty in playing sports. Some students

had to miss school, abstain from play or sports because of pain, or see a

physician for back pain. (Goodgold et al. 2002) The pain was clearly

associated with fatigue during backpack carrying (Negrini and Carabalona

2002). The students felt this pain when carrying their backpack, and almost

all of them reported feeling relief when they taking off their backpack

(Siambanes et al. 2004). The most difficult activities which gave the most

difficulty were carrying a school bag, sitting at school, and sports activities

(Watson et al. 2002).

 53

2.2.4. BACKPACK TYPE AND MUSCULOSKELETAL INJURIES

Many companies manufactured backpacks that do not met ergonomic

features of the backpack. The designed backpacks may help to alleviate the

physical demands of school students; they will only serve their purpose if

school students choose to use this type of backpack. Other factors such as

style, cost and availability may also determine school students decision to

use a specifically designed backpack on a regular basis. Because of these

other factors, In addition other types of backpacks that seem more

fashionable or desirable might prove to be the preferred choice of school

students despite the ergonomic benefits of backpacks that have been

specifically designed for use by school students (Mackie et al. 2003).

As a result of the concern for the musculoskeletal health of school

students, several backpack manufacturers have developed a specific

backpacks designed for school use and to maintain students muscle for

skeletal health. Some of the features of the purpose backpack design is

include separate compartments so that load movement can be controlled,

compression straps to hold the load closer to the center of mass of the body,

specially design for lumbar areas that are shaped so that some of the load is

borne by the top of the buttocks, and information tags to remind the user of

correct load carrying habits (Mackie et al. 2003). Chest and hip belts, rigid
 54

internal and external frame with wide, padded shoulder straps and multiple

compartments for distribution of load (Goodgold et al. 2002).

Mackie et al. (2003) compare school students perceptions of four

different backpacks, 12 students with mean age of 12 years, asked about

the first impression about four different backpacks, and then they had to

walk with each backpack on treadmill, finally asked about their last

impression about each backpack and which backpack they preferred. Result

showed that Students preferred choice of stylish backpack changed over

time suggests that initially the style of the backpack was the most

influential attribute as they first chose the most stylish backpack, but as

students became more familiar with the backpack, function became more

important. They concluded that style, colors and the overall look of the

backpack was still important and should not be overlooked when designing

an ergonomically sound backpack. An important part of backpack

ergonomics must be to attract school students to it so they will use it in the

first instance. If the student chooses not to use an ergonomically designed

backpack because another backpack initially looks more stylish, then all of

the ergonomic principles that have been installed in the design of the

backpack will have been lost.

Legg et al. (1997) used two different backpacks with different

features, backpack A with pivoting hip belt, side stabilizer strap to align the

individual centre of gravity and ultra-lock strap system to minimize excess

 55

movement of backpack. Backpack B, diagonal hip belt, wide shoulder

attachment. Both backpacks were well padded shoulder, hip, lumbar and

waist strap, internal contoured frame design.Ten subjects walked on

treadmill for 30 minutes with carrying each backpack weigh 20 kg. Each

student asked to answer a questionnaire pre and post walking regarding the

comfort of the use of the backpacks. They used a visual analogue scale,

body diagram and assessed the heart rate during walking on treadmill. The

result showed that no significant differences in the VAS, body diagram and

heart rate about the two backpacks, the response to the questionnaire

indicate that the backpack A was preferred by most of the subjects because

of its good back support, fit, size, balance while walking and ease of

adjustment.

Another type of backpack is the wheeled backpack or called rolling

backpack, but these bring their own array of challenges, such as difficult

manipulation on stairs, storage within schools and passage through

crowded hallways and buses (Goodgold et al. 2002). But Students with

wheeled backpacks were 14 times more likely to carry heavy loads than

those who used backpacks without wheels. Forjuoh et al. (2004) and

Alhazzaa (2006) also found that wheeled backpacks were significantly

heavier than the regular backpack.

 56

2.2.5. BACKPACK WAY OF CARRYING AND

MUSCULOSKELETAL INJURIES

The problems that come with the use of backpack are most often

occurs when the loads are excessive or the bag inadequately distributed the

weight (type of bag, single strap, position of the bag) (Pascoe et al. 1997).

The best position to carry school bag is backpack carrying using two

shoulder straps as indicated by a study conducted on twelve sedentary

males with mean age 12.58 years.The results revealed that carrying

backpack leads to decrease in flexor muscle activity (rectus abdominis) and

increase the extensor muscle activity (Abdolhamid 2009).

Dockrell et al. (2006) found almost all students, 95% used backpack

style schoolbags, but only 65% carried their schoolbags on their backs

using two straps. Sheir-Neiss et al. (2003) found that 87.6% of the students

carried their backpacks using both shoulder straps. Another study by

Goodgold et al. concluded that 94.2% of the children used a standard two

straps backpack without a frame but 80% of them reported using both

straps and only 3.8% of respondents reported using a hip belt. Murphy et

al. (2007) found that two thirds of their sample distributed the weight well

carrying the load on both shoulders. Korovessis et al. (2004) reported that

91% of the students carried their backpacks over both shoulders, while only

(9%) carried them over one shoulder.

 57

Skaggs et al. (2006) found that the preferred method of carriage was

two straps in 1245 children (81%) versus one strap in 212 children (14%)

and forty one children (2.7%) used waist strap. Siambanes et al. (2004)

found that most students wore their backpacks either on two shoulders

(85.0%) or over one shoulder (13.6%) and found no significant relationship

between the method of wear and the prevalence of back pain. (Ibrahim in

press) In a study conducted in Saudi Arabia found in a group of 136 girls

(age9-10 years) 71.3% of them prefer to carry their backpack using two

straps and in a group of 118 girls (age 11-14years) about 50% prefer to

carry their backpack using only one strap.

Chansirinukor et al. (2001) found no significant difference from

baseline (unloaded) condition when the students carrying own backpack

over both shoulders for all angles (craniohorizontal angle, craniovertebral

angle, sagittal shoulder posture and anterior head alignment), which

indicate that carrying a backpack over both shoulders has the smallest

effect on the postural angles measured. Abdolhamid (2009) indicate that

the best position for carrying schoolbags is backpack carrying (two strap),

because carrying backpack leads to decrease in flexor muscles activity and

increase in extensor muscles activity; so that in situations that students have

to carry a bag with overload, specific training for the improvement of

power of extensor muscles, might eliminate the possibility of trunk

disorders.
 58

Some school students carry their school bag on one shoulder as

reported by Korovessis et al. who studied 7 different schools, student aged

between 12-18 years. Their study showed that asymmetric carrying of

backpacks over one shoulder increased significantly the intensity and the

relative risk for dorsal pain (DP) and low back pain (LBP), and this even

reported during holidays as compared with carrying backpacks

symmetrically over both shoulders. The latter theoretically should be due to

asymmetrically applied forces along the spine that are derived from

asymmetric spine loading. Asymmetric backpack carrying with one strap

increased frontal shoulder level shift, caused statistical significant elevation

of the strap bearing shoulder, they recommended symmetric backpack

carrying (Korovessis et al. 2005).

Hong et al. (2003) found that one strap backpack caused a greater

trunk range of motion than the two strap backpack during stair descent. The

authors recommended attention should be paid to the loads of school bags

carried by children when stair walking is required in school activities. They

concluded that the backpack found to be safer than the one strap bag for

children stair walking. (Pascoe et al. 1997) reported that 73.2% from 61

students were carried their backpack with only one strap. Skoffer (2007)

found that the weight of the school bag was not associated with LBP, but

carrying the school bag on one shoulder was positively associated with

LBP and function limiting LBP. This association might be a coincident

 59

finding, or it might be caused by asymmetric load on the trunk. As shown

that the backpack design influence the posture and may cause back pain.

An equal proportion of carrying backpack was found in a study by

Forjuoh et al. (2003) who reported that 46% of students carrying their

backpacks over both shoulders or only on one shoulder. In Saudi Arabia,

Alhazzaa (2006) found equal proportion of students carried their backpack

on one shoulder (32.3%) or two shoulders (33.0%) and approximately 20%

of school boys used single strap bags that were carried by hand and 14.5%

of the students had bags with wheels.

2.2.6. BACKPACK POSITION AND MUSCULOSKELETAL

INJURIES

Position of the load on the backpack load is another factor that has

been shown to affect energy expenditure, posture, and movement. Many

backpacks commonly used by children feature adjustable straps to allow

varied placement of the backpack on the user's back. Choice of placement

by children is most often based on personal comfort, ease in donning and

doffing backpack, or peer acceptance (Goodgold et al. 2002).

Grimmer et al. (2002) examined the response of adolescents

standing posture in sagittal plane to different loads and position of the

 60

school backpack on 250 students age between 12 to 18 years randomly

selected from five Australian high schools. They found that carrying

backpack centered at the level of third lumbar vertebra (low on the back)

associated with least postural displacement. Brackley et al. (2009) stated

that the low load placement in the backpack produced fewer changes in

cranio vertebral angle (CVA) from the initial standing baseline measure

than the high and mid placements and there were fewer changes in lumbar

lordosis in the low load placement. They suggested that future backpack

designs should place loads lower on the spine in order to minimize

childrens postural adaptations.

2.3. BACKPACK LAOD AND POSTURE

Good posture is considered to be the state of musculoskeletal

balance with minimal amount of stress and strain of the body. An ideal

posture is considered to exist when external auditory meatus is aligned with

the vertical posture line. The vertical posture line, as seen from side view is

passes slightly in front of the ankle joint and the center of the knee joint,

slightly behind the center of the hip joint and through the shoulder joint and

the external auditory meatus (Yip et al 2008). The focus today has been on

the harmful effects of backpack weight especially on posture changes.

School age children have soft bone because they are facing a period of
 61

accelerated growth and development of skeletal and soft tissue. As growth

of the spinal structures extends over a longer period of time than the other

skeletal tissues, difference in growth rate can pose a threat to postural

integrity (Leveace and Bernhardt 1984). The understanding of adolescent

postural responses to backpack loads, positions, and the time they exposed

to load is limited. The good erect human posture in space is maintained by

least amount of physical activity. The external force applied to the body

like backpack weight, is commonly associated with postural abnormalities

and leading to deviation from close alignment with the gravitational axis.

Unloaded posture that habitually deviates from gravitational alignment has

been associated with spinal pain (Grimmer et al. 2002 and Watson & Trott

1993).

Consequently, posture in adolescent can be affected by both internal

and external influences, which may make adolescent more susceptible to

injury. Studying postural responses to loads will help us to understand the

impact of carrying school bags on children. When load is positioned

posterior to the body in the form of backpack it changes posture because of

changes to center of gravity. The body tries to keep the center of gravity

between feet, so with a backpack, the trunk is in a more forward position,

placing abnormal forces on the spine. Load carried in a backpack shift the

center of gravity behind the body in order to compensate, the center of the

gravity of the body plus the load is moved back over the base of the
 62

support. This is accomplished by either leaning forward at the ankle or hip

or inclining the head; the rigidity of postural muscles controlling these

adjustments increases to support the load (Mohan et al. 2007).

Chow et al. (2006) recruited 20 healthy schoolgirls their age ranged

from 10-15 years as a control group and a second group of 26 girls with

mild adolescent idiopathic scoliosis (AIS), their age ranged from 11-14

years. The researchers measure standing posture of both groups for 90

second while carrying a backpack loaded at 7.5%, 10%, 12.5% or 15% of

the subjects BW, or without backpack. They found that carrying backpack

load causes similar sagittal plane changes in posture and balance in both

normal and AIS groups. Increasing backpack load causes a significantly

increased flexion of the trunk in relation to the pelvis and extension of the

head in relation to the trunk. The increased backpack load causes increased

antero-posterior range of COP motion. While the increase in backpack load

lead to increased antero-posterior COP sway distance and the mean of

antero-posterior position of the COP. No changes in the medio-lateral

position of the COP with respect to the pelvis were seen with increasing

backpack load.
 63

2.3.1. BACKPACK LOAD AND SHOULDER POSTURE

A study conducted on 60 subject youth aged 11 to 13 years old to

determine the impact of different methods of carrying book bags on static

posture and gait kinematics. Subjects participated in four trails: without

backpack, one strap backpack, two strap backpack, and one strap shoulder

supported athletic bag. The backpack loaded with 7.7 Kg which

represented 17% of the student's BW. Static and dynamic walking was

recorded by using a video camera. The results revealed that during one

strap bag carriage the shoulder elevated on the ipsi-lateral side of carrying

and a leftward curvature of the spine away from the weight of the book

bag. This lateral bending was also observed during the dynamic trail

conditions, decrease in stride length and increase in stride frequency also

founded. In regards to the angle and range they found significant greater

lean during one strap backpack and two strap backpack. Only one strap

athletic backpack increase angular range of motion of the trunk during

walking. The head was tilted forward in all trails and was greater for the

trails in which only one strap was used (pasceo et al. 1997).

Negrini and Negrini (2007) studied the postural effects of

symmetrical and asymmetrical loads on the spines of 43 schoolchildren,

with mean age of 12.5 years. Data were collected using the Automatic

Scoliosis Analyzer. Loads of 8 and 12 Kg (16.8 % and 25.2% of BW)

 64

which represent the average and maximal loads carried on a week basis by

these school children. All subjects asked to walk on treadmill for 7

minutes. The result showed that both types of load induce changes in

posture, without statistical significant differences between 8 and 12 kg, and

the asymmetrical one in all anatomical planes shoulder elevation and lateral

trunk deviation.

Debrunners Kyphometer and Scoliometer were used to measure

cranio-cervical angle (CCA), thoracic kyphosis, lumbar, lordosis and

shoulder level shift of 1263 students with age between 12-18 years. The

measurement recorded with and without backpacks load. The result

revealed that carrying backpack cause decrease of CCA and changed

shoulder and upper trunk shift. A symmetrically carrying of backpacks

increased back pain and shoulder shift in holidays, while the upper trunk

was shifted away from the plumb line contra laterally (Korovessis et al.

2005).

Mohan et al. (2007) investigated the response of shoulder posture to

backpack load and determine whether the weight of the backpack or time

carried affected the static posture of adolescents aged 10-15 years. One

camera was used to take still photographs of subject's under three loading

conditions, without backpack, static loading with 10% BW, after dynamic

activities (walking, stair climbing) with 10% BW. They measured the

cranio-horizontal angle (CHA), cranio-vertebral angle (CVA) and sagittal

 65

shoulder Posture (SSP). A significant changes in cranio-vertebral angle was

found in two loading conditions, static loading (10% BW). Results revealed

that both backpack weight and time carried influenced cervical and

shoulder posture by decrease in craniovertebral angle and increase in

sagittal shoulder posture. They suggested that carrying school bag

weighing 10% of BW would be too heavy for students aged 10-14 years to

be able to maintain their normal postural alignment. In other words

carrying a load of less than 10% of BW school bag is recommended to

maintain good postural alignment.

Ramprasad et al. (2010) recruited 209 healthy male children between

1213 years from six schools of Mangalore city. Bodyweight and height

were measured using a force plate and stadiometer, respectively.

Photographs used to determine Lower limb angle (LLT), Trunk angle (HT),

Head and neck on trunk angle (HNTA), Head on neck angle (HNA) and

Craniovertebral angle (CVA). Postural angles were compared with no

backpack and with backpacks weighing 5%, 10%, 15%, 20% and 25% of

their bodyweight 25% of the subjects. The result showed that the CV angle

changed significantly after 15% of backpack load. The HNA and HNTA

angles changed significantly after 10% of backpack load. The trunk and

lower limb angle also changed significantly after 5% of backpack load.

And they concluded that carrying a backpack weighing 15% of BW change

all the postural angles in preadolescent children.

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2.3.2. STUDIES USED EMG TO TEST POSTURE

Twelve sedentary males with mean age of 12.581.4 years were

studied to determine the effect of backpack carrying with difference loads

(10%, 15%, and 20% BW) on trunk muscles. The electromyography used

to assess muscle contraction of; Upper trapezius, Central part of rectus

abdominis and Upper pectoralis major. The students were asked to do

maximum voluntary isometric contraction without the backpack. They

tested with carrying backpack weigh 10, 15 and 20 percent of BW, and

signals for each weight were recorded for 15 seconds in static position. The

result showed that there is a significant difference between carrying bags

with 10% and 20% of BW for rectus abdomins. Likewise, there is a

significant difference among carrying bags with different loads in upper

trapezius and Upper pectoralis muscles. Based on the comparison of the

EMG findings the upper trapezius muscle had the maximum activation and

rectus abdomins had the minimal activation while carrying a bag

(Abdolhamid 2009).

One of the most recent studies was by Alkabbaz et al. (2008) who

used EMG to analyze trunk-lower extremity muscle activities and trunk

postural changes during carrying backpacks. Nineteen university students

aged 21 years asked to stand carrying backpack loaded 10%, 15% and 20%

BW (BW) to compare with unloaded standing. Muscles activity of the

 67

trunk and lower extremity was recorded through using bilateral EMG

which attached to the erector spine (trunk extensor), rectus abdominis

(trunk flexor), vastus medialis (knee extensor) and biceps femoris (knee

flexor). The trunk inclination, rotation, and side flexion was assessed using

a VICON motion analysis system. Results showed that rectus abdominis

muscle activities increased progressively and disproportion as the backpack

heaviness increased. No significant changes occurred to erector spinae,

vastus medialis or biceps femoris. As for the trunk posture, almost the same

backward inclination was adapted even with increasing backpack

heaviness. A 20% BW of the backpack weight causes the most significant

muscular and postural changes so it should be avoided.

Effect of prolonged walking with carried load on muscle activity and

fatigue was investigated on fifteen Chinese male children aged 6 years

recruited from local primary school. The electrodes of the EMG were

attached to upper trapezius (UT), lower trapezius (LT) and rectus

abdominis (RA). The signals were recorded at several time intervals (0, 5,

10, 15 and 20 min). The participants were instructed to stand up and

perform maximum shoulder elevation, then lie supine on the floor, and

perform upward and forward trunk flexion both under resistance. Then

asked to wear a two strap backpack and walk 20 minutes on treadmill with

different backpack loads 0%, 10%, 15% and 20% BW. Results showed that

a 15% (BW) load significantly increased muscle activity at lower trapezius

 68

when the walking time reached 15 min. When a 20% BW load was being

carried. Increase in muscle activity was found from 5 min, and muscle

fatigue was found from 15 min. In upper trapezius, increase of muscle

activity was not found within the 20 min period, however, muscle fatigue

was found from 10 min. There was no increase of muscle activity or

muscle fatigue in rectus abdominis. The researchers recommended that

backpack loads for children should be restricted to no more than 15% BW

for walks of up to 20 min duration to avoid muscle fatigue (Hong et al.

2008).

2.3.3. BACKPACK LOAD AND PRESSURE UNDERNEATH

SHOULDER STRAPS

Macias et al. (2005) studied the pressure under the shoulder straps of

backpacks of five males and five females with mean age of 13 years. The

result revealed that the contact pressure beneath the shoulder straps was

significantly increased at 10%, 20%, and 30%BW. The pressure was

significantly higher on the right shoulder than the left shoulder at 10%,

20%, and 30% BW. Contact pressures were essentially zero with an empty

backpack. Perceived pain correlated significantly with increasing contact

pressure over the range from 10% to 30% BW. Another study conducted by

Jones and Hooper (2005), they found that the pressure underneath the
 69

shoulder will not decrease or get relieved by wearing multiple garments,

even in layers, when carrying a backpack.

Mackie et al. (2005) studied the pressure underneath the shoulder

straps of a mannequin representing a 5th percentile Canadian armed forces

female (weight 52.8Kg and height 1.55m) as it most closely resembled the

anthropometric characteristics of 13 year old school students. A load

carriage simulator was used to compare shoulder strap forces and shoulder

pressure for 32 combinations of gait speed, backpack weight, load

distribution, shoulder strap length and use of a hip-belt. The results showed

that the manipulation of backpack weight, hip-belt use and shoulder strap

length had a strong effect on shoulder strap tension and shoulder pressure.

Backpack weight had the greatest influence on shoulder strap tension and

shoulder pressure as the weight of backpack increase the strap tension and

shoulder pressure increase as well. When the shoulder strap was loose, the

tension and pressure under the shoulder strap decrease.

2.3.4. BACKPACK LOAD EFFECT ON STATIC AND DYNAMIC

POSTURE

The trunk inclination methods angle has been used to determine the

effects of backpack load on the changes of posture in two boys recruited

from local primary school in Malaysia. Each boy was asked to walk with
 70

four different load conditions; without backpack, backpack with load 10%,

15%, and 20% of BW, with backpacks carried on both shoulders. Result

showed that the subjects walked with a forward lean of the trunk in all four

different backpack load conditions. The trunk inclination angle increases

more than 5 degree with loads of 15% and 20% of the BW compared to

that of 0% and 10% load conditions (Abdrahman et al. 2009).

Singh and Koh (2009) investigated the impact of backpack load

carriage and its vertical position of loads on the back on temporal-spatial

and kinematic parameters associated with gait and postural stability for

static and dynamic condition of 17 participants with mean age 9.65 years.

No significant differences were found between any two loaded conditions.

Placing load low on the back affected the spatiotemporal parameters more

than when loads were placed high on the back. Results showed slightly

higher forward lean of the trunk than the upper configuration. For all

conditions, maximum trunk lean for the dynamic condition was

significantly higher than the static condition. The findings on

spatiotemporal parameters indicated that a reduction in gait velocity and

cadence and an increase in double support time for the 20% BW could be

compensatory mechanism for children to minimize either the induced gait

instability or mechanical strain on the musculoskeletal system. Higher

forward trunk lean for dynamic conditions compared to static conditions

 71

indicating differences in strategies employed to maintain balance for static

and dynamic conditions.

