The musculoskeletal problems and psychosocial status of teachers giving online education during the COVID-19 pandemic and preventive telerehabilitation for musculoskeletal problems

1.Introduction

Coronavirus disease 2019 (COVID-19) first app-eared at the end of 2019, spread throughout the world at the beginning of 2020 and was then declared a pandemic by World Health Organization (WHO) [1]. Countries affected by the COVID-19 pandemic were forced to impose wide restrictions on public and private life. Restrictive precautions based on social distancing rules were applied to prevent human-to-human transmission and spread of the virus. The reg-ulations introduced covered all areas of life such as social life and included the education system [2]. In order to ensure social isolation during the pandemic, all formal education has been suspended and distance (online) education has been implemented in many schools, with the assumption that the pandemic will be prolonged. Online education is a training system in which live video and audio lessons are carried out in a completely virtual environment through existing computer technologies without the obligation of the student and teacher to come to school, completely independent of time and space [3]. In the distance education system, the use of online education tools such as computers is greater than it is in the traditional education system.

Many studies involving office workers who use computers have shown that prolonged work in a sit-ting position and using computers have created mu-sculoskeletal problems and exacerbated existing pro-blems [4, 5]. It is known that the main reason for this is the frequent repetitive movements of the up-per extremities, as well as the prolonged computer working times, and therefore increased loads on the musculoskeletal system [6]. An examination of the literature reveals that postural imbalances caused by personal and work-related factors such as long wor-king hours, inappropriate rest breaks, increased and inappropriate use of smart devices, wearing of gla-sses, stress and anxiety, and factors related to the work environment such as poor placement of the com-puter screen and keyboard and/or mouse, poor chair and table selection, and the physical and environmental conditions of the room appear to increase musculoskeletal disorders in employees using com-puters [4, 7]. At the same time, it is stated in the literature that in the individuals working in jobs that require excessive use of computers, mental loads increase, anxiety and depression occur, physical act-ivity levels decrease, and in a vicious cycle these situations have negative effects on the musculoskeletal system and general health status [8–10].

Examination of the normal working conditions of teachers showed that the bad posture caused by standing in front of the board for long periods, communicating with the students and evaluating their classroom activities while bending over, and carrying heavy books and equipment causes musculoskeletal system problems, especially in the upper and lower extremities [11, 12]. For elementary and secondary school teachers working in the distance education sy-stem implemented during the pandemic, it might also be supposed that musculoskeletal system and psychosocial problems may be experienced, as seen in studies conducted with people working at computers for a long time.

In studies conducted in 2020 during the COVID-19 pandemic, it is reported that in people who had to stay at home as a result of restrictions applied to ensure social isolation musculoskeletal system and psychosocial status problems emerged due to immobility, poor working conditions, and anxiety and depression that developed in parallel with fear of the pandemic. In addition, it has been stated that employers and employees do not have time to adapt to this situation personally and environmentally, as the transition to compulsory home work is very sudden [13–15]. Similarly, it can be expected that teachers who conduct online education activities may develop musculoskeletal system and psychosocial problems and existing ones may become more serious. Preventive rehabilitation is needed in these situations, but face-to-face applications cannot be performed due to the pandemic. This has directed clinicians and researchers towards the use of telerehabilitation methods, which include using technology such as phones, e-mail, and video conferences to provide sug-gestions, applications, or information exchange [16–18]. The World Confederation for Physical Therapy (WCPT) published reports in April 2020 about the application of these digital physiotherapy and rehabilitation methods during the pandemic, which have existed since the 2000s but not been widely used [19,20].

Therefore, by examining the effects of online education methods on teachers during the COVID-19 pandemic, it was considered necessary to determine whether preventive programs are necessary for the health of individuals in such cases. For this purpose, the present study was planned to make necessary evaluations, to provide telerehabilitation applications including information about posture and ergonom-ics, and to guide further protective rehabilitation programs that can be applied to teachers working in online education by evaluating the effects of telerehabilitation during extraordinary situations such as pandemics.

2.Materials and methods

Forty teachers who applied distance education methods online at primary and secondary schools volunteered to participate in our study, which was conducted in a quasi-experimental order in a single group between May 2020 and July 2020. Due to the pandemic, all of the data collection and applications were conducted online. Ethics committee approval of the study was obtained by the decision of Nevşehir HacıBektaş Veli University Non-Interventional Clinical Research Ethics Committee dated 30.04.2020 and numbered 2020.10.97. All individuals participating in the study provided informed consent.

