---
title: "Tablet Tilt Angle and Clinically Significant Neck Pain in University Students: Nationwide Cross-Se"
id: "plos-one-20-clinically-significant-neck-pain-and-tablet-tilt-angles-in-real-world"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-20-clinically-significant-neck-pain-and-tablet-tilt-angles-in-real-world"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358968"
published_at: "2026-09-24T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Tablet Tilt Angle and Clinically Significant Neck Pain in University Students: Nationwide Cross-Se
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-20-clinically-significant-neck-pain-and-tablet-tilt-angles-in-real-world
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358968)
- **Published At:** 2026-09-24T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This national cross-sectional survey evaluated associations between **tablet tilt angle** and clinically significant **neck pain** (defined as NRS ≥ 4) in undergraduate students across 17 Thai universities. - 328 responses were collected (95% complete); participants were mainly female, median age 21 years (IQR 20–22), median BMI 21.3 kg/m2. - The period prevalence of tablet-related neck pain (NRS ≥ 4) was 42.17% among respondents. - Univariable analysis identified age, sex, academic year, tablet tilt angle, and posture during tablet use as variables associated with neck pain at p < 0.20. - In multivariable stepwise logistic regression, fourth-year students had lower odds of clinically significant neck pain than first-year students (adjusted OR 0.30, 95% CI 0.14–0.66; P = 0.003). - Compared with a 0° tilt, **tablet tilt angles of 10° (aOR 3.93, 95% CI 1.83–8.46; P < 0.001)** and **60° (aOR 2.94, 95% CI 1.15–7.51; P = 0.024)** were independently associated with increased odds of neck pain. - The final model including academic year and tilt angles had moderate discriminatory ability (AUC = 0.69, 95% CI 0.63–0.75). - The authors interpret a possible U-shaped relationship between tilt angle and neck pain, with both low and high tilt angles increasing cervical mechanical demand. - The study used a validated 22-item self-report questionnaire (content validity IOC 0.88) and applied exclusion criteria to remove spinal/systemic conditions, neurological deficits, pregnancy, regular analgesic use, and regular structured exercise to limit confounding. - Data were collected August 2024–February 2025; analyses were performed in R 4.3.2. The study reports no specific funding and no competing interests.
## Clinical Analysis & Structured Key Points
Clinically significant neck pain and tablet tilt angles in real-world educational settings: A nationwide cross-sectional study of university students | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Introduction Tablet use has been steadily increasing, particularly among students. However, the long-term effects of tablet tilt on neck pain remain underexplored. Purpose This study examined tablet tilt angles and factors associated with neck pain (Numeric Pain Rating Scale; NRS ≥ 4) among university students. Methods A cross-sectional survey was conducted among undergraduate students using a self-administered questionnaire. Results A total of 328 responses were collected from 17 universities, with 95% being complete. Participants were predominantly female, aged 21 (20,22) years old. The prevalence of tablet-related neck pain (NRS ≥ 4) was 42.17%. Fourth-year students had lower risk (aOR = 0.30, 95% CI: 0.14–0.66), whereas 10° and 60° tablet tilt angles increased the risk (aOR = 3.93, 95% CI: 1.83–8.46; aOR = 2.94, 95% CI: 1.15–7.51) with moderate predictive ability (AUC = 0.69, 95% CI: 0.63–0.75). Conclusions Tablet tilt angles of 10° and 60° were associated with increased neck pain. Proper tablet positioning and posture are essential to reduce musculoskeletal strain. Citation: Chuachan S, Thawornrattanachot J, Sen J, Chanpen N, Roynarin N, Kosura N (2026) Clinically significant neck pain and tablet tilt angles in real-world educational settings: A nationwide cross-sectional study of university students. PLoS One 21(9): e0358968. https://doi.org/10.1371/journal.pone.0358968 Editor: Tomoyoshi Komiyama, Tokai University School of Medicine, JAPAN Received: June 1, 2026; Accepted: September 8, 2026; Published: September 24, 2026 Copyright: © 2026 Chuachan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All relevant data are within the paper and its Supporting Information files. