The Impact of Backpack Loads on School Children: A Critical Narrative Review
2. Materials and Methods
2.1. Search Strategy
2.2. Screening and Selection
2.3. Inclusion and Exclusion Criteria
2.4. Critical Appraisal and Data Extraction
3.1. Critical Appraisal of Studies (CAS)
3.2. Participant Characteristics
3.3. Nature of the Load Carriage
3.4. Contexts of Measurement
3.5. Load Weight
3.6. Biomechanical Outcome Measures
3.6.1. Posture-Related Biomechanical Measures
3.6.2. Gait-Related Biomechanical Measures
3.7. Physiological Outcome Measures
3.8. Measures of Physical Discomfort and Pain
4.1. Age Groups of Participants
4.2. Contexts of Load Carriage That Have Been Studied
4.3. Natures and Weights of Loads Carried
4.4. Biomechanical Impacts of School Backpack Loads
4.5. Physiological Impacts of School Backpack Loads
4.6. Physical Discomfort Caused by School Backpack Loads
4.7. Summation of Findings
4.8. Limitations of This Review
Conflicts of Interest
- Mackenzie, W.G.; Sampath, J.S.; Kruse, R.W.; Sheir-Neiss, G.J. Backpacks in children. Clin. Orthop. Relat. Res. 2003, 409, 78–84. [Google Scholar] [CrossRef] [PubMed]
- Brackley, H.M.; Stevenson, J.M. Are children’s backpack weight limits enough?: A critical review of the relevant literature. Spine 2004, 29, 2184–2190. [Google Scholar] [CrossRef] [PubMed]
- Cottalorda, J.; Rahmani, A.; Diop, M.; Gautheron, V.; Ebermeyer, E.; Belli, A. Influence of school bag carrying on gait kinetics. J. Pediatr. Orthop. 2003, 12, 357–364. [Google Scholar] [CrossRef]
- Drzal-Grabiec, J.; Truszczynska, A.; Rykala, J.; Rachwal, M.; Snela, S.; Podgorska, J. Effect of asymmetrical backpack load on spinal curvature in school children. Work 2015, 51, 383–388. [Google Scholar] [CrossRef] [PubMed]
- Lasota, A. Schoolbag weight carriage by primary school pupils. Work 2014, 48, 21–26. [Google Scholar] [CrossRef] [PubMed]
- Pau, M.; Corona, F.; Leban, B.; Pau, M. Effects of backpack carriage on foot-ground relationship in children during upright stance. Gait Posture 2011, 33, 195–199. [Google Scholar] [CrossRef] [PubMed]
- Dockrell, S.; Simms, C.; Blake, C. Schoolbag carriage and schoolbag-related musculoskeletal discomfort among primary school children. Appl. Ergon. 2015, 51, 281–290. [Google Scholar] [CrossRef] [PubMed]
- Hong, Y.; Cheung, C.K. Gait and posture responses to backpack load during level walking in children. Gait Posture 2003, 17, 28–33. [Google Scholar] [CrossRef]
- Hong, Y.; Li, J.X. Influence of load and carrying methods on gait phase and ground reactions in children’s stair walking. Gait Posture 2005, 22, 63–68. [Google Scholar] [CrossRef] [PubMed]
- Ramprasad, M.; Alias, J.; Raghuveer, A.K. Effect of backpack weight on postural angles in preadolescent children. Indian Pediatr. 2010, 47, 575–580. [Google Scholar] [CrossRef] [PubMed]
- Hong, Y.; Li, J.X.; Fong, D.T. Effect of prolonged walking with backpack loads on trunk muscle activity and fatigue in children. J. Electromyogr. Kinesiol. 2008, 18, 990–996. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Bauer, D.H.; Freivalds, A. Backpack load limit recommendation for middle school students based on physiological and psychophysical measurements. Work 2009, 32, 339–350. [Google Scholar] [PubMed]
- Siambanes, D.; Martinez, J.W.; Butler, E.W.; Haider, T. Influence of school backpacks on adolescent back pain. J. Pediatr. Orthop. 2004, 24, 211–217. [Google Scholar] [CrossRef] [PubMed]
- Puckree, T.; Silal, S.P.; Lin, J. School bag carriage and pain in school children. Disabil. Rehabil. 2004, 26, 54–59. [Google Scholar] [CrossRef] [PubMed]
