Title of Research:

Low Back pain due to heavy backpacks in school going children in Lahore, Pakistan.

Introduction:
Mostly school-going children walking to and from the schools are seen carrying their heavy backpacks in every morning. It may seem harmless enough but it can cause painful back and neck problems and injuries for students who do not carry their backpacks properly. Thesechildren sometimes carry as much as 30% to 40% of their body weight that is too much. Many medical and health professionals advise that individuals carry no more than 10-15% of their body weight on their backs( ) . A child weighing 50 lbs. should carry no more than 7.5 lbs. 100 lbs. should carry no more than 15 lbs. 150 lbs. should carry no more than 22.5 lbs. 1 (No need here to put detail)

Dr. Seymour Zimbler - Associate in Orthopedic Surgery at the Children's Hospital in Boston, Massachusetts - recommend that children should carry no more than 15 percent of their total body weight, and preferably less than that.2 A study was conducted by Simmons College (February, 2001) that found that 55% of students carry more than the recommended guidelines of 10-15%. In October 1999, the American Academy of Orthopedics stated that of the more than 100 physicians surveyed: 71% felt that backpacks are a clinical problem for children 58% have seen patients complaining of back or shoulder pain related to backpacks 52% feel that backpack injury is a significant problem2 No need to interpret result of researches
here.

When the school children walk with a heavy load on their back or shoulders they may change their posture: they lean forward and raise their heads. According to an Australian physiotherapist both backpack weight and time carried influence cervical and shoulder posture. Forward head posture increased when carrying a backpack, especially one with a heavy load. (Chansirinukor W et al. 2001). 3 One study was conducted in Texas that revealed that mostly parents do not check the weight of their childrens backpack. A heavy backpack is a strong contributor to low-back pain in children, says Avitzur, a board-certified neurologist and medical adviser to Consumer Reports. According to the report carrying a heavy pack for long periods of time, carrying it on one shoulder instead of two, and climbing stairs with a heavy load can worsen the problem. Girls

and smaller children are more likely to have back pain from backpacks, due to their short stature. 4 A cross-sectional study of 1126 children, reported that the use of heavy backpacks and backpack weight( do not repeat words) are independently associated with back pain. 5 Another study performed in Italy found that 11-year-old children carried backpacks as heavy as 20% of their body weight, and also that 58.4% had experienced back pain more than once in their lifetime.6 In Pakistan, now and then an article or two is published in newspapers to lament the pathetic situation of school-going children7, but no serious research work has ever been conducted to highlight this problem and to create awareness among parents and educators. The aim of this study will be to determine whether backpack weight is related with back pain and other back problems.

Rationale of study:
The rationale of my study is to find out how much heavy backpack is causing back problems such as upper and lower back pain among school-going children and how to prevent them from future complications. (Give at least 3 objectives)

Literature Review:
Background: Everyday hundred and thousands of primary, middle and secondary school students rush towards their schools with overstuffed and heavy backpacks hanging over their shoulders. Academic requirements are increasing day by day with the amounts of books students are carrying to and from school. In developed countries there is growing concern among parents, school administrators, educators and health care providers with the increased amount of weight being carried each day. A recent news-article reveals that the issue has emerged as a serious concern; and pediatricians have said that school children should not carry more than 10 % to 15% of their own body weight. Dr. Wayne Yankus, of the American Academy of Pediatrics said that there is a rising concern that youngsters may have long-term back problems from tramping about with such heavy weights. It typically imbalancesthem and gives them a posture that increase low back pain. A lot of kids don't suffer it immediately, but over the long run they might.8 Epidemiology:

Incidence and prevalence: (What does the newspaper article says about prevalence in Pakistan) ? A report-study by Auburn University revealedthat heavy backpacks might be dangerous to spinal column. In their survey sample, the average pack was 17% of the childs weight. 67.2% of the children felt back muscle soreness, 50.8% back pain, 24.5% numbness and 14.7% shoulder pain.1 In a different study 1403 school children were examined. Out of these, 61.4% had backpacks that were 10% of their body weight. Students holding the heaviest backpacks had a 50% higher risk of back pain (OR 1.50 CI 95% 1.06 to 2.12) and a 42% higher risk of back pathology. Girls experienced a higher risk of back related problems compared with boys due to their short stature and thin body mass.6Korovessis et al stated in his study that girls are 5.6% more vulnerable to have back pain than boys. 9 Ideal weight of school bags for children: Dr. Zubeir Patel, an Indian physiotherapist, stated that a child should carry maximum of one tenth (10%) of his/her total body weightincluding all things i.e. their water bottle and lunchbox.10According to other medical professionals a child weighing: 50 lbs. should carry no more than 7.5 lbs. 80 lbs. should carry no more than 12 lbs. 100 lbs. should carry no more than 15 lbs. 130 lbs. should carry no more than 19.5 lbs. 150 lbs. should carry no more than 22.5 lbs.1 (no need here)

