© 2018 IJSRST | Volume 4 | Issue 9 | Print ISSN: 2395-6011 | Online ISSN: 2395-602X

Themed Section: Science and Technology

Assessment of Co-Morbid Factors Associated with Text-Neck

Syndrome among Mobile Phone Users
M. Vijayakumar, Sanika Mujumdar, Aishwarya Dehadrai
Dr. D. Y. Patil College of Physiotherapy, Pimpri-Chinchwad, Maharashtra, India

ABSTRACT

Objective: To assess the co-morbid factors associated with Text-neck syndrome among mobile phone
users and also identify their severity.
Materials and Methods:59 confirmed cases of Text-Neck syndrome within 18-25 years of age who use
mobile phone on an average of about 3 or more than 3 hours in a day and having 3 out of 6 symptoms of
Text-Neck were taken and Forward head posture, Grip strength, Active cervical joint ROM and Neck
muscles’ strength were assessed in them and the measurements were noted.
Results: 100% showed neck pain and Forward head posture while 94.91% with upper back pain, 89.83%
with headache and poor grip strength and 59.32% with shoulder pain.
Conclusion: There are various co-morbid factors of Text-Neck syndrome out of which severity of Neck
pain and upper back pain is more followed by headache, shoulder pain. Also Forward Head Posture is one
of the main serious co-morbid factors. Along with that, cervical joint ROM mainly flexion, extension and
lateral flexion (left and right both) are restricted. As stated above, smartphone induced neck pain and other
co-morbid factors are of chronic, progressive nature, timely interpretation and interventions along with
postural correction will be the key entities to deal with Text-Neck syndrome.
Keywords: Text Neck Syndrome, Forward Head Posture, Grip Strength

I. INTRODUCTION smartphone use might be related to sleep disturbances

and depression.3
Smartphones are becoming increasingly indispensable
in everyday life and offer a substantial variety of The weight of an adult‟s head in neutral position is 10-
mobile applications for information, communication, 12 pounds. There is an increase in load towards the
education and entertainment purposes. While mobile neck with the flexion of the head and the weight is
applications offer several ways to prevent and treat calculated to be 27, 40, 49 and 60 pounds at 15°, 30°,45°
chronic diseases such as diabetes or alcoholism, there and 60° respectively. When using a smartphone,
are also obvious adverse effects on physical and people usually have a downward gaze to stare at the
mental health caused by their overuse. 1 Recent lowered objects and maintain the head in a forward
investigations have shown that smartphone users tend position for long periods of time which may cause
to report pain in the neck, shoulder and thumb and neck pain. Moreover, the maintenance of a head-
the severity of the symptoms as the total time spent forward posture decrease cervical lordosis of the lower
using the smartphone increases. Prolonged use causes cervical vertebrae and creates a posterior curve in the
faulty posture such as forward neck posture, slouched upper thoracic vertebrae to maintain balance. This is
posture or rounded shoulders.2 Regarding mental known as Forward Head Posture/ Turtle Neck posture.
health, recent studies showed that increased This causes strain on the muscles, ligaments and joints

IJSRST18495 | Received : 01 July 2018| Accepted : 15July2018 | July-August-2018 [4 (9): 38-46]