The inclusion criteria were as follows: age between 20 and 65 years, working as a teacher for at least 1 year, teaching via online education methods for at least 4 weeks during the pandemic, and using visual display terminals (VDTs) for at least 10 hours a week. Individuals with a history of traumatic injury, any neurological conditions, or who underwent spinal or other musculoskeletal operations were excluded.

3.Results

Forty teachers who gave online education during the COVID-19 pandemic participated in the study. Their sociodemographic characteristics are shown in Table 1.

Technological device use times of the participants are given in Table 2. It was found that the use periods of technological devices for educational and noneducational purposes during the online education period of the participants increased significantly compared to the pre-online education period (p < 0.05) (Table 2).

The total score from the CMDQ and the other scores including neck, right shoulder, left shoulder, back, right forearm, right wrist, left wrist, lower back, and hip scores during the online education period were significantly higher compared to the pre-online education period (p < 0.05). Similarly, it was determined that the scores from the ODI, BDI, and BAI during the online education period were significantly higher compared to the pre-online education period (p < 0.05). In addition, the scores from the ProFitMap (total and subscale), UEFI, and WLBS during the online education were significantly lower compared to the pre-online education period (p < 0.05) (Table 3).

Only 18 individuals participated in the telereha-bilitation training we prepared in line with the information obtained from the individuals participating in the study in the first assessment. The other individuals did not want to participate in telererehabilitation training. However, we continued the study with 18 participants. When the results from the three asse-ssments of the participants (pre-online education, during the online education, and after training) were compared, the scores from the CMDQ (total scores and other scores from it including neck, back, lower back, right forearm, right wrist, and hip) and the scores from the ProFitMap (total and subscales), ODI, UEFI, BDI, BAI, and the WLBS were significantly different (p < 0.05). Post-hoc comparisons of these differences are shown in Table 4. No statistically significant difference was found in the other parameters (p > 0.05). Overall, the results differed between the pre-online education period and during online education, and between during online education and after training (p < 0.05). The participants’ results after training were similar to those pre-online education (Table 4). There were statistically significant differences when comparing the percentages of people with pain (prevalence) in the neck, back, right wrist, lower back, and hip regions between the pre-online education period, during the online education period, and after the training (p < 0.05). No statistically significant difference was observed in the number of participants with pain in all parts of the right and left lower extremities except for the hip regions and in the right and left shoulders, upper arms, forearms, and left wrist regions (p > 0.05) (Table 5).

4.Discussion

With the COVID-19 pandemic, individuals have remained inactive at home due to the restrictions and quarantine, and because they have had to continue with their intensive work schedules in an unergo-nomic and unfamiliar environment musculoskeletal system problems have arisen. Furthermore, musculoskeletal problems caused by this intense period, combined with the effect of the pandemic provoking anxiety and depression, have affected individuals’ psychosocial status [14]. In our study, teachers who, without preparation, had to begin giving online education during this period were examined and in agreement with the literature it was seen that musculoskeletal problems and depression and anxiety increased significantly. It has been determined that the duration of using VDTs increased due to the transition of teachers to online education, and this situation is accompanied by an increase in the intensity and duration of pain and related limitations. All these changes have caused the work–life balance to deteriorate. After the posture and ergonomics training given via tele-assistance, there were significant improvements in the musculoskeletal system problems. However, the increased anxiety and depression experienced during the pandemic did not improve as much as the musculoskeletal system did.

Analyzing the literature, it can be seen that one of the profession groups with the most musculoskeletal problems in normal working conditions is teachers. Ng et al. reported that the prevalence of musculoskeletal system problems was 80.1%in their sample of teachers. When these problems were analyzed in detail with the CMDQ, it was seen that the most of these problems were in the wrist, upper leg, upper arm, and lower leg regions. Spinal pain and hip pain were found in lower percentages [11]. These results were different from ours. The examination of teachers under normal working conditions in the study by Ng et al. may have caused this difference in results. During formal education, teachers are more likely to experience pain in their weight-bearing lower extremities because they mostly work standing in front of the board, and especially in their wrists and upper extremities, as they are often writing. However, during the pandemic, the working positions of the teachers changed completely and they had to spend most of their working hours in a static sitting position in front of the computer, but they had not prepared suitable work stations. As a result of this situation, as shown in our study, the pain in the neck, back, lower back, and hip joints carrying the load more in the sitting position was increased. If studies investigating office workers using computers for long periods are examined, it is seen that their findings were similar to ours [5, 6, 31]. Compared with the literature, the results obtained from our study show that during the pandemic teachers experience musculoskeletal system problems similar to those seen in office workers using computers intensively. When spinal and upper extremity musculoskeletal problems were examined in detail, it was observed that not only did the pain prevalence increase, but also the neck pain intensity, frequency, and limitations related to neck pain, low back pain, and related limitations increased as well and upper extremity functionality decreased.