Hong and Cheung (2003) studied the trunk posture during walking;

the results showed that the 20% BW load induced significant forward lean

of trunk. The forward inclination of trunk would increase as the walking

distance increased. The same result obtained by Hong and Brueggemann

(2000) who found that the trunk forward lean angle was significantly

increased with the loads of 20 and 15% of BW when compared to the

0%and 10% load conditions. No significant difference in trunk forward

lean angle was observed between the 20 and 15% load conditions. Trunk

angular motion was significantly decreased with carrying a load of 20%

BW when compared to the 0% load condition.

Changes of trunk posture in fifteen boys aged 10 years have been

reported by Li et al. (2003). The participant was examined with backpacks

weighed 10%, 15% and 20 % of subject's BW. The backpacks were leveled

at waist level, with two straps. The subject participated in four walking

trials on a treadmill; a backpack load 0%, 10%, 15%, and 20% of BW. The

results showed that the trunk inclination angle progressively increased as

the load increased. The trunk motion range progressively decreased with

the increase of the load carried. No significant differences in trunk

inclination angle between any of the loads over 10% of body mass during

the first minute.

 72

Chansirinukor et al. (2001) studied the effect of backpack load on

cervical and shoulder static and dynamic posture on thirteen children, six

female and seven male ages between 13-16 years. Four angles were

measured (craniohorizontal angle, craniovertebral angle, sagittal shoulder

posture and Anterior head alignment) during walking with load. The result

showed that the craniovertebral angle in all four experimental conditions

reduced in comparison with that produced by the unloaded condition, and

after a 5min walk, the angle increasing in the loaded conditions. In contrast,

an increase in the average sagittal shoulder posture was found. A

significant difference between carrying the backpack was equivalent to

15% of BW and the unloaded condition for the anterior head alignment.

They found significant difference of the craniohorizontal angle between

carrying the backpack over the right shoulder and unloaded. They

concluded that both backpack weight and time carried influenced cervical

and shoulder posture. Carrying a backpack weighing 15% of BW appeared

to be too heavy to maintain standing posture for adolescents.

Changes in immediate spinal posture of 985 students aged 12 to 18

years in response to backpack load, were examined by Grimmer et al.

(1999) using anatomic landmarks in head and neck. Students were

photographed in the relaxed standing position. Photographs were taken

under four set order load carrying conditions; carrying the backpack in the

preferred manner, carrying it over two shoulders with safety features

 73

adjusted waist strap and compression straps, and unloaded condition. A

significant change in craniovertebral angle was found at every year level,

when comparing standing posture with no backpack with posture when

carrying a backpack. The change was greatest for the youngest students.

Incremental change in craniovertebral angle was not strongly associated

with backpack loads.

The changes in posture were examined under different dynamic

conditions by Seven et al. (2008) who studied the effects of back loading

on the kinematics and kinetics sit to stand motion on fifteen children, 8

boys and 7 girls with mean age of 9 years. The subjects were tested with no

back load and with back load of 10% and 20% BW by using motion

analysis system with six infrared cameras and two force plates. The result

showed that backpack loading affects the biomechanics of sit to stand

motion substantially even at low loads. The different levels of loading did

not cause a significant change in the total duration of sit to stand motion.

The children stayed within the general pattern of sit to stand motion, but

made selective adjustments including changes in initial joint angles, timing

and magnitude of critical kinematic parameters and increasing joint

moments during different phases of the motion. The main kinematic

adjustments were increased trunk flexion and greater ankle dorsiflexion,

while the main kinetic adjustment was increased knee extension moment.

Increasing amounts of backpack loading yielded increasingly pronounced

 74

effects at the ankle. A similar study by Goodgold et al. (2002), who

investigated the combined effects of increased backpack load and task

demand on posture of two school aged children age 9 and 11years.

Reflective markers were placed on 20 anatomical landmarks. Subjects were

videotaped under nine experimental conditions, three levels of backpack

carrying load (0%, 8.5%, 17% BW) and three levels of task demand (stand,

walk and run), to examine the effect of prolonged backpack usage on

posture. The result revealed that trunk forward lean, for the most part,

increased with increases in backpack load and task demand.

Different changes in posture while carrying the backpack were

observed by Chow et al. (2007) when they examined the spinal curvature

and repositioning consistency of 15 male ages of 15 and 16 years. The

examinations were conducting with free standing and while carrying a

special adapted backpack with two straps loaded at 10%, 15% and 20%

BW. Spinal curvature and repositioning performance were recorded using a

five-camera motion analysis system. The result showed that the carriage of

a loaded backpack causes immediate changes in spinal curvature and

appears to have a direct effect on the repositioning consistency. A

significant flattening of the lumbar lordosis and the upper thoracic kyphosis

was found with increasing backpack load, as well as a significant decrease

in the thoraco-lumbar and lumbar repositioning consistencies. The

influence of carrying a backpack on pelvic tilt, rotation, and obliquity in

 75

female college students were studied on thirty subjects with mean age 22

years college students (Smith et al. 2006). Gait was analyzed in three

conditions; walking without a backpack, carrying a backpack unilaterally,

and carrying a backpack over both shoulders. The backpack was loaded

15% of BW. The results revealed that the angular pelvic tilt was greatest

with bilateral backpack carriage compared to unilateral carriage or walking

without a backpack. Angles of pelvic obliquity and rotation were not

changed across the three walking conditions. Range of motion for pelvic

obliquity and rotation was significantly decreased when walking with a

backpack. These results suggest that backpack carriage could cause

permanent posture deviations in young female college students.

In a study by Grimmer (2002), conducted on 250 adolescents age

between 12 to 18 years selected randomly from five Australian high

schools. Nine experimental conditions were used 3%, 5%, and 10% BW,

carried in a backpack positioned with its center at upper (T7), middle (T12)

and lower spinal (L3) positions. Sagittal plane photographs were taken of

unloaded standing posture, and standing posture under the experimental

conditions. Results revealed that the backpacks positioned at T7 produced

the largest forward (horizontal) displacement at all the anatomical points.

Loaded sagittal standing posture was the most horizontally displaced when

adolescents carried a typical school backpack with its center positioned

midway between the shoulder blades, compared with lower positions. The
 76

backpack position associated with least postural displacement was at center

positioned approximately at the student's waist or hip.

Marsh et al. (2006) examined if backpacks with an abdominal

support improve posture and decrease exertion while walking among 22

adolescents aged 13-16 years. Subjects walked on a treadmill for 5 minutes.

Using photographic measurement of posture and responded to the Borg

scale of perceived exertion before and after ambulation. On day two, they

repeated the trial four more times wearing a backpack randomly loaded

with either 10% or 20% of BW and with or without the Back Balancer

abdominal support. The result showed that the forward lean while wearing

a backpack with abdominal support were significantly lower while carrying

both 10% and 20% of BW versus no abdominal support. The perceived

exertion at 10% and 20% of BW was significantly greater without

abdominal support.

2.4. BACKPACK LOAD AND PHYSIOLOGICAL CHANGES

There is a positive relationship between change in the posture during

carrying the backpack and the changes in the vital signs, changes of trunk

position and motion range due to the load being carried which might

influence the response of respiration. Children carrying heavy loads have to

bend their trunks forward to maintain body posture and balance while
 77

walking. Significant increase in forward lean and limit trunk motion range

appears to affect the movement of the thorax and seems to reduce the

volume of the abdomen as the muscles are contracted in order to gain

stability, preventing abdominal breathing. Thus, the only way that the

subject could increase oxygen uptake to support the increased metabolic

cost might be to use costal breathing and breathing faster (Li et al. 2003).

Lai and Jones (2001) have reported the effects of backpack loading

on lung volumes, specifically forced expiratory volume (FEV), forced vital

capacity (FVC), and peak expiratory flow rate (PEF). They measured these

parameters with 0%, 10%, 20%, and 30% BW as load in the backpack of

43 children, 9-11 years old. Significant decreases were found in the FEV

and FVC for 20% and 30% BW, but not 10% BW, versus 0%. These

results showed that 20% and 30% BW loads have similar effects as

standing in a kyphotic posture (maximually rounded shoulders and back).

Therefore, loads greater than 10% BW has a restrictive effect on lung

volume, similar to kyphotic postural effect.

Hong and Brueggemann (2000) measured the heart rate before

walking, throughout and after 5 min walking on treadmill using a

cardiopulmonary function system were measured on 15 boys with mean

age 10.3 years. Blood pressure was measured before walking, immediately

afterwards, and at 3 and 5 min after every trial. They reported that there

was no significant change in heart rate and blood pressure but except at
 78

15% load condition induced significant prolonged blood pressure recovery

time. They referred that increase muscular stress and power output would

induce higher cardiovascular demand on the subject, walking for 5 minutes

elicited a significant increase in heart rate, from the standing pre-exercise

heart rate. However, during the next 15 min walking period, heart rates did

not show a significant difference, indicating that the children had reached a

fairly steady exercise state at each workload.

Forty three students from primary school with mean age of 9 years

participated in a study to measure spirometer lung function while adopting

five conditions in random order; free standing, kyphotic standing, standing

wearing a backpack weighing 10%, 20% and 30% of BW. The result

revealed that there were no significant difference of forced expiratory

volume (FEV) and forced vital capacity (FVC) between free standing and

the 10% BW. However, both Forced expiratory volume (FEV) and forced

vital capacity (FVC) decreased significantly when the student adopted the

kyphotic posture and when the load in the backpack was increased to 20%

and 30% of BW. They concluded that when school bag load is heavier than

10% of a childs BW there is restrictive effect on lung volumes and the

back pack weight should not exceed 10% of BW in 10 year old boys. The

results confirm the detrimental effect of a kyphotic posture on pulmonary

mechanics and the necessity for health care professionals to advocate

proper posture (Hong & Brueggemann 2000).

 79

Li et al. (2003) examined 15 boys aged 10 years walked on treadmill

for 20 min, each child was sit before the test and wear a face mask for 5

min to measure respiratory condition. Electrocardiography was

continuously monitored as a safety requirement, using a cardiopulmonary

system. The result showed that walking with 20% load induced

significantly higher thoracic respiratory muscle activity (increased thoracic

volume) than other loads. The volume change in the abdomen indicated a

reversed trend with decreasing volumes by abdominal muscles activities.

The 20% of body mass load induced a significant increase in respiratory

rate when compared with the 0% load condition.

One of the most recent studies conducted by Chow et al. (2009) who

assessed the effects of backpack load placement on pulmonary capacities of

22 normal schoolchildren with a mean age of 12 years. Forced vital

capacity (FVC), forced expiratory volume in 1s (FEV1), peak expiratory

flow (PEF), and forced expiratory flow (FEF2575%) were measured during

free standing and when carrying a backpack of 15% BW with its center of

gravity positioned at T7, T12 and L3. Significant effect of load was found

on FVC and FEV1. However, no significant effect of load placements on

the pulmonary function of schoolchildren was found. Manipulation of load

placements may not alleviate the restrictive effects exerted on the

pulmonary function resulted from backpack load. In contrast a study by

Stumpfle et al. (2004) who found that the oxygen consumption, minute
 80

ventilation, and rating of perceived exertion were significantly lower in the

high position compared to the low position. Heart rate (HR) and respiratory

rate (RR) did not change significantly as the load was moved from the high

to the low position. They recommended that load placement is an important

factor in the physiological and perceptual responses to load carriage, and

that packing heavy item high in the backpack may be the most energy

efficient method of carrying a load on the back.

2.5. BACKPACK LOAD AND MUSCLES FATIGUE

Fatigue can be caused by carrying heavy backpack for prolonged

time or/and transporting the heavy backpack from home to school and

back, as not all children have a way for transportation (car, bus or bicycle)

and they have to walk the distance while carrying heavy backpack.

Korovessis et al. (2005) found a total of (59%) of students went to school

walking, (40%) were transported by buss or cars, and (1%) by bicycle. The

time spent with backpacks during transportation from and to school was 29

-33 minutes (range 6200 minutes). Murphy et al. (2007) reported that

most of the children travelled to school by car (41%) or by bus (24%) and

30% walking the whole way. A small number of children cycled and a

small number boarded at school.

 81

Negrini and Negrini (2007) were found that the fatigue caused by

walking with an 8 kg backpack worn in both shoulders for 7 minutes,

prompted a further reduction of the angle of lumbar lordosis (18), a

statistically significant reduction of the angle of kyphosis (19) and a

further forward trunk flexion (2 cm). After removing the load, only the

angle of lumbar lordosis continued to show statistically significant

difference versus basal conditions.

EMG was used to assess muscles activity during prolonged walking

by Hong et al. The results showed that a 15% BW load significantly

increased muscle activity at lower trapezius and upper trapezius when the

walking time reached 15 min. When a 20% BW load was being carried

increase in muscle activity was found from 5 min in the lower trapezius.

No increase in muscle activity or muscle fatigue was found in rectus

abdominis. They recommend that backpack loads for children should be

restricted to no more than 15% BW for walks of up to 20 min duration to

avoid muscle fatigue (Hong et al. 2008).

Negrini and Carabalona (2002) conducted a study on 237 students

on 6th grade in Italy in three schools using questionnaire. They completed a

questionnaire includes questions about fatigue and back pain due to

carrying backpack. The result revealed that students carry backpack for 5 to

15 minutes (48.2%) or more (37.3%). School backpacks are felt to be

heavy by 79.1% of children and caused fatigue by 65.7%. Back pain was
 82

clearly associated with fatigue during backpack carrying, but not with

feeling that the backpack was heavy, whereas life prevalence of back pain

was associated with the time spent bearing backpacks on the shoulders.

2.6. BACKPACK LOAD AND BALANCE

Balance can be defined as the ability to maintain the bodys center of

gravity (COG) over its base of support (BOS) with minimal sway or

maximal steadiness (Horak 1987). Smith (1996) defined balance as the

body relative to the arrangement of the limb segments, for specific activity,

or the characteristic that one bears the weight of one's body. The position of

the whole body center of mass (COM) has been determined as one of the

variable that the central nervous system (CNS) utilize to control posture

(Aruin and Zatsiorsky1989). The ability to maintain balance is a complex

process that depends on three major components; (1) sensory system for

accurate information about the body position relative to the environment;

(2) the brains ability to process this information; and (3) the muscles and

joints for coordinating the movements required to maintain balance. The

CNS takes information from the visual, somatosensory, and vestibular

systems and integrates them in order to control posture in a feed forward

manner (Peterka & Loughlin 2004). Normally, balance control is

accomplished automatically without requiring our conscious attention.

 83

When our balance is disrupted, we have to exert intense conscious effort to

try to overcome the abnormal sensations and maintain control of our

balance. This intense effort, in turn, is what leads to the common secondary

fatigue.

Human bipedal stance is inherently unstable, small deviations from a

perfect upright body position result in gravity induced torque acting on the

body, causing it to accelerate further away from the upright position.

Corrective torque must be generated to counter the destabilizing torque due

to gravity. This process of corrective torque regarding the organization of

sensory and motor systems is contributing to postural stability (Peterka &

Loughlin 2004).

Indeed, when a small load is carried, the control of posture is well

known and easy to manage. However, this is not the case when carrying a

large load or when a load is positioned asymmetrically. Furthermore,

postural asymmetry occurs in everyday life and is produced by both

intrinsic and extrinsic factors. Intrinsic factors are related to internal body

characteristics or pathologies that affect balance. Extrinsic factors are the

environmental factors that alter posture, such as foot wear, base of support,

flooring, etc. it is the extrinsic factors of base of support (BOS), load

placement, and load magnitude. (Chow et al. 2006) it has been described in

recent literature that the extrinsic factor of wearing a backpack affects

standing posture and balance.

 84

The effects of backpack load carrying on dynamic balance has not

been studied or taking enough investigation from researchers so we try to

explain the relation between balance and postural stability with backpack

load by studying studies done on young adults. Palumbo et al. (2001)

investigated the effect of backpack load carrying on dynamic balance. They

recruited fifty college students from the Ohio University with mean age of

22.8 years. All subjects completed a questionnaire related to years of

backpack use, and any current medical conditions including balance

disturbances or musculoskeletal impairments. Limits of stability (LOS) was

assessed using the Smart Equitest Balance Master System, a standard

double strap backpack containing 7.7 Kg was used during the assessment.

Subjects tested for limits of stability twice with the backpack and twice

without backpack for five measures (reaction time (RT), movement

velocity (MVL), end point excursion (EPE), maximum excursion (MXE),

and directional control (DCL). They found that the backpack had a

significant effect on movement velocity and directional control. Movement

velocity demonstrated a significant difference with backpack load carrying,

Movement velocity was significantly slower in all directions with backpack

load carrying. The effect of the backpack on directional control reported a

significant difference in directional control in regards to direction with

backpack loading, difference in directional control with backpack loading

existed between frontal and sagittal planes of movement. An improvement

 85

in directional control was noted to the left and right targets when compared

to the front and back targets during backpack trials. They found no

significant difference noted in reaction time, maximum excursion, or end

point excursion with backpack load carrying. They concluded that

backpack load carrying has an impact on dynamic balance. As school age

children regularly use backpacks load as a mode of transporting books,

Palumbo et al. (2001), recommended further studies to investigate the

effect of this load carrying for this age group. They expected that children

may demonstrate an even greater difference in their control of dynamic

balance with backpack loading, due to their developing nervous and

musculoskeletal systems.

Hong and Brueggemann (2000) examined the changes in gait

patterns in 10 year old boys with increasing load when walking on

treadmill. The results showed that carrying a load of 15% or 20% BW

induced a significant increase in trunk forward lean when compared with

0% or 10% load conditions when walked on treadmill. The heavy load

carried on the back would force the subjects to alter their body position to

counteract the deviations from the normal kinematic pattern when body

posture and balance were disturbed by carrying the substantial additional

load. Pascoe et al. found that carrying a two strap backpack by 17% of the

BW of youths significantly promoted forward lean of head and trunk

compared to the walking without a bag. The increased load carried on the
 86

back would bring the center of gravity of the body load system closer to the

rear limit of the base of support, thus reducing stability in this direction. In

response to this change, children were leaning forward to bring center of

gravity over their base of support to maintain their walking stability

(Pascoe et al. 1997).

Chow (2006) examined the effects of backpack load on the posture

and balance of 26 schoolgirls with mild adolescent idiopathic scoliosis

(AIS) aged 13 years with Cobb angle 1025 and 20 normal controls.

The static standing postures was recorded for both groups for 90 second

while carrying a backpack loaded at 7.5%, 10%, 12.5% or 15% BW, or

without a backpack. The backpack used was a standardized dual strap

design, with the center of gravity of the backpack located between the 11th

and 12th thoracic vertebrae of each subject. While Kinematics of the pelvis,

trunk and head were recorded using a motion analysis system (The mean

angles between the pelvis, trunk and head in space were recorded in the

sagittal, coronal and transverse planes). The center of pressure (COP) data

was recorded using a force platform. They found that increase backpack

load caused increased antero-posterior range of COP motion. While the

total antero-posterior COP sway distance and the mean antero-posterior

position of the COP with respect to the pelvis both decreased. With

increasing backpack load in both groups, there was decrease in the medio-
 87

lateral position of the COP with respect to the pelvis was seen with

increasing backpack load.

Talbott et al. (2004) investigated the stability changes of forty

students with different types of backpacks and with backpacks placed on

different locations on the spine. The researchers used six camera motion

analysis systems with a strain gauge force plate. Data was recorded while

standing and while performing a dynamic task. The type of backpack, the

location of the backpack and the load of backpack were varied. Sway

length and sway area were calculated from the force plate measurements.

Results showed that during static and dynamic tests, sway length and sway

area were significantly greater with an increase in backpack weight. The

type of backpack and the location of the backpack on the back were not

significant.

Another studies that done in adult populations (Zultowski and Aruin,

2008) investigated and compared the postural sway produced by load

placement and magnitude of 10 university students with mean age of 24.5

years. Subjects were instructed to carry a purse, backpack, single strapped

bag or briefcase. Textbooks and blinders were placed in different bags to

produce loads of 10% and 20 % BW. Each subjects tested for all bags one

by one as a subject asked to carry a load of 10% or 20% and stand erect on

a force platform to measure ground reaction force in three directions, in the

direction of gravity, in the anterior posterior direction, and medial lateral

 88

direction. They found that the effect of load magnitude was statistically

significant only for anterior posterior displacement in the 10% and 20%

BW with single strap bag, and was statistically significant in the medial

lateral direction when carrying single strap bag and briefcase. The increase

in load magnitude for all conditions was found that COP velocity increased

in the medial lateral direction. They found that a larger increase in the

medial lateral COP velocity when subjects carried asymmetrical loads

(single strapped bag, briefcase, or purse). Additionally a larger COP sway

was recorded in conditions of standing with decreased base of support (feet

together).

The objective of a study done by Goh et al. (1998) was to compare

the differences in lumbosacral spine forces under varying backpack loads

using a biomechanical model. Ten healthy male infantry soldiers with age

of 19 years were asked to walk with no load, walking with backpack load

of 15% BW, and walking with backpack load of 30% BW, for three trails.

Stride characteristics and kinematic data obtained from 5 cameras Vicon

motion analysis system to determine the changes in peak forces in the

L5/S1 with increasing backpack load during level walking. The results

revealed that there were significant increase in peak lumbosacral forces

with backpack carrying walking with no external loads to 15%BW load

increase the peak force at the lumbosacral spine by 26.7% and from 15-
 89

30%BW backpack load the peak lumbosacral force increased by 29.5% -

64% due to compensatory trunk flexion .

2.6.1. BACKPACK LOAD, FATIGUE AND BALANCE

Gribble and Hertel (2004) examined the effects of fatigue on the

sagittal plane movers at the hip, knee, and ankle on postural control during

single leg stance. This study conducted on fourteen subjects with mean age

of 21 years. The test consisted of isokinetically fatiguing the sagittal plane

movers of the ankle, knee, or hip with measures of static postural control.

