Prevalence and Risk Factors of Text Neck Syndrome Among Palestinian Medical Students: A Multicenter Cross-Sectional Study

1. Introduction

Neck pain is the second most prevalent musculoskeletal disorder after back pain, and the fourth most prevalent cause of disability worldwide [1]. It represents a significant burden to patients as it is associated with disability and reduced quality of life [2]. Because of the technological advancements of the 21st century, lifestyles have become more sedentary owing to the reliance on smart devices for work, entertainment, communication, as well as academic activities, most of which are usually done with suboptimal posturing, thus giving rise to new musculoskeletal pathologies that have emerged as major public health concerns [3].

Text Neck Syndrome (TNS) is an overuse syndrome defined as “prolonged, repetitive, and frequent maintenance of a flexed head and neck position while using mobile devices such as smartphones or tablets, often characterized by typing below eye level, leading to strain, injuries, and stiffness in the cervical spine”. Biomechanically, flexion of the cervical spine causes increased mechanical stress on the neck up to five times the load experienced in the neutral position [4], leading to a change in the normal alignment of the cervical spine. This results in muscle fatigue, ligament strain, postural imbalance, and chronic neck pain.[5] TNS commonly manifests neck pain, upper back pain, shoulder pain, headaches, tingling sensations, and sleep disturbances [6]. If prolonged and unaddressed, these biomechanical stresses may increase cervical disc loading, potentially leading to disc compression, disc herniation, cervical radiculopathy, and, in severe cases, irreversible nerve or muscle injury [4]. The Neck Disability Index (NDI) was used to evaluate neck-related functional disability, as it is a validated and reliable tool that allows standardized assessment of the impact of neck pathology on quality of life. Young adults are the most affected group by such conditions, with medical students being some of the most vulnerable subgroups to this condition, as their intense academic demands require prolonged studying and screen time along with sustained static neck posture, which predisposes individuals to prolonged cervical flexion, which is a well-documented associated factor of TNS [6].

Available literature indicates that posture-related neck disorders associated with smart device use affect a significant proportion of the global population, with students being among the most vulnerable groups due to their heavy reliance on digital devices for academic activities. Several studies conducted specifically among medical students have reported high prevalence rates of TNS. In Jordan, a study among medical students reported a prevalence of TNS of 31.7% [7], while similar studies among medical students in Pakistan, Iraq, and Saudi Arabia reported prevalences of 43.6% [8], 64.5% [9], and 68.1% [10], respectively. Studies conducted among general university student populations have also demonstrated a substantial burden of TNS, including a prevalence of approximately 46% in Benin and 34% in South Korea [11]. Some associated factors have also been identified, which include weight, BMI, female gender, duration of device use, purpose of device use, and degree of neck flexion.

Although TNS has been studied internationally, evidence regarding its associated factors remains limited in certain regions. To the best of our knowledge, no previous study has investigated the prevalence of TNS among medical students in Palestine (West Bank). Therefore, this present study was aimed at assessing the prevalence of TNS, evaluating its impact on neck dysfunction, and examining its association with sociodemographic, ergonomic practices, and smart device usage patterns among medical students in the West Bank.

2. Methods

2.1. Study Design and Settings

This study is a cross-sectional observational study conducted using a structured online self-administered questionnaire. The cross-sectional design was chosen in order to assess the prevalence of TNS as well as to identify associated factors among medical students enrolled in universities across the West Bank. Data collection took place from November 2025 until February 2026.

2.2. Study Population, Inclusion and Exclusion Criteria

The population of this study consisted of medical students in universities across the West Bank, Palestine. To ensure methodological clarity and reproducibility, those with previous traumatic injury to the neck, surgical history of the neck, congenital deformities, or cervical disc herniation were excluded.

2.3. Sample Size and Sampling Techniques

The minimum required sample size was calculated for a cross-sectional prevalence study using the single-proportion formula:

$$n_0={\displaystyle \frac{Z^{2}p(1-p)}{d^2}}$$

where Z = 1.96 for a 95% confidence level, p was estimated from previous literature, and d = 0.05. Based on these parameters, the initial calculated sample size was 333 participants. Considering the finite population of medical students in West Bank universities (N ≈ 7200), finite population correction was applied:

$$n={\displaystyle \frac{n_0}{1+\frac{n_0-1}{N}}}$$

The adjusted minimum required sample size was 319 participants. To compensate for potential non-response, a higher number of participants was targeted. Participants were recruited using a non-probability convenience sampling method through online distribution. A total of 358 students were ultimately included in the final analysis, exceeding the minimum required sample size

2.4. Variable Definitions

Sociodemographic data collected included the participant’s age, gender, year of study, height, and weight. While ergonomic data was collected about the participant’s posture, degree of neck tilting, break-time duration, the use of tablet holders, armrests and backrests, TNS was defined according to previously published criteria, which were at least 4 h of screen time daily along with three of the six characteristic symptoms being neck pain, upper back pain, headache, hand numbness, tingling, insomnia, and shoulder pain [12,13]. Neck disability was assessed using NDI, which is a validated self-administered questionnaire consisting of 10 items: pain intensity, personal care, lifting, reading, headaches, concentration, work, driving, sleeping, and recreation. each item giving a score of 0–5, which totals 50 points[14]. However, when the driving item was not applicable, it was omitted, and the total NDI score was calculated as a percentage of the maximum obtainable score (either 50 or 45 points), consistent with previous reporting of this approach in the literature [15].

