Neck Pain

In GBD 2017, as in previous GBDs, causes of mortality and morbidity are structured using a four-level classification hierarchy to produce results that are mutually exclusive and collectively exhaustive. GBD 2017 estimates 359 causes of DALYs, 77 of which are a source of disability but not a cause of death (eg, attention-deficit hyperactivity disorder, headache disorders, low back pain, and neck pain), and five of which are causes of death but not sources of morbidity (sudden infant death syndrome, aortic aneurysm, late maternal deaths, indirect maternal deaths, and maternal deaths aggravated by HIV/AIDS). In the GBD hierarchy, the number of mutually exclusive and collectively exhaustive fatal and non-fatal causes in each level for which GBD estimates is three at Level 1, 22 at Level 2, 169 at Level 3, and 293 at Level 4. The full GBD cause hierarchy, including corresponding International Classification of Diseases (ICD)-9 and ICD-10 codes and detailed cause-specific methods, is in GBD 2017 publications on cause-specific mortality11 and non-fatal health outcomes12 in the corresponding appendices.
GBD 2017 includes 195 countries and territories that are grouped into 21 regions on the basis of epidemiological similarities and geographical proximity.15 (link) For the purposes of statistical analyses, we further grouped regions into seven super-regions (central Europe, eastern Europe, and central Asia; high income; Latin America and Caribbean; north Africa and Middle East; south Asia; southeast Asia, east Asia and Oceania; and sub-Saharan Africa). Each year, GBD includes subnational analyses for a few new countries and continues to provide subnational estimates for countries that were added in previous cycles. Subnational estimation in GBD 2017 includes five new countries (Ethiopia, Iran, New Zealand, Norway, and Russia) and countries previously estimated at subnational levels (GBD 2013: China, Mexico, and the UK [regional level]; GBD 2015: Brazil, India, Japan, Kenya, South Africa, Sweden, and the USA; and GBD 2016: Indonesia and the UK [local government authority level]). All analyses are at the first level of administrative organisation within each country except for New Zealand (by Māori ethnicity), Sweden (by Stockholm and non-Stockholm), and the UK (by local government authorites). All subnational estimates for these countries were incorporated into model development and evaluation as part of GBD 2017. To meet data use requirements, we present all subnational estimates excluding those pending publication (Brazil, India, Japan, Kenya, Mexico, Sweden, the UK, and the USA); these results are presented in appendix tables and figures (appendix 2). Subnational estimates for countries with populations larger than 200 million people (as measured according to our most recent year of published estimates) that have not yet been published elsewhere are presented wherever estimates are illustrated with maps but are not included in data tables.

The following background characteristics were assessed: age, sex, marital status, duration of current pain period, and localization of pain (mainly back pain, neck pain including cervicobrachialgia, widespread pain including fibromyalgia, pain in an extremity including shoulder pain, other).

Launch of the study
In June 2021, an online questionnaire prepared by a team of four medical students, in cooperation with two orthopedic surgeons was released. The questionnaire was distributed to students from several Greek universities through university communication platforms. All participants were informed about the purpose of the study and the security of their anonymity and their personal data, according to the Greek and European legislation before replying. All students were encouraged to answer with honesty and as further motivation for participating and finishing the questionnaire, a home exercise guide that aimed to relieve common symptoms of low back and neck pain was provided after submission of the questionnaire.
One month later, 1,430 responses were received out of the 1,826 distributed questionnaires (response rate 78%). Exclusion criteria were age <18 and >29 and students studying in military schools or the police academy. Blank and partially filled questionnaires were also rejected. A flowchart summarizing the above is available in Figure 1.
Structure of the questionnaire
The questionnaire was divided into four sections. The first section covered demographic and physical characteristics questions including sex, age, weight, and height. The second section included questions regarding students’ habits during online education such as the type of device used, hours of attendance, and the existence or not of an ergonomic position. The third section consisted of questions regarding the participants’ musculoskeletal health, namely the intensity and location of pain prior to, during, or after the lockdown and the possible need for consultation. Finally, the fourth section inquired students about the physical activity before and during quarantine. The questionnaire is available in the Appendix.
Data management and statistical analysis
All data were analyzed using the SPSS statistical package, version 21.0 for Windows (https://www.ibm.com/analytics/spss-statistics-software, IBM Corp., Armonk, NY, USA). Descriptive and inferential statistics were performed. The level of statistical significance was set at 0.05.
The paired-samples t-test was used to assess differences in the visual analog scale (VAS) for pain scores before and during the lockdown. The VAS for pain is considered a valid and reliable method of assessing pain and in fact, it seems to be less influenced by non-pain intensity factors [8 (link)]. The one proportion Z test was used to assess differences in students’ proportions. A Spearman's rank-order correlation was run to assess the relationship between VAS Pain score (during lockdown) and BMI, distance learning time, total screen time, frequency of walking intervals, frequency of ergonomic position, break time, frequency of physical activity before lockdown and during the lockdown. The monotonic relationship was assessed by visual inspection of a scatter plot.
Institutional ethics statement
The research was conducted in accordance with the principles embodied in the Declaration of Helsinki and in accordance with local statutory requirements. All participants were informed about the purpose of the study and gave written informed consent to participate in it.

PhysiotherapistsTwenty-eight physiotherapists working in primary care were invited to participate in the feasibility study. These physiotherapists were also from the authors’ professional network, and were different to those in the first phase. Physiotherapists were eligible to participate if they treated at least four new patients with neck and/or shoulder complaints per month.
PatientsPatients with sufficient mastery of the Dutch language were eligible for participation if they had experience of subacromial pain syndrome, biceps tendinosis, shoulder instability or non-specific MSK pain of the neck and/or shoulder (not caused by acute trauma (fracture or rupture) or by systemic disease) [21 , 22 (link)]. Patients were excluded if their neck and/or shoulder disorder was caused by a specific pathology (e.g. shoulder pain with loss of active and passive range of motion [frozen shoulder], vertebral fracture, tendon rupture, Parkinson’s disease, herniated nucleus pulposus, cervical stenosis), except for subacromial pain syndrome, biceps tendinosis and shoulder instability.