38
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which leads to impingement of nerves resulting into  Flattening of the spinal curve
tingling, numbness in the hands. Such increase in  Onset of early arthritis
biodynamical stress followed by forward head posture  Spinal misalignment
becomes a cause of musculoskeletal problems such as  Disc compression
neck pain, headache and temporomandibular  Nerve damage
dysfunction.4  Muscle damage
 GI problems
The excessive usage of smartphones reported to have a  Depression, stress
negative influence on our anxiety and stress levels.  Headaches6
Lack of proper sleep may lead to fatigue, tiredness and
shortfall of energy during morning hours.5 The physical exposure when text messaging on a
mobile phone consists of low physical load, repetitive
A recent study shows that 79% of the population thumb movements and neck flexion. The time spent
between the age 18-44 have their cell phones with using a mobile phone and its small keyboard for
them almost all the time, with only 2 hours of their texting is likely to increase because of the increased
walking day spend without their cell in hands. 6 multifunctionality of the smartphones and thus will
According to recent Times Of India survey, 82 million increase the risk of Text neck and it‟s associated co-
Indian Adults were smartphone users in 2014. morbidities.7
Smartphone users in India usually spend an average of
3 hours a day on their smartphone while heavy II. MATERIALS AND METHODOLOGY
smartphone users spend 8-10 hours in a day.
(DurgeshNandanJha, July 23, 2014, 12:11 AM 59 confirmed cases of Text-Neck syndrome in the age
m.timesofindia.com) group of 18-25 yrs who use mobile on an average for
about 3 or more than 3 hours in a day and having any
“Text neck” is the term used to describe the neck pain 3 out of 6 symptoms of Text-Neck i.e. neck pain,
and damage sustained from looking down at the cell upper back pain, shoulder pain, headache, insomnia,
phone, tablets or other wireless device too frequently tingling, numbness in hands were included in the
and for too long. Most commonly it causes neck pain study. The analytical design study was conducted.
and soreness. In addition to it, upper back pain Exclusion criteria were individuals who have any
ranging from chronic, nagging pain to sharp and congenital, traumatic and surgical conditions of the
severe upper back muscles spasm, shoulder pain and cervical, thoracic spine and shoulder that alters Neck-
tightness, possibly resulting in painful shoulder shoulder complex, subjects diagnosed with migraine,
muscle spasm. The term “Text neck” was coined by Dr. tinnitus and any neurological condition leading to
Dean L. Fishman, who is a US chiropractor. This term memory problems, depression and headaches.
is used to describe a repetitive stress injury or an Materials such aspen, book, Hand grip dynamometer,
overuse syndrome where a person has his/her head Goniometer, mobile camera, Pressure Biofeedback
hung or flexed in a forward position and is bent down were used for the assessment.
looking at his/her mobile for prolonged periods of
time. Permission was obtained from institutional ethical
committee. Informed consent was taken from the
If text neck is left untreated, it can lead to some individuals willing to participate as per the inclusion
serious permanent damage, such as:

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 M. Vijayakumar,et al. Int J S Res Sci. Tech. 2018 July-August-201; 4(9) : 38-46

and exclusion criteria and purpose of the study was while the handle should rest on middle of four
explained to them and the samples were screened. fingers. When ready, the sample squeezes the
dynamometer with maximum isometric effort, which
Procedure: is maintained for about 5 seconds. No other body
Demonstration room with adequate ventilation, movement is allowed. Recordings in kgs were noted
proper light and plain coloured walls was chosen for each sample.
where the study was going to be carried out. Text
neck samples were confirmed based on it‟s symptoms. Active Cervical joint ROM of each sample was
Photographs of an each individual were taken in a assessed by using Goniometer. Samples were in an
saggital plane with the help of mobile camera (13mp, upright sitting, looking straight ahead, arms resting
resolution:4128×3096) to find out the Forward Head on their lap and feet flat on the floor during all range
Posture. Forward Head Posture measurement in terms of motion tests.
of angle was conducted with the photos by using
ImageMeter application (Kinovea software). Neck muscles‟ strength wasassessed with the help of
Pressure Biofeedback and values were noted. Samples
The angle was calculated between the true horizontal laid hook-lying position on a therapy table with a
line through the jaw and the spinous process of C7 neutral neck position where their head and neck
and the line connecting both of them with the tragus lined up and straight. The pressure cuff of the
of the ear. This angle was chosen as it is considered to pressure biofeedback was placed underneath the
be the clinical standard for measuring sagittal occiput. Samples were instructed to tuck their chin
craniocervical posture, which refers to the degree of gently as if saying „yes‟ without using the neck
Forward head posture. motions which may substitute the
sternocleidomastoid muscle. The testing range was
Grip strength of dominant and non-dominant hands from 20 mmHg to 30 mmHg and the pressure should
of each sample was assessed with the help of Hand- maintain for 10 seconds in each 2mmHg without
grip dynamometer. In this,the sample holds the resting.
dynamometer in the hand to be tested, with the arm
at right angles and elbow by the side of the body. On the basis of samples, severity of co-morbid factors
The handle of the dynamometer is adjusted if of Text neck was evaluated.
required- the base should rest on first metacarpal