2.5. Study Tools, Validity, and Reliability

Information was obtained through a structured, self-administered questionnaire that incorporated established and previously validated tools, including the Neck Disability Index (NDI), in addition to published criteria for defining Text Neck Syndrome. This questionnaire is a previously published and validated questionnaire assessing Text Neck Syndrome and associated factors was used in this study, with permission from the original authors [7]. The content of the questionnaire was reviewed by experts to ensure its appropriateness and clarity. Furthermore, the use of well-recognized instruments supported the validity and reliability of the collected data based on their documented psychometric properties. The internal consistency of the NDI in the present study was acceptable (Cronbach’s α = 0.787), indicating reliable measurement of neck-related disability among the participants.

2.6. Statistical Analysis

Data analysis was done through the Statistical Package for the Social Sciences (SPSS) version 27. Descriptive statistics were used to analyze the data, including frequencies, percentages, means, and standard deviation. TNS was calculated using percentages. Associations between variables were done using the chi-square test, Fisher’s exact test, T test, and Mann-Whitney U. Continuous variables were analyzed using appropriate statistical tests based on data distribution. Multivariable logistic regression analysis was applied to variables with a p-value of <0.2 to identify independent associated factors. Statistical significance was set to a p-value of <0.05.

2.7. Ethical Approval

Ethical approval was granted by the Institutional Review Board (IRB) of the Arab American University of Palestine (AAUP). Participation was anonymous and voluntary; no personal identifiers were included in the questionnaire. Only the team working on the research had access to the data. Participants were informed of their right not to participate in this study. All methods were carried out in accordance with relevant guidelines and regulations and in accordance with the principles of the Declaration of Helsinki.

3. Results

A total of 358 medical students were included in the analysis; the median age of participants was 22 years. Females represented the majority of the participants in this study, with a total of 223 females and 135 males. All medical schools of the West Bank, and all years of study were represented, with senior students being the most represented. Substantial screen exposure was reported by participants, with a median of 6 h of exposure daily, and a median of 7 h of daily sitting duration. Most students used multiple digital devices. Moderate neck tilting was commonly reported, and 46.6% of students met the criteria for TNS diagnosis. Characteristics of participants were further described in Table 1, Table 2 and Table 3. 

The analysis showed that TNS had significant associations with multiple sociodemographic, academic, and ergonomic factors. The prevalence of TNS was higher among females (62.3%). TNS also had a higher incidence among shorter participants. Academic factors that demonstrated significant associations included academic year and university affiliation, suggesting a cumulative effect of higher workload and learning environment. As for ergonomic factors, longer daily time on devices, increased daily sitting duration, shorter break time from digital devices, greater degrees of neck tilting, as well as tablet holder non-use all had significant associations with TNS prevalence.

The p-values of these significant associations were (< 0.001), (p =0.036), (p = 0.01), (p = 0.01), (p < 0.001), (p = 0.005), (p = 0.026), (p < 0.001), (p < 0.001) respectively. All can be found in Table 4 and Table 5. 

In multivariable logistic regression analysis, female gender, higher academic year (years 3-5), longer daily screen time, severe neck tilting, and non-use of smartphone/tablet holders remained independently associated with TNS. In contrast, height, sitting duration, break time, BMI, and number of digital devices did not retain statistical significance after adjustment, suggesting that ergonomics posture and screen exposure are stronger independent predictors than general anthropometric or lifestyle factors.

P values were (0.022), (0.046), (0.038), (0.012), (0.010), (0.002), (0.003), (0.002) as is shown in Table 6. 

4. Discussion

The prevalence of TNS was found to be 46.6% which is consistent with the literature, as the prevalence ranged from around 40% to 70% [8,9,10,11,16], with studies done on general student population having a lower prevalence [11], highlighting the growing magnitude of TNS among medical students, the high prevalence may be due to the high academic demand placed on medical students leading to prolonged screen exposure, and sustained posture.

Female gender was associated with TNS prevalence, which is consistent with the literature, showing females had a significantly higher TNS prevalence than that of males [7]. The analysis showed that females had higher time spent on digital devices than males, which could help explain this finding.

Height was inversely associated with TNS; however, this finding has not been widely reported in previous literature. However, this association did not remain significant after multivariable adjustment, suggesting possible confounding by other factors such as gender.