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Introduction Neck pain is a leading cause of disability worldwide, affecting approximately 30% of the global population annually and ranking among the top contributors to years lived with disability [ 1 – 3 ]. This condition leads to impairments in daily functioning, mental health, and quality of life [ 4 , 5 ]. The one-year prevalence of neck pain has been reported to be high across various populations, including approximately 45.5% among office workers and up to 54.7% among healthcare professionals [ 6 , 7 ]. Notably, research suggests that neck pain often begins during early adulthood, particularly during the university years, and may persist beyond graduation, leading to recurrent or chronic conditions [ 8 , 9 ]. Among undergraduate students, the prevalence of neck pain remains consistently high across different populations, ranging from 30% to 66% [ 10 – 12 ]. In health science–related student populations, such as nursing and physiotherapy students, the one-year prevalence ranges from 34.6% to 54.8% [ 7 , 10 ]. Longitudinal evidence suggests that early onset of neck pain may worsen over time and persist into working life [ 13 , 14 ]. A three-year follow-up study reported that 21% of nursing students who initially experienced moderate to severe neck pain developed more severe symptoms after entering the workforce [ 14 ], highlighting its potential long-term impact. A recent systematic review further emphasizes that neck pain is a significant and growing concern among college students [ 15 ]. Despite the growing body of evidence, most studies have primarily focused on prevalence and occupational risk factors, while modifiable behavioral factors particularly those related to digital device use and ergonomic behaviors such as device positioning remain insufficiently explored. In recent years, the rapid integration of information technology into daily life has fundamentally reshaped patterns of work and learning [ 16 ]. Among various digital devices, tablets have become increasingly prevalent due to their portability and versatility, particularly in educational and professional settings [ 17 ]. Undergraduate students frequently use tablets for academic activities, including note-taking, reading, online learning, and entertainment [ 16 , 18 ]. The average daily duration of tablet use ranges from 1.2 to 3.4 hours [ 19 ]. The increasing reliance on digital devices, particularly tablets in educational settings, has coincided with a rise in musculoskeletal disorders, especially neck pain. Neck pain is often associated with prolonged use and suboptimal posture [ 12 , 20 ]. This association may be explained by sustained neck flexion and altered upper limb positioning during device use. Previous studies have reported that approximately 40–50% of individuals using smartphones, computers, or tablets experience neck and shoulder pain [ 21 – 24 ], highlighting the importance of ergonomic factors, particularly device positioning and viewing angles. To date, few studies have specifically examined the role of tablet tilt angle in real-world educational use. Neck pain in tablet users is strongly associated with poor posture, frequent use, and prolonged screen exposure [ 25 ]. Evidence suggests that prolonged digital device use is associated with altered cervical posture and impaired proprioception, both of which contribute to the development of neck pain [ 26 ]. One important ergonomic factor is tablet tilt angle, as tablets allow flexible positioning, typically ranging from 0° to 60° using case-supported configurations [ 19 , 27 , 28 ]. Variations in tablet tilt angle are associated with differences in neck posture, muscle activation, and perceived discomfort [ 19 , 29 ]. Experimental studies have shown that discomfort develops after 20 minutes of tablet use in a flat position (0°), whereas a moderate tilt (e.g., 30°) may delay the onset of discomfort [ 27 ]. Greater tilt angles (e.g., 45°–63°) have been associated with reduced neck flexion [ 19 , 28 ]. Differences in tablet angles have also been linked to variations in cervical flexion and muscle activity [ 19 , 29 – 31 ]. Biomechanically, increased neck flexion can elevate the load on cervical extensor muscles by up to two to three times, contributing to the development of neck pain [ 32 , 33 ]. Tablet tilt angle is associated with changes in cervical flexion, which may alter the mechanical load on the cervical spine. These biomechanical effects are strongly influenced by device positioning. Despite these findings, studies investigating the long-term impact of tablet tilt angle and usage behaviours on neck pain during daily use particularly in educational settings among university students remain limited. Therefore, this study aimed to examine the association between tablet tilt angle and neck pain among undergraduate students in educational settings and to identify modifiable behavioral and demographic factors contributing to this condition. Understanding these factors may inform ergonomic guidelines and preventive strategies for reducing neck pain in student