Sunday, July 12, 2020

Do Heavy School Bags Cause Back Pain In Children?

I had a nine year old girl come to our clinic to see me this week complaining of neck pain. Her grandmother who brought her thought it may be related to her very heavy school bag that caused it. That along with the extra time on screens during home based learning recently during the circuit breaker.

After examining the little girl, I explained to her grandmother that what she thought may not be true.

You would have seen plenty of advertisements on the internet suggesting you buy your child an ergonomic bag pack for your child to avoid back and neck pain. However, when I searched the literature, there were no convincing proof in the last 20 years between heavy school bags and posture/ back pain among the young.

Many of you would have seen a young child with a big school bag on their shoulders. You would have read about it in the papers. There are many articles available online regarding this topic too. Many of the articles quoted above suggest that your child should not carry more than 20 percent of their body weight. After searching, I found out that this figure is taken from an article by Dockrell et al in 2013).

The most recent evidence published was from a systematic review in 2018 conducted by a team of Australian Physiotherapy researchers. They examined 69 eligible studies with a total of more than 72,600 children.

Many of the articles were rated as either having a moderate to high risk of bias due to high attrition rates, mixed testing methods, confounding factors and poor prognosis. As a result, most of the articles did not find an association between school bag characteristics and low back pain even though there were mixed sample sizes, different school bag weight and different definitions of back pain.

The authors suggested that due to variables in school bags, measuring instruments and timing of data collection, there were no straight "yes" or "no" answers. Hence, no strong conclusions can be formed.

An older systematic review in 2008 examined 10 qualified trials with more than 17,000 children/ teens on neck, upper back and shoulder pain. The authors found that static postures, depression, stress, psychosomatic symptoms, age and gender (girls had higher reports of pain than boys, especially those who were depressed (Prins et al, 2008).

If I may digress here, even among adult research there was insufficient evidence for association between spinal curves (e.g. scoliosis) and all other health related outcomes. This includes low back pain, disc herniation, neck pain, fractures, headaches, symptomatic degenerative lumbar disc disease and thoracic pain (Christensen et al, 2008).

Perhaps many of us (including all the online articles you read) after seeing a child hunched forward with a heavy school bag while walking home assume that heavy back packs causes neck and/or low back pain.

This may have fueled further beliefs among doctors, physiotherapists, other clinicians and the general public that heavy back packs can cause neck/ back pain.

Personally, I do get concerned whenever I see a young child carrying a heavy back pack even if the evidence does not suggest that it will hurt them permanently.

As my wife says (quoting Tom Myers), children have very elastic connective tissue and they are very resilient. Unless your child is perpetually carrying a super heavy school bag, it probably will not affect their necks and backs permanently.


Dockrell S, Simms C et al (2013). Schoolbag Weight Limit: Can It Be Defined? J Sch Health 83: 368-377.

Prins Y, Crous L et al (2008). A Systematic Review Of Posture And Psychosocial Factors As Contributors To Upper Quadrant Musculoskeletal Pain In Children And Adolescents. Phy Theory Pract. 24: 221-242. DOI: 10/1080/09593980701704089

Yamato TP, Maher CG et al (2018). Do Schoolbags Cause Back Pain In Children And Adolescents? A Systematic Review. BJSM. 52: 1241-1245. DOI: 10.1136/bjsports-2017-09827.

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