- Goodgold, S.; Corcoran, M.; Gamache, D.; Gillis, J.; Guerin, J.; Coyle, J.Q. Backpack use in children. Pediatr. Phys. Ther. 2002, 14, 122–131. [Google Scholar] [CrossRef] [PubMed]
- Levin, H. Laptops Unleashed A High School Experience. Learn. Lead. Technol. 2004, 31, 6–12. [Google Scholar]
- Kujala, U.M.; Salminen, J.J.; Taimela, S.; Oksanen, A.; Jaakkola, L. Subject characteristics and low back pain in young athletes and nonathletes. Med. Sci. Sports Exerc. 1992, 24, 627–632. [Google Scholar] [CrossRef] [PubMed]
- Pau, M.; Mandaresu, S.; Leban, B.; Nussbaum, M.A. Short-term effects of backpack carriage on plantar pressure and gait in schoolchildren. J. Electromyogr. Kinesiol. 2015, 25, 406–412. [Google Scholar] [CrossRef] [PubMed]
- Joseph, A.; Wiley, A.; Orr, R.; Schram, B.; Dawes, J.J. The Impact of Load Carriage on Measures of Power and Agility in Tactical Occupations: A Critical Review. Int. J. Environ. Res. Public Health 2018, 15, 88. [Google Scholar] [CrossRef] [PubMed]
- Orr, R.M.; Pope, R.; Johnston, V.; Coyle, J. Soldier occupational load carriage: A narrative review of associated injuries. Int. J. Inj. Control Saf. Promot. 2014, 21, 388–396. [Google Scholar] [CrossRef] [PubMed]
- Negrini, S.; Carabalona, R.; Sibilla, P. Backpack as a daily load for schoolchildren. Lancet 1999, 354, 1974. [Google Scholar] [CrossRef]
- Sheir-Neiss, G.I.; Kruse, R.W.; Rahman, T.; Jacobson, L.P.; Pelli, J.A. The association of backpack use and back pain in adolescents. Spine 2003, 28, 922–930. [Google Scholar] [CrossRef] [PubMed]
- Knapik, J.J.; Reynolds, K.; Orr, R.; Pope, R. Load Carriage-Related Paresthesias: Part 1: Rucksack Palsy and Digitalgia Paresthetica. J. Spec. Oper. Med. 2017, 16, 74–79. [Google Scholar]
- Kohl, H.W., III; Cook, H.D. Educating the Student Body: Taking Physical Activity and Physical Education to School; National Academies Press: Washington, DC, USA, 2013. [Google Scholar]
- Brown, J.; Jinkins, S. At tech-savvy DFW districts, netbooks are joining textbooks. Star Telegram, 19 May 2010. [Google Scholar]
- Adeyemi, A.J.; Rohani, J.M.; Rani, M.R.A. Backpack-back pain complexity and the need for multifactorial safe weight recommendation. Appl. Ergon. 2017, 58, 573–582. [Google Scholar] [CrossRef] [PubMed]
- Downs, S.H.; Black, N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J. Epidemiol. Commun. Health 1998, 52, 377–384. [Google Scholar] [CrossRef][Green Version]
- Eng, J.; Teasell, R.; Miller, W.; Wolfe, D.; Townson, A.; Aubut, J.A.; Abramson, C.; Hsieh, J.; Connolly, S.; Konnyu, K. Spinal Cord Injury Rehabilitation Evidence: Method of the SCIRE Systematic Review. Aust. J. Physiothery 2002, 48, 43–49. [Google Scholar] [CrossRef] [PubMed]
- Kennelly, J. Methodological Approach to Assessing the Evidence. In Reducing Racial/Ethnic Disparities in Reproductive and Perinatal Outcomes; Springer: New York, NY, USA, 2011. [Google Scholar]
- Tomes, C.; Orr, R.M.; Pope, R. The impact of body armor on physical performance of law enforcement personnel. Ann. Occup. Environ. Med. 2017, 29, 12–26. [Google Scholar] [CrossRef] [PubMed]
- Moher, D.; Liberati, A.; Tetzlaff, J.; Altman, D.G. Preferred Reporting Items for Systematic Reviews and MetaAnalyses: The PRISMA Statement. PLoS Med. 2009, 6. [Google Scholar] [CrossRef] [PubMed]
- Chow, D.H.; Ou, Z.Y.; Wang, X.G.; Lai, A. Short-term effects of backpack load placement on spine deformation and repositioning error in schoolchildren. Ergonomics 2010, 53, 56–64. [Google Scholar] [CrossRef] [PubMed]
