The Impact of Non-Classroom Teaching on Musculoskeletal Pain in University Students Amid the COVID-19 Pandemic

Introduction

The COVID-19 pandemic has profoundly altered the daily routines of millions worldwide, largely due to the lockdown measures enforced by governments [1]. In Spain, a state of emergency was declared on March 14, 2020, which imposed strict restrictions on fundamental rights such as free movement, social gatherings, and participation in cultural, recreational, or sporting activities, while also suspending all face-to-face teaching [2]. As a result, the Spanish university system was forced into an abrupt transition to online and distance learning models, without the benefit of a preparatory period [3]. Although institutions sought to adapt as effectively as possible, the state mandated the continuation of existing schedules and workloads, delivered through virtual classes, recorded lectures, and greater emphasis on student autonomy. This shift posed challenges not only for instructors, who had to redesign pedagogical strategies and teaching practices [4, 5], but also for students, who were required to adapt their approaches to skill and knowledge acquisition [6, 7]. These academic disruptions coincided with the broader uncertainty and psychological strain of the pandemic, which research has shown to significantly affect students’ emotional well-being [8, 9]. However, little attention has been given to the impact of lockdown on students’ musculoskeletal health.

Previous studies highlight links between stress, anxiety, maladaptive coping, and the onset or aggravation of pain [10–12]. Musculoskeletal pain, beyond causing discomfort, can restrict students’ daily and leisure activities, elevate psychological stress, and generate financial costs due to repeated use of healthcare services. Moreover, persistent musculoskeletal pain may negatively influence academic performance and compromise future employability and health outcomes as students transition into the workforce [13]. Such pain is also widely documented among workers, where it arises from physical, psychological, and environmental stressors [14, 15]. University students face similar challenges: long hours of sitting, high academic workloads, and, in many cases, early exposure to professional environments through internships and practical training [16].

Additionally, students spend extensive time using laptops and mobile devices, both for academic purposes and leisure. Poor postural habits during device use are strongly associated with musculoskeletal discomfort, particularly in the spine and upper extremities [17, 18]. These factors create a context of elevated risk, where musculoskeletal pain becomes a threat to students’ health, quality of life, and overall well-being.

The lockdown further compounded this risk by limiting opportunities for physical activity (PA), a factor closely linked to musculoskeletal health [19, 20]. In Spain, regulations prohibited outdoor exercise and restricted access to public spaces, likely reducing students’ capacity to maintain active lifestyles.

Given these circumstances, this study was designed with the following objectives: (a) to examine the prevalence of musculoskeletal pain among students from two Spanish universities before and during lockdown; (b) to assess students’ physical activity habits and self-perceived stress during the lockdown period; and (c) to explore personal variables—including sex, average daily sitting time, household composition during lockdown, and whether students had a dedicated study space or used common areas—that may be related to physical activity habits during confinement.

Experimental Section

Study design and sample

A cross-sectional study was conducted among students from two Spanish universities—Universidad de León and Universidad de Valladolid—using convenience sampling. The total student population comprised 31,293 individuals: 18,650 from Universidad de Valladolid and 12,643 from Universidad de León. To achieve a 99% confidence level with a 4% margin of error, a minimum sample of 1,007 participants was required. Inclusion criteria were: (a) enrollment at either university for at least six months; (b) active participation in virtual teaching during the COVID-19 lockdown in Spain (16 March–11 May 2020); (c) completion of all survey questions; and (d) provision of informed consent in accordance with the Declaration of Helsinki (2013).

Data collection occurred via email in April and May 2020, coordinated by the Research Vice-Rectorates of both universities. Students accessed the questionnaire through a digital link, where they first reviewed and accepted the informed consent form. Completion of all questions was required to submit the survey. Data were anonymized to protect participants’ privacy. The study protocol was approved by the Ethics Committee of Universidad de León (ETICA-ULE-015-2020) and the Health Area of East Valladolid (PI 20-1787).

Study variables

The survey included the following instruments and measures:

1. Spanish Standardized Kuorinka Modified Nordic Questionnaire (SNQ): Used to assess musculoskeletal symptoms in ergonomic and occupational contexts [21, 22]. The Spanish version demonstrates good to very good test–retest reliability (k = 0.6–0.81), acceptable internal consistency (Kuder–Richardson 20 = 0.74–0.87), and solid construct validity [22]. Only the general section, consisting of 27 yes/no questions covering nine body regions (neck, shoulders, elbows, wrists/hands, upper back, lower back, hips/thighs, knees, and ankles/feet), was employed. Questions were adapted to the lockdown context and pre-tested with a convenience sample of 15 university participants to ensure clarity. For example, questions regarding pain in the last 12 months and the last seven days were modified to specifically refer to the period prior to or during lockdown. The analysis focused on the total number of painful areas reported.
2. Perceived Stress Scale (PSS, Spanish version): Assesses individuals’ perception of environmental demands as unpredictable and uncontrollable, reflecting perceived control over these demands. The instrument has demonstrated reliability (α = 0.82, test–retest r = 0.77) and adequate validity and sensitivity [23–25].
3. Physical Activity (PA) Frequency: Assessed with the questions “Did you engage in any PA before the lockdown?” and “Did you engage in any PA during the lockdown?” Response options included: (1) no; (2) occasionally (some days per month); and (3) frequently (several days per week).
4. Type of Physical Activity: Assessed with the questions “What type of PA did you mainly do before the lockdown?” and “What type of PA did you mainly do during the lockdown?” Response options were: (1) none; (2) aerobic; (3) strength exercises; and (4) other (e.g., stretching).
5. Additional Variables: Sex, average daily sitting time, number of household members during lockdown, and whether students used a dedicated space for study and virtual classes or a common area

Statistical analysis

Descriptive statistics were calculated for all study variables, including means to represent central tendency and standard deviations to indicate variability. The Kolmogorov–Smirnov test confirmed normal distribution of the variables (p > 0.05), and homogeneity of variances was verified using Levene’s test. Independent t-tests were conducted to assess differences between sexes and to compare the prevalence of painful areas before and during the lockdown. One-way ANOVA with Bonferroni correction was applied to examine differences in physical activity patterns across sex groups. Correlation analyses were performed to explore associations between physical activity, reported painful areas, and self-perceived stress.

