Smartphone use health outcomes in children and adolescents: A systematic review of behavioral, developmental, and environmental risk pathways

Table 8 Summary of musculoskeletal outcomes associated with smartphone use in children and adolescents (by age and domain)

Ref.	Country	Age group	Study design	Exposure definition	Musculoskeletal domain	Key findings	Statistical association	Primary bias considerations	Overall risk
Mongkonkansai et al[63], 2022	Thailand	Primary school (6-9 years)	Cross-sectional	Continuous use > 60 minutes; posture type	General musculoskeletal pain	53% used phone lying down; prone posture strongly associated with pain	Prone posture OR = 7.37	Strengths: Explicitly analyzed specific postures (prone, sitting, lying) in primary school children. Limitations: Reliance on parental reports for child posture habits	Moderate
Aziz and Bakir[64], 2022	Iraq	Children and adolescents	Cross-sectional	> 3 hours/day use	Neck pain (“text neck”)	69% prevalence of text neck syndrome	Higher disability scores with > 3 hours/day	Strengths: Large clinical sample from primary health centers. Limitations: Diagnosis of “text neck” was based on a combination of self-reported symptoms and duration rather than imaging or clinical exam	Moderate
Yang et al[65], 2017	Taiwan	Adolescents	Cross-sectional	Talking > 3 hours/day	Neck, shoulder, upper back pain	Nearly 50% reported discomfort	Upper back discomfort OR = 4.23	Strengths: Focused on phone-call duration specifically. Limitations: Does not account for posture during calls; potential recall bias in duration estimation	Moderate
Parra-Fernandez et al[66], 2025	Colombia	Adolescents (10-18 years)	Cross-sectional	Mobile phone dependence score	Neck and upper back pain	56.3% reported pain; upper back most common (30.4%)	MPD score significantly higher in pain group (P < 0.001)	Strengths: Robust sample size (n = 622); utilized a validated MPD scale to categorize exposure	Low to moderate
Tokgöz[67], 2023	Turkey	Adolescents	Cross-sectional	Smartphone addiction scale	Postural curvature (head and shoulder)	Moderate correlation between addiction and forward posture	Significant positive correlation (P < 0.05)	Strengths: Utilized objective photogrammetric measurements and ImageJ software to analyze craniofacial symmetry and FHP	Low to moderate
Namwongsa et al[73], 2018	Thailand	Adolescents/young adults	Ergonomic assessment	Observed smartphone posture	Neck and trunk posture risk	80%-90% had RULA grand score = 6 (action level 3)	Neck/trunk posture correlated with neck MSD (P < 0.01)	Strengths: Employed the RULA, a validated objective tool for identifying postural risks in musculoskeletal disorders	Low
Mokhtarinia et al[71], 2022	Iran	University students	Cross-sectional	Addiction; mean use 685 hours/day	Neck, shoulder, wrist, upper back pain	53.3% addiction prevalence; higher pain with addiction	Significant correlation (P < 0.001)	Strengths: Comprehensive assessment across multiple domains (neck, shoulder, wrist, back). Limitations: Potential self-selection bias in university-based survey	Moderate
Al’Saani et al[69], 2023	Saudi Arabia	University students	Cross-sectional	> 4 hours/day; 1-hour continuous use	Upper limb disability (QuickDASH)	Higher disability with longer use and short viewing distance	P < 0.05	Strengths: Used the QuickDASH scale for upper limb disability. Limitations: Online distribution may limit sample representativeness	Moderate
Mersal et al[68], 2024	Egypt	University students	Cross-sectional	> 5 hours/day use	Neck and shoulder pain	38.8% neck pain; 20.3% shoulder pain	Higher prevalence among females (P < 0.001)	Strengths: Specific focus on gender differences in symptom prevalence. Limitations: Convenient sampling of nursing students may limit generalizability to all adolescents	Moderate
Alghadir et al[72], 2025	Saudi Arabia	Young adults	Cross-sectional + biomarkers	≥ 5 hours/day	Neck and hand pain; oxidative stress	Higher pain scores; reduced TIMP-1/2; increased MDA	Significant biochemical differences (P < 0.05)	Strengths: Exceptionally robust due to the inclusion of biochemical markers (MDA, TIMP-1/2) to correlate physical pain with oxidative stress	Low
Czępińska and Wiśniewska[70], 2024	Poland	Young adults	Cross-sectional	Early phone ownership	Chronic neck pain	Earlier ownership associated with neck pain	P < 0.05	Strengths: Investigated the longitudinal impact of “early ownership” on chronic pain. Limitations: Small, specialized sample of physiotherapy students	Moderate

Risk of Bias assessment has been performed using the Joanna Briggs Institute checklist for analytical cross-sectional studies and ergonomic assessments. OR: Odds ratio; RULA: Rapid Upper Limb Assessment; MDA: Malondialdehyde; TIMP-1: Tissue inhibitor of metalloproteinase-1; MSD: Musculoskeletal disorder; MPD: Mobile phone dependence; FHP: Forward head posture.