What happens when the weight of backpack exceeds the recommended limit? (no need) When a child carries a backpack that exceeds his/her own body weight, itcan lead to different musculoskeletal problems such as forward head posture, upper and low back pain and shoulder pain.And if children carry the bag on one shoulder it puts extra pressure on that side, hence tilting the spine. (DrZinal Unadkat10)The back will compensate for any weight applied to it for prolong period of time. A heavy weight carried in backpacks can: Deform the natural curves in the middle and lower backs, causing muscle strain and discomfort in the spinal joints and the rib cage. Lead to rounding of the shoulders. Ill effect Pronea person to lean forward, reducing balance and making it easier to fall. 11

Immediate and Long-term Effects of Heavy Backpacks on the Childs Health: ( no need)

Immediate ill-effects: (again no need here) Nerve Compression:Heavy backpacks cause nerve compression followed by nerve damage symptoms liketingling, numbness and lack of strength in the hands and arms.According to Dr. Pierre D'Hemecourt, sports-medicine specialist at Children's Hospital Boston, kids habit tobend their shoulders and back when leaning forward and to tilt their heads upward to see where they are going can lead to pain in the back and neck muscles and cause nerve damage in the neck.12Nerve compressionsalso occur when straps are very thin and dig into the neck and shoulders. Back, Neck and Shoulder Pain: Studies at Johns Hopkins Children Center show overloaded backpacks as the cause of shoulder or lower back pain and poor posture.1 Fatigue and an Early Development of Poor Posture.When children carryoverstuffed packs on their shoulders and move towards their schools and way back to their homes they get exhausted and start complaining about pain in the back and the shoulders.In another study Dr. RusselWindsor, M.D., an orthopaedic surgeon atNew York City's Hospital, said that students with heavy backpacks in the fourth and fifth grades are complaining about backaches, fatigue, and physicalstress.13

Long term ill-effects: (again no need here) Spinal Compression: Wearing heavy backpacks causes spinal compression in children. The spinal column is composed of 33 bones called vertebrae; it is the back's shock absorber and is held upright by the muscles and ligaments around it. But placing a heavy backpack on the shoulders bend the body backward. To balance the weight of the backpack, children have to lean forward and arch their backs. This forward-leaningputs pressure on the spine and the alignment of the column is also disturbed, causing it to bend, mostly forward or sideways. (From Children's Hospital of Pittsburgh website)12 Loss of Balance: Children may lose balance by carrying heavy backpacks. Wearing backpacks to school and on hiking trips can be dangerous. Leaning forward or backward and trying to walk do not give children a sense of direction. They can lose their balance and fall, causing both minor and major injuries. Cottalorda et al reported in a study that carrying a 10-kg backpack on one shoulder give rise to an instability and, after the swing, children need a greater propulsive force to regain balance.3 Strain on the Neck and Shoulder Leading to Headaches Reduced Breathing Capacity Due to Pressure on the Lungs Resulting From a Forward or Sideways Bent Posture.

Reducing the Effects of Heavy Backpacks in Children: (do not give your suggestions)

Doctors and physical therapists recommend that school children should carry packs of no more than 10% to 15% of their body weight. Students should evenly distribute the backpack, put the heavier items on the bottom to keep the weight off of their shoulders and maintain better posture. Children should wear both shoulder straps. Bags that sling over the shoulder or across the chest or that only have one strap are not as effective as bags with two wide shoulder straps, because these bags may cause muscle strain.14 Parents and guardians should choose backpacks that have heavily padded shoulder straps and a lumbarsupport. Parents should persuade kids to take and bring school only the books needed for homework or studying each day. Students should not carry backpack low on the back, a study on 10 healthy children aged 10-14 showed that those who carried the backpack low on their backs developed more pressure on their shoulders and back when wearing it properly high on the backs.

Objectives: (good)
To assess the prevalence of back pain in school children carrying heavy backpacks. To investigate whether backpack weight is associated with back pain in school children. To identify the school, family, and personal factors that determine the backpack load. To create awareness among school students, parents and educational authorities about the problem caused by heavy school backpacks.

