Musculoskeletal pain intensity and perceptions during distance learning: A cross‐sectional study

Technological developments and the pandemic have popularized the distance learning model at universities. In this educational model, students spend more time in front of screens, and screen‐related health conditions have become important. This cross‐sectional study of 177 undergraduate students was designed to investigate the effect of block and traditional scheduling in online distance education (ODE) on their musculoskeletal pain and to investigate their perceptions of block scheduling. A two‐stage method was used: a quantitative design to compare pain levels, and a qualitative design to determine the students' perceptions of block scheduling using an online survey. Pain intensity was assessed using the Numeric Rating Scale (NRS‐11). Data were collected in the university health sciences department. Pain intensity following the block and traditional lessons was analyzed using a paired t‐test. Students in the block schedule had significantly more pain, with a large effect size on the whole trunk and upper limbs. Pain levels were also clinically meaningful for the upper (5.73 ± 2.75), lower (5.59 ± 2.87), and neck (4.92 ± 2.60) regions. Students reported positive experiences with block scheduling in ODE such as saving time (43%) and maintaining subject integrity (26%), but also negative experiences such as distraction (56%), fatigue (33%), pain (17%), and boredom (11%). Block scheduling in ODE could cause clinically significant neck and back pain. In distance learning, keeping the course duration short and ensuring student mobility in the classroom are important.

students emphasize the significance of course scheduling in distance education.
The schedules can be designed to follow either a traditional format with a single lesson of 40-50 min followed by a break, or a block format with a minimum of two lessons, each lasting over 50 min (Huelskamp, 2014;Queen, 2000).In block scheduling, students attend classes for more extended periods with fewer transitions each day, which results in an earlier end of the school day.It is thought that roughly 50% of American secondary schools employ some form of block scheduling (Maltese et al., 2007).Previous studies have shown that block scheduling in traditional face-to-face education has several advantages, disadvantages, and drawbacks.Its benefits include increased academic achievement, more time to develop concepts and themes, fewer interruptions throughout the day, more significant individual interactions between teachers and students, and more opportunities for innovative teaching strategies (Ilchenko et al., 2022).However, it has also been criticized for cognitive overload, monotonous and boring sessions, and difficulties in focusing on the same or similar material over long periods.
Digital learning environments also require long periods spent in front of screens (Ilchenko et al., 2022).These advantages and disadvantages of block scheduling should be redefined for ODE, especially those relating to the health aspect (Azevedo et al., 2023).
The shift to distance learning has led to an increase in student reports of back pain, headaches, visual impairment, and attention problems (Pohorilyak et al., 2023).During distance learning, many students attend classes in non-ergonomic positions that can cause problems such as pain, abnormal muscle activity, and postural problems (Hawamdeh et al., 2022).According to qualitative studies, students find sitting in one position for long periods during lessons challenging; it can be tiring and demotivating, especially when looking at a screen (Goodwin et al., 2022).However, to our knowledge, no study has evaluated musculoskeletal pain in students following block scheduling in ODE.There is evidence that approximately one in four to five students experienced head or back pain during the pandemic.However, those studies did not investigate the cause of the pain; that is, whether it was due to staying at home and reducing physical activity during the pandemic, or to the distance learning course schedule.
Examining different course scheduling models from a student health perspective is essential as distance education becomes more prevalent.The primary aim of this study was to compare trunk and upper limb pain between traditional and block scheduling in ODE.The second aim was to determine the students' perception of block scheduling.We hypothesized that students would experience more musculoskeletal pain after taking block courses in distance education.

| Study design
A survey method was used to examine the effect of traditional and block scheduling on musculoskeletal pain in health science students and to report their attitudes toward ODE.

