INTRODUCTION
As the accessibility of digital technology and online activities have been rising rapidly in the last years, information and communication technology have become an important part of lives of children and adolescents. Most of the children regularly use digital devices for many reasons mainly like chatting, surfing on the Internet and playing games. It has been reported that 8–12 group of age spend more than 4.5 hours, and 13–18 group of age spend more than 6.5 hours a day in front of a screen (TV, smartphones, computers, video games etc.) on average.[1]
In literature, benefits of digital games for children like hand-eye coordination, imagination, spatial ability, mathematical high thinking with geometry, integrating space forms, visualization of chemistry and physics objects have been emphasized.[2] However, intense use of games and social media is often related to behaviors like addiction.[3] No matter what terminology is used, researchers usually admit that excessive use of computer and video games causes behavioral addiction.[4] World Health Organization (WHO) has classified the extensive urge for digital and video games as a mental disorder in the 11th revision of International Classification of Diseases (ICD-11) on June 18, 2018.[56] American Psychiatric Association also considered Internet game disorder as a potential diagnosis.[7]
Children's becoming acquainted with digital devices at early ages, during their development process, increases the risk of suffering from musculoskeletal problems. This research has been planned with the aim of detecting digital game addiction, playing positions and as a result of them the possible musculoskeletal system problems in secondary school children in Kayseri.
MATERIALS AND METHOD
The study received ethical approval from the Nuh Naci Yazgan University Ethics Committee on 04.17.2018 with the decision of the assembly numbered 002.
The study data have been collected by the researchers through questionnaire technique. The questionnaire forms have been generated by the researchers and adjusted for the understanding of the children. In 2017/2018 Academic Year, 1000 healthy secondary school children from Kayseri, who do not have any physical or mental disabilities and accept to participate, have been included in the research. The consents of the legal guardians of the children, who would participate in the research, have been taken. In the introduction of the questionnaire, questions about socio-demographic information of the children (gender, age, weight, height, chronic disease background etc.) and the types of digital devices they use have been listed. They were asked for how many hours a day and in which position they use those devices. They were asked to pick the closest of the visuals, which have been added into the questionnaire, to their position of use. In addition to that, as it can be related to their musculoskeletal system, questions to detect children's levels of physical activity and duration of study have been added.
In the following part, pain evaluation has been made to detect the musculoskeletal problems. Within this scope, the place and level of the pain have been tried to be determined. As means of assessment, along with body diagram, visual analogue scale (VAS) has been employed for children elder than 7.[8] The criteria for pain have been determined as the pain's continuation for more than 3 months.
To see the game addiction of children, Computer Game Addiction Scale for Children has been employed.
Computer game addiction scale for children
It is a valid and reliable scale, which has been published in the 3rd Volume of the 30th issue of Turkish Psychological Counseling and Guidance Journal. This questionnaire, which has been developed to detect digital game addiction of children, consists of 4 main parts and 21 questions in total and the score changes between ''21 and 105''. There are no reverse entries in the scale. The higher the score, the higher the level of addiction to computer games. The rating system of the scale is 5-point Likert (1 = never – 5 = always).[2]
Statistical analysis
For the statistical analysis of the data, Windows-based SPSS 21 analysis program has been used. To compare the differences in between unrelated groups, independent samples t-test has been employed. In the analysis of the relationship among continuous variables, Pearson correlation analysis has been used. To compare the independent parameters, Mann–Whitney U test has been used. In all the analyses, P < 0, 05 has been accepted to be statistically meaningful.
RESULTS
A total of 78 of the 1000 subjects, who participated in the research, were 10 years old (7.8%), 312 of them were 11 years old (31.2%), 298 of them were 12 years old (29.8%), 207 of them were 13 years old (20.7%), 101 of them were 14 years old (10.1%), and 4 of them were 15 years old (0.4%). A total of 436 of them are female (43,6%), and 564 (56,4%) of them are male [Table 1]. The percentages of obesity, musculoskeletal disorders and chronic diseases in the subjects are shown in [Table 2].
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Table 1: Information about some demographic and digital devices usage of the subjects
Table 2: Diseases of the subjects and their percentages
The average age of the 1000 students is 11.95 ± 1.12 years, their average height is 153 ± 10.09 cm, their average weight is 45.95 ± 11.2 kg, and their average body mass index (BMI) is 19.39 ± 3.30 kg/m2 [Table 3].
Table 3: Demographic and clinic characteristics of the subjects
The average time the participating students spend in front of computers to play games has been found out to be 86.96 ± 67.30 min, for tablet it is 65.18 ± 55.99 min, for phone it is 75.88 ± 70.78 min [Table 3].
When the children's complaints about pain, which lasted more than three months, have been analyzed, 93 of them had headache, 69 of them had shoulder pain, 48 of them had elbow pain, 50 of them had writs pain, 128 of them had back pain, 82 of them had low back pain, 25 of them had hip pain, 83 of them had knee pain and 75 of them had ankle pain. Pain averages according to VAS has been shown in Table 4. The average total score for computer game addiction scale for children has been found to as 39.38 ± 16.92 [Table 4].
Table 4: Averages of visual analog scale score and scale of computer game addiction for children
When the relationship between the duration of use of electronic devices and pain is analyzed, a statistically significant positive relationship between duration of computer use and neck pain has been detected (P = 0.02). Between duration of tablet use and headache, a statistically significant negative relationship has been detected (P = 0.018). Between phone use and neck pain, statistically significant positive relationship has been detected (P = 0.015) [Table 5].