Postural control was assessed with three trails, each for 30 second trials

during unilateral stance with eyes open. The result revealed that fatigue at

the knee and hip led to postural control impairment in the frontal plane,

whereas fatigue at the ankle did not. In the sagittal plane, fatigue at all 3

joints contributed to postural control impairment. They concluded that

there is an effect of localized fatigue of the sagittal plane movers of the

lower extremity on center of pressure excursion velocity. It appears that

fatigue about the hip and knee had a greater adverse effect on center of

pressure excursion velocity.

The purpose of Yaggie and Armstrong (2004) study was to quantify

changes in balance indices after a generalized fatiguing activity. The

balance was assessed on sixteen participants with mean age of 24 years

 90

using the KAT-2000 system before and immediately and 10 min after serial

Wingate tests and at similar time points under non fatigue conditions. The

result showed that fatigue adversely affects balance indices and recovery

might occur within 10 minutes. However both studies were done in adult

sample.

2.6.2. BACKPACK LOAD, GAIT AND BALANCE

Using a backpack allows a person to carry more items than would be

possible by the arms and hands alone. The risk, however, is overload,

which can strain the back, neck or shoulders and affect gait. A study by

Singh and Koh, aimed to analyze how different load weights and the

vertical positioning of these loads on the back affect trunk forward lean and

spatiotemporal parameters and how these variables in turn possibly affect

balance during gait. Seventeen primary school boys with mean age of

9.651.58 years participated in the study. They asked to walk on treadmill

at self- selected speed under three loaded conditions of 10%, 15% and 20%

of BWs. They use motion analysis system for gait measurement. They

found that walking velocity, cadence and double support time for 20% load

condition were significantly different compared to the unloaded condition

indicating that gait changes may have occurred to minimize gait

destabilization. The findings on spatiotemporal parameters indicate that a

reduction in gait velocity and cadence and an increase in double support

 91

time for the 20% lower configuration could be a compensatory mechanism

for children to minimize either the induced gait instability or mechanical

strain on the musculoskeletal system in terms of possible higher lower limb

joint moments or both (Singh and Koh 2009).

The impact of carrying different weight of schoolbags on gait

pattern was studied by Hong and Brueggemann; they recruited fifteen boys,

aged 10 years old from a local primary school. Each subject participated in

all four trials walking on a treadmill; without a bag and with a school bag

of 10%, 15% and 20% of BW for 20 minutes. The gait was filmed using a

video camera. They found that carrying backpacks of 20% BW resulted in

significant increase in double support duration, and a significant decrease

in the swing duration when compared with the 0 and 10% load conditions.

No significant differences were found among other load conditions (Hong

and Brueggemann 2000).

Cottalorda et al. (2003) examined the effects of carrying a backpack

weighing 10 kg on one or both shoulders on ground reaction forces, stride

length, stance, double stance, and a symmetry index in 41 children with an

average age of 12 years using the treadmill. Once without a bag and with a

one strap backpack and with a two straps backpack. A significant increase

of stride, stance and double stance duration was observed when the

backpack carried on one or two shoulders compared with the normal

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condition, no backpack. Significant differences were found in average

vertical force and maximum peaks of breaking and take off phases between

baseline and one or two shoulder carriage. No difference was found

between one strap and two straps backpack.

The effect of backpack carriage on gait parameters was

investigated on a sample of 32 seventh grade children between the ages of

12 and 13 years was investigated by (Connolly et al. 2008). The GAITRite

System was used to record the walking patterns of the subjects under two

loading conditions 15% of BW once with one strap backpack and once

with two straps. Significant increase was observed in double limb support

with both load conditions when compared with the baseline. Stride length

decreased in both legs when backpack was worn over one shoulder and

increased in both legs when the backpack was worn over two shoulders

compared without backpack. No significant difference was found between

one shoulder and two shoulders carriage. Some changes were found in the

width of walking, base of support (BOS) decreased in both conditions of

backpack carriage compare to without backpack, but this changes was not

significant, No significant difference reported in velocity under either

carriage condition but the velocity decreased when the backpack was worn

on one shoulder and increased from baseline when the backpack was worn

on two shoulders. They speculated that carrying the backpack either on one
 93

shoulder or two shoulders affected balance. However, they used only

indirect methods of assessing balance.

Pascoe et al. (1997) observed that the load of the backpack lead to

shorter stride length and increase in stride frequency. They observed

shorter stride length and higher stride frequency during load carriage and

this was associated with changes in transverse plane kinematics. During

unloaded walking, there is increase in pelvic rotation contribute to

increases in stride length with increasing walking speed. The decreased

pelvic rotation during load carriage was compensated with increase in hip

excursion. However, the increase in hip excursion is insufficient to fully

compensate for the observed decrease in pelvis rotation, as it requiring an

increase in stride frequency during load carriage to maintain a constant

walking speed.

A group of 22 normal schoolgirls between the ages of 10 and 15

years were recruited by Chow et al. (2005) to study their gait pattern while

carrying a standardized backpack of different loads of 0%, 7.5%, 10%,

12.5% and 15.0% of BW. Temporal-distance, ground reaction force and

joint kinematic, moment and power parameters were analyzed. The result

showed that walking speed and cadence decreased significantly with

increasing backpack load, while double support time increased. Kinematic

changes were most marked at the proximal joints, with a decreased pelvic

motion but a significant increase in the hip sagittal plane motion. Increased
 94

moments and power at the hip, knee and ankle showed increasing demand

with backpack load. Parameters showed different responses to increasing

load, and those that suggested a critical load indicated this to be

approximately 10% BW.

LaFiandra et al. (2002) examined the effects of wearing a backpack

on transverse plane upper and lower body torque during walking on twelve

subjects with mean age of 26 years. They walked with and without a

backpack that containing 40% of their BW on a treadmill. The upper and

lower body torques was calculated from angular acceleration and moment

of inertia. The result showed increase walking speed, increased stride

frequency, decreased stride length, and higher levels of upper and lower

body torque were observed during load carriage than during unloaded

walking, the increase in upper body torque was 225%, while upper body

moment of inertia increased by 400%. And they concluded that differences

in torque between loaded and unloaded walking suggest that a goal of

loaded walking is to minimize upper body torque, which may reduce the

likelihood of injury.

Hong and Li (2005) investigated the effects of load and carrying

methods on ground reaction force and gait temporal characteristics during

both stair modes in thirteen students with mean age of 12.21 years recruited

from a secondary school. The examined methods were included the

backpack and one strap athletic bag. The load weights were 0%, 10%, 15%,
 95

and 20% of BW. All subjects performed two modes of stair walking, an in-

shoe pressure measurement system was used to record and analyze the

insole pressure during stair walking with different loads. The insoles were

placed inside both of each subjects shoes to record the vertical reaction

forces of each sensor during contact against time. They were then asked to

walk on level ground then the stair walking trial began. In each trial, the

subjects climbed the 33 step stair-case, then turned around and walked

down to the starting point by following the same path. They found that the

load that caused a significant increase in the peak force in each bag and

stair mode was 15% of BW, except for stair ascent carrying the athletic

bag, where the load was 10% of BW. The maximum peak force that was

induced by this load in stair descent was 1.25 times that in descent with no

load, 1.89 times that in ascent with the same load, and 2.19 times that in

ascent with no load. The force-to-time ratio in descent was about three

times that in ascent. In both conditions weight of 15-20% was significantly

increased double support time.

Hong and Cheung (2003) recruited 23 primary school boys aged

between 9 and 10 years old. The subjects were assigned to carry backpack

load that was equivalent to 0%, 10%, 15%, or 20% of their BW. In each

session, the subject was walking around the perimeter of a basketball court

for 23 laps which resample the children walking from home to school. The

subjects were required to walk at their natural cadence with a two straps
 96

backpack. Gait was filmed in two dimensions. Result showed that the

walking pattern, including stride and temporal parameters, was not affected

by the carriage of loads up to 20% of BW. The walking velocity did not

change substantially even when subjects were carrying a load of up to 20%

of their BW. And there are no changes in the stride length, or cadence. The

similar results were found by Goh et al. (1998) who reported that there

were no significant changes in the gait pattern, walking speed, stride and

cadence over the loading condition with increase load of the backpack.

In addition Holt et al. (2005) observed increase ground reaction

forces and increase joint stiffness while walking with loads. There were

adaptations in the gait pattern that maintain force transmission at

acceptable levels. Increased variability in the acceleration of the head and

in the transmission ratios suggest a potentially destabilizing effect of load

carriage on the head trajectory.

There are many ways to measure the balance which such as force

platform (Chow 2006; ultowski and Aruin 2008), Accusway foreplate

(Gribble et al 2004), strain gauge force plate ( Talbott et al. 2004) , KAT

system (Yaggie and Armstrong 2004) and balance master (Palumbo et al.

2001; Ibrahim et al. 2006; Ibrahim & AbdElAzeem 2002). The balance

master found to be fair to good and even excellent reliability for most

parameters in children (Geldhof et al. 2006), and Liston et al. (1996) found

that in 20 stroke patients the test-retest reliability of data obtained using

 97

balance master is greatest for complex tests of balance and that dynamic

rather than static balance measures are valid indicators of functional

balance performance, and in a study by (Palumbo et al. 2001) the balance

master found to be moderate to high test-retest reliability for a healthy,

young subject population, both with and without the backpack.

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CHAPTER III

MATERIAL AND METHODS

 99

3. MATERIAL AND METHODS

A cross-sectional study was conducted on Saudi girls from the

intermediate stage, their ages ranged from 12 to 15 years. The aims of

this study were to measure the backpack weight carried by Saudi

schoolgirls aged 12-15 years, determine the different influences of

backpack loads on ear and shoulder level posture, determine the

different influences of backpack weight on musculoskeletal pain, and

Investigate the effectiveness of daily load of backpack used by Saudi

schoolgirls aged 12-15 years on dynamic balance and postural stability.

3.1. SUBJECTS

Healthy 175 Saudi girls from intermediate governmental schools in

Riyadh city who met our criteria were participated in the study. The girls'

age was between 12 to 15 years old, (Table 1). The study was conducted

from 12/2010, 1/1430 H to 1/2010, 1/1431 H.

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Table 1. Recruitment of the sample

No. of

Forms
No. of Not Without Rejected Agreeed Distributed

participants returned signature No. No. Forms

Schools

School A 230 95 11 5 102 40

School B 199 71 5 4 119 39

School C 161 43 2 15 100 34

School D 50 42 8 - - 39

School E 171 75 7 10 79 23

Total 811 326 33 30 400 175

No. : Number

INCLUSION CRITERIA

1- Saudi girls aged 12-15 years old.

2- Healthy girls without any acute or chronic disease.

3- Their BMI <95% to prevent misinterpretion of balance master results

for overweight subjects.

4- No recent fractures of upper or lower extremities.

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EXCLUSION CRITERIA

1- Sensory or motor neurological manifestations.

2- Postural deformity as scoliosis or kyphosis.

3- Musculoskeletal disorders as leg length discrepancy.

4- Any cause of balance disturbance as vertigo, inner ear infection and

blurred vision.

5- Girls with BMI equal to or more than 95%.

6- Any cause leading to inability of the student to stand upright on both

feet.

3.2. ETHICAL APPROVAL

This study was approved by the Health Rehabilitation Sciences

Department, Collage of Applied Medical Sciences, King Saud University.

Approval was obtained from the Directories of Ministry of Education for

the procedure, questionnaire, consent form and the information sheet

(Appendix I & II). The Ministry of Education allowed the researcher to

conduct this study in governmental intermediate girls schools in Riyadh

city.
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3.3. PROCEDURES

3.3.1. STUDY DESIGN

A descriptive cross-sectional study was designed to investigate the

effect of backpack's load on posture, the impact of backpack's load causing

musculoskeletal pain in different parts of girl's body, and investigate the

influence of daily backpack's load used by schoolgirls on dynamic balance.

3.3.2. INSTRUMENTS

QUESTIONNAIRE

We modified a questionnaire that was designed originally by Mehta

et al (2002), to assess backpack uses, neck and back pain (musculoskeletal

problems). We translated the questionnaire to the Arabic language, and

then the researcher selected the most important questions to concise the

questionnaire. The questionnaire (Appendix III) consists of five sections;

(section 1) contains demographic information about the girl (name, age,

date of birth, grade and class), (Section 2) contanies questions asking about

conditions that might be associated with neck and back pain, (Section 3)

includes questions asking about the presence or absence of pain, the

severity of pain (using happy face-sad face visual pain scale) Figure (1),

frequency and duration, and location of neck or back pain or others in the
 103

time frame of the present school year using a body diagram chart Figure

(2), (Section 4) asking about backpack use, the duration and frequency of

backpack use, the method of backpack carriage, other methods of carrying

school supplies, items carried in the backpack, and perception of the

backpack as "heavy" and " hard to carry", and the last part is (Section 5)

that ask about physical activities during the current school year, such as

participation in sports, and the amount of time spent in sitting activities

such as watching TV or working on computer.

Figure 1. Visual analog scale and happy face-sad face pain scale (Wong-

Baker)
 104

Figure 2. Body Diagram (Mehta 2002)

POSTURAL MIRROR

Portable single postural mirror (178cm height and 85cm width)

Figure (3) with hard metal frame, horizontal and vertical grids (10X10cm)

was used to assess the posture in different plane and was used for treatment

as a bio-feed back to correct mal-aligned posture. In this study the postural

mirror was used to assess the level of the shoulders and the level of ears

once without backpack and another while carrying the backpack, with the

use of two rulers (50cm lenght).

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Figure 3. Postural Mirror

DIGITAL WEIGHING AND HEIGHT SCALE

Electronic body scale (TCS-200-RT, China) was used to

electronically measure the weight of the participants. Measuring rod in the

same machine was used to measure the height of the students (Figure 4).
 106

Fiure 4. Digital Weighting Scale

ASSESSMENT SHEET

An assessment sheet (Appendix IIII) prepared by the researcher was

used to document the name, grade, class, the menstrual period, BW, BW

with backpack, backpack weight, height, body mass index (BMI), way of

carrying, percentage of backpack weight to the BW, and includes two

charts of the upper body diagram one resemble the posture without the

backpack and one resemble the body while carrying the backpack to

document the differences in level of shoulders and level of ears. The

assessment sheet includes a section where the researcher records her

observations.
 107

BALANCE MASTER SYSTEM

Balance Master System (Version 8.2 with version 7.0 software,

July 6, 2004) Figure (5) was used to measure the dynamic balance of the

students. The balance master measured the balance through electronic

walkway (force plate form) Figure (6).

The subject stands on the dual force-plate form and faces the monitor,

Figure (7) monitor showed a person standing on the force plate.

Figure 5. Balance Master Machine

 108

Figure 6. The electronic walkway

Figure 7. The monitor

Force sensors under the force-plate form measure the vertical forces

exerted by the subjects feet. A cable carries this information from the dual

force plate form to the computer.

 109

The electronic walkway is connected to the serial port of a computer;

this computer receives force measurements from the dual force plate form,

analyzes the information and generates a screen display and/or printed

report. The data and results from each test are stored on the hard disk of the

computer. The Balance Master System accepts patient heights from 10 to

99 inches (25-253 cm); it assumes that subject weight is between 40 and

300 pounds (18-136 kg).

One of the purposes of this study is to investigate the effect of the

backpack load on the dynamic balance of the students through using the

Balance Master Machine to test; (1) limits of stability (LOS); (2)

Step/Quick Turn (SQT); and (3) Step Up/Over (SUO) (Neuro Com

protocols 2011).

(1) limits of stability (LOS) quantifies the maximum distance a

person can intentionally displace their Center of Gravity (COG), i.e. lean

their body in a given direction without losing balance, stepping, or reaching

for assistance. This assessment quantifies several movement characteristics

associated with the subjects ability to voluntarily sway to various locations

in space, and briefly maintain stability at those positions. The measured

parameters are

1. Reaction Time (RT), which is the time in seconds between the

command to move and the patient's first movement.

 110

2. COG movement velocity (MVL), which is the average speed of

COG movement in degrees per second.

3. Endpoint Excursion (EPE), which is the distance of the first

movement toward the designated target, expressed as a percentage of

maximum LOS distance. The endpoint is considered to be the point

at which the initial movement toward the target ceases.

4. Maximum Excursion (MXE), which is the maximum distance

achieved during the trial.

5. Directional Control (DCL), which is a comparison of the amount of

movement in the intended direction (towards the target) to the

amount of extraneous movement (away from the target).

The length of each target trial is eight seconds. The LOS

consists of eight trials, normally conducted in the following order:

forward, forward-right, right, backward-right, backward, backward-

left, left and forward-left. During this assessment, the location of the

subjects center of gravity (COG) is displayed on-screen as a cursor,

providing visual feedback to the subject. The subject controls the

cursor by weight shifting. To perform the assessment task, the

subject must move quickly and accurately so that the cursor

coincides with targets that are also displayed on the screen Figure

(8).
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Figure 8. Limits of stability results (Neuro Com protocols 2011).

FUNCTIONAL IMPLICATIONS OF LIMIT OF STABILITY

TEST

Ability to voluntarily move the COG to positions within the LOS is

fundamental to mobility tasks such as reaching for objects, transitioning

from a seated to standing position (or standing to seated), and walking.

Limitations in a subject's LOS may correlate to risk for fall or instability

 112

during weight shifting activities such as leaning forward to take objects

from a shelf, leaning back for hair washing in the shower, opening the

refrigerator door, etc. Subjects with reduced stability limits in the antro-

posterior (AP) direction tend to take smaller steps during gait, while

laterally reduced limits can lead to broad-based gaits.

(2) The second dynamic test is the step/quick turn (SQT); this

assessment quantifies two movement characteristics as the subject takes

two forward steps, quickly turns 180 degrees, and steps back to the start

location. The measured parameters are turn-time and turn-sway velocity.

The SQT assessment consists of three trials to each side: left foot first and

then right foot first.

1. Turn Time (TT) quantifies the number of seconds required for the

individual to execute the 180-degree in-place turn. Time begins

when forward progression is arrested and ends when forward

progression in the opposite direction is initiated.

2. Turn Sway (TS) quantifies the postural stability of the individual

during the turn time defined above. Turn sway is expressed as the

average COG sway velocity in degrees/second.

3. The shaded area on each graphic represents performance outside of

the normative data range. Green bars indicate performance within the
 113

normal range; red bars indicate performance outside the normal

range. A numerical value is given at the top of each bar, Figure (9).

Figure 9. Step quick turn results (Neuro Com protocols 2011).

FUNCTIONAL IMPLICATIONS OF STEP/QUICK TURN

(SQT)

Ability to quickly change direction of travel is a critical component

of normal mobility. The task is sensitive to impairments of balance because

the subject must maintain stability during the turn while the visual and

vestibular inputs are being disturbed by rapid turning of the head and eyes.

The functional consequences are an inability to perform activities requiring

rapid turns, such as dancing or sports, and increased risk for falls during
 114

normal activities of daily living that requires turning (Neuro Com protocols

2011).

(3) The third dynamic test is the Step up/ over (SUO); this

assessment quantifies motor control characteristics as the subject steps up

onto a curb with one foot, lifting the body through an erect position over

the curb, swings the other foot over the curb and then lowers the body to

land the swing leg on the force plate form. The measured parameters are

raising index (force to rise), movement time, and impact index (impact

force). The SUO assessment consists of three trials for both sides: left foot

first and right foot first.

1. The COG trace for each trial is shown on the left side of the report.

2. Lift-Up Index (LUI) quantifies the maximum lifting (concentric)

force exerted by the leading leg and is expressed as a percentage of

the individuals weight.

3. Movement Time (MT) quantifies the number of seconds required to

complete the maneuver, beginning with the initial weight shift to the

non-stepping (lagging) leg and ending with the impact of the lagging

leg onto the surface.

4. Impact Index (II) quantifies the maximum vertical impact force as

the lagging leg lands on the surface, expressed as a percentage of

BW.
 115

5. The shaded area on each graphic represents performance outside of

the normative data range. Green bars indicate performance within the

normal range; red bars indicate performance outside the normal

range. A numerical value is given at the top of each bar. Figure (10)

FUNCTIONAL IMPLICATION OF STEP UP/OVER TEST

Climbing stairs and negotiating curbs and other obstacles is a critical

and complex element of gait in daily life. In the present study, the

reasercher tries to investigate the participants' ability to maintain balance

during climbing stair, descending stairs as it can be one of the most

challenging demands in their school daily activities (Neuro Com protocols

2011).
 116

Figure 10. Step up over result (Neuro Com protocols 2011).

The Balance Master Machine was moved by medical engineer from

the collage of applied medical sciences after getting the approval from the

head of the physical therapy department to the schools and placed in a

private room chosen by the principle of each school. The machine was

calibrated once move from school to another and tested for accuracy by the

medical engineer.
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3.4. PROCEDURE OF DATA COLLECTION

3.4.1. PILOT STUDY TO TEST VALIDITY AND

RELIABILITY OF QUESTIONNAIRE

Before starting this study, content validity of the questionnaire was

tested by developing a draft based on the literature and supervisors

experience. The researcher tests the validity and reliability of the translated

questionnaire on a convenience random sample of 20 girls from a private

school in Riyadh city age between 14-15 years old in grade 8. Instructions

were given to girls who seated in a quiet area to fill the questionnaire. The

content validity of the questionnaire was compared with questionnaire of

Mohan et al. (2007). To assess test-retest reliability, the same students

asked to answer the same questionnaire on the next day at the same time.

The data from the questionnaire was statically analyzed for validity and

reliability using SPSS version 18. To establish content validity (2experts of

physical therapists were evaluated the content validity of the

questionnaire). Test re-test reliability was computed using the intraclass

correlation coefficient (ICC). The results of Pearson correlation coefficient

found to be good with interclass correlation co efficient ICCs ranged

between 0.84 and 0.91. Which means the questionnaire is valid and

reliable.
 118

3.4.2. SELECTION AND PREPARATION OF THE SCHOOLS

Riyadh city was divided into five geographical regions, each public

school as follows: south region (school A), east region (school B), north

region (school C), center region (school D) and west region (school E).