| Sampling
The study included students from the first, second, and third years of the Faculty of Health Sciences departments including physiotherapy, occupational therapy, speech therapy, child development, audiology, and social services.We excluded participants who used painkillers, had tested positive for COVID-19 during the past year, took medications for musculoskeletal system complaints, or had consulted a physician for musculoskeletal system complaints within the previous 6 months.Participants who had recently experienced pain before starting the course were also excluded to determine the effect of block scheduling on pain.
A research assistant, not involved in the assessment process, invited 480 students on traditional and block courses at ODE to participate in an online survey.We received completed surveys from a total of 250 students for both traditional and block scheduling courses.Seventy-three participants were excluded from the study.
Fifty-one of them reported using painkillers or having pain on the study day, 10 had a history of corona virus in the last year, seven did not complete the questionnaire, and five had been diagnosed with a musculoskeletal disease.The study was completed with 177 participants (Figure 1). the camera and microphone settings, and it was the student's choice to activate the camera.

| Demographics
We recorded the participants' gender, age, section, grade, use of painkillers, and whether they had COVID-19.We recorded their daily screen time in two categories: when they were in class and when they were out of class.The recorded duration of screen usage outside the classroom was based on the students' reports.The durations of the courses were recorded and the listening positions of the participants were self-reported.

| Assessment of pain
Pain was assessed using the Numeric Rating Scale (NRS-11), a short and widely used clinical scale that is easy to administer.A systematic review of pain rating scales revealed high-quality evidence that the NRS scored best for measurement error.There is moderate evidence of inconsistent responsiveness to NRS.Since it is a single-item scale, construct validity and internal consistency do not apply (Chiarotto et al., 2019).Participants were requested to rate their pain using positive integers on a scale ranging from 0 to 10 (including 0 and 10) after traditional and block scheduling in ODE.The 0 rating represents no pain; 10 represents the most severe pain (Hartrick et al., 2003).

| Qualitative data
The data were automatically transferred from the Google Survey program to an Excel file.An experienced qualitative researcher (Şafak Kıran) and the second author of the study analyzed participants' responses to identify emerging themes.Participants who did not respond to the open-ended questions were excluded from the qualitative analysis.The responses showed the main perspectives of students on the ODE block scheduling course.The frequencies and percentages of student expressions for these themes were calculated when the themes were identified.

| Ethical consideration
Ethical approval for the study was obtained from the Non-Interventional Research Ethics Committee of Uskudar University.
Participation in this study was voluntary, and informed consent was obtained from all students.

| Sample characteristics
Among the 177 participants, 77.4% were female (age 19.69 ± 1.12 years) and 22.6% were male (age 20.20 ± 1.39 years).Nearly half of the participants were first-year students, and 63.3% belonged to the Department of Physical Therapy and Rehabilitation.They had an average daily screen time of 3.08 h in the classroom and 2.74 h outside the school (Table 1).

| Course duration in distance education
The

| Comparison of pain in traditional and block scheduling
The pain intensity of the participants was significantly ( p < 0.001) higher in the block scheduled model than the traditional model in all the body parts we assessed.In the block scheduled model, students' pain intensities were higher in the upper back (d = 0.96), neck (d = 0.94), and lower back (d = 0.86) with medium effect size, shoulder (d = 0.68) with small effect size, elbow (d = 0.41) and wrist (d = 0.49) with very small effect size (Table 2).

| Student's attitudes for block scheduling in ODE
Twenty-one participants were excluded from the qualitative analysis as they did not report positive or negative block scheduling experiences.The responses of the remaining 156 students were analyzed.
Two themes emerged from analysis of their preferred features: saving time, and maintaining subject integrity.Six themes were obtained from their least preferred features: distraction, fatigue, pain, need for a break, productivity problems, and boredom (Tables 3 and 4).

| Positive views of block scheduling in ODE
Seven out of 10 participants mentioned that they did not like any feature of the block program.Most students cited "saving time" as the One of the features of block scheduling that appealed to the students was the maintenance of subject integrity.Participants reported being more focused and attentive when completing a topic in one block session (Table 3).

| Negative views of block scheduling in ODE
The most commonly cited feature that students did not like was being distracted.More than half of them reported that they could not concentrate, focus, or follow the lesson because it was too long.
The second most common issue that students disliked about block scheduling was fatigue.One-third of the students reported that a lengthy lesson was tiring and necessitated a break.
Another aspect of block scheduling that students disliked was pain.Students reported that they experienced the greatest pain in their eyes, necks, and backs during block scheduling.
Students also expressed their dissatisfaction with productivity.
They commented that concentration in a distance learning class was very challenging, causing a decline in productivity owing to poor understanding of the subject matter.
Another feature of block scheduling in ODE that students disliked was the feeling of boredom.They found the constant tone of voice and monotonous lectures of teachers during block scheduling to be the underlying reasons for this.

