Pediatrics: Overstuffed and Misused

Backpacks cause problems for schoolkids

This article originally appeared in BioMechanics Magazine, November 2000.

By Jerry Karp

When we think of the burdens of our school days, what usually comes to mind is homework, tests, and the social pressures of fitting in. But to an increasing extent, the physical burden of heavy, overstuffed backpacks can now be added to the list. Over the past several years, complaints of back pain and injuries have risen among schoolchildren of all ages, and awareness has grown among health professionals, educators, and parents that overweighted backpacks are likely to be a strong contributing factor to the trend. The problem is not with the backpacks themselves, sources agree, but with the books and other equipment young people are jamming into the bags they sling onto their backs.

A number of factors have combined, not only to add more weight to students’ backpacks, but also to keep those packs fully loaded and on the students’ backs throughout the day. Many school systems are eliminating student lockers as a response to overcrowding and in an attempt to keep drugs and weapons out of the schools. Students at these schools now have to haul all their books around all day. Other frequently cited factors include a general increase in the size of textbooks, and less time between classes — for those students who do have lockers — to drop off and pick up the books they need during the day.

“There has been a lot of controversy about the source of the increasing back pain in children,” said Sally Evans, MD, a pediatric physiatrist and practitioner of rehabilitation and physical medicine for children at Children’s Hospital Oakland in Oakland, CA. “One theory is that it’s related to the significant increase in the use of backpacks by kids as young as elementary school (age).”

Evans cited a study done over two years in a middle school in Indiana in which all the children were issued rolling suitcases to replace their backpacks. The incidence of back pain overall went down among that school’s population. The children were also compared to students in another school who were using backpacks as usual, and the incidence of back pain among the rolling suitcase users was lower.

The American Academy of Orthopaedic Surgeons (AAOS) conducted a survey of its own in which 58% of the responding orthopedists reported seeing pediatric patients complaining of back and shoulder pain caused by heavy backpacks. While presenting the results of the survey at an AAOS Orthopedics Update press conference on Oct. 13, 1999, Charlotte B. Alexander, MD, an orthopedic surgeon at Houston Sports Medicine Associates, reported that overloaded backpacks are contributing to the higher number of visits to physicians’ offices.

“Orthopedic surgeons are starting to notice an increase in children visiting their offices with muscle fatigue problems that we usually did not see until later in their adult years,” she said.

In addition, the AAOS notes a Consumer Product Safety Commission report that counted 10,062 backpack-related visits to physicians’ offices, clinics, and hospital emergency rooms among children five to 14 years old nationwide during 1998, and 2719 such visits by teens 15 to 18 years old.

Opinions vary, particularly between physicians and chiropractors, regarding the specific nature and long-term consequences of the injuries being observed, and the degree to which they’re being caused by backpack use. But there is widespread consensus that a problem exists, and that the rise in reported back pain among students corresponds to a growth in the use of backpacks in schools and, especially, the amount of weight students are carrying and the amount of time they spend each day with the packs over their shoulders. All sources agree that no student should be wearing a backpack that weighs more than 15% to 20% of his or her body weight.

The AAOS survey cited muscle fatigue and strain as the most frequent consequences of consistently overloaded backpacks. Other studies, plus the anecdotal observations of practitioners, educators, and parents, point to posture problems as an additional hazard.

“You can watch children put backpacks on,” Evans said, “and you can watch what happens to their posture and their whole body mechanics: it changes. Posture is not as good when children are carrying heavy backpacks, especially when they’re carrying them on one shoulder, which most people tend to do.”

Back in the mid-90s, reports Marvin T. Arnsdorff, DC, with Advanced Chiropractic Centers in Mt. Pleasant, SC, his practice began seeing a lot of parents bringing their children in and complaining about how much weight their kids were carrying in their packs.

“We’re seeing 80-pound girls carrying close to 25 or 30 pounds of books in their backpacks,” he said. “And one of the things we’re really starting to see a lot of is a shift in their posture. We’re starting to see them carrying the head forward of their shoulders, putting more stress in the mid and lower back.”