- Chow, D.H.K.; Kwok, M.L.Y.; Au-Yang, A.C.K.; Holmes, A.D.; Cheng, J.C.Y.; Yao, F.Y.D.; Wong, M.S. The effect of backpack load on the gait of normal adolescent girls. Ergonomics 2005, 48, 642–656. [Google Scholar] [CrossRef] [PubMed]
- Ozgul, B.; Akalan, N.E.; Kuchimov, S.; Uygur, F.; Temelli, Y.; Polat, M.G. Effects of unilateral backpack carriage on biomechanics of gait in adolescents: A kinematic analysis. Acta Orthop. Traumatol. Turc. 2012, 46, 269–274. [Google Scholar] [CrossRef] [PubMed]
- Rodriguez-Oviedo, P.; Ruano-Ravina, A.; Perez-Rios, M.; Garcia, F.B.; Gomez-Fernandez, D.; Fernandez-Alonso, A.; Carreira-Nunez, I.; Garcia-Pacios, P.; Turiso, J. School children’s backpacks, back pain and back pathologies. Arch. Dis. Childhood 2012, 97, 730–732. [Google Scholar] [CrossRef] [PubMed]
- Soares, M.M.; Jacobs, K.; Sharan, D.; Ajeesh, P.S.; Jose, J.A.; Debnath, S.; Manjula, M. Back pack injuries in Indian school children: Risk factors and clinical presentations. Work 2012, 41, 929–932. [Google Scholar]
- Spiteri, K.; Busuttil, M.L.; Aquilina, S.; Gauci, D.; Camilleri, E.; Grech, V. Schoolbags and back pain in children between 8 and 13 years: A national study. Br. J. Pain 2017, 11, 81–86. [Google Scholar] [CrossRef] [PubMed]
- Vieira, A.C.; Ribeiro, F. Impact of backpack type on respiratory muscle strength and lung function in children. Ergonomics 2015, 58, 1005–1011. [Google Scholar] [CrossRef] [PubMed]
- Connolly, B.H.; Cook, B.; Hunter, S.; Laughter, M.; Mills, A.; Nordtvedt, N.; Bush, A. Effects of backpack carriage on gait parameters in children. Pediatr. Phys. Ther. 2008, 20, 347–355. [Google Scholar] [CrossRef] [PubMed]
- Viera, A.J.; Garrett, J.M. Understanding interobserver agreement: The kappa statistic. Fam. Med. 2005, 37, 360–363. [Google Scholar] [PubMed]
- Mackie, H.; Legg, S.; Beadle, J.; Hedderley, D. Comparison of four different backpacks intended for school use. Appl. Ergon. 2003, 34, 257–264. [Google Scholar] [CrossRef]
- American Physical Therapy Association (APTA). Is Your Child’s Backpack Making the Grade? 2004. Available online: http://www.apta.org/Media/Releases/Consumer/2009/4/14/ (accessed on 19 October 2018).
- JanSport. Backpacks. Available online: http://www.jansport.com/shop/en/jansport-us/backpacks/all-baclpacks (accessed on 8 February 2018).
- Knapik, J.J.; Reynolds, K.L.; Harman, E. Soldier load carriage: Historical, physiological, biomechanical, and medical aspects. Mil. Med. 2004, 169, 45–56. [Google Scholar] [CrossRef] [PubMed]
- Grimmer, K.; Dansie, B.; Milanese, S.; Pirunsan, U.; Trott, P. Adolescent standing postural response to backpack loads: A randomised controlled experimental study. BMC Musculoskelet. Disord. 2002, 3, 10. [Google Scholar] [CrossRef][Green Version]
- Devroey, C.; Jonkers, I.; De Becker, A.; Lenaerts, G.; Spaepen, A. Evaluation of the effect of backpack load and position during standing and walking using biomechanical, physiological and subjective measures. Ergonomics 2007, 50, 728–742. [Google Scholar] [CrossRef] [PubMed]
- Bobet, J.; Norman, R. Effects of load placement on back muscle activity in load carriage. Eur. J. Appl. Physiol. Occup. Physiol. 1984, 53, 71–75. [Google Scholar] [CrossRef] [PubMed]
- Buhagiar, A.; Borg Xeureb, C.; Camilleri, C.; Felice, A.; Grench, G.; Mangion, C.; Palmier-Cecy, C. Committee on the Handling of Heavy School Bags 2000; Report No. 433/2000; Ministry of Education: Floriana, Malta, 2000.