| Student preferences for distance learning course length
All participants responded, "How do you prefer to schedule your distance learning classes?"Among them, 161 (91%) favored traditional scheduling in ODE.

| DISCUSSION
The aim of our study was to compare the musculoskeletal pain in health science students under traditional and block scheduling and investigate their perceptions of block scheduling in ODE.Our results indicate that students experienced significantly more pain in the whole back and upper extremities after block scheduling, with very small to medium effect sizes.They reported a preference for saving time and maintaining subject integrity in the block-scheduled courses.
However, they also disliked the distraction, fatigue, pain, productivity issues, and boredom in such courses.
The pain levels in the upper and lower back, neck and shoulder regions were significantly higher after completing a block scheduled course than a traditional ODE course, with a medium effect size.
Block-scheduled courses lasted an average of 30 min longer than traditional courses.The nature of distance education means that participants must maintain a static position while looking at a digital screen throughout the course.The literature clearly describes the negative effects on the musculoskeletal system of prolonged static sitting positions (Baradaran Mahdavi et al., 2021) or atypical sitting postures (Salameh et al., 2022).Many students engage in distance learning from home, which does not necessarily offer the requisite tools for ergonomic sitting such as a desk chair (Hawamdeh et al., 2022).In our study, pain intensity did not differ with listening position in either scheduling model.The literature shows that four factors are related to pain during sitting: sitting position, sitting activities, sitting dynamics (i.e. the amount of movement while sitting), and spine angles (David et al., 2021).In our study, students had similar characteristics in terms of those parameters in both sitting and lying positions.We found that phone/tablet users had more pain in the elbows and wrists than lap- Prolonged static postures can increase physical stress on the musculoskeletal system, potentially leading to injury and pain in soft tissues.
Moreover, it can decrease the viscoelastic properties of muscles and passive structures, which can eventually cause musculoskeletal dysfunction (Beach et al., 2005).Furthermore, distance learning removes the physical activity required for individuals to travel to school (Katona et al., 2021).Muscle strength and endurance problems in the neck and back can also contribute to pain.Deep neck extensor and flexor muscles are important for providing neck stability (Ghamkhar & Kahlaee, 2019), the multifidus has a key role in spine alignment (Ranger et al., 2017), and the trapezius muscle is crucial for connecting the spinal column to the upper arm (David et al., 2021).Fatigue of these muscle groups while looking at the screen could have caused pain.When a screen is used, the head posture is typically positioned forward (neck flexed) with reduced tilt (Fontenele et al., 2024), there is kyphosis in the thoracic spine (Tsang et al., 2023), and the shoulder goes into forward and medial rotation, which can have a negative effect on muscle ergonomics (Yip et al., 2008).The atypical posture could have exerted a negative effect on the ergonomics of the muscles in the whole back, neck, and shoulder areas, causing them to fatigue quickly.Additionally, the flexed head and cervical spine position could have caused pain in all areas owing to compression of the foramina, through which the nerves supply the neck, back, and shoulders (Xu et al., 2021).In our study, the neck, shoulder, and back muscles exhibited the highest pain levels in both scheduling models.The pain in these areas could have been caused by one or more of the aforementioned factors.
Online distance education through technology provides various benefits such as promoting greater engagement and achievement among students, flexible delivery options, and access to high-quality resources (Ilchenko et al., 2022).Nevertheless, overexposure to technology can result in physical health issues such as fatigue, headaches, shoulder stiffness, eye strain, back pain, sleep disruption, and depression (Pohorilyak et al., 2023).This emerging tendency is known as "video conferencing fatigue", which denotes the experience of exhaustion and fatigue when using video conferencing (Oducado, MaACV, & Villaruz, 2022).Like the literature on technology-enhanced learning (He et al., 2021), our study unveiled certain advantages and disadvantages of block scheduling in distance education.Students pointed out two positive aspects of block scheduling (time-saving and maintaining subject integrity) and five negative aspects (distraction, fatigue, pain, need for breaks, productivity problems, and boredom).