DATA ANALYSIS
Table 1
Age Gender Dominance

Mean SD Female Male Right Left

22.06 1.49 91.52% 8.47% 93.22% 6.77%

Table 2. Co-morbid Factors of Text-neck Syndrome

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 M. Vijayakumar,et al. Int J S Res Sci. Tech. 2018 July-August-201; 4(9) : 38-46

Neck Pain Upper back Headache Shoulder Forward Grip

Pain pain Head Strength
Posture
No. of 100% 94.91% 89.83% 59.32% 100% 89.83%
samples
(%)

1.2
Co-morbid Factors
100% 100%
1 94.91%
89.83% 89.83%
No.of samples (%)

0.8
59.32%
0.6

0.4

0.2

0
N. Pain U.back pain Headache Sh.Pain FHP Poor Grip

Graph 1
Interpretation : Graph 2 shows that there are 100% samples with neck pain and Forward head posture while
94.91% samples with upper back pain, 89.83% with headache and poor grip strength and 59.32% with shoulder
pain.

Table 3. Severity of neck pain, upper back pain, shoulder pain and headache(VAS)
VAS Neck Pain Upper back Pain Headache Shoulder pain
Mean 5.27 4.79 3.91 2.10
Median 6 5 4 2
Mode 7 6 2 0

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 M. Vijayakumar,et al. Int J S Res Sci. Tech. 2018 July-August-201; 4(9) : 38-46

Interpretation : Table 3 shows that mean, median and mode of neck pain is 5.27, 6 and 7 resp. while that of
upper back pain is 4.79, 5 and 6. Mean, median and mode of headache is 3.91, 4 and 2 while that of shoulder
pain is 2.10 ,2 and 0.

Forward Head Posture

25 23
18
No. of samples
20
15 12
10
4
5 2
0
30-35 35-40 40-45 45-50 50-55
Angle (Degrees)

Graph 4. Forward Head Posture

Interpretation: Graph no.4 shows maximum no. of samples (23) having forward head posture in the range of
40°-45°.

Table 5. Grip Strength

Grip Strength Females Males
Poor 49 5
Below Average 4 0
Average 1 0
Interpretation : Table 5 shows that 49 females and 5 males having Poor Grip Strength while 4 females having
below average strength.
Table 6. Cervical joint flexion ROM
Angle (Degrees) No. Of samples
< Or =30 2
31-35 8
36-40 18
41-45 23
46-55 8
Interpretation: Table 6 shows maximum no. of samples (23) having cervical joint flexion ROM in the range of
41°-45°.
Table 7. Cervical joint Extension ROM
Angle ( Degrees) No. Of Samples
31-40 7
41-50 35
51-60 17
Interpretation: Table 7 shows maximum no. of samples (35) have cervical joint extension ROM in the range of
41°-50°.

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Table 8. Cervical joint Lateral flexion (Left and Right) ROM