Logistic regression (logit) was employed to investigate the relationship between independent variables and the dichotomous outcome of musculoskeletal pain during lockdown (0 = no, 1 = yes). Adjusted odds ratios (ORs) with 95% confidence intervals were calculated using a multivariate model, initially adjusted for age. Statistical analyses were conducted using STATA version 12 (StataCorp, College Station, TX, USA), with significance set at p < 0.05 for all tests.

Results

A total of 1,198 students participated, of whom 846 were women (70.6%; Table 1), yielding a response rate of 3.8%. Significant sex differences were observed in age, the number of painful areas reported in the year prior to lockdown, areas of pain limiting daily activities in the previous year, painful areas experienced during lockdown, and perceived stress. Women were significantly younger and reported higher values in all other variables showing significant differences. Conversely, the number of household members and the type of study space (dedicated or common) did not differ significantly between sexes.

PA12: painful areas during de previous 12 months; AL12: areas with limiting pain during the previous 12 months; PAC: painful areas during lockdown; PSS: Perceived stress scale. The t-test between sex: * p < 0.05; ** p < 0.01;

*** p < 0.001.

Analysis comparing musculoskeletal pain reported during the 12 months prior to the lockdown with pain experienced during the confinement period showed a significant overall decrease in the number of painful areas for the entire sample as well as for both male and female subgroups (p < 0.001) (Table 1).

Nonetheless, when focusing on the spinal regions—the cervical, dorsal, and lumbar areas—an increase in reported pain was observed across the total sample and in both sexes. This increase reached statistical significance only for dorsal pain in the total sample and among women (p = 0.01 for both) (Table 2). In contrast, pain in other body regions generally declined during the lockdown, except for women, who exhibited a significant rise in bilateral shoulder pain (p = 0.03).

Comparison between painful areas during the previous 12 months vs. during lockdown: * p < 0.05; ** p < 0.01;*** p < 0.0001.

Physical activity patterns shifted significantly during the lockdown (pre- vs. post-lockdown comparison: p < 0.001 for the total sample and for both sexes) (Figure 1). Among women, the proportion engaging in frequent physical activity rose by over 12%. In contrast, 5.1% more men reported not exercising at all during lockdown (p = 0.03), reflecting a decline in the percentages of men performing physical activity either occasionally or regularly.

Lockdown led to notable changes in the types and frequency of physical activity (pre- vs. post-lockdown: p < 0.001 for both sexes and the total sample) (Figure 2). Among female students, engagement in aerobic exercise and other activities declined (p = 0.01 and p < 0.001, respectively), while participation in strength training rose significantly (p < 0.001). Male students mainly reduced aerobic exercise (p = 0.01) and showed an increase in the proportion reporting no physical activity (p = 0.03).

Further analyses using ANOVA revealed no significant associations between activity frequency or type and age, daily sitting hours, number of painful areas, or perceived stress in men (p > 0.05). In contrast, female students displayed significant patterns: those who did not exercise at all were older (23.5 ± 7 years) than those exercising frequently (21.8 ± 4.2 years; p = 0.01) and lived with fewer household members (2.3 ± 1.1 vs. 2.6 ± 1.2; p = 0.01). Additionally, non-active women lived with fewer people than those engaging in occasional activity (2.3 ± 1.1 vs. 2.5 ± 1.2; p = 0.03).

Examining activity type in women also revealed significant differences. Participants performing no activity or aerobic exercises were younger than those engaging in other activities (p < 0.001). Moreover, women who did not exercise were older than those who practiced strength training (23 ± 6.1 vs. 21.7 ± 3.6 years; p = 0.03). Daily sitting time varied as well: women doing aerobic exercise sat longer (8.2 ± 2.8 h) compared to non-active women (7.3 ± 2.7 h; p = 0.04), and also relative to those practicing strength training (6.9 ± 2.5 h; p < 0.001) or other forms of exercise (6.9 ± 2.6 h; p = 0.01).

Among women, differences were observed between those who performed no physical activity and those engaged in strength training during lockdown. Non-active women lived with fewer household members (2.3 ± 1.1) compared to women performing strength exercises (2.6 ± 1.1; p = 0.01). Additionally, women practicing strength training reported fewer areas of musculoskeletal pain during lockdown (3.2 ± 2) than those who did not exercise (3.7 ± 1.9; p = 0.01).

Correlation analyses revealed that older students spent more time sitting (r = 0.6; p = 0.03) and experienced pain in a greater number of body regions during lockdown (r = 0.68; p = 0.01). Sitting time was inversely associated with the frequency of physical activity (r = −0.8; p < 0.01) and positively correlated with perceived stress (r = 0.96; p < 0.001). Furthermore, the frequency of physical activity was positively related to the number of household members (r = 0.68; p = 0.02) and inversely related to the number of painful areas reported (r = −0.83; p = 0.01).

Logistic regression analysis identified sex (0 = male; 1 = female), age, and frequency of physical activity as significant predictors of musculoskeletal pain during lockdown (Table 3). These variables collectively increased the likelihood of experiencing pain (OR range: 0.632–1.852; p < 0.02). In contrast, daily sitting time and self-perceived stress did not show significant effects in the regression model.

OR: odds ratio; SE: standard error; IC 95%: 95% confidence interval.