The academic year had a significant association with the prevalence of TNS up until the 6th year, which is consistent with the literature, suggesting a cumulative effect of academic workload with prolonged device use and static posture over time, as higher year medical students showed higher prevalence of TNS. The lack of significance with 6th year medical students may be explained by the change in academic structure, as the 6th year is more about clinical exposure than 4th and 5th years, making this group of participants less prone to high amounts of screen exposure.

A significant association between TNS prevalence and university affiliation was found in the analysis, however, There were significant discrepancies between universities pertaining to TNS prevalence, with the (Palestine Polytechnic University) having the highest prevalence of TNS, which may be attributed to differences in academic requirements, as well as study environments, as environments with higher screen time and suboptimal ergonomics are more likely to cause neck pain [10,17,18].

Daily time spent on digital devices had a significant association with TNS prevalence, as participants with higher screen time showed a higher prevalence of TNS, as forward head posture increases the burden on neck muscles, thus increasing the burden on the ligaments and muscles of the neck [6,19,20]. Longer device use has also been linked to neck pain [10,17,18].

Higher daily sitting duration was also associated with TNS prevalence, as it typically involves a static posture of the neck. Prolonged sitting duration has been associated with neck pain in numerous studies [20,21,22,23].

Degree of neck tilting was significantly associated with TNS prevalence, with greater amounts of neck tilting amounting to higher TNS prevalence, which could be attributed to biomechanics, as greater neck tilting causes extreme loading on the cervical spine and may, over time, disrupt the normal alignment of the cervical spine. It has been associated with neck pain and musculoskeletal dysfunction [20].

Tablet holder non-use has been associated with a higher prevalence of TNS, as participants who did not use smartphone/tablet holders showed a higher prevalence of TNS than the participants who used them, highlighting the significance of posture while using digital devices, as forward head posture and neck tilting have been associated with neck pain [6,19,20].

Factors like body weight, BMI, sitting duration, and physical activity level were not linked to increasing the likelihood of developing TNS, indicating that posture-related behaviors play a larger role than general lifestyle characteristics.

The combined findings of this study, along with the accumulating scientific data, suggest that TNS constitutes a widespread and multifactorial musculoskeletal pathology that causes significant morbidity to medical students, evidenced by a high prevalence rate and a biologically plausible association with prolonged screen time and increased amounts of neck flexion. Beyond transient inconvenience, TNS represents a significant cause of disability and decreased quality of life, positioning it as an emerging occupational health challenge that must be addressed.

Limitations and Strengths of This Study

Several limitations of this study should be acknowledged. First, the cross-sectional design prevents establishing causal relationships between the variables and TNS. Second is the use of a questionnaire as the source of data, which may be subject to recall bias and reporting inaccuracy, especially in variables such as device use and physical activity level. Third, even though multiple confounders were included in the multivariable analysis, some residual confounders may still be present from unmeasured sources, such as detailed workstation ergonomic characteristics.

Strengths of this study include taking a large sample of medical students, who were drawn from multiple universities and academic years across the West Bank, which enhances the generalizability of the study findings.

The study used a structured questionnaire, which allowed for assessment of a wide range of sociodemographic, academic, lifestyle, and ergonomic factors, thus providing a more holistic view of TNS and the factors associated with it.

The focus on modifiable ergonomic behaviors offers practical implications for prevention strategies and targeted interventions in academic settings.

The results of this study have important clinical and educational implications for medical students and academic institutions, most important of which is the high prevalence of TNS among medical students in West Bank universities and its association with modifiable ergonomic factors, highlighting the need for early identification and prevention strategies to reduce the burden.

These strategies may include incorporating ergonomic education into medical curricula, thus promoting healthier posture and screen positioning, as well as employing adequate break time.

Another strategy may be for institutions to promote ergonomically supportive learning environments and encourage healthy studying behaviors, which may contribute to improving musculoskeletal health and overall well-being among medical students.

5. Conclusions and Recommendations

In this cross-sectional observational study, the prevalence and associated factors of TNS were evaluated among a population of medical students in universities across the West Bank, Palestine. Analysis revealed that TNS was highly prevalent within this population. Several factors were significantly associated with TNS, ranging from ergonomic, sociodemographic, and academic performance to device use habits. These results draw attention to daily habits such as prolonged smart device use and sustained neck flexion.

Per the cross-sectional design, causal relationships cannot be determined.

Based on these findings, the implementation of targeted educational programs aimed at raising awareness of TNS and its risk factors and potential health consequences is strongly recommended. Universities should promote proper ergonomic practices, including optimal screen positioning, supportive seating, and the use of device holders. Integrating ergonomic education into medical curricula may contribute to the development of long-term healthy study habits among future healthcare professionals.

Further studies are recommended to use interventional or longitudinal designs to better establish causal relationships and to evaluate the effectiveness of preventative measures. Understanding the incidence and risk factors of TNS among the general population, or other student populations, is also crucial.