An approval letter was given from the ministry of education to the

principle of each school. The principals in the selected schools were

contact and hand the ministry of education approval letters to initiate

school participation. The purpose of the study and details of the procedures

were explained to the principle of each school.

3.4.3. COLLECTION OF SAMPLE

In each school, class number two in all intermidate grades was

chosen as the main class to conduct the study and class number three

chosen as alternative class. This system was followed in all five schools. A

brief explanation about the study was given to the possible participants, a

consent form and an information sheet was given to each student for parent

approval, and the students asked to return them in the next day.

A total of 811 consent forms were distributed in the five schools. A

total of 326 (40.2%) consent form were returned with parents agreement.
 119

The remaining forms either rejected, not returned or returned without

signature as shown in Table (1)

The researcher chose the day and the date of visit to conduct the

study. The study was planned to take one week in each school. A wide and

quite room was chosen in each school to conduct the test.

After filtration of the consent form, 151 students did not met our

inclusion criteria so they were excluded either because of ear infection,

high or low blood pressure, vision problems, diabetes, recent fracture,

anemia, obese, heart disease, non-Saudi, and any girl has a menstrual

period in the day of the test. Students and their parents were blinded to the

day of data collection to prevent any unusual loading or unloading of the

backpacks.

3.4.4. PROCEDURE OF DATA COLLECTION

The researcher divided the collection of data into four stages:

1- Questionnaire data collection.

2- Demographical data Collection.

3- Postural mirror data collection.

4- Balance Master data collection.

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3.4.4.1. QUESTIONNAIRE DATA COLLECTION

The researcher explained the questionnaire items to each school

principle before distributing it to the participants. The day and date of

questionnaire distribution as well as collecting it was agreed upon with

each school principle.

A copy of the questionnaire was distributed to each participant who

gathered in their class, the researcher instructed the girls on how to

complete and answer the questionnaire. The girls were allowed the time

they need to complete the questionnaire, and the reasercher help them when

necessary to understand the questions. All questionnaires were reviewed by

the researcher to ensure that all questions were answered. This was

repeated in all five schools.

3.4.4.2. DEMOGRAPHIC DATA COLLECTION

Students and their parents were blinded to the day of data collection

to prevent any unusual loading or unloading of their backpacks.

The researcher called five participants to the examination room to avoid

crowdedness and non-accurate measurements. The researcher ensured that

the selected girls had no menstrual period in test day. Test was started by

measuring the weight of the student

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1- The student stood bare feet and was asked to her to remove her

jacket and scarves. The researcher measured the student's weight

times, without carrying backpack and with carrying backpack and

the weight of backpack alone to be more accurate. All weights were

measured in kilograms.

2- Standing height was measured while the student was in standing

relaxed position and erect with barefoot. The measurements recorded

in centimeter.

3- The BMI were calculated online using a web site that measured the

BMI instantly (Figure 11)

http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx . Any student with

BMI> 95 was excluded.

 122

Figure 11. BMI calculations

(http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx)

4. The way of carrying the backpack was observed once they walk in to

the room and documented and all of these informations were

documented in the assessment sheet.

3.4.4.3. POSTURAL MIRROR DATA COLLECTION

Each girl was asked to stand barefeet with her back facing to the

postural mirror and her face facing the researcher (Figure 12). The girl was

asked simply to stand erect and relaxed with her knees extended and head

in the center.
 123

Figure 12. Standing in front of mirror

As the mirror has grids, the level of shoulders were measured using two

rulers one to mark the level of the shoulders and another ruler to measure

the distance between the mark to the nearest grid (Figure 13), the same was

done regarding the level of ears (Figure 14) .

 124

Figure 13 . Measurement of Shoulder Level

Figure 14. Measurement of Ear Level

 125

The girl was asked to carry her backpack as she usually used to do and

to stand again in erect position. The level of shoulders and level of ears was

re-measured again. All measurements were written in the body diagram in

the assessment sheet.

3.4.4.4. BALANCE MASTER DATA COLLECTION

First the researcher explained the test to the participants and showed

them a demonstration of each test before starting. The researcher asked

each girl to remove her shoes and any extra clothes of jackets, sweaters or

scarfes. The data of the girl (name, weight, height, date of birth) were

entered to the balance Master system. Each girl was automatically given a

file number by the system where all information and tests were stored.

The researcher applied three dynamic balance tests, (Figure 15).

A. Limit of stability (LOS).

B. Step/Quick Turn (SQT)

C. Step up/over (SUO).

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Balance
Master

Limits of Step /quick Step up/

stability turn over

RT TT (L) LUI (L)

RT+ TT (L)+ LUI (L)+

MVL TT ( R) LUI

MVL+ TT (R)+ LUI (R)+

EPE TS (L) MT (L)

EPE+ TS (L)+ MT (L)+

MXE TS ( R) MT( R)

MXE+ TS (R)+ MT (R)+

DCL II (L)

DCL+ II (L)+

II ( R)

II (R)+

Figure 15. Dynamic Balance Tests.

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LIMITS OF STABILITY

The researcher makes sure that the feet of the girl were fixed in the

platform marks that specifically designed for this test. The girl was asked to

keep the feet in place and not to remove them or move them from the

platform marks. The girl was asked to keep her body straight and arms

beside her body and to look forward toward the screen of the computer.

The test was explained to each girl before starting. The instruction

for this test was to keep your cursor in the center target. When the blue

circle appears in the yellow outer target, move your cursor as quickly,

accurately and as far as you can towards the yellow target containing the

blue circle, and holds it steady. This procedure was repeated for all 8 points

(forward, forward-right, right, backward-right, backward, backward-left,

left and forward-left). If the girl failed to do the test at any point, the test

was repeated again. Once the girl finished the limits of stability test, the

researcher asked her to wear the backpack as she usually do and the test

was repeated again in the same manner but while carrying the backpack.

STEP/QUICK TURN

The researcher showed the girl how to do this test to ensure that they

understand the movement well, and showed a short video on the screen

explaining this test. Each girl was asked to place her feet in the platform
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marks set for this test. The instruction was; when the test begins, you will

see the HOLD STEADY sign at the top of the screen. Stand upright and as

steadily as possible. When you see GO sign, start with your left foot and

take two steps forward, turn around quickly to your left and return to the

end of the force plate where you started. You do not need to turn around to

face the monitor. After each trial, the girl was instructed to return to the

starting position. This test was applied for three trails and repeated to start

with right foot again for three trails too, then the girl was asked to wear the

backpack and the test was performed again while wearing the backpack. If

the girl failed to do the test for any reason, the test was repeated again.

STEP UP/OVER

The last test is the Step up/Over (SUO), the test explained by the

researcher first to ensure that the girl understand the test, and showed a

short video on the screen explaining the test. A step (45.5cm length, 33cm

width and 10cm high) was placed in the forceplate (Figure 16), and then

the girl stood with her feet fixed in the platform markers. The instruction

was when the test begins; you will see the HOLD STEADY sign at the top

of the screen. Stand upright and as steadily as possible. When you see the

GO sign, quickly step up onto the curb with your left foot, lift the other foot

over the curb and step down with your right foot, and stand as steadily as

possible. After each trial, the girl was instructed to return to the starting
 129

position. This test was performmed for three trails and repeated to start

with right foot again for three trails. The girl was asked to repeat the test

again while wearing the backpack. If the girl failed to do the test at any

point, the test will repeated again.

Figure 16. Placement of the step on the force plate

All of these data were given a number and saved in the hard desk of

the computer and printed at the end of the day. Any observation during

performing these tests was documented in the assessment sheet. These

procedures were repeated with each girl.

 130

In each school, we spent one week and after that the Balance Master

Machine was moved to the next school and placed in a special room. The

machine was then calibrated again by the medical engineer. The same

process of procedure was done in all schools. After finishing the tests, the

researcher thanks the girls and presented a memorizing gift to them as

gratitude.

3.5. DATA ANALYSIS

A descriptive statistical analysis of all data was presented by mean

and standard deviation.

The percent of the backpack to the BW was calculated using the equation;

Backpack weight / BW X 100 =

The level of the shoulders and level of ears were calculated by

subtracting the differences between values of with the backpack and

without the backpack using the following equations.

Level of ear with backpack level of ear without backpack =

Level of shoulder with backpack level of shoulder without

backpack=

To test the hypothesis, paired t- test was used to test the effect of

backpack load on posture, musculoskeletal pain and the dynamic balance

 131

measurements at baseline without carrying backpack and with carrying

backpack. ANOVA test was used to compare between means differences of

backpack weight and age, grade and way of carrying. Questionnaire items

were representing as percentage. The Pearson correlation coefficients were

used to find the relation between the age, BMI, the backpack percentile

weight, the backpack weight and the different variables. The data were

analyzed using the Statistical Package for the Social Sciences (SPSS)

version 18 and Microsoft Excel (2007) program to draw the figures.

 132

CHAPTER IV

RESULTS
 133

4. RESULTS

The aims of this study were to measure the backpack weight carried

by 175 Saudi schoolgirls aged 12-15 years, to measure the backpack load,

to determine the influences of backpack loads on ear and shoulder posture

level, determine the different influences of backpack load on

musculoskeletal pain and to investigate the effect of daily load of backpack

on dynamic balance and postural stability. All 175 students recruited for

the study completed all tests.

Table 2. The descriptive statistics of the demographic variables

Number of participants

NO 13 58 61 43 Tot min max mea SD (K- P

al n S)
No.
age 12 13 14 15 175 12 15 13.7 0.91 0.7 0.66
7 3
Weight 41.98 44.73 47.37 49.7 175 24.8 64.9 46.6 7.54 0.6 0.76
(kg) 0 6 7
Height 150.6 151.5 154.3 155. 175 127 169. 153. 6.40 0.8 0.47
(cm) 9 0 3 5
backpac 5.51 4.57 4.45 4.46 175 2.1 7.40 4.57 1.05 1.0 0.20
k weight 7
(Kg)
BMI 18.34 19.2 19.81 20.6 175 13.7 23.9 19.7 2.24 1.0 0.23
0 0 5
Backpac 13.27 10.62 9.58 9.1 175 4.54 19.7 10.0 2.92 1.2 0.11
k% 6 8 0
No. : Number Min: minimum
Max: Maximum SD: stander deviation
K-s: Kolmogrov-smirnov test P: p value
 134

Participant characteristics in addition to the values of backpack

weight, backpack percentile to BW are presented in (Table 1). (The mean

value of age was (13.77 0.91 years), the mean of girls' weight was (46.66

7.54 kg), the mean of height was (153.286.40cm), and BMI percentile

was (19.701.05%)). The mean of the backpack weight and backpack

percentile to the BW of the girls were (4.571.07Kg), and (10.081.20%)

respectively. The participants in this study were 13 subjects aged 12 years,

with mean weight and height of 41.98Kg and 150.69cm respectively. Their

backpack weight and backpack percentile were 5.51Kg and 13.27%

respectively. The participants aged 13 years were 58, with mean of weight

44.73Kg, height 151.5cm and BMI 19.2. Their backpack weight mean were

4.57Kg and backpack percentile mean 10.62%. The participant aged 14

years were 61, with means of weight, hight & BMI of 47.37 Kg, 154.3cm

and 19.81 respectively. Their backpack weight mean were 4.45Kg and

backpack percentile mean 9.58%. The participant aged 15 years were 43,

with mean of weight 49.7Kg, height 155 cm and BMI 20.6. Their backpack

weight mean were 4.46Kg and backpack percentile mean 9.1% (Table 2).
 135

Table 3. Frequency distribution of subjects regarding the

Grade, way of carrying and period variables

Variable Ccategories Frequency Percentage

(%)
Grade 7 57 32.6
grade Grade 8 65 37.1
Grade 9 53 30.3
Total 175 100
R 117 66.9
Way of L 40 22.8
carrying B 18 10.3
Total 175 100
Menstrual Yes 143 81.7
period No 32 18.3
Total 175 100
R: Right L: Left B: Both

Table (3) showed that the frequency distribution of the participants

regarding the grade was 32.6% (57) of girls in grade 1, 37.1% (65) in grade

2, and 30.3% (53) in grade 3. Way of carrying backpack was 66.9% (117)

on right shoulder, 22.8% (40) on left shoulder and 10.3% (18) on both

shoulders. About 81.7% (143) of girls got menstrual period and 18.3% (32)

of them not.

Figure (17), showed the backpack percentile according to the girls

age. Girls aged 12 years recorded the highest backpack percentile

(13.27%), while girls aged 13, 14, and 15 years carried backpack percentile

of 10.62%, 9.8%, and 9.1% respectively.

 136

14 13.27%

12
10.62%
9.8%
10
9.1%
Backpack %

12 13 14 15

Figeure (17). The backpack percentile according to the girls age.

Table (4): one way ANOVA test of backpack load regarding the age, grade,
and way of carrying.
Variable Variation source Sum of DF Mean f- sig

squares square value

Backpack Between Groups 12.88 3.00 4.29 4.09 0.01

Age Within Groups 179.46 171.00 1.05

Backpack Between Groups 1.54 2.00 0.77 0.69 0.50

Grade Within Groups 190.80 172.00 1.11

Backpack Between Groups 7.94 2.00 3.97 3.70 .027

Way of carrying Within Groups 184.40 172.00 1.07

DF: Degrees of freedom Sig: Significant

 137

Table (4) showed that there is a significant difference in means of

backpack load regarding the age, and way of carrying (p<0.01, 0.027)

respectively. There was no significant difference between backpack and

students grade (p>0.05).

Table (5): Least Significant Differences (Post Hoc) test of assigning the
differences in means of backpack weight and age.
Variable Age (years)

Mean 12 13 14 15

12 5.51 * * *

Age 13 4.57

(years) 14 4.45

15 4.46

The post hoc tests, which is LSD Least Significant Difference, as

shown in table (5) showed the differences in means between the age 12

compared with 13,14 and 15 age, which means that the mean of

backpack load of the subjects of age 12 was significantly more than of

each one of the other age groups.

 138

Table (6): Least Significant Differences test of assigning the differences in

means way of carrying and body weight
way of carrying

mean R L B

R 4.44

L 4.73

B 5.09 *

R: Right L: Left B: Both

The LSD post hoc test between the means of backpack and way of

carrying revealed that the backpack weight is high with students carrying

backpack on both shoulders than students carrying backpack on the right or

left shoulder Table (6).

Table (7 ): Pearson correlation coefficients between backpack load and

Other variables

Variables r value

Weight -0.58 **

Height -0.53 **

BMI -0.49 **

** The value of r is significant at level of significant 0.01

BMI : Body mass index

 139

Pearson correlation in table (7) showed that there is a significant negative

relationship between the backpack load and each of the variables: weight (r

-0.58), height (r -0.53), and BMI (r -0.49), which means that with the

increase of weight, height or BMI, the backpack load will decrease, and

vice versa.
 140

The questionnaire consists of five sections; section (1), asked about

demographic information of subjects is presented in table (2).

Table (8). Questions about Back, neck and shoulder pain locations.

Question number Answers frequenc %

-1 110 62.9

/
62 35.4

Missing 3 1.7

-2 49 28

/ ,
57 32.6

13 7.4

15 8.6

42 24

76 43.4
3

4 2.28

1 .74

5 2.85

7 4

3 1.71

3 1.71

%: percentage
 141

Section 2, represents the description of suffering and location of back

and neck pain (table 8). Hundred ten girls (62.9%) reported neck or back

pain at some time since beginning of the school year. There was a variation

in the responses to questions about the location of the neck pain, back pain

or pain in other areas. About 76 (43.43%) of the grils shaded the shoulder

area, 57 (32.6%) shaded the neck area and 42 (24%) of girls shaded low

back area but some students selected more than one region in the body

diagram as they dectected pain in more than one location.

 142

Table (9). Questions about Back, neck and shoulder pain intensity,
duration, and frequency.

Question number Answers frequenc %

- 3 30 17.1

35 20

55 31.5

32 18.3

20 11.4

Missing 3 1.7

-4 , / 142 81.1

32 18.3

Missing 1 .6

-5 87 49.7

87 49.7

Missing 1 .6

-6 3-1 59 33.7

7-4 35 20

11-8 36 20.6

11 10 5.7

Missing 35 20

%: percentage
 143

Section (3), included questions that gave more specific information

about the location, duration, and frequency of pain. Fifty five of girls

(31.5%) reported tolerable pain feeling, and 20 girls (11.4%) reported

severe pain, and 30 girls (17.1) reported no pain (Table 9).

Only 32 girls (18.3%) recorded no pain in the neck or back during

carrying backpack, and 142 girls (81.1%) recorded that they have pain

during carrying backpack. The answers reported about the question of the

repetition of feeling neck or back pain was equal; 87 girls (49.7%)

answered either for yes or no. Fifty nine girls (33.7%) checked that they

suffered from one to three times neck or back pain since beginning of the

academic year, 35 girls (20 %) suffered from 4 to 7 times, 36 girls (20.6%)

suffered from 8-10 times and 10 girls (5.7%) suffered more than ten times.

Table (10) showed the results of the third section of the questionnaire

about backpack use and way of carrying. Most of the girls 153 (87.4%)

carryied their backpack on one shoulder either on right or left, 17 (9.7%) of

girls carried their backpack on both shoulders and only 4 girls (2.2%) used

trolley. Seventy nine girls reported that their backpack was heavy and 58

girls (33.1%) reported it is very heavy. The weight of backpack was very

difficult to carry most of the weeks days were reported by 84 girls (48%),

59 girls (33.7%) reported from two to three times per week and 16 girls

(9.1%) reported that the backpack sometimes is difficult to carry.

 144

Table (10). Questions about the frequency of backpack use, perception and
way of carrying

Question number Answers Frequency %

-1 4 2.3

153 87.4

17 9.7

Missing 1 .6

-2 1 .6

36 20.6

79 45.1

58 33.1

Missing 1 .6

( 4 5 -3
84 48

).

( 23 59 33.7
).

( 1 ) 16 9.1

( 1 8 4.6
)

5 2.9

Missing 3 1.7

%: Percentage
 145

Table (11). Questions about, difficult activities during carrying backpack

Question number Answers Frequency %

4 , - 124 70.9

85 48.6

32 18.3

71 40.6

36 20.6

76 43.4

8 4.6

%: Percentage

According to the response of question about difficulty of doing some

activities during carrying backpack, 124 girls (70.9%) reported that the

most difficult task was going up stairs carrying their backpack, compared

to 85 girls (48.6%) getting up or down from car or bus was the most

difficult task for them, 32 girls (18.3%) indicated that it is difficult to walk

up. Thirty six girls (20.6%) reported difficulties during walk down, while

girls (43.4%) found difficulties during pick up of things and only 8 girls

(4.6%) found difficulties with opening doors, some girls reportd more than
 146

one activity were difficult to do and they selected more than one choice

(Table 11).

Table (12). Questions about, the frequency of backpack use, and use of
additional bag.

Question number Answers Frequency %

-5 5-1 66 37.7

15-5 77 44

31-16 15 8.6

45-31 4 2.3

45 < 2 1.1

Missing 11 6.3

-6 5-1 45 25.7

15-5 61 34.9

31-16 16 9.1

45-31 8 4.6

45 < 5 2.9

Missing 40 22.8

, -7 73 41.7

97 56


Missing 5 2.8

%: Percentage
 147

The answers about the period of carrying backpack to school

revealed that 66 girls (37.7%) carried their backpack 1-<5 minutes, 77 girls

(44%) carried their backpack 5-15 minutes, 15 girls (8.5%) carried their

backpack 16-30 minutes, 4 girls (2.3%) carried their backpack 31-45

minutes and only 2 (1.1%) carried their backpack more than 45 minutes.

Forty five girls (25.7%) reported that they carried their backpack from

school to home 1-<5 minutes, 61 girls (34.9%) of girls carried their

backpack 5-15 minutes, 16 girls (9.1%) carried their backpack 16-30

minutes, 8 girls (4.6%) carried their backpack 31-45 minutes, and only 5

girls (2.9%) reported that they carrying their backpack more than 45

minutes. More than two third of the girls 98 (56%) answered (no) for the

question about the use of additional bag to carry their things to school and

73 girls (41.7%) checked yes hat they use additional bag (Table 12).

Table (13). The frequency of time spent in watching TV or using

computer

Question number Answers Frequency %

-
4 2.3

2-1 20 11.4

4-3 31 17.8

4 98 56

Missing 22 12.6

%: percentage
 148

The last section of the questionnaire was about the amount of time

spent in watching TV or using computer. Ninety eight girls (56%) reported

that they spend 4 hours or more, 31 girls (17.8%) spend 3-4 hours, 20 girls

(11.4%) spend 1-2 hours and only 4 girls (2.3) spend less than one hour

(Table 13).

Table (14). Paired t-test for the mean difference of the right and left level

of ear and shoulder.

Variable Mean Std. Std. Error t df Sig. (2-

Deviatio Mean tailed)
n
Ear L -.00629 .57727 .04364 -.144 174 .886

Ear L+

Shou. L .51714 1.50785 .11398 4.537 174 .000

Shou. L+

Ear L: Ear level without carrying backpack

Ear L+: Ear level with carrying backpack
Shou L : Shoulder level without carrying backpack
Shou L+: Shoulder level with carrying backpack
Std. standere DF: Degrees of freedom Sig: significant

Table (14) showed that there was no significant difference between

the mean of the right and left ear level (p<0.886). The mean difference

between right and left shoulder showed a highly significant difference

(p<0.000).
 149

Table 15. Limit of stability of girls without and with carrying different
backpack percentile.

