Prevalence of text neck syndrome among junior college students in Sangli, India: a cross-sectional study

INTRODUCTION

The widespread use of smartphones and electronic gadgets has increased considerably among adolescents and young adults.¹ Globally, mobile phone usage has been reported among 87% of adolescents aged 14-18 years and 79% of children aged 12-15 years.² Prolonged usage of mobile devices with sustained neck flexion can lead to repetitive stress injuries commonly referred to as text neck syndrome (TNS).³ Text neck syndrome is characterized by neck pain, stiffness, muscular imbalance, postural abnormalities, and functional limitations caused by poor ergonomics during smartphone use.⁴ The prevalence of text neck syndrome in India ranges from 25% to around 47%.⁵

The cervical spine is designed to support the head in a neutral posture. However, sustained forward head posture increases the mechanical load on cervical structures, including muscles, ligaments, facet joints, and intervertebral discs.⁶ Chronic exposure to abnormal cervical loading may result in muscular fatigue, degenerative changes, headaches, shoulder pain, and decreased functional capacity.⁷

Students are among the highest users of smartphones because of academic activities, social networking, and recreational use.^8-10 Increasing screen time and poor postural habits may negatively affect musculoskeletal health and quality of life.^11,12 Although several studies have reported the prevalence of TNS among college students, limited evidence is available among junior college students specifically in Sangli, Maharashtra.^13-15 Therefore, this study aimed to determine the prevalence of text neck syndrome and assess its association with neck disability among junior college students.

METHODS

Study design

A cross-sectional observational study was conducted among junior college students aged 16-19 years in Sangli, Maharashtra, India, over a duration of six months from August 2025 to February 2026. Ethical approval was obtained from the Institutional Ethics Committee of Bharati Vidyapeeth Medical College and Hospital, Sangli, Maharashtra, India. Written informed consent was obtained from all participants and their parents or guardians before data collection.

Inclusion criteria

Students who were willing to participate and able to understand and fill the questionnaire in English were included. Both males and females between the ages of 16 and 19 years were considered eligible. Participants were required to have a duration of smartphone use of at least one hour per day and to have been using smartphones, tablets, or laptops for a period of six months or more.

Exclusion criteria

Exclusion criteria included individuals with pre-existing medical conditions known to cause neck and shoulder pain, such as cervical radiculopathies, congenital cervical dysfunctions, and traumatic or pathological cervical problems, as well as those with a history of acute traumatic brain or spinal cord injuries.

Data collection instruments

The Neck Disability Index (NDI) is a validated 10-item self-report questionnaire designed to assess functional disability related to neck pain16. Each item is scored from 0 to 5, yielding a total score of 0–50. Scores are interpreted as follows: 0-4 points = no disability, 5-14 points = mild disability, 15-24 points = moderate disability, 35-50 points = complete disability. Written permission was obtained from the original authors prior to use.

The Text Neck Questionnaire (TNQ) is a validated instrument used to evaluate smartphone usage patterns, posture awareness, and symptoms related to text neck syndrome17. Based on existing literature, a text neck questionnaire was utilized to gather information regarding the duration and pattern of smartphone use, associated symptoms, and factors that alleviate pain. Written permission was obtained from the original authors prior to use.

A structured sociodemographic questionnaire was additionally used to capture participant age, gender, and daily smartphone usage duration.

Sample size and sampling

A total of 260 students were included using convenience sampling. The sample size was calculated using Cochran's formula for prevalence studies:

n = Z²P(1-P)/E²

where; Z=1.96 (at 95% confidence interval), p=0.47 (expected prevalence of 47% from previous literature), and E=0.06 (margin of error of 6%).⁵ This yielded a minimum required sample of 266; and 260 students were rounded for feasibility.