In a meta-analysis examining studies planned for the prevention of musculoskeletal problems occurring in office workers, it was observed that ergonomic recommendations such as computer distance; keyboard, mouse, and screen position; and chair and desk suitability were given through face-to-face training. The office employees who had received the training had better results than those who had not [32]. In our study, similar training was given by tele-assistance, as it could not be done face-to-face due to social isolation during the pandemic. The importance of telerehabilitation methods has grown in recent years. Before the pandemic, since 2017 the WCPT has reported studies to make these methods more widespread, and during the pandemic it has recommended digital physiotherapy for musculoskeletal system physiotherapy as in all other physiotherapy areas [33]. In our study planned on this subject, even if in person training could not be provided, comparable results were obtained with tele-assistance. In a study conducted by Shuai et al. in 2014, similar to our study, teachers were informed about posture and ergonomics through presentations and posters, and it was observed that their musculoskeletal system problems began to decrease after the training and continued to decrease even after 12 months [34]. In our study, the long-term effects of training, like in the study by Shuai et al. could not be determined, but 6–12 months after the study, it is planned to contact the same individuals to re-evaluate them in order to establish the long-term effects.

Another effect of the pandemic and changing work conditions is an increase in anxiety and depression among individuals. Regardless of whether teachers give online education or not, the pandemic on its own can increase their anxiety and depression, as a result of their fear of ill health or even death [35]. In a study conducted by M.Z. Ahmed et al. in China during the pandemic, it was reported that anxiety, depression, and alcohol use increased significantly and mental well-being decreased [36]. In studies that investigated the relationship between working conditions and the musculoskeletal pain, anxiety, and depression that developed due to these working conditions, it was stated that increased pain and working times and harder working conditions cause anxiety and depression by increasing mental stress [8, 10, 37]. In our study, it was thought that the combination of increased work stress caused by giving online education and mental stress due to the pandemic may have increased the findings of anxiety and depression in teachers.

The occurrence of musculoskeletal pain, changes in psychosocial status, and changes in the usual work and lifestyle may also have led to a deterioration in teachers’ work–life balance during the pandemic. The fact that all family members, including children, have to perform their daily tasks, education, and work in the home environment or that individuals living alone live all their daily lives in the same environment during the pandemic negatively affects the work–life balance [14]. In our study, in parallel with this situation, there was a deterioration in the work–life balance of teachers during the pandemic as well. However, a statistically significant difference was not found, as there were minimal changes in depression, anxiety, and work–life balance scores after training. We supposed that the main reason for this is that the training we provide mostly focuses on musculoskeletal problems. Nevertheless, minimal clinical improvements in depression, anxiety, and work–life balance may show that improvements in musculoskeletal problems affect them. At the same time, this situation may indicate the importance of psychosocial support during the pandemic.

Due to the short time between the start of the pandemic and the start of the schools’ summer holiday we had limited time for our study. In addition, as teachers had a very busy working schedule due to online education some did not want to participate, resulting in the small sample size of our study. On the other hand, in our study, we had to apply the assessments, some of which were mostly applied in person normally, online due to the pandemic. These are other limitations of our study; however, the important results obtained in our study will contribute to the literature as they are statistically significant and concern public health. Further studies with more participants can be performed in the future to reinforce our results.

Consequently, it has been observed that increased musculoskeletal system problems, anxiety, depression, and deterioration in work–life balance occurred in teachers who switched to online education due to social isolation during the COVID-19 pandemic. These findings can be considered an indication that this period, which started suddenly and was not prepared for, has negatively affected the lives of individuals in many ways. In addition, our study showed that telerehabilitation that can be applied via digital tools is effective in reducing the musculoskeletal system problems of individuals in times like this period when it is not possible to implement preventive rehabilitation programs in person. Thus, whether social isolation continues or not, digital rehabilitation will be effective for individuals who do not have access to rehabilitation programs face-to-face. It is thought that our study will be a guide for professionals working in this field to use these methods. In addition, it should be noted that it will be beneficial to give this kind of training in order to prevent musculoskeletal problems that may occur in individuals working online in every field, including the public and private sectors.

Conflict of interest

The authors declare no potential conflict of interest.