5- 10- 15-
Total Std. Std. Std. Std.
LOS <10% <15% <20%
Mean Deviation Deviation Deviation Deviation
Mean Mean Mean
RT
0.97 0.25 0.97 0.25 0.99 0.23 0.98 0.28
RTBP
0.88 0.21 0.9 0.23 0.87 0.19 0.82 0.15
MVL
4.84 1.56 4.8 1.59 4.87 1.53 5.12 1.72
MVLBP
5.23 1.44 5.19 1.56 5.28 1.25 5.34 1.49
EPE
74.64 11.61 74.32 11.07 75.20 12.40 74.60 12.49
EPEBP
76.81 11.41 75.97 10.83 78.22 11.66 74.51 14.80
MXE
93.47 9.37 93.6 9.05 92.83 10.04 95.13 7.87
MXEBP
93.38 9.66 93.27 9.35 93.45 10.16 93.16 10.27
DCL
67.50 11.35 66.61 11.26 68.48 11.87 69.03 9.38
DCLBP
65.51 10.87 65.32 10.33 65.34 12.15 67.78 7.47

RT: Reaction time without backpack

RTBP: Reaction time with packpack

MVL: Movement velocity without backpack

MVLBP: Movement velocity with backpack

EPE: End point excursion without backpack

EPEBP: End point excursion with backpack

MXE: Maximum excursion without backpack

MXEBP: Maximum excursion with backpack

DCL: Directional control without backpack

DCLBP: Directional control with backpack

Std. Stander
 150

Table (16). Paired Samples t-Test of limit of stability without and with

carrying backpack.

Paired Differences

Std. 95% Confidence Interval

Deviati Std. Error of the Difference Sig.

Mean on Mean Lower Upper t df (2-tailed)

Pair 1 RT RT+ .088 .233 .018 .05363 .123 5.018 174 .000

Pair 2 MVL - MVL+ -.387 1.194 .090 -.565 -.209 -4.289 174 .000

Pair 3 EPE- EPE+ -2.171 9.618 .727 -3.606 -.736 -2.986 174 .003

Pair 4 MXE -MXE+ .086 6.153 .465 -.832 1.004 .184 174 .854

Pair 5 DCL -DCL+ 1.984 8.182 .619 .763 3.204 3.207 174 .002

Rt. Reaction time Rt+. Reaction time with carrying backpack

MVL. Maximum velocity MVL+. Maximum velocity with carrying backpack

EPE endpoint excursion EPE+ endpoint excursion with carrying backpack

MXE maximum excursion MXE+ maximum excursion with carrying backpack

DCL directional control DCL+ directional control with carrying backpack

Std. : standere df: Degree of freedom sig. significant

Table (15) showed the descriptive statistics of LOS in relation to

backpack weight without and with carrying backpack. The table devides

the data according to the backpack weight percentage to the BW in three

catagories 5-<10%, 10-<15%, and 15-<20% and showed that he effect of

backpack load on LOS variables started from 5<10% .Table (16) recorded

the paired t-test of all LOS variables. It showed the highly significant

differences between reaction time (RT), maximum velocity (MVL) without

 151

and with carrying backpack (p< 0.000). The end point excursion without

(EPE) and with (EPE+) carrying backpack showed significant difference

(p<0.003), also directional control without (DCL) and with carrying

backpack (DCL+) reported significant difference of P<0.002. There was no

significant difference between maximum excursion (MXE) with and

without carrying backpack (p>.854) (Figure 18 & 19).

6
5.229
4.842
5

Without BP
3
With BP

2
0.974 0.885
1

0
Reaction Time Reaction Time + MVL MVL+

Figure (18). The reaction time and maximum velocity without and with

backpack
 152

100

90

80
EPE
70
EPEL
60
MXE
50
MXEL
40 DCL
30 DCLA
20

10

0
EPE EPEL MXE MXEL DCL DCLA

Figure (19). The mean of endpoint excursion, maximum excursion, and

directional control without and with carrying backpack.

 153

Table 17. Step/quick turn (SQT) of girls without and with carrying
different backpack percentile.
Variables Total Std. 5- Std. 10- Std. 15- Std.

Mean Deviation <10% Deviation <15% Deviation <20% Deviation

TTSQTL 2.13 0.94 2.1 0.72 2.19 1.15 2.133 1.17

TTSQTLA 1.88 0.76 1.88 0.72 1.87 0.79 1.935 0.95

TTSQTR 1.94 0.85 1.93 0.82 1.96 0.88 1.892 1.12

TTSQTRA 1.70 0.67 1.73 0.74 1.68 0.58 1.535 0.52

TSL 26.45 6.41 25.96 5.57 26.93 7.11 28.05 8.93

TSLA 26.1 6.60 25.5 6.23 26.36 6.57 29.84 8.91

TSR 26.9 7.27 26.4 7.19 27.12 6.40 30.32 11.99

TSRA 25.3 5.70 25.0 6.04 25.62 5.33 26.0 5.46

TTSQTL: Turn time step quick test left leg without backpack in seconds.
TTSQTLA: Turn time step quick test left leg with carrying backpack.
TTSQTR: Turn time step quick test right leg without backpack.
TTSQTRA: Turn time step quick test right leg with carrying backpack.
TSL: Turn sway left without carrying backpack.
TSLA: Turn sway left with carrying backpack.
TSR: Turn sway right without carrying backpack.
TSRA: Turn sway right with carrying backpack.
Std: Stander
 154

Table (18) Paired Samples Test of STEP/QUICK TURN (SQT)

Paired Differences
95% Confidence
Variables Std. Std. Interval of the Sig.
Deviatio Error Difference (2-
Mean n Mean Lower Upper t df tailed)
TTSQTL .254 .742 .056 .144 .365 4.536 174 .000
TTSQTL+
TTSQTR .241 .622 .047 .1481 .334 5.127 174 .000
TTSQTR+
TSL .395 6.683 .505 -.602 1.392 .781 174 .436
TSL+
TSR 1.628 6.731 .509 .624 2.632 3.200 174 .002
TSR+
TTSQTL: turn time step quick test left leg without backpack in seconds.
TTSQTL+: turn time step quick test left leg with carrying backpack.
TTSQTR: turn time step quick test right leg without backpack.
TTSQTR+: turn time step quick test right leg with carrying backpack.
TSL: turn sway left without carrying backpack.
TSL+: turn sway left with carrying backpack.
TSR: turn sway right without carrying backpack.
TSR+: turn sway right with carrying backpack.
Std.: standere DF: Degree of freedom sig. significant
 155

2.2
2.15
2.1
2.05
2
TTSQTL
1.95
TTSQTLA
1.9
1.85
1.8
1.75
1.7
Total 5-<10% 10-<15% 15-<20%

Figure(20). The mean of Turn time (left foot) without and with carrying
backpack.

1.8

1.6

1.4

1.2
TTSQTR
1
TTSQTRA
0.8

0.6

0.4

0.2

0
Total 5-<10% 10-<15% 15-<20%

Figure(21). The mean of Turn time (right foot) without and with carrying
backpack.
 156

35

30

25

20
TSR
TSRA
15

10

0
Total 5-<10% 10-<15% 15-<20%

Figure(22). The mean of Turn sway (right foot) without and with carrying

backpack.

Paired sample t-test for the step quick turn variables revealed

significant difference in turn time of left and right limb without carrying

backpack (TTSQTL, TTSQTR) and with carrying backpack (TTSQTL+,

TTSQTR+) (P<0.000). A significant difference recorded for the turn sway

right limb without carrying backpack (TSR) and with carrying backpack

(TSR+), (P<0.002). There is no significant difference in the turn sway for

the left limb (Table 17&18) (Figure 20, 21& 22).

 157

Table 19. Step up/ over (SUO) of girls without and with carrying different
backpack percentile.
Variable Std. 5- Std. 10- Std. 15- Std.
Total
Deviation <10% Deviation <15% Deviation <20% Deviation
LUIL
17.42 5.99 16.91 5.33 18.09 6.60 18.18 7.55
LUILA
18.19 6.16 17.8 5.89 18.85 6.54 17.73 6.58
LUIR
18.56 6.25 17.75 5.82 19.58 6.82 18.81 5.71
LUIRA
17.82 6.42 17.39 5.91 18.51 7.22 17.03 5.83
MTL
1.95 0.46 1.94 0.45 1.95 0.48 1.9264 0.49
MTLA
1.80 0.40 1.82 0.41 1.77 0.40 1.83 0.42
MTR
1.81 .44 1.83 .44 1.82 .45 1.68 .32
MTRA
1.8 .39 1.92 .4 1.78 .38 1.76 .39
IIL
21.68 10.39 21.27 10.17 21.53 10.10 27.00 13.54
IILA
21.91 9.79 20.95 9.98 22.23 9.17 28.51 11.26
IIR
22.14 10.14 21.07 10.64 22.89 9.30 27.73 9.09
IIRA
20.96 9.17 20.13 9.21 21.30 8.54 27.18 10.53

LUIL: Left up index left leg without backpack

LUILA: Left up index left leg with backpack
LUIR: Left up index right leg without backpack
LUIR: Left up index right leg with backpack
MTL: Movement time left leg without backpack
MTLA: Movement time left leg with backpack
MTR: Movement time right leg without backpack
MTRA: Movement time right leg with backpack
IIL: Impact index left leg without backpack
IILA: Impact index left leg with backpack
IIR: Impact index rght leg with backpack
IIRA: Impact index right leg with backpack
Std: Stander
 158

Table (20). Paired Samples t-Test for Step up/ over test without and with
carrying backpack

Paired Differences
Mean 95% Confidence Sig.
Variables Differ Std. Std. Interval of the (2-
e- Deviati Error Difference tailed
nces on Mean Lower Upper t df )
.145 .331 .025 .096 .195 5.803 174 .000
MMTL- MTL+
.016 .249 .019 -.021 .053 .855 174 .394
MMTR -MTR+
-.224 7.03964 .532 -1.274 .826 -.421 174 .674
IIL IIL+
1.179 6.888 .521 .151 2.207 2.264 174 .025
IIR IIR+
MTL: movement time left without carrying backpack.
MTL+: movement time left with carrying backpack.
MTR: movement time right without carrying backpack.
MTR+: movement time right with carrying backpack.
IIL: impact index left without carrying backpack.
IIL+: impact index left with carrying backpack.
IIR: impact index right without carrying backpack.
IIR+: impact index right with carrying backpack.
Std: Stander DF: Degree of freedom Sig.: significant

Table (19, 20) showed the descriptive mean and standard deviations and

paired sample t-test of the step up/over test. The results revealed significant

difference between the movement time of the left limb without carrying

backpack (MTL) and the movement time of the left limb with carrying

backpack (MTL+) P<0.000. The impact index for the right limb without

carrying backpack (IIR) and the impact index for the right limb with

carrying backpack (IIR+) showed significant difference (P<0.025).

 159

CHAPTER V

DISCUSSION
 160

5. DISCUSSION

The aims of this study were to measure the backpack weight carried

by 175 Saudi schoolgirls aged 12-15 years, to determine the influences of

backpack loads on ear and shoulder level posture, to determine the different

influences of backpack weight on musculoskeletal pain and investigate the

effectiveness of daily load of backpack on dynamic balance and postural

stability. All 175 students recruited for the study completed all tests.

5.1. BACKPACK LOAD

5.1.1. WEIGHT OF THE BACKPACK

The weight of backpack being carried in this study by Saudi schoolgirls

aged 12-15 years ranged from 2.1 to 7.4 Kg with a mean of 4.57Kg.

The average backpack weight carried by girls in the present study are

nearly similar to that reported by by Cavallo et al. (2003) who examined

39 fourth graders students and found that the mean of backpack weight

was 3.90 Kg. Watson et al. (2003) recorded a five day bag weight diary of

1446 students with age between 11 to 14 years; they found that the median

five days average load was 4.5 kg. And by Forjuoh et al. (2004) who

found that elementary school students carried a mean weight of 4.9 kg.
 161

The same results reported by Skaggs et al. (2006) found the mean

backpack weight was 4.0 kg on a sample of 1540 students. Present study

conducted in Saudi Arabia and in Riyadh city, the same is done by Al

Hazzaa (2006) who studied 702 boys aged 6-14 years, from elementary

school in Riyadh city, his results of backpack mean weight (3.2 kg) was

less than our results.

The mean weight of backpack in this study is less than that reported

by Forjuoh et al. (2003) who found that the mean weight of backpack was

2.6 kg in three elementary schools in central Texas on 745 students. And

also higher than a study by Murphy et al. (2007), who found the mean bag

weight on the day of the study was just over 3 kg.

The mean weight in the current study is lighter than that found by

Pascoe et al. (1997) in USA reported that the mean of backpack weight was

equal to 7.7 Kg. In Italy Negrini et al. (1999) examined school children

with mean of age 11.6 years old and found that the average load which

calculated over a period of 3 weeks for 237 students was 9.3 Kg. and

Whittfield et al. (2005), in New Zeland, found that the mean weight of the

backpack of third former (7kg) and sixth formers was (6.3kg) with overall

mean of 6.6 kg. Dockrell et al. (2006), in Ireland, the recorded schoolbag

weight carried by first year secondary school students was equal to 6.2kg.

In India, Mohan et al. (2007) found that school students with age of 10-15

years carried school bag with mean weight of 6.1Kg. The highest record is
 162

reported by Ibrahim (in press) who measured the backpack weight of a

group of girls aged 11-14 year; she found that the mean and standard

deviation of backpack weight carried was 10.9413.044.

The results of present study revealed that girls age 12 years, in spite of

their smaller height and weight, carried heavier backpack than other ages

with mean of 5.51Kg and the mean weight of backpack decreased with

increase age increment which is consistence with the results of Goodgold

et al. (2002) was consistence with our results; they found that younger

children carried proportionally greater backpack loads in 345 students

aged between 11 to 14 years. Whittfield et al. (2005) found that the third

grade carry heavier schoolbag than sixth grader students. Skaggs et al.

(2006) who found younger children had a greater ratio of backpack weight

to BW and were more likely to have back pain. The finding of Skaggs et

al. (2006) who found younger children had a greater ratio of backpack

weight to BW and was more likely to have back pain. But our findings is

in contrast with the finding of Forjuoh et al. (2003) and Forjuoh et al.

(2004) who found that the weight of backpack increased significantly with

increasing grade level.

The differences between the results of the current study and other

studies can be referred to the differences in the culture, school

requirements, school curriculums, differences in number of books and

accessories, quality of books and quality of the backpacks. The wide range
 163

of bag weights in this study (from 2.10 to 7.40 kg) might be explained by

the fact that there is differences between schools, grades or school students

brings more books to school each day than others. Some empty schoolbags

may have been heavier than others, but empty schoolbags were not

measuered in the current study. In addition, a greater number of subjects

taken at school by the younger age group, or may reflect the inexperience

or inability of this age group in deciding the necessary books or supplies to

take to school. The differences between girls in the same class, as some

girls may carry to school objects not needed for the day in additional to the

lack or inadequate adult supervision.

5.1.2. BACKPACK WEIGHT AS A PERCENTAGE OF BW

The different international organizations have recommended carrying

backpack percentile between 5-20% of ones BW as a safe maximum load,

however, no universal guideline has been determined.

The backpack percentile to the BW of the girls in the current study

were (10.081.20%) ranging from 4.54 % to 19.76 % which a slightly

increase above the recommended limit of less than 10% of BW. However

this backpack percentile in present study reaches the maximum of 19.76%

which is far from the recommended limit of less than 10% of BW.
 164

The results of present study are consistent with the study by Cavallo

et al. (2003) who reported that the backpack weight percentage of BW was

more than 10% in age between 9 and 10 years old. In a study conducted by

Korovessis et al. (2005), they found that the weight of backpacks

represented 10.6 3.5% of the students BW. And consistence with a

study conducted in Saudi Arabia by Al Hazzaa (2006) who found that the

mean percentage of backpack weight to the BW was 10.7% in 702 boys

aged 6-14 years with range from 6.2% to 12.05% BW. Whittfield et al.

(2005) found that the mean of schoolbag weight in their study was 11.7%

of BW. Our results is also consistence with the study by Dockrell et al.

(2006) recorded that the mean schoolbag percentage was 12% and ranged

from 3%-30% of 57 students with mean age of 13.1 years. And Mohan et

al. (2007) who found that most of Indian children with age 10-15 years

carried school bag weighing between 10%-18% of their BW.

In contrast to our results, Forjuoh et al. (2003) conducted a study on

745 students from three elementary schools, they found that the percentile

of backpack was 8.2% of student BWs, 26% only of the students carried

a backpack that weighed at least 10% of their BWs.

The mean percent of backpacks weight to the students' BW carried

by the students in present study are much lighter than those reported by

Negrini and Negrini (2007); Negrini et al. (1999) 22%, Pascoe et al.

(1997) 17%, Mohan et al. (2007) 17.5%, Ren et al. (2005); Goodgold et al.
 165

(2002) more than 15%. This might be caused by societies and cultural

differences as in our country female students don't have musical or sport

classes as their children need to carry musical instruments and sport wear

or can be referred to difference in body configurations between countries.

The results of present study revealed that the range of backpack

percentile to the BW was 4.54 % to 19.76%, the lower range of the

percentile might cause by measuring the backpack in the lightest day of

lower demand as some of the girls mentioned during the day of the

measurement their backpacks were lighter than other days of the week, so

we can expect the lower range to increase if we consider the average

weight of the whole week. The upper range of the current study was about

20% of the student's BW, this may explained the demand of the school

requirements carrying many books, school suppliers or due to teachers'

demands of bringing heavy note books and bringing all books of the

schedule day instead of keeping some of them in the school or at home.

Teachers and students may do not follow a specific schedule and bringing

most of the books every day.

Comparing with the literature data and various professional

associations (American Chiropractic Association 2004; American Physical

Therapy Association 2009; American Occupational Therapy Association

2009), they recommended to limit the backpack weight to the BW between

5 to 20% BW and this limit are not evidence based. Mohan et al. (2007)
 166

suggested that carrying school bag weighing 10% of BW would be too

heavy for students aged 10-14 years to be able to maintain their normal

postural alignment. In other words carrying a load of less than 10% of BW

school bag is recommended to maintain good postural alignment. Guyer

(2001) recommended that students should carry no more than 10% of their

BW on their backs and carry their backpacks properly.

In addition, Ren et al. (2005) reported that, percent of BW does not

take into account the childs height, body fat, or muscle strength so the

risk of injury may be different for two children of the same weight

carrying the same backpack load. For example, a 15 year old boy who is at

an ideal weight for his height may well be able to safely carry a heavier

backpack than a classmate who is sedentary and overweight. Therefore,

rather than a specific percent BW limit, students are taught how to

recognize when their backpack is too heavy, this was observed by

Goodgold et al. (2002) who found no significant differences for children

reporting that their backpack was uncomfortable and those carrying

greater than 15% of BW as compared with children carrying lighter loads.

They referred this to the varied abilities of children to carry proportionally

similar loads, and conclude that percentage of BW does not take into

consideration upper body strength or the childs height, which affects the

position of the backpack on the back. For children who are smaller or

weaker, compensatory strategies that alter posture and strain

 167

musculoskeletal structures may be needed with proportionally lighter

loads. In additional, Alkhabbaz et al. (2008) also reported that this

percentage lacks consideration of other factors (distance, period of

carrying a backpack and backpack design).

5.2. WAY OF CARRYING

Besides the concern over backpack weights, the method of carrying

these packs has a huge impact on any potential health hazards. The results

of this study revealed that few of the students 10.3% (18) carry their

schoolbag using the backpack carrying style on both shoulders. While the

majority of the students carry their schoolbag using one strap either on

right (66.9% (117)) or left shoulder (22.8% (40)) (Figure 15).

Findings of this study are consistent with the study of Pascoe et al.

(1997) who found that 73.2% of 61 students carry their backpack with only

one strap. On the other hand the results of the current study are contrast

with most of the studies whom found that the majority of their samples

carry their backpack on both shoulders, (Dockrell et al. (2006) 95%,

Goodgold et al. (2002) 94.2%, Korovessis et al. (2004) 91%, Sheir-Neiss et

al. (2003) 87.6%, Siambanes et al. (2004) 85.0% and Skaggs et al. (2006)

81%. Other studies found equal proportions between carrying backpack

using two straps versus one strap such as by Forjuoh et al. (2003) who
 168

found that 46% of students carry their backpacks over both shoulders or

only on one shoulder. In Saudi Arabia study by Ibrahim (in press) found

that about 50% of girls aged 11-14years preferred to carry their backpack

using only one strap. Alhazzaa (2006) found equal proportion of students

carried their backpack on one shoulder (32.3%) or two shoulders (33.0%).

5.3. BACKPACK DESIGN

Many backpacks commonly used by children feature adjustable

straps to allow varied placement of the backpack on the users back. Choice

of placement by children is most often based on personal comfort, ease in

donning and get off the backpack, or peer acceptance (Goodgold et al.

2002). In present study the way of carrying is different as no single article

has mentioned the way of carrying schoolbag that we found in our sample.

The students carried the single strap bag that sling down from the shoulder

to reach the level of the thigh, at knee and sometimes to reach below the

level of the knee joint as they loosen the shoulder strap sometimes to

maximum Figure (23). This may be due to the trend of fashion of the

wearing the backpack that the students follow to be stylish and trendy.
 169

Figure 23. way of carrying

Studies found the use of the two straps has least effect on posture, their

findings indicated that carrying a backpack over both shoulders has the

smallest effect on the posture (Chansirinukor et al. 2001; Pascoe et al.

1997).

5.4. BACKPACK LOAD AND MUSCULOSKELETAL

PROBLEMS

The results of the second section of the questionnaire represents the

description of back and neck pain. It showed that one hundred ten girls
 170

(62.9%) reported that they sometimes experienced neck or back pain since

beginning of the school year. This number should raise our concern about

the causes of this pain that experienced by our children. The low back pain

prevalence among school children varies from country to country and

ranges from 20-51% (Negrini and Carabalona 2002; Salminen et al. 1995;

Viry et al. 1999).

