Department of Physiotherapy, Gleneagles Global Health City, Chennai, Tamil Nadu, India


BACKGROUND: Nowadays, a large number of students experience spinal pain quite early in life due
to heavy school bag loads. Moreover, external forces in the form of school bags may influence the
normal growth, development of children and adolescents, and also maintenance of alignment of their
bodies, which can pose a huge threat to postural integrity under external load. Awareness about the
appropriate load and placement of backpack is thought to be important in reducing musculoskeletal
complications among children’s.
METHODS: A systematic review of randomized controlled trials (RCTs) was conducted to determine
the influence of postural deviations due to backpack load among school children’s. Electronic databases
were searched, and a reference list of retrieved articles were relevant to postural changes among school
children with the backpack were screened. Reviewers graded the papers according to Lloyd‑Smith’s
hierarchy of evidence scale. Papers were quality appraised using a modified Crombie tool.
RESULTS: Twelve papers were identified for inclusion in this review. Methodological difference
limited our ability to collate evidence.
CONCLUSION: Most of the articles recommended that backpack load limit for school children should
be 10–15% of body weight. However, the appropriate load limit for school children is limited due to
lack of articles, the low hierarchy of evidence, and small sample size. This review constrains the use
of published literature to inform good load limit of school pack among the school children.


1. Balamurugan J. School bags and musculoskeletal pain among
elementary school children in Chennai city. Int J Med Sci Clin
Interv 2014;1:302‑9.
2. Janakiraman B, Paulraj A, Nagaraj S, Ramachandran A. Intra rater
and inter rater reliability of sway graph in elderly subjects. Int J
Curr Res Rev 2012;4:106‑11.
3. Dianat I, Javadivala Z, Allahverdipour H. School bag weight and
the occurrence of shoulder, hand/wrist and low back symptoms
among Iranian elementary schoolchildren. Health Promot
Perspect 2011;1:76‑85.
4. Pascoe DD, Pascoe DE, Wang YT, Shim DM, Kim CK. Influence
of carrying book bags on gait cycle and posture of youths.
Ergonomics 1997;40:631‑41.
5. Iyer SR. Musculoskeletal pain in school children. In: Proceedings
of the International Ergonomics Association 2000; Human
Factors Ergonomics Society; Congress, Washington, DC: 2000.
p. 5.419‑5.422.
6. Iyer SR. An ergonomic study of chronic musculoskeletal pain in
schoolchildren. Indian J Pediatr 2001;68:937‑41.
7. Mwaka ES, Munabi IG, Buwembo W, Kukkiriza J, Ochieng J.
Musculoskeletal pain and school bag use: A cross‑sectional study
among Ugandan pupils. BMC Res Notes 2014;7:222.
8. Pereira DS, Castro SS, Bertoncello D, Damião R, Walsh IA.
Relationship of musculoskeletal pain with physical and functional
variables and with postural changes in school children from 6 to
12 years of age. Braz J Phys Ther 2013;17:392‑400.
9. Mayank M, Upender S, Nishat Q. Effect of backpack loading on
cervical and shoulder posture in Indian school children. Indian J
Physiother Occup Ther 2007;1:4‑6
10. Brink Y, Louw Q, Grimmer‑Somers K. The quality of evidence
of psychometric properties of three‑dimensional spinal
posture‑measuring instruments. BMC Musculoskelet Disord
11. Lloyd‑Smith W. Evidence‑based practice and occupational
therapy. Br J Occup Ther 1997;60:474‑8.
12. Crombie IK. The Pocket Guide to Critical Appraisal. London: BMJ
Publishing Group; 1996.
13. Wong AS, Hong Y. Ergonomic analysis on carrying of school bags
by primary school students. Hong Kong J Sports Med Sports Sci
14. Kennedy L, Lawlor F, O’Connor A, Dockrell S, Gormley J. An
investigation of the effects of schoolbag carriage on trunk angle.
Physiother Irel 1999;20:2‑8.
15. HongY, Brueggemann GP. Changes in gait patterns in 10‑year‑old
boys with increasing loads when walking on a treadmill. Gait
Posture 2000;11:254‑9.
16. Chansirinukor W, Wilson D, Grimmer K, Dansie B. Effects of
backpacks on students: Measurement of cervical and shoulder
posture. Aust J Physiother 2001;47:110‑6.
17. Grimmer K, Dansie B, Milanese S, Pirunsan U, Trott P. Adolescent
standing postural response to backpack loads: A randomised
controlled experimental study. BMC Musculoskelet Disord
18. Hong Y, Cheung CK. Gait and posture responses to backpack
load during level walking in children. Gait Posture 2003;17:28‑33.
19. Talbott, Nancy R. The Effect of the Weight, Location and Type
of Backpack on Posture and Postural Stability of Children. PhD
PhD Dissertation, University of Cincinnati; 2005.
20. Devroey C, Jonkers I, de Becker A, Lenaerts G, Spaepen A.
Evaluation of the effect of backpack load and position during
standing and walking using biomechanical, physiological and
subjective measures. Ergonomics 2007;50:728‑42.
21. Brackley HM, Stevenson JM, Selinger JC. Effect of backpack load
placement on posture and spinal curvature in prepubescent
children. Work 2009;32:351‑60.
22. Singh T, Koh M. Effects of backpack load position on
spatiotemporal parameters and trunk forward lean. Gait Posture
23. Chow DH, OuZY, WangXG, Lai A. Short‑term effects of backpack
load placement on spine deformation and repositioning error in
schoolchildren. Ergonomics 2010;53:56‑64.
24. Palumbo N, George B, Johnson A, Cade D. The effects of backpack
load carrying on dynamic balance as measured by limits of
stability. Work 2001;16:123‑9.