- Morris, J. Factors influencing the quality of student learning on practice placements. Learn. Health Soc. Care 2007, 6, 213–219. [Google Scholar] [CrossRef]
- Harsha, D.W.; Berenson, G.S. The benefits of physical activity in childhood. Am. J. Med. Sci. 1995, 310, S109–S113. [Google Scholar] [CrossRef] [PubMed]
- Shultz, S.P.; Deforche, B.; Byrne, N.M.; Hills, A.P. Fitness and fatness in childhood obesity: Implications for physical activity. In Global Perspectives on Childhood Obesity; Elsevier: Cambridge, MA, USA, 2011; pp. 371–381. [Google Scholar]
- Dollman, J. Changing associations of Australian parents’ physical activity with their children’s sport participation: 1985 to 2004. Aust. N. Z. J. Public Health 2010, 34, 578–582. [Google Scholar] [CrossRef] [PubMed]
|Database||Date Searched||Search Terms||Filters||Results|
|CINAHL||30/8/2017||(Load* OR carriage OR carrying OR carried OR backpack* OR bag* OR knapsack* OR rucksack* OR pack*)|
AND (Child* OR adolescent* OR juvenile* OR minor* OR pubescent OR youth* OR teen*)
Child 6–12 years
Child 13–18 years
|EMBASE||30/8/2017||(Load* OR carriage OR carrying OR carried OR backpack* OR bag* OR knapsack* OR rucksack* OR pack*)|
AND (Child* OR adolescent* OR juvenile* OR minor* OR pubescent OR youth* OR teen*)
School Child 6–12 years
Adolescent 13–18 years
|Authors (Year) and Title||Participant Details||Loading Conditions||Outcome Measures Used and Context||Main Findings||Critical Appraisal Score (%)|
|Chow et al. (2010)|
Short-term effects of backpack load placement on spine deformation and responding error in school children .
|Y6 Primary school children in Hong Kong.|
Mean Age 11.4 ± 0.5 years
Mean Height 148.2 (standard deviation (SD) 7.7) cm
11 males and 8 females (19 Total)
|Commercial backpack, double strapped.|
Load 15% of student’s Body Weight (BW)
|Six gravitationally referenced accelerometer (ADXL311, Analog Devices (National Instruments Corporation, Austin, TX, USA) were placed on the student’s body measuring spinal curvatures of cervical, upper and lower thoracic, upper and lower lumber regions as well as pelvic tilt.|
Testing was conducted in a laboratory setting.
Students in stationary standing position.
|The objective of this study was to research the outcomes of backpack placement options on spinal deformation and repositioning error in school children.|
Changes to spinal curvature and repositioning error with backpack posterior and anterior positioning (p < 0.05) (repositioning error is associated with the backpack positioning).
Less changes with backpack positioned on T12.
Changing backpack from posterior to anterior helps reduce the effects on the spine.
|56% = Fair|
|Chow et al. (2005)|
The effects of backpack load on the gait of normal adolescent girls .
|Y5, Y6, Y7 and Y8 Primary and Secondary school girls in Hong Kong.|
Mean Age 13.4 (SD 1.1) years
Mean Height 1.45–1.67 (SD 0.06) cm
|Dummy designed backpack, double strapped.|
Load 15% load of student’s BW
|Six-camera gait analysis—25 mm diameter retro-reflector markers attached to the skin surface (pelvis and lower limbs: thigh, knee, shank, ankle and foot).|
Walk with bare feet for 10 m, along a designed walkway in controlled environment (two force platforms mounted along the walkway).
Students walking with a loaded backpack (7.5%, 10.0%, 12.5%, or 15.0% of the student’s BW) and without load.
|The aim of this study was to explore the causes of carrying a variety of school backpack loads on the gait patterns of normal adolescent schoolgirls.|
No gross changes in gait observed
Statistical analysis showed significant changes of the measured gait parameters with increased load.
Increased load → decreased step length (p < 0.047), cadence (p < 0.047), walking speed (p < 0.004), single support time (p < 0.001).
|52% = Fair|
|Dockrell et al. (2015)|
Schoolbag carriage and schoolbag-related musculoskeletal discomfort among primary school children .
|Y4 and Y5, Primary school students in Ireland.|
Mean Age 13.4 (SD 1.1) years
Mean Height 1.45–1.67 (SD 0.06) cm
55.8% (n = 295) males and 44.2% (n = 234) females (12 different schools-529 total)
|Student’s own school bag loaded with school equipment and unloaded.||Students height was measured and weight under three conditions:||This study recognized schoolbag-related discomfort with the association of individual, physical and psychosocial factors.|
Carried bag only short distances and duration, thus limiting the exposure to load carriage as primary students leave bag in classroom all day.
No physical factors were significantly associated with discomfort, but students did perceive that if a schoolbag was heavy it was also associated with an increased prevalence of back discomfort (p < 0.05).
|74% = Good|
|Drzal-Grabiec et al. (2015)|
Effect of asymmetrical backpack load on spinal curvature in school children .
|Y4, Y5 and Y6, Primary school students in Poland.|
Age 11–13 years
80 males and 82 females (126 total)
|Load at 10% of student’s BW||Body posture was measured using a specialized electronic system for machine picture diagnosis called the “CQ Electronik”.|
Test 1. Baseline asymmetrical load with student standing up right without a backpack on.
Test 2. Backpack on right shoulder (10% BW).
Test 3. Backpack on left shoulder (10% BW).
|This study’s aim was to assess postural parameters in the sagittal plane for an uneven/unbalanced backpack load equal to 10% of a child’s body mass.|
Increase in lumbosacral region angles with carriage of asymmetrical load (p < 0.054).