The causation of musculoskeletal problems in children has many

limiting factors in finding specific cause and effect relationship between

backpack use and musculoskeletal disorders. For a musculoskeletal

disorder to occur, the amount of time required to demonstrate injury from

overuse is wide. In addition, the association between cause and effect may

be affected by multiple factors such as physical activity, childs growth and

development, and spinal posture in addition to pack-related variables such

as load carried, duration of backpack use, backpack design, and fit of the

pack. Controlling all of these variables for extended periods of time has not

yet been completed. Therefore, correlations between backpack use and pain

or injury are the best indications, to date, of what backpack use is doing to

children (Brackley & Stevenson 2004).

 171

5.4.1. LOCATION OF PAIN

The answer about the location of the pain the girls felt in neck, back

or other areas on a body diagram (Appendix III), showed variation in the

responses. The majority of the students (43.43%) shaded the shoulder area,

(32.6%) shaded the neck area and (40%) shaded on the upper, middle and

lower back area, and low back pain was the most frequent back pain

compliant (24%). A study by Whittfield et al. (2005) found similar to our

result as higher percent reported suffering shoulder pain 57.9%, 44%

reported neck pain and 35% reported low back pain.

The same compliance of our results were found in the study by Pascoe

et al. (1997) who found that as the students transport all their materials in

book bags, this has led to physical complaints by the students such as

muscle soreness (67.2%), back pain (50.8%), numbness (24.5%), and

shoulder pain (14.7%)

The pain that the girls felt in back, shoulder and neck can be caused

by postural changes during wearing the backpack, the postural changes will

cause increase in muscles activity which leads to muscles strain and

eventually muscles soreness.

Shoulder pain could be caused by pressure caused by the single

strap bag with carrying a heavy load, and when the students carry their

backpacks, they tend to elevate their shoulder, this cause muscles

imbalance and lead to muscle spasm and muscles pain. The same results
 172

were found by Macias et al. (2008) when they studied the pressure

underneath the shoulder straps suggest that the higher contact pressures

over the loaded shoulder are probably due to posture. It is possible that the

subjects alter their posture by elevating their loaded shoulder, thereby

increasing the contact pressure and loading the right shoulder more to

support the backpack load. They also found that the pain in the low back

was significantly higher while wearing the backpack with one shoulder

strap.

Neck pain also caused by postural changes as the students move their

heads forward when they moved their body forward, Pascoe et al. (1997)

found that the forwarded head observed with the one strap and both strap

backpack may counterbalancing the book bag weight located on the back.

Grimmer et al. (1999) reported a forward head posture, which placed

additional stress on the structures of the cervical spine. These changes in

posture might cause neck pain.

Back pain also might be caused by forward leaning of the students'

body once they wear their backpack which is accompanied by lateral

bending when they wear their backpacks unilaterally. Back pain has been

shown to increase about 10% each year after the age of 11 (Burton et al.

1996). Watson et al. (2002) has shown a high prevalence of low back pain

among children aged 1114 years (24%), also Murphy et al. (2007) found

that approximately 22% of children had low back pain lasting one day or
 173

more during the last month. Several authors have reported a relationship

between back pain and school bag weight (Grimmer & Williams 2000;

Whittfield et al. 2005). Korovessis et al. (2004) reported overall prevalence

of low back pain (21%) and found the peak prevalence at age 12 years for

girls and with the onset of puberty, there was a progressively increasing

LBP prevalence until the age of 15 years. Siambanes et al. (2004) found

over 64% of the students reported having back pain at some time. Beeter

Health Channel (2010) found that 46.1% of students report back pain

caused by their backpack. Chow et al. (2007) reported an immediate

decrease in repositioning ability of the lumbar spine which appears to arise

directly as a result of backpack carriage in schoolboys and there may be an

increase range in the stresses and strains acting on this part of the spine in

normal erect posture.

5.4.2. PAIN WHILE CARRYING BACKPACK

The results of the present study reported that only 32 girls (18.3%)

recorded no pain in the neck or back during carrying backpack, and 142

girls (81.1%) recorded that they have pain during carrying backpack. this

may be caused by the demand of the weight of the backpack placed on their

small bodies. Our results are consistence with Siambanes et al. (2004) who

found that 41.3% of the sample felt pain when carrying their backpack, and
 174

almost all of the students reported feeling relief upon taking off their

backpack.

5.4.3. FREQUENCY OF PAIN

When the students were asked about the frequency of the pain they

experienced, equal proportion of the students (49.7) answered either yes or

no. Many girls (41.5%) reported that they suffered from neck and back pain

one to three times since beginning of school, (24.6%) girls reported 4 to 7

times, (25.7%) 8-10 times and (7%) girls reported more than ten times. The

girls reported back and neck pain at variable rate which indicate that the

cause of pain is persistence for a long period of time.

Burton et al. (1996) studied the natural history of low back pain in

adolescents (n = 216) and found the annual incidence of low back pain rose

from 11.8% at age 12 years to 21.5% at 15 years. They found that the

lifetime prevalence of back pain rose from 11.6% at age 11+ years to

50.4% at age 15+ years. They concluded that the experience of back pain

was frequently forgotten and recurrent pain was common, usually

manifesting from a single episode.

 175

5.4.4. INTENSITY OF PAIN

Regarding the intensity of pain, using a visual analog scale (Happy

Face-Sad Face scale) (Figure 1), our result showed that 20 (11.4%) girls

reported severe pain, 55 (31.5%) of girls were reported feeling tolerable

pain, and 30 (17.1%) of girls reported no pain. (Navuluri and Navuluri

2006) also found the intensity of pain in their sample was moderate to

extremely strong pain, and Watson et al. (2002) recorded that 60% of the

sample reported high intensity of pain ranged from 6 to 10 in VAS.

5.4.5. WAY OF CARRYING AND USE OF BACKPACK

When the students asked about the most frequent backpack used to

school the result showed that 153 (87.4%) of the girls reported carrying

their backpack on one shoulder either on right or left, 17 (9.7%) of girls

reported carried their backpack on both shoulders and only 2 (1.1%) used

trolley. Almost the same result we gathered during the day of the test when

we recorded the way of the carrying which showed 157 of the girls wore

one shoulder backpacks while only 18 girls wore two straps backpacks.

Skoffer (2007) found that the weight of the school bag was not associated

with LBP, but carrying the school bag on one shoulder was positively

associated with LBP and function limiting. Alhazzaa (2006) concluded that
 176

the shoulder pain was also more frequently experienced by those students

carrying their bags on one shoulder.

5.4.6. DIFFICULT ACTIVITIES

The majority of the students reported that the difficult activities they

faced during carrying backpack were going up and down stairs (70.9%),

followed by getting up or down from car or bus (48.6%) while (43.4%) of

the girls found that pick up of things was the most difficult for them while

carrying backpack. Sheir-Neiss et al. (2003) found that back pain was

associated with students increased use of stairs while carrying backpacks.

Our results are consistence with Lockhart et al. (2004) who found

that 31.0% of participants reported having difficulty participating in at least

one activity as a result of pain from using a backpack especially carrying

their books. Taimela et al. (1997) reported that the students' lower back

pain interfered with school and leisure activities.

5.4.7. PERCEPTION OF BACKPACK

Our findings support that many children find their backpacks heavy,

79 girls were reported that their backpack is heavy, 58 reported it is very

heavy and only one girl reported that backpack is light. Our findings are
 177

consistence with the findings of Goodgold et al. (2002), who found that

many students reported that their backpacks were heavy and uncomfortable

and few students reported that their backpacks were light. The findings of

this study are similar to the study by Ibrahim (in press) who reported that

97 out of 254 girls students in a study conducted in Saudi Arabia found that

their backpack heavy and causing back pain and few girls reported that

their backpack was light in weight. Beeter Health Channel (2010) stated

that 79.1% of children said that their backpacks feel heavy.

The weight of backpack is very difficult to carry most of the weeks

days were reported by 48% of girls, and difficult to carry from two to three

times of the week by 33.7% of girls. This results are consistence with the

study by Negrini and Carabalona (2002) found that the feeling of the

backpack was heavy during backpack carrying was reported by 79.1%.

Navuluri & Navuluri (2006) who found that 47% of girls reported difficulty

in carrying backpack 4 days in a week.

In addition, the present study showed that 41.7% of the girls reported

the use of additional bag to carry their things to school which may indicate

that they felt their backpack was heavy and they needed extra space to

carry their belongs. The perception of girls about their backpacks as heavy

or very heavy gave a sign that their backpack could be overloaded and the

variations reported in school students responses to carrying loads may be

 178

because a persons carrying capacity is affected not only by the magnitude

of the load they carry but also by the way the load is carried, the duration of

carriage, the frequency of carriage and the physical capabilities of the

person.

5.4.8. TIME CARRYING BACKPACK

Results of the current study showed that most of the students carry

their backpack for a quite long time, 77 (44%) carry their backpack 5-15

minutes from home to school and, 15 (8.5%) has to carry their backpack

16-30 minutes. The time carried from school to home was varied as 45

(25.7%) of girls reported that they carried their backpack from school to

home for 1- 5 minutes, 61 (34.9%) of girls carried their backpack 5-15

minutes, 16 (9.1%) of girls carried their backpack 16-30 minutes, 8 (4.6%)

of girls carried their backpack 31-45 minutes, and only 5 (2.9%) of girls

reported that they carred their backpack more than 45 minutes. Negrini &

Carabalona (2002) found that 48.2% of students carried backpack for 5 to

15 minutes and more than 15 minutes by (37.3%). Korovessis et al. (2005)

found a total of (59%) of students went to school on foot, and time spent

with backpacks during transportation from and to school were 29 -33

minutes.
 179

In current study we didn't ask the students about the mean way of

transportation however the majority reported carrying backpack for 5 to 15

minutes. Alhazzaa (2006) found the majority of school boys travel to and

from school by cars, and stated that elementary schools in Riyadh as well

as in the rest of the country are usually located in nearby communities and

should be in close proximity to the students homes. From these results we

can see that our students carry their backpack for a quite long time either

from home to school or from school to home and this might cause pain as a

result of carrying heavy backpack that strain the muscles of back, shoulder

and neck for long period of time and also the long time carrying backpack

affects energy expenditure which leads to fatigue and in turn fatigue affects

cardiopulmonary functions.

Negrini & Carabalona (2002) reported that back pain was associated

with the sensation of fatigue during backpack carrying, and with the time

spent bearing backpacks on the shoulders. On the contrary, back pain was

not associated with either average or maximal backpack weight percentage.

Sheir-Neiss et al. (2003) found that back pain was associated with the

wearing of backpacks during standing and waiting. Siambanes et al. (2004)

found that 43% of the students walked to and/or from school, they observed

a significant relationship between back pain and walking to and from

school. Negrini & Negrini (2007) found carrying heavy backpack

accentuates the postural effects in the sagittal plane after walking 7

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minutes. Hong et al. (2008) observed during the test, most of the subjects

suffered from fatigue with heavy loads (1520% BW) and in prolonged

walking (1020 min), which confirmed by the analysis of the

electromyography data.

Chansirinukor et al. (2001) found that there was a significant

difference in the craniovertebral angle when carrying a backpack,

compared with the unloaded condition, after a 5min walk. This angle

reduced after carrying the subjects own backpack weight for five minutes,

indicating that time carrying a load influences neck on upper trunk

position, and similar result obtained by Mohan et al (2007) whom found

changes in cervical posture, decrease in CVA after 5 minutes walking with

15% BW. Negrini et al. (1999) suggested that prolonged loading of the

spine raises the risk of lower back pain in youth, and the most common

contributing loads are from backpacks. Grimmer & Williams (2000)

reported that the amount of time spent carrying a backpack increases pain.

Negrini & Carabalona (2002) also reported an association between pain

and fatigue, and the duration of backpack use.

In Saudi Arabia Alhazzaa (2006), found that the majority of the

students did not walk to and from school. He suggested that with such high

prevalence of obesity among Saudi school children, walking to and from

the school can boost the childs energy expenditure and contribute to

energy balance. Walking will also increase the level of daily physical
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activity for the children. However, walking to and from the school while

child is carrying heavy backpack could place an enormous strain on the

spinal column and back muscles of the child.

5.4.9. PHYSICAL ACTIVITY

This result revealed that the majority of the girls 98(67.4%) spend

more than 4 house between watching TV and using computer this may

indicate that our students appear to spend a significant amount of time in

sedentary leisure such as watching television and using computer, and this

might affect their physical fitness as well as will cause, contribute or

aggravating in feeling of pain in shoulder, back and neck. Our result is

consistence with the study by Lockhart et al. (2004) they found that

between 25% to 50% of students watch television more than two hours per

day and found that 33% of students played video games three to seven

times each week. Similar to Sheir-Neiss et al. (2003) who found about half

of the sample watched TV for more than 2 hours and Larsen et al. (1999)

states that the public health recommended that the adolescents should

participate in at least 30 minutes of physical activity every day to maintain

health. Burton et al. (1996) stated that the 12 to 14 year old age range

coincides with a period of rapid growth and increased time spent sitting in

class, watching television, and using a computer. In addition, children

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typically begin competing at more demanding levels of sport around this

age. With greater involvement in physically demanding activities, the

prevalence of back pain seems to rise dramatically. Videman et al. (1995)

found that over time there is an inverse linear association between leisure

time physical activity among adult males and changes in low back

symptoms possibly because of improved aerobic fitness and increased

muscle strength. There is evidence that a lack of muscle strength and

endurance is present when pain is felt.

From our finding we can appreciate the importance of improve our

students physical fitness and the role of engage our children in physical

activities such as sport to build their physical fitness and to maintain their

health. The results of the questionnaire help to report the rates and

magnitude of musculoskeletal disorders amongst schoolchildren in our

sample. The cause of the musculoskeletal problems could be caused by

load of the backpack. The transportation of backpack is a task which

repeatedly loads the musculoskeletal system, and this load bearing could

contribute to the production of pain.

Another factor is postural changes carrying a backpack lead to changes

in trunk posture and muscle activity, these biomechanical changes may lead

to musculoskeletal symptoms in the trunk area as a result of way of

carrying, Korovessis et al. (2005) found that asymmetrical carrying of

backpacks over one shoulder increased significantly the relative risk of DP

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and LBP as compared with carrying backpacks symmetrically over both

shoulders due to asymmetrical applied forces along the spine that derived

from asymmetrical spine loading. They found that carrying backpacks with

one strap increased significantly the intensity of back pain during the

holidays which persistence for up to 3 months after school finish. Hong and

Cheung (2003) suggest that discomfort, pain, and musculoskeletal

disorders can be reduced through the prevention of postural deviations.

Another factors that could cause musculoskeletal pain, position of

backpack, size and shape of the load, load distribution, improper way of

lifting and lowering backpack, type of backpack, time of back pack

carrying, frequency of uses, improper way of sitting or standing. Age also

can be another factor that could affect the extent and severity of the

musculoskeletal problems (Leboeuf-Yde et al. 1998). A study of 29,424

men and women, aged 12 to 41 years, revealed a rapid increase in the

prevalence of low back pain during early adolescence. The steepest rise in

the incidence of low back pain was specifically reported in 12 to 13 year

old girls and in 13 to 14 year old boys, suggesting a temporal relationship

between back pain and adolescence. Grimmer & Williams (2000) stated

that this rapid increase in the experience of low back pain during

adolescence is associated with puberty, a time of bone growth and spinal

maturation.
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A very important factor is lack of physical fitness due to sedentary

life style as long time watching TV, work in computer, or playing computer

games (play station, Game boy, X box and PSP) without engaging in any of

the sport activities. Lack of sport activates will leave the children more

liable to have problems in their general health. Sheir-Neiss et al. (2003)

found that there was an association between the numbers of hours spent

engaging in sedentary leisure time activities and the reporting of back pain.

The adolescents with back pain reported significantly more hours watching

television, both during the week and also on weekends, than those without

back pain.

From the previous finding, we can find a lot of factors that might

cause musculoskeletal problems, it is difficult to demonstrate that loads

carried by school students are directly associated with reported

musculoskeletal problems. However, load of backpack is a very important

and serious factor in causing musculoskeletal problems.

5.5. POSTURE

Carrying books in a backpack altered the posture of the students.

Today children are carrying greater book bag load, which accentuate this

potential problem. In present study we measured the level of the ears and

level of shoulders compared between unloading and loading conditions.

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5.5.1. BACKPACK WEIGHT AND LEVEL OF EAR

The result showed that there was no significant difference between the

mean of the right and left ear levels. In contrast with the study of

Chansirinukor et al. (2001) who found changes during loading with

backpack in the anterior head alignment angle which is the angle describing

the tilt of the head in the coronal plane when the subjects loaded with

backpack 15% of BW. However, they found this change with load of 15%

of BW but in present study the mean load was 10.08%.

Our finding of no changes in the level of ears may be caused as the

girls corrected their heads position to compensate for their trunk mal-

alignment and doing so gives them the feeling that they are standing

correctly.

5.5.2. BACKPACK WEIGHT AND LEVEL OF SHOULDER

The mean difference between right and left shoulder showed a highly

significant difference. The changes found in the current study is

consistence with the study of Pascoe et al. (1997) who found that during

one strap bag carriage, the shoulder elevated on the ipsilateral side of

carrying and a leftward curvature of the spine away from the weight of the

school bag in 61 students with age of 11 to 13 years. Korovessis et al.

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(2005) found that carrying backpack asymmetrically caused decreased

craniovertebral angle CCV and shoulder and upper trunk was shifted away

from the plumb line contra laterally. Mohan et al. (2007) found that there

are decrease in craniovertebral angle and sagittal shoulder posture (SSP)

during backpack loading. Another studies conclude that backpacks carried

unilaterally cause lateral spinal bending and shoulder elevation, and

backpacks carried bilaterally reduced lateral spinal bending and shoulder

elevation, and both carrying configurations promoted forward trunk lean

(Chansirinukor et al. 2001; Pascoe et al. 1997; Smith et al. 2006). Negrini

& Negrini (2007) found the same results as asymmetrical loading noticed

an elevation and retro-positioning of the loaded shoulder as well as a lateral

flexion of the trunk away from the load. This retro-positioning could

depend on the load itself (too heavy in relation to the functional response

capacities of the subjects), or alternatively reflect the need to bring towards

the central body line a load that is positioned too laterally.

The result of the present study revealed a significant changes in the

level of shoulders which can be explained as the majority of our sample

153 (87.4%) using the one strap school bag, that sling down at thigh or

knee joint level. This way of carrying leaves the schoolbag suspended in

one shoulder and that singles shoulder joint will take all the load and the

bag slings down without any support except that shoulder. As a result, the

gravity pulls the loaded shoulder down, the weight of the backpack will
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pull the spine away from the loaded shoulder then the child will

compensate for this postural changing by lifting the shoulder upward in

order to stand erect and to balance the uneven weight distribution. This will

cause muscular strain, so we can conclude that the way of carrying is one

of many factors cause change of the posture.

Another possible factor is fatigue which may explain the change of the

shoulder level upward or downward Figure (24). Fatigue due to increase

muscles activity resulting from the load of the backpack and carrying time

lead to compensation of postural, by this way the students will change the

level of shoulders to relief fatigue. EMG was used to assess muscles

activity during prolonged walking with backpack weight 15%BW. They

found significant increased muscle activity at lower trapezius and upper

trapezius when the walking time reached 15 min, in additional to changing

in the level of shoulders (Abdolhamid 2009; Hong et al. 2008; Smith et al.

2006).
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Figure 24 . Changing in the level of shoulders

Third possible factor affected shoulders level, may be pain

produced by the strap of the backpack as one shoulder only bear the whole

load of the backpack. Our findings supported by Macias et al. (2005) who

found that the contact pressure beneath the shoulder straps significantly

increased at 10%, 20%, and 30% BW. The pressure underneath the

shoulder will gain no or very little relief from applied pressure by wearing

multiple garments, even in layers, when carrying a backpack, found by

(Jones and Hooper 2005).

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The spinal structures of children are thus markedly different from

those of adults. As growth of the spinal structures extends over a longer

period of time than the other skeletal tissues (Leveau & Bernhardt 1984).

Spinal ligaments and muscles are not fully developed until after the 16 th

year of age, children experience rapid growth and have immature bony

ossification compared to adults, their bones are particularly soft and as a

result they can easily bend (Patrick 2006). It is widely believed that

prolonged carriage of heavy backpacks will cause additional stress on the

rapidly growing spine of especially younger children. This will make them

more prone to postural change that will eventually lead to lower back

problem. Thus for younger children, who are not yet fully grown to cope

with stresses of load carrying, the increase in load carriage will force them

to lean forward in order to bring the center of gravity back over the base of

support. Haisman (1988) suggested that load requirements for adult

females should be lower than adult males to account for physiological and

biomechanical differences.

Once this developing body face postural changes resulted from

carrying backpack load many problems can happen to the young

population. Rateau (2004) found that the use of backpacks in children can

produce a multitude of negative postural changes, and over a prolonged

period of time, children may experience back pain. Triano (2007) stated

that habitually carrying backpacks over one shoulder will strain muscles to
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compensate for the uneven weight. The spine leans to the opposite side,

stressing the middle back, ribs and lower back more on one side than the

other. This type of muscle imbalance can cause muscle strain, muscle

spasm and back pain in the short term and speed the development of back

problems later in life if not corrected. The weight can also pull on the neck

muscles, contributing to headache, neck pain and arm pain.