Public perception notwithstanding, the general medical establishment consensus is that, while the concerns are real, there hasn’t been a proven link between increased backpack use and permanent spine conditions. As Alexander noted, the AAOS survey findings “do not suggest a link between backpack use and the development of a serious pediatric condition like scoliosis or spondylolysis.”

John M. Gray, MD, a pediatric orthopedic practitioner in the orthopedic departments of California General Hospital in San Francisco and Marin General Hospital in Greenbrae, CA, does a lot of work with children and scoliosis. He says that almost every week a new patient will come in with scoliosis and the mother feels the backpack is what’s causing it.

“A lot of pediatricians are feeling that way too. They wonder why the child is starting to get scoliosis and they worry that the backpack is causing it, or even making it worse. I disagree with that,” he said. “Basically, you should think of scoliosis as a genetically programmed growth and development pattern. You don’t know how tall a child is going to be until the child stops growing. That’s the kind of genetic program scoliosis is compared to. (It doesn’t happen) because of a mechanical thing like a backpack.”

Gray was the only source contacted for this article who felt that the concern about heavy backpacks was being overstated.

“I think society is getting into a disability mindset and it’s unhealthy,” he said. “I reason with kids and say, ‘Well, if you want to limit your backpack, let’s not allow you to do baseball or football.’ Talk about playing Russian roulette with your back; it’s riskier to be doing some of these significant sports activities. Or running, for that matter. It’s very easy for schools to say, ‘Go out and run a mile,’ but I think running is much more damaging than a backpack.”

JanSport, a manufacturer of backpacks — from technical packs for climbers to daypacks for casual use — and other sports gear, this year developed a new generation of packs for children. Their FreeFall model was rated highest for comfort and ergonomics among the children’s packs tested in a Consumer Reports evaluation (September 2000).

“There’s a difference between back pain and scoliosis, which is the term a lot of the media are throwing around,” said Brian Curry, president of Milwaukee-based Functional Design, the design and consulting firm hired by JanSport to design the new packs. “The conversation when I walked into JanSport was, ‘We’re very concerned. We don’t want our product causing back problems. Solve scoliosis.’ And I said, ‘I don’t think backpacks are causing scoliosis.’ But I told JanSport after I did my research that I certainly thought that heavy loads were causing short-term damage, as far as deviating the spine. Those muscles in the back are very small. Plus the kids go through growth spurts, which makes things awkward. You’re wearing this backpack up high, you’ve got 30 pounds in it, you’re leaning forward. That adds up to some big torque. That’s a large part of what’s causing the problem, the poor posture and leaning forward.”

The potential danger to students doesn’t come solely from backpack overloading. Improper use of heavy packs, including slinging the bag across one shoulder instead of using both straps, and improper lifting and fitting of packs, are strong contributing factors as well. Medical professionals and school administrators agree that it’s important for students and parents to be alerted to the hazards and be educated about the proper use of backpacks.

“I don’t really think it’s the backpacks that are causing the problem,” Arnsdorff said. “I think it’s the fact that there haven’t been any guidelines for parents, kids, or educators to really teach the proper use of those backpacks. I’m also an industry injury consultant, and I realize it’s not the box on the floor that causes a back injury, it’s how the worker picks it up. If people are properly educated, they’re not as likely to hurt themselves.”

Arnsdorff became so concerned about the problem that he and associate John Carroll, a public relations and organizational development specialist also from South Carolina, developed Backpack Safety America (www.backpacksafe.com/index.html), a safety and awareness program complete with assembly lectures, school posters, and a video. They have assembled a network of participating chiropractors throughout the U.S. and Canada who present the program to schools in their areas free of charge on request. Included as part of the overall program are informational meetings with teachers and parent groups.

“Right now we’re close to 400 doctors across America,” Arnsdorff said. “Our estimate of how many children we’ve reached just in the last year and a half is well over three million.”

When they put together the Backpack Safety America program, he said, it was with the idea that it’s not the backpacks causing the problem, it’s that kids are not taught to choose the right backpack, don’t know how to pack it properly, and have never been taught how to lift the backpack safely. The program teaches children to face the backpack and bend at the knees, use both hands to check its weight, and lift with their legs. Then apply one shoulder strap after the other, rather than swinging the backpack onto one shoulder. If there’s a waist strap, the child should be using it to distribute the weight better.