Angle (Degrees) Left (No. of samples) Right (No. of samples)
<45 59 58
>=45 0 1
Interpretation: Table 8 shows maximum no. of samples have cervical joint lateral flexion ROM (Left and Right)
< 45°i.e. restricted than normal.
Table 9. Cervical joint Lateral Rotation (Left and Right) ROM
Angle (Degrees) Left (No. of samples) Right (No. of samples)
<70 29 22
>=70 30 37
Interpretation: Table 9 shows maximum no. of samples have cervical joint lateral rotation (left and right) ROM >
or =70° i.e. within normal range.
Table 10. Deep Cervical Flexors' strength
DCF strength (mm of hg) No. Of samples
20-25 11
25-30 39
30-35 9
Interpretation: Table 10 shows maximum no. of Table 5 shows that49 females and 5 males have Poor
samples (39) have Deep Cervical Flexors' strength in Grip Strength while 4 females have below average
the range of 25-30 mm of hg. strength with only 1 female having average grip
strength.
III. RESULTS
Table 6 shows 23 samples with Text-Neck syndrome
Table 1 shows that mean and SD of age are 22.06 and have cervical joint flexion ROM in the range of 41°-45°
+/- 1.49 respectively. Also 91.52% are females and while only 2 samples in the range of <=30°.
8.74% are males. Right side dominance is 93.22%
while left side is 6.77%. Table 7 shows that 35 samples with Text-Neck
syndrome have cervical joint extension ROM in the
Graph no. 2 shows that there are 100% samples with range of 41°-50° while only 7 samples in the range of
neck pain and Forward head posture while 94.91% 31°-40°.
samples with upper back pain, 89.83% with headache
and poor grip strength and 59.32% with shoulder pain. Table 8 shows that59 and 58 samples of Text-Neck
Table 3 shows that mean, median and mode of neck syndrome have cervical joint lateral flexion ROM
pain is 5.27, 6 and 7 resp. while that of upper back (Left and Right resp.) < 45°i.e. restricted than normal.
pain is 4.79, 5 and 6 followed by headache i.e.3.91, 4 Table 9 shows that 30 out of 59 samples with Text-
and 2 resp. and then shoulder pain i.e. 2.10, 2 and 0. Neck syndrome have Left Cervical joint lateral
Graph no. 4 showsthat 23 samples with Text-Neck rotation ROM > or =70° while 37 out of 59 samples
syndrome have Forward Head Posture in the range of have Right cervical joint lateral rotation ROM > or
40°-45° while only 2 samples have Forward Head =70° i.e. within normal range.
Posture in the range of 30°-35°.

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Table 10 shows that 39 samples with Text-Neck head and shoulder posture. In regards to Forward
syndrome have Deep Cervical Flexors' strength in the Head Posture, the head is shifted in front of the
range of 25-30 mm of hg anatomical gravity midline and the head is rotated
towards the back in an attempt to have straight sight
IV. DISCUSSION under such posture.3 This causes an excessive anterior
curve in the lower cervical vertebrae and an excessive
The purpose of the study was to assess the co-morbid posterior curve in the upper thoracic vertebrae to
factors associated with Text-Neck syndrome and maintain balance and place stresses on the cervical
identify their severity. After screening of 300 samples, spine and neck muscles. Previous article has found
59 samples were selected having symptoms of Text- that the head flexion angle was larger when text
neck syndrome. In this study, participants who used messaging compared with web browsing and video
their smartphone every day and almost for more than watching.2 Thus, excessive head flexion causing
3 hours in a day on an average were included. In this Forward Head Posture and protracted shoulders
study, the mean age of the samples is 22.06 years +/- impose risk among heavy smartphone users.
1.49 with 91.52% females and 8.47% males. Also,
right sided dominance was 93.22% while left sided In this study, grip strength of both the hands was
was 6.77%. assessed and result shows that 49 females and 5 males
have Poor Grip Strength while 4 females have below
Present study shows that there are 100% samples with average strength with only 1 female having average
neck pain and Forward head posture while 94.91% grip strength.13 While texting on mobile phone, the
samples with upper back pain, 89.83% with headache hand and fingers are highly exposed to repetitive
and poor grip strength and 59.32% with shoulder pain. movements. EwaGustafsson et al. found differences in
Studies on the prevalence of smartphone use have texting velocity between men and women, with
reported that the distribution of musculoskeletal women texting with higher velocity.7 This can result
symptoms or pain of any severity was most common into wrist and thumb pain associated with below
in the neck, followed by the upper back and then the average to poor grip strength. And grip strength is
shoulders. This study shows that severity of neck pain
6
essential to perform functional activities. Thus, Text-
among Text-neck syndrome patients is more followed Neck syndrome can cause loss of grip strength and
by upper back, headache and then shoulder pain ultimately, loss of ability to perform functional
(Mean, median and mode of neck pain=5.27, 6 and 7 activities.
resp. while that of upper back pain is 4.79, 5 and 6
followed by headache i.e.3.91, 4 and 2 resp. and then Prolonged shearing of the vertebrae from Forward
shoulder pain i.e. 2.10, 2 and 0). Thus, Neck pain is Head Posture eventually irritates the small facet
the prominent symptom seen in the Text-Neck cervical joints as well as soft tissues and ligaments.
syndrome patients followed by upper back pain. This irritation causing neck and upper back pain will
Present study shows that all 59 samples have Forward also lead to trigger points in the trapezius,
Head Posture as all have FHP more than 10°(Normal sternocleidomastoid and rhomboids muscles, along
value). 12 Out of 59, 23 and 18 Text-Neck syndrome with limited cervical joint Range Of Motion.1 When
samples are severly affected as they have Forward assessed Cervical Joint ROM, 23 Text-Neck syndrome
Head Posture angle in the range of 40°-45° and 45°- samples have flexion in the range of 41°-45°,followed
50°. Lemola S. et al. noted that the most common by 18 samples in the range of 36°-40°i.e restricted
condition that contributes to neck pain is Forward (normal range:0°-80°) . Also, extension was found out