Statistical analysis

Data were entered into Microsoft Excel and analyzed using IBM SPSS Statistics version 26 (IBM Corp., Armonk, New York, United States). Descriptive statistics, including frequencies and percentages, were used to summarize participant characteristics. Chi-square tests were applied to assess associations between categorical variables (TNQ score ranges and NDI categories; neck grade and mobile usage duration). Pearson’s and Spearman’s correlation coefficients were calculated to assess the relationship between gender and scores on the NDI and TNQ. Statistical significance was set at p<0.05. The chi-square test was considered appropriate as all expected cell frequencies exceeded the minimum threshold of 5, and independence of observations was assumed.

RESULTS

A total of 260 junior college students participated in this study. The majority of participants were aged 17 years (196; 75.7%), followed by 16 years (36; 13.9%), 18 years (22; 8.5%), and 19 years (6; 1.9%), indicating that most respondents belonged to the mid-adolescent age group. Among the participants, females constituted 153 (59.1%) and males accounted for 107 (40.9%). Demographic distribution is shown in Table 1.

Based on the NDI, 72 (27.7%) participants had no disability, 80 (30.8%) had mild disability, and 58 (22.3%) had moderate disability, 34 (13.1%) had severe disability and 16 (6.1%) had complete disability. TNQ score distribution showed that 94 (36.2%) had mild symptoms (0-10), 131 (50.4%) had moderate symptoms (11-20), and 35 (13.5%) had severe symptoms (21-40). These distributions are summarized in Table 2.

Based on the Neck Disability Index (NDI), the prevalence of text neck syndrome was determined as the proportion of participants with any degree of neck disability (NDI score ≥5). A total of 188 out of 260 participants (72.3%; 95% CI: 66.6%-77.4%) were classified as TNS positive, indicating the presence of neck disability attributable to smartphone-related postural stress. The remaining 72 participants (27.7%) had no disability (NDI 0-4) and were classified as TNS negative. Among the TNS-positive participants, 80 (42.6%) had mild disability, 58 (30.9%) had moderate disability, 34 (18.1%) had severe disability, and 16 (8.5%) had complete disability. The prevalence distribution is summarized in Table 3 and illustrated in Figure 1.

Correlation analysis between gender and the NDI demonstrated a statistically significant but weak positive correlation (Table 3). Pearson’s coefficient was r=0.189 (p=0.001) and Spearman’s rho was 0.214 (p=0.001), indicating a slight tendency for one gender to report higher neck disability scores. A statistically significant association was also observed between gender and TNQ scores: Pearson’s r=0.245 (p=0.031) and Spearman’s rho = 0.203 (p=0.014), reflecting a weak positive correlation (Table 4).

Cross-tabulation analysis was performed to assess the association between TNQ score ranges and NDI categories (Table 5). Participants with mild TNQ scores (0-10) were predominantly classified under the no disability category (52; 55.3%), whereas those with severe TNQ scores (21-40) showed markedly increased proportions of severe and complete disability (42.9% and 34.3%, respectively). The chi-square test confirmed a statistically significant association between TNQ scores and neck disability (χ²=142.596, p<0.001), indicating that increasing TNQ scores were significantly associated with worsening neck disability. The chi-square test was applied to the overall cross-tabulation; all expected cell frequencies exceeded 5, satisfying the assumption for valid chi-square analysis. The asterisk (*) denotes statistical significance at p<0.05.

*p<0.05 denotes statistical significance; χ² = Pearson chi-square statistic; NDI = Neck Disability Index

*p<0.05 denotes statistical significance; χ² = Pearson chi-square statistic; TNQ =. Text Neck Questionnaire

An association between neck grade severity and duration of mobile phone usage was also observed (Table 6). Participants with mild neck grade predominantly used mobile devices for 0-2 hours daily (90; 95.7%), whereas students with moderate neck grade showed longer usage durations, with 25 (71.4%) using mobile devices for 2-4 hours and 8 (22.9%) using them for 4-6 hours daily. Chi-square analysis demonstrated a statistically significant association between neck grade and mobile usage duration (χ²=122.576, p<0.001), suggesting that prolonged smartphone use was significantly associated with increased severity of text neck symptoms.

