Injuries from wearing heavy backpacks are not common in school-aged children


***As a commenter below noted, as of 9/22/17 the link to the AOTA infographic with dubious information is broken/has been removed and now serves a 404 error.  Hopefully this is an indication that there will be more care in the future about quoting statistics. The removal of the infographic does not address the question about whether or not there may be more impactful injury prevention efforts than concern with wearing heavy backpacks.  (edited, 9/22/17, CJA).

According to the American Occupational Therapy Association, heavy backpacks can cause serious injury to children.  The AOTA claims that heavy loads carried by 79 million students across the United States "can cause low back pain that often lasts through adulthood."  The AOTA also claims that according to 2013 statistics from the US Consumer Product Safety Commission nearly 22,200 strains, sprains, dislocations, and fractures from backpacks were treated in hospital emergency rooms, physicians' offices, and clinics.  (Source: https://www.aota.org/Conference-Events/Backpack-Safety-Awareness-Day/Handouts/Infographic-Injury-Stats.aspx ) *** see note above

This level of severe concern was surprising to me.  I am an occupational therapist and I have been treating children for 30 years, and I have never encountered a single incident of strain, sprain, dislocation, or fracture caused by wearing a heavy backpack.  That is just anecdote, and I found it confusing, so I set out to learn a little more about the incidence of these injuries in the United States.

I contacted the Consumer Product Safety Commission and learned that their only regulatory jurisdiction in regards to backpack injuries only covers the amount of lead content that may or may not be present in the materials that make up a backpack (in the plastic clips, metal zippers, etc).  According to the CPSC, these instances of injuries are virtually non-existent.  Certainly, this is not the cause of the alarming statistics provided by the AOTA.

The CPSC operates the National Electronic Injury Surveillance System (NEISS).  According to their website, CPSC’s National Electronic Injury Surveillance System (NEISS) is a national probability sample of hospitals in the U.S. and its territories. Patient information is collected from each NEISS hospital for every emergency visit involving an injury associated with consumer products. From this sample, the total number of product-related injuries treated in hospital emergency rooms nationwide can be estimated.

I attempted to query this database in the broadest possible terms and was unable to replicate a result of 22,000 backpack injuries in 2013.  Then I decided to get some more updated results and I used the following parameters for a search:

Age: between 5 and 18 years of age (corresponds to student population)
Dates: all reported injuries between 1/1/16 and 12/31/16
NEISS Product Code: 5011 (corresponds to Book Bags or Back Carriers)

The query returned these results:

Dislocation injuries (actual reported): 3
Fracture injuries (actual reported): 18
Strain/Sprain Injuries (actual reported): 59  This category was the only one with a large enough sample to even provide possible weighted estimates - which was given as 1556 for this category.

The NEISS system considers national estimates as potentially unreliable when the reported incidence is very low.  It does not calculate extrapolated statistics for dislocations or fractures.

Within each query, you can examine the details of each reported case.  The vast majority of injuries associated with backpacks were caused by tripping over backpacks, swinging backpacks at other children and hitting them, and punching backpacks.  Very few injuries were actually caused by strain of an overly-heavy backpack.  In fact, of the entire dataset, only ten strain/sprain injuries were caused in the 5-10 year old population.  Of those ten injuries, four were caused by overly heavy backpacks and six were caused by tripping over backpacks that were left on the floor.

Incidents of strains and sprains were most common with older children (ages 11-18), but even within that population, the majority of injuries were not actually related to wearing a heavy backpack but more often with trips and falls, thrown backpacks, etc.

These findings are consistent with previously published studies that do not support the premise that heavy backpacks are causing injuries in children (Child Health Alert, 2003; Wiersema, Wall, & Foad, 2003).

These findings support my anecdotal observation that injuries from wearing heavy backpacks are rare events.

Conclusion:

Wearing heavy backpacks is NOT a significant cause of injury in children.  The incidence of these injuries is actually so small that the CPSC is unable to provide statistical estimates about these injuries.

A child may receive an injury from a backpack - but the most likely cause of that injury is tripping over backpacks, swinging backpacks around unsafely, or being hit by a child who has thrown a backpack.