Table 5: The relationship between the duration of electronic device use and pain
When the computer game addiction scale for children is analyzed, there was statistically significant positive relationship between wrist pain and total score of the computer game addiction scale for children (P = 0.009). A statistically significant positive relationship has been found between back pain and total score of the computer game addiction scale for children (P = 0.007). A statistically significant positive relationship has been found between lower back pain and total score of the computer game addiction scale for children (P = 0.011) [Table 6].
Table 6: The relationship of computer game addiction scale score and pain
When the data are analyzed according to the gender variable, uses of digital device are compared, there is a statistically significant difference from the aspect of computer and tablet use (P <0.001, P = 0.028). When game addiction is analyzed according to gender, the average score of scale is 33.84 ± 29 for females, 43.66 ± 17.45 for males. Significant difference has been detected in game addiction between females and males (P <0.001). When pain is analyzed according to genders, significant difference has been found in head, wrist and back pain (P = 0.028, P = 0.027, P = 0.001) [Table 7].
Table 7: Duration of digital device use, game addiction and pain according to gender
DISCUSSION
In this research, it has been found out that using phones and computers for games for long durations, increases neck pain in secondary school children. Between duration of tablet use and headache, a statistically significant negative relationship has been detected. The children, who have high score in scale of computer game addiction for children, have wrist, back, lower back pain. When a gender comparison is made, males use computers, tablets more and they are more addicted to games; while females have significantly higher scores in headache, wrist and back pain. Besides, positions of the children while using digital devices are also related to pain.
When similar researches in literature are analyzed, this research is consistent with the literature. In a research carried out in 2011 on 889 children, it was found out that male students are more addicted to games than female students.[9] In another research carried out in 2015 on 678 students, it was detected that male students, who participated in the research, are more addicted to games than female students.[10] A research carried out in 2007 states that in adolescents, neck occipital pain and shoulder pain were reported by females more than males.[11] Myrtveit et al.[12] stated that females have more neck and shoulder pain. In researches carried out in 2013, it was detected that using laptops for games for long durations is related to increasing pain in fingers and wrists especially in young children and females.[13]
There are studies that show computer use causes pain and discomfort in back, lower back, hands, fingers and wrists. Hakala et al.[14] have stated that computer activities are positively related to lower back pain. Yel et al.[15] have detected that students have the most problems in neck, right shoulder, back and lower back areas during the educational use of desktop/laptop/tablet computers. Ijmker et al.[16] have found positive relationship between computer use and beginning of acute arm-wrist-hand pain symptoms. In our research, positive relationship has been found between the increasing score of game addiction and wrist, back and lower back pain.
Gillespie[17] have found a meaningful relationship between long-duration computer use and neck and upper extremity pain in a research they carried out on 476 adolescents at the ages of 12–13. In a research carried out in Finland in 2012, it was concluded that musculoskeletal symptoms that cause moderate and severe pain and disturbances in daily life are common in adolescents using computers, and the risk of pain in most anatomical regions increases when daily computer use is 2 hours or more.[18] In another research wherein 6143 young athletes at the ages of 6-15, the relationship between musculoskeletal system pain and playing games was being analyzed, the ones who play games for more than 3 hours have meaningfully more complaints about pain than the ones who play less than 1 hour.[19] In a research where prevalence of neck and shoulder pain and if behavioral-sensual factors are related to the risk of neck and shoulder pain was analyzed, 20% of 8890 adolescents were found out to have neck-shoulder pain complaints. They have stated that among adolescents, who suffer from pain, depression symptoms are more common, they do less physical activities and more screen-based activities than the ones who do not suffer from pain. However, different from literature, they have stated that, while digital games are related to lower back pain, they are not related to neck-shoulder pain.[12] In our research, it has been determined that phone and computer use increase neck pain. Moreover, between shoulder and neck pain, there is a positive meaningful correlation (r = 0.487, P = 0.014).
In our research, between duration of tablet use and headache, negative relationship has been found. Headache is a problem that is frequently seen during childhood and increases in adolescence.[20] Headache can emerge as a reflection of neck oriented pain.[21] On chronic neck pain, symptoms change in accordance with the underlying cervical region problem. Blaschek et al. have found a strong association between muscle pain in the neck/shoulder region and headache in adolescents.[22] In our findings, it is obvious that there is a positive, high and meaningful relationship between neck pain and headache (r = 0.674, P < 0.001). We consider that headache develops as a result of increased neck pain, rather than tablet use.
In children who use digital devices to play games for long durations, game addiction is likely to develop; if they use it in wrong posture and position, they spend long hours in front of those devices and consequently if their physical activity decreases, they are likely to suffer from pain. The limitation of this study is that students' own assessments and comments have been used in data collection. Thus, memory bias might have been effective in data. While data are being analyzed, it is required to take this fact into consideration.
CONCLUSION
Our research reveals the increased game addiction in children and adolescents, parallel to technological improvements of our age, and the musculoskeletal system problems that develop in parallel with that. We need to raise awareness about addiction among children and emphasize the importance of right posture while using digital devices to prevent musculoskeletal problems. Furthermore, action is needed to be taken for increasing the physical activity levels of children.
Financial support and sponsorship
This research has been supported by Tübitak 2209 A Support Project of University Students Domestic Research Projects.
Conflicts of interest
There are no conflicts of interest.
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