Significant flattening of Thoracic Kyphosis with right shoulder load (p < 0.040).
10% BW load → increase in upper Thoracic spine curvature and moving head forward thus resulting in the flattening of Thoracic Kyphosis (p < 0.040).
|70% = Good|
|Hong and Cheung (2003)|
Gait and posture responses to backpack load during level walking in children .
|Y4 and Y5, Primary school males in Hong Kong.|
Age 9.43 years
Height 1.34 cm
11 males total
|Loads at 0%, 10%, 15% and 20% of student’s BW||Data was collected in a controlled testing environment (university gym), using a Latin Square design.|
Four sessions used to collect the data, students walked with set loads for each session (0%, 10%, 15% and 20% of student’s BW) for 23 laps of a basketball court (1978 m).
|The aim of this study was to explore the biomechanical stresses of continuous load carriage upon children by examining the adaptations of stride and temporal parameters, and trunk posture in the school setting.|
Gait pattern was not altered by load but a significant increase in trunk inclination (p < 0.05).
20% of students BW load → significant forward lean of trunk especially as walking distance increased (p < 0.05).
|56% = Fair|
|Hong and Li (2005)|
Influences of load and carrying methods on gait phase and ground reactions in children’s stair walking .
|Y4 and Y5, Primary school male students in Hong Kong.|
Mean Age 12.21 (SD 0.98) years
Mean Height 1.59.66 (SD 9.67) cm
|One-strap athletic bag (across right shoulder)|
Double strap backpack (on both shoulders)
Loads at 0%, 10%, 15% and 20% of student’s BW
|Data was collected in a controlled testing environment (university gym) using a Latin Square design.|
An in-shoe pressure measurement system (Novel Pedar System, 99 force sensors) was used to record the temporal and kinetic data during stair walking.
Students gait was assessed during 400 m flat ground walk with 20% of the student’s BW.
Students then stair walked 33 steps up and down 3 consecutive times, while carrying 20% BW load.
|The purpose of this study was to look at the impacts of load and backpack carrying methods on ground reaction force and gait temporal characteristics during ascent and descent stair walking in children.|
No significant difference between left and right foot.
Athletic bag increased peak force on left foot more than right foot.
Load of 15% and above of the students BW showed to induce a significant increase in stance and double support duration with the backpack on (p < 0.05).
|74% = Good|
Schoolbag weight carriage by primary school pupils .
|Y1, Y2 and Y3 Primary school students in Poland.|
Age 7–9 years
54 males and 54 females (108)
|Students own backpacks.||Students’ bags were weighed (by BW scales Zelmer 34Z013, SMARTFIT, Warszawa, Poland) at the start of each school day on five consecutive days (Monday–Friday).|
Students once at school left their bags next to their desk the entire day and did not carry them around at all.
|This study researched the school-bag weight of primary school pupils (aged 7–9 years) and to identify the number of students that carried backpacks in excess of the recommended limit of 10% of their BW.|
No statistically significant differences in bag weights were identified (p < 0.647).
Bag weight varied during the week.Heaviest bag:
Y1—5.5 kg (p < 0.001), Y2—7.0 kg (p < 0.001), Y3—6.2 kg (p < 0.001).
|70% = Good|
|Ozgul et al. (2012)|
Effects of unilateral backpack carriage on biomechanics of gait in adolescents: a kinematic analysis .
|Y7 Primary school males in Turkey.|
Mean Age 13.2 years
|Carrying backpacks at load of 15% student’s BW.||Data collection was done in a controlled environment (university laboratory).|
Kinematic parameters of the subject’s gait at a self-selected speed was analyzed using a six-camera motion analysis system used, with two force plates.
Markers located on student’s bodies (Helen Hayes, 1991 protocol) .
Students were analyzed walking with no backpack vs. walking with backpack on one shoulder at a load of 15% BW.
|The aim of this study was to research the biomechanical changes during walking with asymmetric backpack carrying in adolescents, focusing on the effects of asymmetrical backpack carriage on kinematic parameters of the lower body under both loaded and unloaded conditions.|
When carrying load, and relative to unloaded gait: ankle peak dorsal flexion increased on unloaded side and decreased on loaded side (p < 0.05).
Mean knee varum value increased on unloaded side but decreased on loaded side (p < 0.05).
In the sagittal plane, knee flexion increased at initial contact on loaded side relative to both the unloaded side and unloaded walking (p < 0.05).
Hip joint maximum extension angle decreased on the loaded side compared to unloaded (p < 0.05).
Mean hip adduction increased on loaded side and decreased on unloaded side (p < 0.05).