For the rare incident of a heavy backpack causing an orthopedic injury to a child, nearly all reported cases are for middle and high school aged children.  If OTs are going to dedicate resources to injury prevention with this population, older children aged 11-18 are the most likely to ever incur a rare injury from wearing a heavy backpack.

Occupational therapists are qualified and trained to provide injury prevention education and programs; they are naturally interested in these topics because of the impact that injuries can have on children's occupational participation.  However, the concern about heavy backpacks has been significantly over-inflated.  There are many other areas of pediatric injury prevention (concussion/helmet use, bike accidents, trampoline accidents, motor vehicle accidents, playground injuries) that are a much more significant cause of injury and should be considered important targets for prevention efforts.



References:

Child Health Alert (2003). Backpack injuries in children--not what you think. (2003). Child Health Alert,  21, 4.

Wiersema, B., Wall, E., & Foad, S. (2003). Acute backpack injuries in children. Pediatrics, 111(1), 163-166.



note: Thank you to CPSC staff who provided useful guidance based on a simple consumer query.

Comments

Anonymous said…
You make a conclusion based on a phone call and website search? How about a thorough analysis of literature supporting backpack injuries in children and adults?
Hi Anonymous,

I am willing to place my name on my findings on this issue - why don't you show us all where I am wrong and then put your real name behind your statements? Or is it easier to write a drive-by attack comment and provide no justification for your statements while hidden by your anonymity? If you feel passionately about this issue then I think you should make a more serious statement. Your anonymous comment makes your argument weak and uninteresting.

I am always interested in dialogue - so please explain how these conclusions are incorrect. I have listed the search parameters in a very specific manner so that the search can be replicated. Please educate everyone how the conclusion is wrong.

I question the claim that pediatric/school-aged backpack injuries from wearing heavy backpacks are a high incidence event. The database search was clearly documented. The findings from that database search are nothing new - I cited the article published in a major medical journal from 2003 that came to the exact same conclusion.

If you want to dispute these facts, by all means do so.
Kathleen Foley said…
Hi Mr. Alterio,
I was intrigued when I read the title of your blogpost--especially since the backpack issue is so publicized this time of the year.
Like you, when I am presented with a statistic, I always review the literature to see if the topic has been fully studied and the findings have been repeated in other research. As you know, only a critical appraisal of existing literature can truly support your statement: "Injuries from wearing heavy backpacks are not common in school-aged children" and I did not do one.
However, I do want to point out to those reading your post, there is 10 years+ of studies that conclude that school-aged children carrying backpacks over 10-15% of their body weight as well improper wearing of a backpack CAN contribute to musculoskeletal pain and injuries. I can't comment on whether the incidence of backpack injuries is "high"; however, the rate of "non-specified musculoskeletal pain" of school-aged children is increasing. (For those of your readers not familiar with the medical model of practice, diagnoses are tracked using numbers called ICD codes. Prior to the ICD-10 version, the cause or mechanism of an injury or illness was not as specific as it is now so we have not always captured diagnoses and the reasons behind them in detail). As an OT, I am concerned with whether the weight or improper use of a backpack can impact the health and wellness of a child; it appears that it can.
Most recently, Noll, Silveira, and Avelar, (Feb 2017 in PLOS) published a cross-sectional study of 251 athletes who report severe and frequent back pain. One of the findings in the multivariable analysis showed a statistically significant relationship between high back pain frequency with the method of carrying a backpack. There was an early study published by SPINE that surveyed over 1100 12-18 years old; nearly 75% of them reported back pain that they believed was associated with backpack use. In 2006, there was a paper in the Pediatric Orthopedics journal that found backpack weight seemed directly proportional to the likelihood of back pain in children.
Most interesting to me was a 2009 study in SPINE by Neuschwander, Cutrone, Masias, & Hargens that used MRIs to look at the impact of backpacks on the lumbar spine of school-aged children. The MRIs of the children showed a decrease in vertebral lumbar disc height and significant lumbar asymmetry with typical backpack weight; they concluded that this structural change may be part of the reported back pain. The study was repeated in 2010 with the same outcomes.
In addition, to my knowledge, there are no longitudinal studies to demonstrate whether or not heavy backpacks or improper wearing will affect the development of spinal degenerative changes in adulthood.
Just some thoughts! Good day.-Kathy Foley, OTR/L
Thanks for your comments Kathy - but the issue that I am commenting on is related to incidence, not whether or not various factors can contribute to back pain.