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 M. Vijayakumar,et al. Int J S Res Sci. Tech. 2018 July-August-201; 4(9) : 38-46

to be in the range of 41°-50° by 35 patients i.e.also flexors as well as rhomboids, serratus anterior and
restricted (normal range:0°-70°). 59 samples with often the lower trapezius are weak. Opposite these
Text-Neck syndrome and 58 samples have cervical weak muscles are tight pectoralis major and minor,
joint lateral flexion ROM (Left and Right resp.) < along with upper trapezius and levator scapulae.14
45°i.e. restricted than normal. (normal range:0°-45°).
30 out of 59 samples with Text-Neck syndrome have The use of a smartphone- a small, electronic,
Left Cervical joint lateral rotation ROM > or =70° handheld device causes these musculoskeletal
while 37 out of 59 samples have Right cervical joint impairments which lead to permanent damage of the
lateral rotation ROM > or =70° i.e. within normal joints, soft tissues and ligaments in young age. Hence,
range (normal range: 0°-70°) . So, present study shows
14 the modification of lifestyle to alleviate the muscular
that cervical flexion, extension and lateral flexion pain and discomfort of text neck is essential before the
(Left and Right) ROM are restricted in individuals condition worsens. Taking frequent breaks from
having Text-neck syndrome. People are using texting, doing stretching exercises of neck, posture
smartphone not only in sitting and standing but also focused exercises such as chin tucks, Pilates and Yoga
lying on prone and side lying. Further, people use to improve posture will prevent the young population
their smartphone with one hand often with tilted from this addictive and disabling syndrome and also
head due to the size of the equipment. It may cause proper ergonomics for how the mobile phones should
excessive stress on the related structures that the more be used will increase awareness among young
use of a smartphone could possibly result into reduced population.
lateral flexion of the neck. 11 Due to hypomobility of V. CONCLUSION
cervical joints, chronic neck pain and ultimately
spinal degeneration will occur at an early age.1 Present study concludes that there are various co-
morbid factors of Text-Neck syndrome out of which
Deep Cervical Flexor Muscle strength was found to be severity of Neck pain and upper back pain is more
in the range of 25-30mm of hg by maximum no. of followed by headache, shoulder pain. Also Forward
samples i.e. 39 patients. However, we don‟t have Head Posture is one of the main serious co-morbid
standardized normal values for the Deep Cervical factors. Along with that, cervical joint ROM mainly
Flexors‟ strength which is measured with the help of flexion, extension and lateral flexion (left and right
pressure biofeedback. SeverinHaug et al. stated that both) are restricted.
due to continuous load on the upper cervical and As stated above, smartphone induced neck pain and
lower thoracic vertebrae which causes neck and upper other co-morbid factors are of chronic, progressive
back pain, muscles like trapezius, rhomboids, nature, timely interpretation and interventions along
sternocleidomastoid, deep cervical flexors are the with postural correction will be the key entities to
main to go for weakness. Forward Head Posture can
1 deal with Text-Neck syndrome.
result in adaptive shortening of the occipital muscles.
It also causes the cervical spine to change alignment LIMITATIONS
resulting in increased stress of the facet joints and
posterior discs and other posterior elements. This 1. Small sample size used in the study.
position may lead to weakness of Deep Cervical 2. Study was conducted in limited area.
Flexors. Janda described a cervical “Upper Crossed 3. Wrist and thumb pain were not assessed.
Syndrome” to show the effect of forward head posture
VI. FUTURE SCOPE
on the muscles. With this syndrome, the deep cervical

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phones and musculoskeletal disorders in young

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