populations. Methods Study design This study employed a cross-sectional design utilizing a national self-reported survey conducted among undergraduate students across 17 universities in Thailand between August 2024 and February 2025. Participants The sample size was determined based on a 70% prevalence of neck pain associated with tablet use, as reported by Elsiddig et al. (2022) [ 34 ]. Using the n4Studies Plus program, considering a total population of 3,800 students enrolled in the same program across different universities, a 95% confidence level (Z = 1.96), a 5% margin of error (d = 0.05), and a 10% non-response rate, the final required sample size was calculated to be 328 participants. The study received approval from the Human Research Ethics Committee (REC: 67-289-30-2), Faculty of Medicine Review Board, and was conducted in accordance with the Declaration of Helsinki. Participants were recruited using a convenience sampling method from 17 universities with Faculties of Allied Health Sciences located across four regions of Thailand. Participants were eligible if they were young adults aged 18–25 years, had at least one year of experience using a tablet for educational purposes, such as note-taking or online searching, had normal or corrected-to-normal vision, and reported regular tablet use of at least 2 hours per day on at least 5 days per week [ 11 , 27 ]. Participants were excluded if they had a history of trauma or accidents involving the spinal region; had undergone spinal surgery; or had been diagnosed with spinal or systemic conditions, including congenital spinal anomalies, rheumatoid arthritis, spinal or disc infections, ankylosing spondylitis, spondylolisthesis, spondylosis, spinal tumors, systemic lupus erythematosus, or osteoporosis. Individuals presenting with neurological deficits (e.g., muscle weakness or sensory disturbances), those who were pregnant, and those who reported regular use of medications for musculoskeletal conditions (e.g., analgesics or muscle relaxants) were also excluded. In addition, participants who engaged in regular structured exercise (≥3 sessions per week, ≥ 30 minutes per session) were excluded to minimize potential confounding effects on musculoskeletal outcomes. Questionnaire A self-reported questionnaire comprising 22 items was employed for data collection. It was divided into three sections: Section 1 gathered general demographic information (sex, age, weight, height, dominant arm, academic year, and university [ 11 ]. Section 2 assessed tablet usage patterns, including device brand, model, duration of use, purpose of use, sitting posture, and tablet tilt angle [ 27 ]. Section 3 evaluated neck pain symptoms associated with tablet use. The screening question was based on the standardized Nordic Musculoskeletal Questionnaire and used the term “neck discomfort” to capture a broad range of symptoms, including muscular tension, stiffness, fatigue, soreness, and pain [ 35 , 36 ]. Participants were asked a yes/no question: “Have you experienced any neck discomfort lasting more than 24 hours during the past month?” Participants who responded “Yes” were further assessed for pain intensity using a 11-point numeric rating scale (NRS) [ 37 ] and for the presence of neurological symptoms (i.e., weakness or numbness in the upper limbs). Participants who responded “No” were assigned an NRS score of 0. For the purpose of this study, participants reporting neck discomfort in the screening question were considered to have neck pain when they subsequently reported pain symptoms, and “neck pain” was used consistently as the defined study outcome in the analyses. In addition, participants who reported neck pain were further asked to identify the perceived causes of their symptoms (e.g., sports, hobbies, housework, tablet use, or other causes). Neck pain was considered tablet-related if participants perceived their symptoms to be primarily attributable to tablet use. The questionnaire was originally developed in the native language of the participants (Thai) and underwent expert review by five specialists in health sciences and research methodology to assess content validity, item relevance, and alignment with the study objectives. Based on their feedback, necessary revisions were implemented. Content validity was further determined using the Index of Item-Objective Congruence, yielding a score of 0.88, which indicated a strong alignment between the questionnaire items and the study objectives. The reliability of the questionnaire was assessed using Cronbach’s alpha. Data collection This invitation and online questionnaire link were distributed to staff and students enrolled in allied health science programs across 17 academic institutions, along with a formal request for institutional cooperation. The questionnaire