From the perspective of incidence, this matter is rather simple and the data is located in the NEISS database. Injuries from wearing heavy backpacks are a low frequency event, particularly in 5-10 year old children. The data indicates that incidence of injury from wearing heavy backpacks is higher in older children.

Whether or not wearing heavy backpacks can contribute to low frequency events is an interesting topic and it seems that there is little consensus. I refer anyone interested in that topic to Lindstron-Hazel (2009) who completed a nice evidence review on this topic. She concluded that "Up to this point, the scientific community has not been able to create specific global recommendations for children to safely use backpacks due to the conflicting data that is available in the literature." Additionally, based on her extensive literature review, she stated, "Backpacks are essential for people throughout the world to use in many situations, but findings in the literature are inconclusive for avoiding injury." Some of the articles you mentioned are correlational, or they rely on subjective pain and behavioral reports. This is why the evidence review came back as inconclusive.

In any event, my commentary did not intend to wade into that murky territory of whether or not backpacks cause injury, but was restricted to the low frequency that we can specifically measure as reported in the database by CPSC. That seems as solid a source as any with regard to frequency of injury.

I still feel rather strongly that given the low frequency of injury from heavy backpacks that there are other injury prevention matters which might be more deserving of our attention. According to the data, we would help more children by educating them about not leaving their backpacks where others could trip on them.

Thanks for your comments - Chris

Lindstrom-Hazel, D. (2009). The backpack problem is evident but the solution is less obvious. Work, 32(3), 329-338. doi:10.3233/WOR-2009-0831
Anonymous said…
Thank you for the reply. Just want to emphasize, the database you referenced captures hospital visits only-not pediatrician or urgent care visits. Also, pain is subjective but there are standardized measures that are used. -Kathy Foley
That is absolutely correct - the NEISS system only captures ER visits. As such it is less than perfect, but it is the best data that we have. I tried to be explicit in the blog post that this only represents ER data.

There are other patient data reporting systems for ambulatory care visits, such as the National Ambulatory Medical Care Survey https://www.cdc.gov/nchs/ahcd/about_ahcd.htm

I looked at that data set as well as some other CDC data but did not include it in the analysis. That system is much less granular than the NEISS system and has limited utility at this time. As you said, perhaps the specificity of ICD-10 will change some of that.

The AOTA infographic indicates that their CPSC data includes ER, physician offices, and clinics. I would be very interested in the citation for their data because I spent a lot of time trying to replicate their results and could not find any databases that include that information. In fact, I noticed several internal CPSC reports, some dating back nearly 20 years, where there has been Congressional complaint that the NEISS data was not as thorough as some people wanted (as it was ER only). I am unsure where AOTA got CPSC data on physician offices at that granular level. I think they should provide citation for those materials.

Either way, this is all about resource allocation and efficiency of impact from my perspective. I would prefer to see a nationally directed program be pointed at high impact, high frequency, non-debatable topics. In my view the perennial backpack initiative falls short on that set of criteria.
Anonymous said…
Surprise, surprise -- AOTA seems to have taken down that story (link is broken). I am an OT as well, but I have begun to tire of the association's desperation to attach itself to anything that happens to be timely, regardless of whether it is evidence-based. ((Cough-SIT-Cough)).
Thank you for pointing out the fact that they have removed the infographic. I think that it speaks volumes about how the efforts of people seeking good evidence can make a difference. I hope we don't see those statistics used again.
Karen Keptner said…
I am glad that you are so observant of things that aren't based on appropriate evidence. I have problems with the AOTA statement on Acute Care. The second paragraph (first line) states that OT is the only category of services that reduces re'hospitalization. I find it irresponsible of AOTA to make such broad statements based on ones study. They do this all of the time..

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