Mean anterior pelvic tilt during stance increased on loaded side (p < 0.05).
Pelvis was elevated on loaded side and depressed on unloaded side (p < 0.05).
Both loaded and un-loaded sides were affected by asymmetrical backpack carriage.
Extra load on lumbar vertebral joints and altered frontal knee biomechanics → increase in back pain and pathologies in the knee joint.
|59% = Fair|
|Pau et al. (2011)|
Effects of backpack carriage on foot–ground relationships in children during upright stance .
|Y1, Y2, Y3, Y4 and Y5, Primary school students in Italy.|
Mean Age 6.75 (SD 0.06)–10.82 (SD 0.07) years
Mean Height 120.68 (SD 1.27)–145.12 (SD 1.27) cm
231 males and 216 females (3 different schools—447 total)
|Student’s own loaded backpack.||Students first removed their shoes, then their height, body and backpack weight were all recorded.|
Students stood on a pressure plate with and without backpack load on.
Students used their own school backpacks as per a normal school day.
|This study investigated the outcome of backpack carriage in primary school children from the point of view of possible changes occurring in the foot-to-ground relationship.|
Foot–ground contact was significantly affected by the backpack presence (p < 0.01).
Significant effect of the backpack only on forefoot and midfoot regions (p < 0.01).
Load up to 10% BW increased plantar pressure in the midfoot and forefoot.
Heavy load and exposure time → increase in foot discomfort.
|66% = Good|
|Pau et al. (2015)|
Short-term effects of backpack carriage on plantar pressure and gait in schoolchildren .
|Y1, Y2, Y3, Y4, Y5, Y6, Y7 and Y8, Primary and Secondary school students in Italy.|
Mean Age 6.8 (SD 0.3)–13.4 (SD 0.3) years
Mean Height 116.8 (SD 5.0)–161.5 (SD 7.3) cm
109 males and 109 females (3 different schools—218 total)
|Students own backpack mean weight 5.2 kg.|
Load 15% of student’s BW.
|Students removed their shoes, then stature, BW, and backpack weight were all recorded.|
Static plantar pressure distribution measured in upright stance in quiet controlled conditions was acquired (using a pressure platform).
Students were asked to standing still for 10 s then asked to walk with and without their school backpack.
|The purpose of this study was (1) to evaluate the effects of backpack carriage on planter pressure quantity and issuing, and on spatio-temporal parameters of gait; (2) to examine the association between carried load and plantar pressure parameters.|
Spatio-temporal gait not affected by load
Significantly increased contact areas in the forefoot, midfoot and rear foot (p < 0.001).
Significant increase (up to 25%) in plantar pressure during both standing and walking on the fore foot (p < 0.001).
|77% = Good|
|Puckree et al. (2004)|
School bag carriage and pain in school children .
|Y7 Primary school students in South Africa.|
Mean Age 12.2 (SD 0.8) years
57.5% Indians, 41.0% Blacks and 1.5% Colored’s (4 different schools—195 total)
|Student’s own backpack.||Students were divided into two groups:|
Students experiencing pain were then divided into those who’s bag mass exceed 10% of the student’s BW.
The students bags were then weighted using calibrated digital bathroom scales.
|This study focused on the relationship between school bag carriage and pain in school children. Examined bag type, individual characteristics, the load carried and the pain experience.|
Type of school bag, the manner it is carried in and the gender of the student all associated with level of ‘Shoulder pain’ (p < 0.001).
More females experienced pain than males (p < 0.01).
|70% = Good|
|Ramprasad et al. (2009)|
Effects of backpack weight on postural angles in preadolescent children .
|Y7 Primary school males in India.|
Mean Age 12.5 (SD 0.5) years
Mean Height 142.5 (SD 7.4) cm
410 males (6 different schools)
|Student’s own backpack weight measured at 5%, 10%, 15%, 20% and 25% of student’s BW.||Students removed their shoes and were asked to stand on a force plate, where their weight was recorded before any measurements were taken.|
Students then stood on a stadiometer and their height in centimeters was recorded.
Image Tool version 3.0 digitizing software (University of Texas Health Service Centre, San Antonio, TX, USA) was used for analyzing photographs.
|The aim of this study was to explore the changes in postural angles under various backpack loads in preadolescent children.|
Craniovertebral Angles changed significantly after carrying 15% BW load (p < 0.05).
Head and Neck angles changed after carrying 10% load BW (p < 0.05).
Trunk and lower limb angles changed after carrying 5% BW load (p < 0.05).
Backpack load changed all body angles and affected overall posture.
|74% = Good|
|Rodrigues-Oviedo et al. (2012)|
School children’s backpacks, back pain and back pathologies .
|Y6, Y7, Y8, Y9, Y10, Y11 and Y12 Primary and Secondary school students in Spain.|
Age 12–17 years
Males and females (11 different schools—1403 total)
|Student’s own backpack.|
Mean weight 7 kg.
|Students were weighed with their school backpacks twice on digital scales (with a height meter).|
Student’s height was obtained and recorded.