The heavy bag thats slung over one shoulder can over the 12 years of

schooling, cause chronic back problems that linger into adulthood. Risks

include muscle strain, distortion of the natural S curve of the spine and

rounding of the shoulders (Beeter Health Channel 2010). Alternation of the

spinal curvature owing to improper posture can be medically classified as

functional scoliosis (Luckstead & Greydanus 1993). This is only temporary

because the spinal column resumes its correct alignment once the poor

posture is corrected by removing the load. Pascoe et al. (1997); and

McPhee (1999) stated that back pain commonly associated with backpack

transport may signify a more serious condition called functional scoliosis.

Functional scoliosis may be exacerbated by the use of heavy backpacks,

resulting in excessive stress on the spine and surrounding muscles. This

temporary condition is characterized by a curvature of the spine that

frequently causes muscle discomfort on the affected side and once the

aggravating source is eliminated, the condition most likely will subside.

The change in the posture may lead to musculoskeletal deformities such as

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scoliosis, kyphosis and lordosis, and can be aggravated by backpack use

(Korovessis et al. 2005; Mackenzie et al. 2003).

So we can conclude from our result that the load, way of carrying,

fatigue, and pain contribute with each other and could cause postural

changes as shown in our results changing in the shoulder level, and the

finding suggest that postural responses are sensitive to load carriage

equivalent to 10% of BW, supporting a hypothesis that heavy loads have a

significant effect on postural changes which is critical especially during

rapid growth stage.

5.6. BALANCE

5.6.1. LIMITS OF STABILITY

The limits of stability reflects a persons dynamic balance in which

the maximum distance a person can intentionally displace their COG, i.e.

lean their body in a given direction without losing balance, stepping, or

reaching for assistance. This test helps to find the ability to voluntarily

sway to various locations in space, and briefly maintain stability at those

positions. Our aim was to find if there are differences in limits of stability

of girls without and with carrying the backpack.

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The result of the present study showed that there was significant

changes in the reaction time (RT), COG movement velocity (MVL),

(P<0.000), endpoint excursion EPE (P<0.002), and DCL (P<0.003), and

there was no significant change in the maximum excursion (MXE

P<0.854).

In the present study is consistence with a study done by Palumbo et al.

(2001) who found significant decrease in movement velocity (MVL) and

directional control (DCL) and no significant changes in the maximum

excursion variable; however our result is inconsistent with the same author

who found no significant changes in reaction time and end point excursion.

The differences between our results and those obtained by Palumbo et al.

(2001) might be due to the difference in way of carrying the backpack as

their sample carries standard two strap kind of backpack which evenly

distributed the backpack weight on both shoulders while the majority of our

sample carries their backpack using single strap backpack. The two strap

backpack increased the students weight which might gave more stability

during movements but in our sample unequal weight distributions led to

more disturbance of stability during movement. Another reason may be the

sample age, as Palumbo and his colleague examined college students with

long history of backpack use but this study included younger students age

12 to 15 years, and the older students more mature and can adapt quickly to
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the additional stress of backpack than our younger subjects who unable to

make proper adjustment.

Significant changes in the reaction time (RT) which is the time in

seconds between the command to move and the subject's first movement,

which decreased with backpack than without it, which means that the girls

responded faster while carrying their backpacks, this may be due to that the

weight of the sling backpack will push the girls forward faster once they

attempt to move, or dueto adaptation effectt as they performd the test with

backpack for eight times for the eight points before. However, Palumbo et

al. (2001) stated that the reaction time was not expected to change as this

variable measured the time between a stimulus and the initiation of

movement, a hard wired neural response and the backpack will not affect

the speed of this neural pathway.

The significant increase in COG movement velocity (MVL), which is

the average speed of COG movement in degrees per second may be also

referred to that the weight of the backpack and unilateral sling backpack

will push the girls to lean forward faster and will increase sway movement

of their body in different directions in order to achieve stability and to

avoid falling to reach different targets in the limits of stability test, and in

order to maintain stability, the girls needs to increase their BOS which

cannot be done in this test because their feet were fixed in a standered
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position. Zultowski & Aruin (2008) found that the decreased base of

support is usually associated with increased body sway. A significant

increase also was found in EPE and DCL. However there was no

significant change (MXE P<0.854. Wearing the backpack will alter the

normal postural alignment, the students will compensate for this changes

by leaning the upper body forward in two cases of backpack carriage (two

straps and one strap backpacks) and in additional to forward lean there will

be later lean of the trunk in case of one shoulder strap bag in order to bring

the COM back within the BOS. Our task in this test was asking the girls to

move as quickly and accurately as possible toward each of the eight targets

(forward, forward left, forward right, to right, to left, backward, backward

right, backward left) which made the task more difficult. As students have

to move and to maintain their stability in the same time and the majority of

our sample used a long strap bag, this made the task so complicated and

very difficult. The long strap bag will swing once the student move out of

their BOS and push them ahead toward the target with high velocity

(reaction time and movement velocity scores) and to maintaining stability

during dynamic balance it will be very difficult and eventually will cause

balance disturbance and this requireS increase muscular control.

When the current test was preferred done while carrying the backpack,

the students will compensate changing in the COM while they move

toward the target and in the same time they have to stay stable and maintain
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their dynamic balance. In addition they will try to slow their movement in

order to reach the target accurately without falling. Another explanation for

these changes may be a reflection of the additional energy needed to

control the anterior position of the COM as well as the backpack weight

which end by slowed their movement. Hong & Brueggemann (2000) said

that the heavy load carried on the back would force the subjects to alter

their body position to counteract the deviation from the normal kinematic

pattern when body posture and balance were disturbed by carrying the

substantial additional load.

In contrast, Palumbo et al. (2001) stated that the additional weight

of a backpack coupled with the subject's body mass will cause a greater

mass moment of inertia; this increase in inertia may result in difficulty with

acceleration as well as deceleration of movement leading to decrease in

average movement velocity. Talbott (2005) mentioned that the movement

of the COG would, theoretically, have several effects, first, a more anterior

COM while carrying a backpack would decrease the distance between the

COM and the anterior limits of the BOS. Second, the anterior position of

the COM would alter the line of gravity in relationship to the joints. Third,

the maintenance of the position may require additional energy, a feeling of

falling or a feeling of discomfort.

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Talbott (2005) found that the results of the analysis of stability during

the dynamic task of picking up a pencil indicate that there is greater

instability while wearing the backpack with 20% BW than when no

backpack is worn. Even if contained within a small range of the BOS, these

small oscillations may be perceived by subjects as requiring greater effort.

The oscillations, small or large, may not approach the amount needed to

change oxygen uptake, minute ventilation or heart rate but may reflect a

more local fatigue. Talbott et al. (2004) found that during static and

dynamic tests sway length and sway area were significantly greater with

increased backpack weight while the type or location of backpack were not

revealed significant difference. Chow (2006) found that increasing

backpack load causes a significantly increased flexion of the trunk in

relation to the pelvis and extension of the head in relation to the trunk and

regarding balance they found that increase backpack load caused increased

antero-posterior range of COP motion. While the total antero-posterior

COP sway distance and the mean antero-posterior position of the COP with

respect to the pelvis both decreased with increasing backpack load in

normal and sample with scoliosis, and found no change in the medio-

lateral position of the COP with increasing backpack load. They were

found changes in the balance although their sample carried their backpack

on both shoulders and centered well; in contrast of present study most of

the sample used one strap type of backpacks.

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Zultowski & Aruin (2008) found that the effect of load magnitude of

10% and 20% BW was statistically significant for anterior posterior and

medial lateral displacement in the case of single strap bag. The girl will

compensate for the load placed upon her back by forward lean, which

flattens the natural curve in the lumbar region of the back and increases the

curve in the thoracic region of the back. This compensation can result in a

loss of balance, increasing childhood risk of falls and causing rounding of

the shoulder, increase muscles strain and irritation (Cavallo et al. 2003).

The magnitude of postural sway depends on many factors including: body

position, age, and magnitude of the load carried (Zultowski & Aruin 2008).

Pascoe et al. (1997) have shown postural deviations, such as forward lean

to compensate for a change in center of gravity that occurs with the

increased backpack load. These changes may also cause a difference in

movement pattern used by the subject to reach the target. In this study,

backpack load resulted in increased movement velocity and reduced the

accuracy of movements in all directions during LOS test.

Many studies support our finding, Zultowski & Aruin ( 2008)

carrying a bag using one strap could be coupled with no only flexing the

trunk but also with the lateral shifts of the body. Such a lateral shift could

destabilize the body and produce increased postural sway in the medial-

lateral direction. Increase postural sway in the medial-lateral direction is

also considered one of the best predictors of individual risk for falling.
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Singh & Koh (2009) found that the forward lean of the trunk tries to restore

the COM of the combined backpack and body system to the original

location of the COM of the body, thereby, ensuring that the line of gravity

passes well within the BOS rendering stability to the body and backpack

system.

Hong & Cheung (2003) found that children lean forward they

suggest that these findings indicated that the children counterbalanced the

load on their back by shifting their trunk forward .This trunk inclination

can be explained by the motor control theory. One of the main functions of

motor control is to orient the body with respect to the external world, which

involves maintaining posture to minimize the disturbance of balance, thus

stabilizing the whole body center of gravity, such adjustment helps the

body to minimize the energy expenditure and increase the efficiency of

walking with weight. Hong & Brueggemann (2000) explained this as the

heavy load carried on the back would force the subjects to alter their body

position to counteract the deviation from the normal kinematic pattern

when body posture and balance were disturbed by carrying the substantial

additional load.

Goodgold et al. (2002) relay this to support for a ceiling effect in

which individuals may reach a maximum limit for trunk forward lean. One

explanation is that during running the performer must contend with greater

momentum and less time to make postural adjustments. Second, there may
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be a critical value for trunk forward lean. If this value is surpassed, the

individuals center of gravity is so far anterior that the musculature and soft

tissues cannot withstand the forces. At that point, the strategy is

maladaptive, and the individual would fall forward.

The limits of stability resemble standing and reaching while

standing from our finding we can see the effect of loading the students with

the mean backpack of 10% of BW add difficulty for students to move while

standing and reach in all directions in order to maintain their balance and

to avoid falling.

5.6.2. STEP/QUICK TURN (SQT)

This test measure balance by quantifying turn performance after

taking two steps forward and pivoting 180 degree and taking two steps

back to the starting position, which resembles walking and sudden turn

which can be frequently happening to the students. The heavy backpack

will be the obstacle for them when they need to suddenly turn, cause

balance disturbance and they will try hardly to avoid falling.

The result showed significant changes in Turn Time (TT) for right and

left side without and with carrying backpack (P<0.000). Turn time

quantifies the number of seconds required for the individual to execute the
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180-degree in-place turn. Time begins when forward progression is

arrested and ends when forward progression in the opposite direction is

initiated for both right and left staring. A significant change is recorded in

Turn Sway (TS) to the right side (P<0.002). The turn sway is quantifies the

postural stability of the individual during the turn time, it expressed as the

average COG sway velocity in degrees/second. The turn time for the left

leg showed no significant changes.

Our results showed decreased in turning time as students did this part

of the test faster with the backpack than without it to avoid disturbance in

their balance and to avoid falling if they did it slow, by moving faster they

will feel save and stable. We observed during the test and during the

sudden turn part that the sling backpack will move away from the students'

body and will assist in moving them fast too.

Turn sway toward the right side showed significant difference as the

mean of turn sway without carrying backpack was (26.917.27) and with

carrying backpack was (25.295.7), which means that the turn sway

decrease with backpack which might reflect wrongly that the girls were

more stable during turning, we know that the slower movement velocity

cause increase in COG sway velocity, so we think that students in present

study moved faster while carrying backpack which is coincide with the

decreased in turn sway. Another possible reason for decrease in turn time
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and decrease in sway turn, might be that the girls are young and they did

the test six times without carrying backpack, so they may become familiar

with the test that they did it with greater muscular control and range of

motion and more persist due to learning effects. Moving faster by

increasing walking velocity as a strategy of compensation was also found

by (Chow et al. 2005; LaFiandra et al. 2002; Pascoe et al. 1997; Singh &

Koh 2009).

In contrast with many studies that found decrease in walking

velocity with increase backpack load, whereas their studies examine

straight forward walking but in present study we tested walking and sudden

turn which is an ordinary activity faced our students. Hong et al. (2000);

Hong et al. (2003) and Hong & Li (2005) indicating that backpack load

carriage may affect balance during gait, associated double support time as a

measure of dynamic postural instability that can precipitate a fall. Walking

velocity has also been associated with a stable gait and it has been

suggested that a lower walking velocity is a consequence of induced gait

instability (Singh & Koh 2009). Hong & Brueggemann (2000) stated that

the higher load on the back would raise the subjects center of gravity,

making the walking subject even more unstable. Subjects were forced to

compensate by shortening their swing phase, which may be an attempt to

minimize the duration of unsteady single limb stance. Hong & Li (2005)

found that, during walking with carrying the backpack the students forced
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to adjust their gait to compensate for the change by lengthening the stance

duration and decrease the swing duration to maintain walking stability. The

double support time was significantly increased when weighted backpacks

were worn. Singh & Koh (2009) found that double support time and

cadence indicate that a reduction in gait velocity and cadence and an

increase in double support time for the lower configuration with 20% BW

condition could be a compensatory mechanism for children to minimize

either the induced gait instability or to minimize the strain on the

musculoskeletal system.

Connolly et al. (2008) found that the velocity decreased when the

backpack was worn on one shoulder and increased from baseline when the

backpack was worn on two shoulders. They speculate that the velocity was

decreased during the one shoulder carriage because of the asymmetrical

load causing the center of gravity to shift laterally and to slow down the

walk. They found significant differences in the present of the gait cycle

spent in double limb support which might suggest that the use of backpack

with one shoulder or two shoulders straps create problems with balance.

Cottalorda et al. (2003) stated that carrying a 10kg backpack on one

shoulder brought about an imbalance and after the swing, children needed a

greater propulsive force to get back in balance.

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Another factor was found by Hong & Cheung (2003) who suggested

that the aim of adjusting walking velocity under conditions of load carriage

is to minimize energy expenditure. It has been pointed out that many

biological systems associated with muscle activity are controlled under the

criterion of minimum effort. Thus, as the weight of load increases, the

preferred velocity is expected to decrease to compensate for the additional

energy expenditure required for load carrying. And (Hong & Li 2005)

Subjects tend to minimize the effect of load on their energy coast by

decreasing walking velocity.

5.6.3. STEP UP/OVER

Both load carriage and stair ascent or descent is functional activities

common in normal daily life. These activities may result in increased

dynamic loading of the human musculoskeletal system (Hong et al. 2003).

Step up over test resemble one of the most difficult task that face the

students during the school day as they have to carry their backpacks up and

down stairs in their schools as most of the schools in our country are

multistory buildings.

Our result revealed that there were significant changes in the

movement time (MT) (P<0.000), which is the number of seconds required

completing the maneuver from the initial weight shift to the non-stepping
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(lagging) leg to ending with the impact of the lagging leg onto the surface.

A significant changes in the impact index of right limb (II) (P<0.025),

which is the maximum vertical impact force as the lagging leg lands on the

surface, expressed as a percentage of BW.

The result proved that some difficulties face the students while carry

backpack and going up and down stairs, as our result revealed that there

were significant decreased in the movement time (MT). The girls move

faster while wearing the backpack than without the backpack, this may

referred to the great propulsive force they need to go up stair against the

gravity and the weight of the backpack add more difficulty in doing this

task. During going down the stair the weight of the backpack because of

the gravity force will push the students more forward and also the weight of

the sling bag will advance the students during movement, which make both

cases of going up and down stair difficult to maintain stability and avoid

falling. Another possible reason that caused decrease time to finish the task

is that the girls have fear of fall while wearing their backpack and going up

stair in the same time so they tend to increase their speed to avoid

disturbance in balance and they used to compensate by increasing their

speed of walk once they were their backpacks.

Significant increase in the left up index of left limb, which is the

maximum lifting force by the leading leg. The explanation of this change
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may be that the weight of the backpack adds more weight to the students'

body so the girl's exerted greater force to step up. And our results showed

significant decrease of the impact index right limb, and this may be

explained as when they stepped down they tend toward less impact force to

compensate the backpack load and the sling backpack that swing away

from their body and because they are affired to loss their balance and fall.

The same result obtained by Cottalorda et al. (2003) who found that

carrying a 10 kg backpack on one shoulder brought about an imbalance

and, after the swing, children needed a greater force to get back in balance.

Our results are in agreement with Hong et al. (2003) who found in

the case of stair ascent, the risk of imbalance or the need for stability is

greater than in level walking. When the knee is extended during the late

phase of single leg support time, the weight of the backpack together with

the trunk creates a large backward moment about the point of contact of the

supporting foot. The subjects, therefore, needed at this point to flex the

trunk more to decrease the moment arm in order to keep their balance. The

results of the Hong et al. (2003) provided valuable information about this

interpretation, as they show significant differences in trunk inclination,

even when the load was just 10% of the subjects BWs. They found that

during descending stairs, subjects have to resist gravity, which produces a

force in an anterior direction as subjects propagate forward. This may

destabilize the subjects and lead to a potentially injurious fall if the center
 206

of gravity of the body and the line of gravity fall outside a subject's base of

support. To maintain balance when descending stairs, subjects need to

modify the orientation of the trunk segment, and the location of the center

of gravity to a safer position. Undoubtedly, the potential injury suffered

from falling down the stairs anteriorly is much greater than when falling

posteriorly, which would lead to the subjects just sitting on the stairs.

Therefore, it was not surprising that the subjects kept their trunks erect or

even leaning backward when descending stairs; minimal changes in the

anterior-posterior direction of the upper body induce a large trunk moment,

which causes instability of the individual.

Our results reflect part of the things that might our students face

but doesn't reflect the whole reality that the students face during their

school day while carrying their backpack. Many other factors can cause

balance disturbance elicited in different situations like walking for long

distance, bending, pick up things, and running. Other reasons of changes in

balance found by other studies as the students walk for long time which

was not examined in this study, Many studies found that carry the backpack

which cause leaning forward of the trunk caused restriction of the

respiratory organs which lead to decrease respiratory function and also

caused fatigue caused by carrying backpack for long period of time will

cause instability of posture caused by muscles tiredness. Yaggie &

Armstrong (2004) quantified changes in balance indices after a generalized

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fatiguing activity. The balance was assessed on sixteen participants with

mean age of 24 years, before and immediately and 10 min after serial

Wingate tests and at similar time points under non fatigue conditions. The

result showed that fatigue adversely affects balance indices and recovery

might occur within 10 minutes. Li et al. (2003) found significantly

increased forward lean and limited trunk motion range appears to affect the

movement of the thorax and seems to reduce the volume of the abdomen as

the muscles are contracted in order to gain stability, preventing abdominal

breathing. Thus, the only way that the subjects could increase oxygen

uptake to support the increased metabolic cost might be to use costal

breathing and breathe faster. And suggesting 10% body mass might be a

safe load for the 10 year old child. Gribble & Hertel (2004) They

concluded that there is an effect of localized fatigue of the sagittal plane

movers of the lower extremity on center of pressure excursion velocity. It

appears that fatigue about the hip and knee had a greater adverse affect on

center of pressure excursion velocity.

Other studies found changes during walking while carrying

backpack these changes includes, increased double support time and

decrease swing time, Chow et al. (2005), Connolly et al. (2008),

Cottalorda et al. (2003), Hong & Brueggemann (2000), Hong & Li

(2005), Singh & Koh (2009), with increase walking speed, Chow et al.

(2005), LaFiandra et al. (2002), Pascoe et al. (1997), Singh & Koh (2009),
 208

Chow et al. (2005), LaFiandra et al. (2002), changes in stride length and

frequency, Connolly et al. (2008), Cottalorda et al. (2003), La Fiandra et al.

(2002), Pascoe et al. (1997), and decrease in cadence, Chow et al. (2005),

Singh & Koh (2009) and all of this referred to that student by these changes

try to maintain their balance to avoid falling. Zultowski & Aruin (2008)

stated that, decrease base of support is usually associated with increased

body sway.

Goh et al. (1998) found significant increase in peak lumbosacral

forces with backpack carrying walking with no external loads to 15%BW

load increase the peak force at the lumbosacral spine by 26.7% and from

15-30%BW backpack load the peak lumbosacral force increased by 29.5%.

And speculate that these effects are a result of the subject's attempt to

maintain stability and effective forward progression. The extend of these

problems caused by wearing heavy backpack beyond balance disturbance

and falling. Chow et al. (2006) reported that the impairment of balance due

to backpack carrying may play a role in the development of the scoliotic

deformity. Another concern is that the compromise of balance due to

backpack carriage combined with the poor balance function of subjects

with AIS would increase their risk of fall and injury. In addition, loss of

balance and falls could have contributed to injuries occurring during

wearing, lifting, or taking off the backpacks and to injuries to the head and

neck (Connolly et al. 2008).

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Zultowski and Aruin (2008) found no effect in respect to backpack

load on sway characteristics, a possible explanation for this query is that

carrying a backpack induces the forward inclination described above,

thereby bringing the position of the combined COM close to the position of

the COM in conditions with no backpack. Nevertheless, due to the

compensatory forward lean in conditions of carrying a backpack, changes

postural sway in the sagittal plane might not deviate significantly from

what is observed in the no load conditions.

No changes in some of the variables may be also caused as the

students adapted to the load of backpack and develop their ways to

maintain their balance, or refer to their ability to adjust to small load, in

spite there is individual's differences in the general ability to adapt, another

possible factor is that additional weight of the backpack which added to the

body may increase their stability on the ground or that Long term use of the

backpack during school years may result in adaptive shortening and

lengthening of postural muscles. All of these are adaptations made by

children in order to maintain their balance and stability in various positions

and by various ways.

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In summery

Based on the results of current study we reject the null hypothesis regard

the load of the backpack, effect of backpack on musculoskeletal problems,

effects of backpack on posture and effects of backpack on balance on Saudi

girl students.