DISCUSSION

The prevalence of text neck syndrome among junior college students in the present study was high at 72.3%, with more than half of the participants meeting the TNQ threshold for text neck syndrome. This finding indicates that excessive smartphone usage and poor postural habits are leading to musculoskeletal health concerns among adolescents. Similar findings have been reported in previous studies conducted among medical, university, and physiotherapy students.^13-15,18 A study conducted among medical and dental students at Aljouf University reported that 71.2% of students complained of cervical pain associated with smartphone use.¹³ Another study conducted in India reported that 42.5% of participants had neck disability related to smartphone usage.¹⁴ Likewise, a study among physiotherapy students in India found a prevalence of text neck syndrome of 32%, while a Korean study among university students reported that 34% of participants experienced neck disability.^5,15 These similarities suggest that prolonged smartphone use and sustained forward head posture are common contributors to neck pain and disability across different educational settings.

In the present study, many participants reported mild-to-moderate symptoms associated with neck disability. Similar observations have been reported in previous studies, where most students experiencing neck pain demonstrated only mild disability.^16-18 This may indicate that although symptoms are common among young smartphone users, early-stage musculoskeletal dysfunction predominates and may worsen over time if preventive measures are not implemented. The high prevalence observed in this study may be explained by the increasing dependence on smartphones among junior college students for academic activities, social networking, entertainment, and online learning.^8,9 Adolescents frequently spend prolonged periods looking downward at mobile screens, which increases cervical flexion and biomechanical stress on the cervical spine and surrounding musculature.¹¹ In recent years, increased digital learning and screen exposure have further contributed to prolonged device usage among students.¹

The present study also demonstrated a significant association between TNQ scores and neck disability, suggesting that worsening postural habits and excessive device usage contribute directly to musculoskeletal dysfunction. Similar findings have been reported in previous literature, where increased duration of smartphone use was associated with greater severity and duration of neck pain.¹⁹ Studies have shown that students using smartphones for prolonged durations, particularly more than four hours per day, are more likely to develop neck pain and upper extremity musculoskeletal symptoms.¹⁸ Poor neck posture during smartphone use may also contribute substantially to text neck syndrome. Previous studies have demonstrated that forward head posture and increased cervical flexion are associated with greater neck pain and disability.²⁰ Increased cervical flexion during smartphone use places excessive mechanical stress on cervical muscles, ligaments, and intervertebral structures, thereby increasing the risk of pain and functional impairment.^6,20

The findings of the present study emphasize the importance of early awareness programs, ergonomic education, posture correction strategies, and physiotherapy-based interventions among students. Preventive approaches such as limiting screen time, maintaining proper posture during smartphone use, taking frequent breaks, performing neck stretching and strengthening exercises, and encouraging ergonomic modifications may help reduce the risk of long-term cervical musculoskeletal disorders among adolescents.^21,22

The present study has certain limitations. The study was conducted in a single geographic location, which may limit the generalizability of the findings to other populations. The cross-sectional design prevents establishment of a causal relationship between smartphone use and neck disability. In addition, the use of self-reported questionnaires may introduce recall bias. Furthermore, educational and recreational screen time were not analyzed separately, which may influence the interpretation of smartphone usage patterns and associated symptoms.

CONCLUSION

Text neck syndrome is highly prevalent among junior college students in Sangli, Maharashtra, with more than half of the study participants meeting the validated diagnostic threshold. Prolonged smartphone usage, sustained forward head posture, and poor ergonomic habits were significantly associated with neck pain and functional disability.

These findings highlight the importance of early preventive strategies, awareness programs, ergonomic interventions, and physiotherapy management to reduce the burden of text neck syndrome among adolescents and prevent long-term musculoskeletal complications.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of Bharati Vidyapeeth Medical College and Hospital, Sangli, Maharashtra, India (BD(DU)MC&H/Sangli/IEC/Phy-16/25)

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