Questionnaire was also used to obtain information (information relating to the students lifestyle, including duration and frequency of their sport and sedentary activities).
61% carried 10% BW
18% carried 15% BW
|The objective of this study was to examine the effect of backpack weight on back pain and back pathologies.|
Heaviest backpack resulted in an increase of back pain.
Most students carried loads above 10% BW.
Backpacks altered posture and gait, resulting in modifications to the head–neck angles, shoulder asymmetry and lumber lordosis.
Girls had a higher risk of back pain and an increased risk with age (60.2%).
|52% = Fair|
|Soares et al. (2012)|
Backpack injuries in Indian school children: risk factors and clinical presentations .
|Y7 Primary school students in India.|
Mean Age 12.94 (SD 4.53) years.
Mean BMI 16.70 (SD 2.81)
45% males and 55% females (22 Students)
|Student’s own backpack which recorded a mean load of 5.57 kg.||Main diagnostic criteria were pressure marks (redness or swelling) over neck and shoulders, stooping shoulders, pain or stiffness in neck, upper back, shoulder.|
Body regions were categorized into seven regions for clinical evaluation for the collection of signs and symptoms (i.e., neck, upper back, shoulders, forearm, and wrist, lower back, thigh and wrist).
|The objective of this study was to determine the risk factors and clinical presentation caused by backpacks among Indian school children.|
40% upper back, 27% neck, 20% shoulders, 7% forearm and 6% lower back.
All had pressure marks over shoulders.
54.55% had myofascial pain and the rest Thoracic outlet syndrome.
|22% = Poor|
|Spiteri et al. (2017)|
Schoolbags and back pain in children between 8 and 13 years: a national study .
|Y5, Y6, Y7, Y8 and Y9 Primary and Secondary school students in Malta.|
Age 8–13 years
50% males and 50% females
(63 primary schools and 48 secondary—134 schools = 3852 Students)
|Student’s own backpack recorded median overall bag weight of 5 kg.||Students were asked questions through the use of a body chart, pain intensity (using a face pain scale-revised) frequency and consequence of back pain (questions asked: bag type, how the bag was carried, the use of lockers, participation in sport, presence of back pain, pain location).|
Students weight and bag weight was recorded using stadiometer scales.
Students also underwent a face-to-face interview with a physiotherapist.
|The purpose of this study was to assess the presence of back pain in school children, as well as its link with school bags.|
Over 70% had a backpack that exceeded the 10% BW level.
32% complained of back pain, but 74% said it was low intensity pain (p < 0.001).
Self-reported pain in school children is independently linked to carrying heavy schoolbags (p < 0.001).
|59% = Fair|
|Hong et al. (2008)|
Effect of prolonged walking with backpack loads on trunk muscle activity and fatigue in children .
|Y1 Primary school male students in China.|
Age 6 years
15 male students in total.
|Student’s own backpack.|
Loads at 0%, 10%, 15% and 20% of student’s BW.
|Data was collected in a laboratory over four trials with different backpack loads for each student.|
Students were told to wear specific clothes for the trial (black shorts/tights and no shirt).
Disposable surface electrodes were attached to the students right side of their body (upper trapezius and rectus abdominis).
Students walked on a treadmill for 20 min with each of the 4 loads.
|The aim of this study was to explore the effects of lengthy load carriage on muscle activity and fatigue in children when walking.|
Increased muscle activity was recorded at all loads (p < 0.05).
15% BW load significantly increased muscle activity in upper traps (p < 0.05).
During prolonged walking, the 20% BW load was associated with the most significant muscle activity in upper and lower traps (p < 0.05).
Fatigue in upper traps was identified within 10 min under load and in lower traps within 15 min (p < 0.05).
No increased muscle activity found in rectus abdominus at any load or any duration of walking (p < 0.05).
|63% = Good|
Impact of backpack type on respiratory muscle strength and lung function in children .
|Y5 Primary school students in Portugal.|
Mean Age 10.8 (SD 0.8) years.
Mean Height 148.6 (SD 7.1) cm
12 males and 25 females
|Student’s own backpack.|
Load at 15% of student’s BW.
|Test done in controlled setting at the student’s school, using their own school bags.|
Height and weight was recorded using stadiometer and a scale).
Lung function and respiratory muscle strength data was measured in the following settings:
|The aim of this study was to examine the effects of the backpack type on students’ lung function and strength of inspiratory and expiratory muscles in children (aged between 10 and 12).|
Mono strap restricted and affected lung function, decreasing expiration and muscle strength (p < 0.001).