Since most previous studies of block scheduling have been conducted in face-to-face education, we will compare our findings with theirs (Labak et al., 2020;Morris, 2022;Spence, 2020).
Previous studies of face-to-face block scheduling have also identified the themes emerging from our study, time savings, and continuity of topics (Morris, 2022).In the literature, the benefits of block scheduling are generally described as more in-depth coverage of topics and additional time to process information (Morris, 2022).In our research, students stated that they enjoyed block scheduling since classes ended earlier, so they had more time for personal activities outside of school.It is worth noting that they usually claimed to have more time for their personal interests, hobbies, leisure activities, research, and so forth, rather than for academic growth.Maintenance of subject integrity was the other aspect of block scheduling that students in our study liked, as also found in previous research on face-to-face block courses.Block scheduling provides more time to concentrate on individual subjects and engage in more comprehensive learning (Morris, 2022).Its effect on academic achievement compared to traditional scheduling is controversial, and students who struggle academically can face challenges with it (Labak et al., 2020;Reeves-Wymer, 2023).Block scheduling requires sustained attention, so students who are more academically successful could find it more effective.
In our study, students reported distraction, fatigue, pain, need for breaks, productivity problems, and boredom during block scheduling courses.Students can experience discomfort and fatigue during distance learning, which can make it difficult to concentrate and follow the course for long periods (Wang et al., 2021).Concentration refers to an individual's cognitive ability to focus on a specific topic uninterrupted for a protracted interval.Prolonged exposure to screen-based technologies can cause mental exhaustion (Oswald et al., 2020), which indicates reduced performance during or after prolonged mental activities necessitating concentration and efficiency (Kato et al., 2009).The attention span of an adult for a given topic ranges from 10 to 20 min (Stuart & Rutherford, 1978).In a study of attention in distance learning, 63.1% of students reported that the lack of a physical classroom environment made it difficult to concentrate (Babacan & Dogru, 2022).This makes it even more important to maintain attention and prevent video fatigue in distance learning than face-to-face education (Ebardo et al., 2021).Shorter breaks between classes and longer virtual meeting durations could be associated with higher levels of videoconference fatigue (Oducado, MaACV, & Villaruz, 2022).
Overuse of technology can also lead to problems with self-regulation, persistence, and concentration (Turan et al., 2022).In a study of medical students, half of the participants reported that extended computer usage negatively affected their health (Ilchenko et al., 2022).Digital fatigue increases with longer hours and lower academic performance, women being more susceptible (Oducado, Fajardo, et al., 2022).In another study, even though students' academic performances were comparable in block and traditional scheduling, students felt less successful under the block schedule and preferred the traditional one (Edo et al., 2019).Our study indicates that eye health is also an important factor to consider in distance learning.Ninety-one percent of the students in our study preferred conventional scheduling, which is consistent with their negative experiences with block scheduling in distance education.
Previous studies have suggested that block scheduling benefits academic success and productivity in face-to-face education based on teachers' and students' perceptions (Spence, 2020).Nonetheless, block scheduling does not benefit all students equally, and those with lower academic achievement are less productive in block scheduling (Labak et al., 2020).Adverse conditions such as fatigue, headaches, pain, distraction, and eye strain in block courses have also been previously reported in face-to-face education (Williams & Shapiro, 2018).
According to our research, there are also unfavorable conditions in block courses in ODE.