The girls in our sample are in development age and didn't reach

their skeletal maturation, as 81.7% had menstrual period and 18.3% still

not. The percent of backpack to BW was 10.08% found to cause changes

in posture, dynamic balance and might be one reason that causes

musculoskeletal problems. The results suggested that healthy Saudi girls

tried to control the effect of backpack weight on their musculoskeletal

system, posture, and dynamic balance by selective adjustment including

postural compensation and movement accuracy.

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CHAPTER VI

SUMMARY, CONCLUSION

AND RECOMMENDATIONS
 212

6. SUMMARY, CONCLUSION AND

RECOMMENDATIONS

6.1. SUMMERY

The teenager students during spur are subjected to the influence by

their environment which might affect their maturing musculoskeletal

system. Any disturbance might cause chronic Pain or even spinal

deformities. Studies from different countries showed that heavy backpack

carried by students is one of the factors that might cause disturbance in the

skeletal system. We must raise the level of awareness in our country

regarding this issue and we need to study the magnitude of this problem in

our schools and its effect on our students.

The aims of this study were to study the effects of backpack weight on

girls posture, musculoskeletal problems and balance among the female

students in Riyadh city in Saudi Arabia. Our samples were 175 female

students in the preparatory school, aged 12 to 15 years old. Students were

chosen randomly from 5 schools to represent Riyadh city.

A reliable and valid questionnaire about neck and back pain, pain

intensity and severity, way of carrying and for how long, the difficulties

while wearing backpack and how long spend watching TV and using
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computer was translated into Arabic. A pilot study was conducted on 20

students to test the content validity and test retest reliability of the

translated questionnaire. The Arabic questionnaire was used to collect data

about musculoskeletal pain during carrying backpack. Backpack weight

was measured and backpack weight percentile was calculated to each

student. Shoulders and ear levels were measured using postural mirror with

and without carrying backpacks. The balance master machine was used to

measure students dynamic balance with and without carrying backpack.

The results showed that the average backpack weight was 4.57kg

ranging from 2.1-7.4kg and the percent of backpack weight to the BW was

10.08% ranging from 4.54-19.76%. The resultS revealed that there was

high percentage of students suffering from, shoulder, neck and back pain.

Most of students feel that their backpacks are heavy or very heavy. Going

up and down stairs were the most difficult activity reported by students.

Most of students spent more than 4 hours watching TV and using

computer. The study showed that shoulders level was affected by backpack

carriage which indicates postural changes. The results revealed that there

was disturbance in the dynamic balance while carrying backpacks in many

variables.
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6.2. CONCLUSION

The results of this study showed that the Saudi girls aged 12-15year

carried heavy backpack load of 10.08% which affect their health and

posture. We can conclude that this load cause postural changes include

changes in the level of shoulders, as well as the students reporting high

frequency of musculoskeletal problem such as shoulder, neck and back

pain.

The results showed that there is links between backpack load, posture,

musculoskeletal problems and dynamic balance. We revealed that our

students carry their schoolbag in inappropriate way which is a single long

strap bag, this way induced changes in the posture, dynamic balance started

with load of 5% BW. These changes cause disturbance in balance, and to

maintain their stability and avoid falling they will compensate by leaning to

the other side bringing their center of gravity back to normal.These changes

in the posture will cause instant increase in the muscles activity causing

strain of these muscles and over a long period of time will turn to

musculoskeletal problems which are critical in the rapid growing age.

Reducing the weight of the backpack to 5%BW is recommended.

Increase the awareness of students about the negative effects of carrying

heavy backpack. Further research has to be done to observe changes in

dynamic balance during different school day activities.

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6.3. RECOMMONDATIONS

According to the studies' results, teachers, children, and families are

equally involved in determining the weight of backpacks, and all could

contribute to reducing it (Negrini & Carabalona 2002). In order to avoid

any problems and complications caused by using backpack, many studies

gave many suggestions and recommendations.

MINISTRY OF EDUCATION

Ministry of education authorities at a high level should understand in

depth the extent of the problems caused by backpacks and should study the

problems and how to solve them accompanied with health professionals

and school staff

Some interventions require additional funding, such as a second set

of textbooks (Goodgold et al. 2002; Siambanes et al. 2004). One school

that tried this approach found that not only was it easier for the students,

but it caused less wear and tear on the books. If necessary, a few extra

copies of the books could be in the school library so that they are available

during study halls (Hamilton 2000). Textbooks on CD are just beginning to

be available at this time, the evolution of CD-ROMs and electronic books,

or e-books, could mean that these problems will be overcome completely in

the future. (Goodgold et al. 2002; Negrini & Carabalona 2002). Provide

children with storage facilities (lockers) for materials not needed on a daily
 216

basis (Negrini & Carabalona 2002; Ren et al. 2005; Siambanes et al.

2004). Lighter textbooks and use of lighter computerized educational

resources (Siambanes et al. 2004).

Educational sessions can be taught by health professional consultants

(physical or occupational therapists) and or can be integrated into the

physical education or health education curriculum. Another option is to

integrate the program into the math or science curriculums by incorporating

calculation of the backpack percentage of BW, work or energy expenditure,

data analyses, and graphing into existing learning modules. Posters of

pictures of students wearing their backpack properly and improperly were

placed on school walls. On an informal basis, in class and in the corridors,

teachers also reminded students to use their backpacks properly (Ren et al.

2005).

Another approach may be reduce the risk of wearing heavy backpack

is to limit the amount of time spent carrying the backpack, a major

influence on both back pain prevalence and severity, by supplying a means

of transportation such as carpooling (Siambanes et al. 2004).

Increasing the ratio of physical to sedentary activity, along with

improving fitness levels in students, may assist in not only reducing

musculoskeletal pain in school children, but also in optimizing health

(Wesdock & Dominguez 2003). Organized physical activity during the

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half hour main recess could significantly contribute to general physical

fitness as a part of the daily routine and possibly decrease the tendency

toward less physical activity as children reach adolescence (Wesdock &

Dominguez 2003).

COMMUNITY

The problem of the backpack use, their types, the dangers on our

children health and how to avoid them should be highlighted in our

community to raise the level of awareness of children, parent, teachers, and

health professionals. Establishing a school backpack committee with

administrators, parents, teachers and school health professionals provides a

forum. Members can share knowledge about the effects of heavy backpack

use by children, choose strategies to reduce the risks of injury that best

match their student body, and brainstorm how to reduce potential barriers

to change in their school (Goodgold et al. 2002; Ren et al. 2005). This

provides a platform for committee members to discuss concerns about the

deleterious effects of heavy backpacks as well as the challenges or barriers

to change. This also provides a forum for physical therapy education on

backpack safety and injury prevention. For interventions to be successful,

backpack safety programs need to be sensitive to challenge. The key to

success is collaboration among the physical therapist and health

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professionals, school officials, parents, and students (Goodgold et al.

2002).

Hosting a Backpack Safety Day with raffles for well designed

backpacks, poster competition on how to use a backpack safely, backpack

weigh-in to help students learn to recognize when their backpack is too

heavy, and backpack clean-out to organize the contents of the backpack

and lighten the load (Ren et al. 2005).

PROFESSIONALS

Physiotherapist, orthopaedics, paediatrician and school teachers should

work incorporation with each other.

Mohan et al. ( 2007)found the programs of education about

backpack care showed to be effective which given to the students by

Physiotherapist with the collaboration of school teachers can potentially

reduce the incidence of spinal pain in children. Therefore, it is prudent for

physical therapists to provide leadership in wellness promotion and injury

prevention while awaiting more definitive research evidence. Unless

physical therapists collaborate with school officials in reducing backpack

loads, children most likely will feel forced to carry high loads regardless of

their ability (Goodgold et al. 2002).

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Physiotherapist can play an important role in preventing

musculoskeletal pain associated with carrying heavy school bags in

children by planning more effective preventive strategies for school

children. The students, parents, and teachers should be advised to restrict

the school bag weight to less than 10% of BW. Imparting back care

education program to school children is a professional avenue, which has

been explored by physiotherapist and occupational therapist in different

countries across the world (Mohan et al. 2007). Teach students key signs

include if the child is struggling to put on or take off the backpack, postural

mal-alignment (forward head and/or trunk flexion or lateral listing), and

pain and/or parasthesia associated with wearing the backpack. Education

on how to properly wear a backpack include instruction that backpacks

should be worn close to the body over the strongest back muscles in the

thoracic region of the back, with both shoulder straps (Goodgold et al.

2002).

Backpack safety and injury prevention educational materials and

motivators should be specifically designed to match the developmental

level of the children and can be integrated into the physical education or

health education curriculum. In some schools, math or science teachers

may choose to include calculation of backpack percentage of BW, data

analyses, and graphing into their curriculum (Goodgold et al. 2002).

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Finally, for musculoskeletal problems associated with backpack use,

children may benefit from physical therapy including exercises that

strengthen abdominal and back musculature, improve posture, and increase

flexibility of hamstrings and low back musculature. These may enhance the

childs ability to maintain good postural alignment when wearing a

backpack and reduce the vulnerability of musculoskeletal structures to

injury (Goodgold et al. 2002).

TEACHERS

Teachers should be educated about the backpack and how to use them

in ideal way as they are ideal model for children, and has a great role in

teaching and educating students.

Negrini and Carabalona (2002) their study showed the importance of

teachers in all phases of their work: selecting books, planning the week as

members of the class councils, planning the work for the days ahead, and

educating their students about the problem. They could continue to pay

attention to the problem throughout the year, highlighting awareness of it

among pupils and parents and making sure that children are not asked to

bring books to school unnecessarily. They also could organize book sharing

between classmates.

Teachers should encourage students to carry their backpack with two

straps and use an ergonomic ideal backpack (Hamilton 2000). Teachers

 221

flexibility, such as revising the required number of textbooks, notebooks,

and other supplies that the children carry with them each day (Goodgold et

al. 2002). second set of textbooks to keep in the classroom, reduction in

daily supplies that children are required to carry, use of folders rather than

binders, increased time for locker use during the day, paperback rather than

hardcover texts or texts in volumes (Ren et al. 2005).

Recommended strategies in the classroom to reduce backpack loads

include use of a classroom set of books or classroom overheads, leaving

heavy texts at home (Goodgold et al. 2002). In addition to teacher and

classroom strategies, students need to learn how to recognize when their

backpack is too heavy (Goodgold et al. 2002).

Attention directed at backpack loads and the methods of lifting and

carrying backpacks, lifestyle habits of school students will also be

addressed at the school (Wesdock & Dominguez 2003). Eliminating excess

non educational items from the backpack load (Siambanes et al. 2004).

Develop camping for students to educate them about backpack awareness

are recommended (Wesdock & Dominguez 2003.)

PARENTS

Parents remain the best advocates for safety promotion and should

represent the group most likely to help to significantly reduce the number

of backpack related injuries by checking backpack weights and contents

 222

(Forjuoh et al. 2003). Parents could exercise care when purchasing

backpacks and school materials for their children at the beginning of the

year. They could check what their children are carrying to school each day

to make sure that they are not taking items not relevant to that days

activities. They also could educate their children about the problem

(Negrini & Carabalona 2002).

Parents should not try to save money by buying the biggest backpack

that they find but they have to make sure the backpack is appropriate to

their childs size. Children are fashion conscious and vulnerable to peer

pressure, so parents should take their child with them when buying their

backpack. If the style they choose is uncool, the child may compensate by

carrying the backpack in a cool way, such as over one shoulder (Beeter

Health Channel 2010).

Students and parents need to be educated about the proper use of these

emerging wheeled backpacks. It is also advised that schools should

consider an educational program concerning the risks of carrying

excessively heavy backpacks. This information could be incorporated into

the school curriculum or distributed as a handout for children to take home

to their parents (Forjuoh et al. 2003).

Parents and children can avoid injury by recognizing warning signs

that the backpack is too heavy (change in posture when wearing the
 223

backpack, struggling when putting on or taking off the backpack, Pain

when wearing the backpack, tingling or numbness in arms and legs, mostly

arms, red marks on the shoulders) (Illinois State Board of Education 2006).

STUDENTS

Students should be taught safe, biomechanically sound methods of

putting on, wearing and taking off heavy backpacks. Backpacks need to be

handled in a biomechanically safe manner with their weights controlled to

lessen the risk of potential injury to young students. This is an important

educational message for school health m services, community pediatricians

and public health practitioners (Forjuoh et al. 2004).

Students should avoid carrying their bags over one shoulder and have

backpack properly packed and fitted (Alhazzaa 2006).

Students should know how to choose the right backpack in form of

type and style, how to wear them in a safe way, where to position the

backpack over their shoulders and backs.

PROPER USE OF BACKPACK

The first and important issue is that students should carry no more than

10% of their BW on their backs and that they carry their backpacks

properly (Guyer 2001). Students should wear their backpacks on both

shoulders (Hamilton 2000). And they should limit the amount of weight
 224

carried, use a hip-belt, adjust the shoulders straps to a fairly loose position

and perhaps position the heaviest items closest to the back (Mackie et al.

2005).

Materials in the backpack should be organized with the heaviest items

in the backpack closest to the back, and contents should be limited to only

those required for that day (Goodgold et al. 2002; Hamilton 2000).

Load placement is an important factor in the efficiency of load carriage,

and should be considered in the design and loading of backpacks.

Positioning heavy items high in the backpack may improve the ability of an

individual to perform sustained load carriage. This is important whether the

load carriage is for work or pleasure. And carrying backpack high reduces

the physiological changes (Stumpfle et al. 2004). And for loads above 15%

BW, low load configuration should be avoided (Singh & Koh 2009).

Students should remove and put on backpacks carefully by keeping the

trunk of the body stable and by avoiding excessive twisting (Illinois State

Board of Education 2006).

Students should wear the backpack over the strongest mid-back muscles.

It should rest evenly in the middle of the back. Shoulder straps should be

adjusted to allow the child to put on and take off the backpack without

difficulty and permit free movement of the arms (Illinois State Board of

Education 2006) Figure (25).

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Figure 25. Carrying Backpack

FEATUERS OF ERGONOMIC BACKPACK

On a corporate level, we must encourage companies to make more

ergonomically sound backpacks, and Backpack suppliers need to work with

schools to develop bags that work within school parameters (Hamilton

2000).

Alternatives to the use of heavy backpacks have been suggested, such as

rolling backpacks (Siambanes et al. 2004).

 226

According to (Illinois State Board of Education 2006), the ideal ergonomic

backpack includes;

Wide, padded shoulder straps. Avoid backpacks with tight narrow

straps that dig into the shoulders which can interfere with a childs

circulation and nerves. These types of straps can contribute to

tingling, numbness and weakness in the childs arms and hands.

Two shoulder straps. Backpacks with one shoulder strap that runs

across the body cannot distribute weight evenly.

Waist strap. A waist strap can distribute the weight of a heavy load

more evenly.

Lightweight backpack. The backpack itself should not add much

weight to the load.

A padded back to reduce pressure on the back, shoulders and

underarm regions and enhance comfort

Hip and chest belts to transfer some of the backpack weight from

the back and shoulders to the hips and torso

Multiple compartments to better distribute the weight in the

backpack keep items secure and ease access to the contents.

Reflective material to enhance visibility of the child to drivers at

night.

Rolling backpack. This type of backpack may be a good choice for

students who must tote a heavy load. Remember that rolling

 227

backpacks must be carried up stairs, however this type of school bag

not yet develop its safety as it may cause pain and injuries in the

shoulder when the child drag it and also this type of the school bag

encourage the school children to carry more items which may raise

the possibility of developing shoulder problems (Illinois State Board

of Education 2006).

From the previous reviews of literature we can apply many ideas in the

Saudi community which has its own characteristics so, we need to increase

the awareness of the problem, its course, consequences and the possible

solutions. which can be achieved through the media,conducting school

based seminars and educational lectures for the teachers, students and their

parents regarding the backpack style, weight, way of carrying and its

content of educational materials (books, note books, etc) with the massage

to try to minimize its weight and the duration of the carrying .

To conduct meeting between the authorities in ministry of education and

the ministry of health to formulate a research groups trying to solve the

issue of backpack problems based on our community needs.

To come up with practical recommendations that can be implemented in

the Saudi community educational system that is acceptable to the Saudi

students.
 228

The teachers in our schools should understand how serious this

problem is and this way they should share their views and suggestions

knowing the factors that get affect either by aggravating or reliving the

problem discussing with them the possible solutions to decrease the weight

of the backpack like separating smaller size note book for each chapter for

each subject which eliminate the need to carry large note book for the

whole semester, leaving the accessory materials like coloring books and

pens, geometry equipment, etc. in the school instead of carry them back

and forth, using of folders instead of note books, using flash cards or

external hard disk devises to bring assignments and homework and the

teachers should be creative to find ways of avoid carrying the heavy

backpack and the only thing she needs is a self to keep the additional items

and unneeded note books. The teacher also should instruct and educate the

children about how to choose the right backpack and how to carry it and

also can provide them with a graphs of the ideal backpack and ideal way of

carrying providing the children and their families with a copy of the

instruction and the teachers should be welling to answer any question from

children and their parents.

The students should be recommended not to carry their backpacks un-

necessarily while standing, and waiting for their transportations.

 229

Advice girls at the age of 12-15-year to carry lighter backpack (5%)

BW to avoid postural abnormalities, musculoskeletal pain in different body

areas, and balance instability during school activities.

The implementations of these suggestions suppose to reduce the

incidence of the back pain related to backpack among school children.

6.4. RECOMMENDATION FOR FURTHER STUDIES

Further studies are needed to investigate the static balance and

postural sway of school children while carrying backpack.

Longitudinal studies should be conducted to look at backpack weight

effect on postural stability, musculoskeletal pain and balance.

Study could be conducted on a larger sample.

This study conducted in one province of Saudi Arabia in Riyadh,

studies include other province is recommended.

It is recommended to apply the same study on both sexes (male and

female), to compare between both genders.

Studies include other grades (below 12 and above 15 years) also

recommended.

Including private schools in the study is recommended for

comparison.
 230

The backpack weight should be measure as a mean weight of

backpack of a week to avoid measuring the backpack in the lightest

or heaviest day.

Another area of future research involves examining rolling backpack

and explores effects regarding angle of pulling or effects on the

upper extremity.

This study was a deceptive study in assessing musculoskeletal

problems and the pain was just describe by the children so further

study needed to be done to be more objective in assessing

musculoskeletal symptoms as using EMG.

6.5. LIMITATIONS OF THE STUDY

The limitations of this study are the sample. It is recommended to

apply the same study on larger samples.

This study was limited in sex, as it is conducted on girls only

because ministry of education refused to allow women in boy's

schools.

Backpacks were only measured at one time, which possibly is not

representative of the actual weight children carries in the backpack.

Some of teachers and principals were not cooperative which gave

some difficulties.
 231

Limited time, because we had to start with the school day / time and

end at 12pm.

The study was limited to 5 intermediate schools selected from

Riyadh public schools.

This is not a blinded study, in that students being asked questions

about backpacks and back pain may suspect that the survey was

geared toward finding a relationship between backpacks and back

pain, and thus influence their responses.

 232

CHAPTER VII

REFRENCES AND APPENDICES

 233

REFERENCES

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Abdolhamid, H. (2009) Weight varying effects of carrying schoolbags on

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Gait & Posture, 28 ( 2) August, pp. 297-302.

 234

American Academy of Orthopedic Surgeons Bulletin. (1999) AAOS tells

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 235

Aruin, A. & Zatsiorsky, V. (1989) Occupational Biomechanics.

Maschinostroenie publishing house, Moscow. Cited in: Zultowski, I. &

Aruin, A. (2008) Carrying loads and postural sway in standing: the effect

of load placement and magnitude. Work, 30, pp. 359-368.

Barbara, H. Brad, C. & Stacey, H. (2008). Effects of Backpack Carriage

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 257

APPENDIX I

............................................................................................................. ....:

.....................................................:..................................................

...................................................................................... ............:

.......................................................................................................:

............................................................... .......................................:

......................................................................................................:

.2 : .1 :

....................................................: ....................................................:

....................................................: ....................................................:

....................................................: ....................................................:

o .

o .

o .
 258

o .

o .

......................................................................................................:

................................................................:....................................:
 259

APPENDIX II

.................................................................................:

.
 260

:
 261

APPENDIX III

.................................................................................. :.....................:

16 15 14 13 12

-1 :

...................................................................................................:

-2

, .

......................................................................................................................

-3 , /

 262

-4 /

-5 ,

/

-6 ,

 263

-7 , :

-8 , /

11 - 8 3 -1

11 7 -4

-9 , (

 264

-11

-11

( ).
-12

( 4 5 ).
 265

( 2 3 ).

( 1 )

( 1 )

(

-13

).

( 4 5 ).

( 2 3 ).

( 1 )

( 1 )

-14 ,

( ).

 266

-15

5 5

15-5 15-5

31 -16 31 -16

45 -31 45 -31

45 45

-16 ,

, .

.........................................................................................................................

.........................................................................................................................

( )
-17

. .

....................................................................................... ...............

........................................................................................................................
 267

-18

5 1

***************************************************

 268

APPENDIX IIII

Assessment Sheet

Student Name:Class:...

Does she have the Period? Yes No

BW:

BW with backpack: Backpack weight:

High:

BMI:

Way of carrying: ..

Measurements:

Without Backpack With Backpack

Notes:

.....
 269

 270

1432 2111 -
 271

272
 273

-1 .

-2 -3 .

-4 .

. 175

12 15 .

 274

) (43.43% ) (32.6% ) (40%

( )%1.54

. ( )%4117 4

457 742 -212

% 1228 .%1976 -4154

) (P<0.000

) (P<0.000, 0.002,0.003

(P<0.854).

) (P<0.000, 0.002 ) .(P>0.436

) (P<0.000, 0.025
 275

) (P<0.394, 0.674

. 12 15

) (10.08%

. %5

: .