“If we can teach kids correctly, we can prevent most of the problems, he said.”

The term used by many chiropractors for the condition they are seeing from overweighted and misused backpacks is “functional scoliosis,” defined as a condition in which a structurally normal spine appears curved due to one or more underlying conditions. Functional scoliosis is generally considered correctable if the external cause of the curvature is eliminated.

“You can develop functional scoliosis where the muscles develop more on one side, which causes a curvature of the spine,” said Bob Graykowski, DC, of Carmichael Creek Chiropractic in Carmichael, CA. “You can create problems with shoulders, and hips, and knees, because the whole gravitational stress is going to certain areas of the body. Kids, because of the heavy loads on one side, are more prone to symptoms like headaches, middle back discomfort, and lower back pain. The situation is causing a lot of problems at critical years of growth for the spine.”

As a practical matter, chiropractors are generally less inclined to emphasize the distinction made by the medical establishment between genetic scoliosis and functional scoliosis. For example, when told that the orthopedists responding to the AAOS survey had not observed a direct correlation between backpacks and scoliosis, Graykowski objected.

“They’re waiting until the problem has evolved," he said. "I would disagree. A child carrying a backpack on one shoulder for four, five, six years, would be likely to develop a functional curvature of the spine.”

Evans, of Children’s Hospital Oakland, is one MD who does take the issue of functional scoliosis seriously, while cautioning that the relationship between backpacks and specific back ailments has yet to be nailed down clinically.

"Scoliosis matters long-term is if it can’t be corrected," Evans said. "It will eventually start to change the shape of the chest and alter the volume that’s available for the lungs. In the short run, any muscle imbalance can lead to pain and stress across joints. I think that what the chiropractors are talking about is right, that the source of pain is functional scoliosis. If you consistently carry your pack on one shoulder, you are going to get different muscle development, and a muscle imbalance pulls the spine out of alignment.”

Unless the situation is addressed with proper stretching exercises and with redistribution of weight, it can lead to musculoskeletal problems and musculoskeletal/soft tissue back pain. Although as long as the curve can be corrected, it won’t lead to the problems that would cause someone to need a body brace or a surgical correction of the spine, Evans concluded.

Evans also acknowledges that healthcare professionals are concerned about what may be in store for today’s students as they reach adulthood.

Everyone’s worried about that,” she said. “Particularly because, in the U.S. adult working population, back pain is the leading cause of health problems and expenditure of healthcare dollars. If you’re taking a population of children now who have a higher incidence of back pain than previous generations, there’s good reason to be concerned that their rate of back pain will also be higher when they become adults.”

The backpack industry is taking the situation seriously, Curry said, pointing to the extensive research his firm did for JanSport in the design of the manufacturer’s new line of packs. Curry worked with 6th through 12th graders, making it a science class project. He put Fuji pressure film under the kid’s shoulder straps, using different weights, to see where the real pressure gets applied on the body.

“Going in, I would have thought it was all in the top of the shoulder,” he said. "But it turned out that a lot of the pressure is at the posterior, the rear of the top of the shoulder. The difference is only one of inches.”

He also used a pressure transducer to measure the pressures at various locations on their bodies. Curry said that his research led to a backpack with improved straps and a design built for heightened comfort, and adds that future generations of JanSport packs will address the issues of posture and biomechanics.

“I think the concern is there with all the pack manufacturers for kids,” he said. “All the companies I’ve talked to consider this a hot topic, and they’re all very concerned.”

But Evans points out that the best backpack design in the world won’t help if the students refuse to wear the packs correctly. Particularly with older students, slinging the bag across one shoulder is the cool way to do it, and that’s often the end of the story.

Arnsdorff said this issue was taken into account when the Backpack Safety America program was on the drawing board.

“That’s why the program is designed for kindergarten through 8th grade,” he said. “We’re really trying to get to them early, and show them that it’s cool to do it properly.”

Graykowski believes that this kind of early education can work.

“It would be great if disseminating this information could become standard,” he said. It would prevent a lot of back problems in children and prevent them from having more problems when they become adults.”

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