Operational Definitions:
Prevalence: It is the total number of cases of school children having back pain. Back pain: It refers to upper and lower back pain and pain in the shoulders. Children: it includes children of class 3-7(8-13 years),they will be weighed individually. School: 2-3 schools of Lahore. (private and govt schools have different protocols of bags, ideally do 2 private and two govt schools and collect sample size of both genders) Also discuss about sample size formula in your synopsis with your statistician at this stage) Backpack weight: weight of bags stuffed with books and other material. School children will be weighed with and without their backpacks. Their backpacks will also be measured separately by weight measurement machine in kg.

Material and Methods:

Settings: Study will be conducted in the selected 2 -3 schools in Lahore. Duration of study: 4 months from November 2013 to February 2014. Sample Size: Total 150 male and female school students will be included in the study. (equal or not) Sample Selection: Sample will be selected by following criteria: Inclusion Criteria: Students of selected Lahore school. Students willing to participate. Students age group 8 to 13 yrs. studying in 3 to 7 class (grade).

Exclusion Criteria: Students who are not available at the time of data collection. Students who are not carrying their school bag by their own. Students suffering from any musculoskeletal disorder. Students suffering from any metabolic or neuroplastic disorder(rare but do mention its a red flag in LBP)

Sampling Technique: Simple Random sampling Study Design: Simple cross sectional survey Data collection procedure: A cross sectional study will be conducted in the local schools of Lahore during 2013 to2014 including students of age 8-13 years.An informed consentwill be taken from the concerned authorities of the respectiveschoolsby explaining purpose and objectives of the study.The students will be selected by simple random sampling and will be screened according to inclusion and exclusion criteria. Awell-structured questionnaire will be used to collect the

information.Privacy, Confidentiality and Anonymity will be maintained with honesty and impartiality.

Data Analysis: Tools/scales: (send questionnaire also) With the help of well-structured questionnaire the following variables like age, gender, class(grade) of student, weight of student, weight of backpack, if back pain is present its symptoms and duration will be mentioned. Pain will be assessed by using the Faces Pain ScaleRevised(FPS-R).Next, i will test the gender differences using chi-square tests at the 0.05 significance level. Finally, with logistic regression analysis, I will find the associations between the heavy backpack and presence of back pain.The data will be analyzed by Statistical Package for Social Sciences (SPSS) version 16.0 (SPSS).

5 to 8 references are fine in synopses. Also write your style? Be in contact with statistician hire one in your study as soon as possible search market do not hesitate to pay them they will refine your work stats work becomes very confusing if you dont focus on it from the start. good work

25/10/13

Reference:
1. Airpacks Systems Inc. (Aug 9, 2011).Facts about Carrying Backpacks and Backpack Injuries.Available at http://www.airpacks.com/documents/facts_about_backpacks_and_injury.pdf

2. Scott Greenberger (February 13, 2001). Heavy Backpacks Harmful to Students, Simmons Study Says, Boston Globe. 3. JrmeCottalorda, MD; Vincent Gautheron, MD; Sophie Bourelle, MD(November 2004).Effects of Backpack Carrying in Children. Orthopedics, Volume 27 Issue 11. 4. Tara Parker-Pope(July 21, 2009).Weighing School Backpacks, The New York times, 21 July. 5. Sheir-Neiss GI, Kruse RW, Rahman T, Jacobson LP, Pelli JA. The association of backpack use and back pain in adolescents. Spine. 2003; 28:922-930. 6. Paloma Rodrguez-Oviedo, Alberto Ruano-Ravina, Mnica Prez-Ros(2012). School Children's Backpacks, Back Pain and Back Pathologies.Medscape, 2012. 7. AnwerSumraApril (10, 2013). Is your childs backpack too heavy?The Express Tribune, April 2013. Available at http://blogs.tribune.com.pk/story/16714/is-your-childs-backpack-too-heavy/ 8. Jeanne Ohm. (December 1999) Carrying the Backpack into the School. I.C.P.A. November/December 2012. 9. Amal H. Ibrahim. (2012). Effect of School Bag Weight and Carrying Way. World Applied Sciences Journal, Vol. 17. 10. KritiSaraswat. (June 24, 2013). The ill-effects of carrying heavy schoolbags. Available at http://health.india.com/diseases-conditions/the-ill-effects-of-carrying-heavy-schoolbags 11. John J. Triano. Backpacks and Back Pain in Children. Available athttp://www.spinehealth.com/wellness/ergonomics/backpacks-and-back-pain-children 12. Ariz., Cicely A. Richard. Back Problems Related to Heavy Backpacks on Children. Available at http://www.trails.com/list_7762_problems-related-heavy-backpacks-children.html 13. Tamra Orr. (September 2000) Backpack May Spell Backache. Current Health Sciences Journal. 14. Steven Dowshen. (August 2013). Backpack Safety. Available at kidshealth.org/parent/positive/learning/backpack.html