| Limitations
The self-reporting survey method used to collect data from college students is a limitation of this study.When young people are asked about their perceptions of their experiences, there is a view that they do not yet have enough information or mature insight to be valuable sources of data and perspectives.In our study, this was reflected in

ORCID
Turgay Altunalan https://orcid.org/0000-0002-6970-0959 We carried out the study in theoretical ODE shared among all departments in the Faculty of Health Sciences such as Anatomy, Physiology, Pathology, and Internal Medicine.Uskudar University, where the study took place, has a regulation that mandates ODE course duration to be at least 35 min.Nonetheless, no standard for the maximum course length has been set.The ODE courses were delivered via the Zoom Pro platform.In the ODE sessions, students had autonomy over Flow diagram for study participants.
Two open-ended questions were asked to determine students' perceptions of the block scheduling course in ODE.The first question was, 'What did you like most about the block course?'The second question was, 'What did you like least about the block course?'An additional structured question was aimed at comprehending students' scheduling preferences regarding their ODE courses: 'How would you prefer to schedule your distance learning classes?' ('Block' or 'traditional').2.5 | Data analysis 2.5.1 | Calculation of sample size A minimum of 174 students were deemed a representative sample for this study by an online calculator for sample size estimation (https:// www.calculator.net/sample-size).The survey comprised 480 participants enrolled in their first to third academic year at Uskudar University, with a population proportion of 50%, a margin of error of 5%, and a confidence level of 90%.2.5.2 | Quantitative data SPSS (Statistical Package for Social Sciences) 24.0 was used for the analyses.Descriptive statistics were reported as frequencies, percentages, means, and standard deviations.Kolmogorov-Smirnov and histograms showed the data to be normally distributed.Missing data were not included in the respective analysis.The pain levels of the same participants were compared after traditional and block classes using a paired t-test.Pain intensity was analyzed in relation to the listening position and the technological device using an independent ttest.The effect size of the difference between the two assessments was calculated using Cohen's d-score and 95% confidence interval using the Jamovi R Program (The Comprehensive R Archive network, 2020).The effect size was defined as follows: d (0.01) = very small, d (0.2) = small, d (0.5) = medium, d (0.8) = large, d (1.2) = very large, and d (2.0) = huge(Sawilowsky, 2009).
top/desktop users.If those students held the tablet or phone throughout the lesson, that could have caused them to feel it more pain in their arms.Distance education is unlike face-to-face education in several respects, including technological equipment and the absence of standard tables and chairs.However, in the literature, students reported neck, back, and shoulder pain most frequently in face-to-face education; common factors cited included reading time, seat pan inclination, and posture awareness(Gheysvandi et al., 2019).Although students in distance education and face-to-face education can experience pain in similar body parts, the mechanisms underlying such pain could differ.The pain mechanisms should be explained from different perspectives.Prolonged sitting continuously compresses the intervertebral discs, limiting their nutrition.Compressive loads during prolonged sitting can deform the intervertebral disc tissue(Kwon et al., 2018).
students' incomplete or very short answers to the open-ended questions.Our study was conducted on common courses in the Faculty of Health Sciences, but course content can differ among departments.Physiotherapy students formed almost half of the total population in our study, so there was a risk of departmental bias in the responses.Participants' phone use outside of class was recorded through selfreports, which could have caused recall bias.5 | CONCLUSIONSAccording to the quantitative data in our study, block scheduling caused significantly more pain than traditional scheduling in the upper limb, trunk, and eyes (from qualitative data) in all areas where pain was measured, with a large effect size.The increase in neck, upper back, and lower back pain was also clinically significant.Both scheduling models in ODE entail increased upper and lower back pain.The quantitative data from our research show that many students expressed dissatisfaction with block planning in ODE owing to distraction, exhaustion, and discomfort.Nevertheless, a few individuals found it effective regarding time-saving and subject integrity.ACKNOWLEDGMENTSWe would like to thank the Social Worker Şafak Kıran for helping us to conduct the qualitative analysis.We would like to thank the Dean's Office of Health Sciences at Üsküdar University and Prof. Dr. Deniz Demirci, Head of the Physiotherapy and Rehabilitation Department, for their help during the data collection process.This study is based on the Master's thesis titled "The effect of block scheduling in distance education on the level of musculoskeletal system pain and fatigue level of students and the attitudes of students" by Burak Şevket Vuran, accepted by the Department of Physiotherapy and Rehabilitation, Institute of Health Sciences, Üsküdar University, under the supervision of Associate Professor Turgay ALTUNALAN in 2022.
T A B L E 1 T A B L E 3 Students' most liked features with block scheduling in distance education.
T A B L E 4 Students' least-liked features with block scheduling in distance education."Itis too long, and I get distracted.I cannot focus.""Icannot focus without a break."