Double strap backpack a preferable option (p < 0.001).
Walking with a backpack more than 10% BW increases trunk forward lean and increases breathing rate and decreases trunk Range of Movement (p < 0.001).
|63% = Good|
|Cottalora et al. (2003)|
Influences of school bag carrying on gait kinetics .
|Y6 Primary school students in France.|
Mean Age 12.2 (SD 0.5) years
Mean Height 152 (SD 8.0) cm
Males and females
|Set double-strapped backpack.|
Load 10 kg of student’s BW
|Parents asked to complete a questionnaire relation to gait patterns and movement (locomotion, physical activity and disease) and backpack carrying methods of their children.|
Students gait was assessed in a controlled environment (3 trials)
Students were asked to walk bare-foot on an ADAL (Techmachine, Andre’zieux Bouthe’on, France) treadmill for 3 min at 3.5 km/h.
Students were tested with the both the school backpacks straps on and then carrying the pack with one/single strap on.
|This study determined the impact of a variety of methods of how students carry their book bags on gait kinetics (children age 11–13 years).|
Treadmill ergometer measured the student’s ground reaction forces of their right and left feet.
Carrying a backpack on both shoulder is the preferred method.
Carrying the backpack increases the students stride, stance and double stance.
Vertical forces increase with the use of just one strap.
|63% = Good|
|Siambanes et al. (2004)|
Influence of school backpacks on adolescent back pain .
|Y7 and Y8 Middle school students in California USA.|
Mean Age 12.75 yearsMean Weight of backpack 9.33 kg
49.5% males and 50.5% females
(4 schools and 3497 students in total)
|Student’s own backpack||Student’s shoes were removed and they were weighed as well as their backpacks (using two calibrated digital electronic scales).|
The content of the backpack was not assessed.
Students were then sked 22 questions in an administered questionnaire (chronicity, prevalence, severity and frequency of back pain).
|This study identified the associations between school backpack weight (recorded as a percentage of the student’s overall BW), how the students wore their backpack, how long they carried the backpack, their socioeconomic status, and the prevalence, severity and chronicity of back pain.|
Students who walked to and from school and method of wearing the backpack were associated with level of pain.
64% reported back pain.
41% felt pain whilst carrying backpack.
Girls reported a higher level of back pain.
|77% = Good|
|Goodgold et al. (2002)|
Backpack use in children .
|Y5, Y6, Y7 and Y8 primary and middle school students in Boston USA.|
Age 11–14 years
169 males and 176 females
(345 students in total)
|Student’s own backpack.||Questionnaire was used to gather information (student demographic, play and leisure activity levels, bag type and carrying methods).|
Students were weighed with and without their normal school backpack.
Students reported they did not carry their backpacks around with them on a school, they store them in lockers.
|The purpose of this study was to describe backpack use by children to assess the severity of the problem. The study examined:|
Younger students were found to carry heavier loads.
|77% = Good|
|Connolly et al. (2008)|
Effects of backpack carriage on gait parameters in children .
|Y7 Primary school students in Tennessee USA.|
Age 12–13 years
15 males and 17 females
(32 students in total)
|Student’s own backpack, 1 and 2 shoulder straps tested.|
Load at 15% of student’s BW
|GAITRite system was used to test the students’ walking patterns (six sensor pads) measuring temporal and spatial gait parameters.|
Electronic walkway was used in controlled environment.
Students walked under the backpack load and under no-load a total of 8 m.
|This study investigated the effects of different backpack carrying methods on school-aged children.|
No significant difference found during loaded walk with student’s base of support, stride length and velocity when compared with the unloaded walk.
Double limb support significantly increased with the loaded walk (little difference between one strap carry or two strap carry).
Little change in temporo-spatial gait parameters with 15% BW load when compared with no load.
|63% = Good|
© 2018 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Perrone, M.; Orr, R.; Hing, W.; Milne, N.; Pope, R. The Impact of Backpack Loads on School Children: A Critical Narrative Review. Int. J. Environ. Res. Public Health 2018, 15, 2529. https://doi.org/10.3390/ijerph15112529
Perrone M, Orr R, Hing W, Milne N, Pope R. The Impact of Backpack Loads on School Children: A Critical Narrative Review. International Journal of Environmental Research and Public Health. 2018; 15(11):2529. https://doi.org/10.3390/ijerph15112529Chicago/Turabian Style
Perrone, Michelle, Robin Orr, Wayne Hing, Nikki Milne, and Rodney Pope. 2018. "The Impact of Backpack Loads on School Children: A Critical Narrative Review" International Journal of Environmental Research and Public Health 15, no. 11: 2529. https://doi.org/10.3390/ijerph15112529