was administered via Google Forms, with the link included in the invitation letter, ensuring anonymity and exclusion of personally identifiable information. Participants were informed that they could decline the survey at any time. Incomplete responses were excluded from the data analysis. Data analysis Neck pain severity was assessed using the Numeric Rating Scale (NRS). For analytical purposes, NRS scores were dichotomized. Participants were classified as having neck pain (cases group) if they met both of the following criteria: (1) reported neck discomfort lasting more than 24 hours during the past month, and (2) reported a pain intensity ≥ 4 of the NRS [ 38 ]. Participants who did not meet these criteria, including those with NRS scores of 0–3, were classified as the reference group and coded as 0. This binary variable was used as the dependent variable in subsequent analyses. Neck pain was defined as symptoms occurring during the past month, consistent with the definition of period prevalence. Statistical analysis Descriptive statistics were used to summarize demographic characteristics and tablet usage data. Categorical variables were presented as frequencies and percentages; continuous variables were reported as means and standard deviations (mean ± SD) or median and IQR. Pearson’s chi-square test and the Mann–Whitney U test were performed to examine the associations between tablet-related neck pain, with p < 0.20 used to evaluate the significance of associations between variables. Stepwise multiple logistic regression, with variable selection based on the Akaike information criterion (AIC) was used to analyse relationships between variables in the regression model. The strength of associations was presented as odds ratios (OR) with 95% confidence intervals. Statistical significance was set at p < 0.05. All analyses were conducted using R Software (version 4.3.2). Results A total of 328 responses were collected from 17 universities across 4 regions: central (41.9%), north (20.8%), northeast (12.1%), and south (25.2%). Fifteen participants met the exclusion criteria. Participants were predominantly female, with a median age of 21 years (IQR: 20–22) and a median BMI of 21.3 kg/m2. ( Table 1 ) Download: PNG larger image TIFF original image Table 1. General demographic characteristics of participants. https://doi.org/10.1371/journal.pone.0358968.t001 The prevalence of tablet-related neck pain (NRS ≥ 4) was 42.17%. Univariable analysis indicated that age, sex, academic year, tablet tilt angle, and posture during tablet use were significantly associated with neck pain (p < 0.2). Other factors, including height, BMI, and time spent using the device per day, showed no significant association. ( Table 2 ) Download: PNG larger image TIFF original image Table 2. Bivariate and multivariable stepwise regression analysis of factors associated with neck pain (NRS ≥ 4) among undergraduate students. https://doi.org/10.1371/journal.pone.0358968.t002 Stepwise multiple logistic regression, fourth-year students had significantly lower odds of neck pain than first-year students (aOR = 0.30, 95% CI: 0.14–0.66; P = 0.003). Compared with a tablet tilt angle of 0°, tilt angles of 10° and 60° were independently associated with increased odds of neck pain (aOR = 3.93, 95% CI: 1.83–8.46; P < 0.001 and aOR = 2.94, 95% CI: 1.15–7.51; P = 0.024, respectively). ( Table 2 ) For these three factors, the area under the curve (AUC) was 0.69 (95%CI: 0.63–0.75) for predicting neck pain among undergraduate students, indicating a moderate discriminatory ability of the model. Discussions This study investigated the factors associated with developing neck pain due to long-term tablet use behaviour among young adults, particularly undergraduate students who frequently use tablets for various purposes. Academic year, tablet tilt angle, and posture were significantly associated with neck pain among these students. The prevalence of neck pain The prevalence of neck pain (NRS ≥ 4) observed in this study (42%) was slightly lower than that reported in previous studies among undergraduate populations (45–55% over the past 12 months) [ 10 , 11 ]. This discrepancy may be attributable to differences in case definition and recall period. While earlier studies employed binary measures that classify pain as present or absent without capturing severity, thereby including mild or transient symptoms, this may have led to higher prevalence estimates. The present study applied a stricter threshold (NRS ≥ 4), reflecting moderate pain intensity based on established classifications [ 39 , 40 ]. Pain at this level is more likely to be clinically meaningful and associated with functional impairment [ 41 ]. This approach provides a more conservative and clinically relevant estimate, better reflecting clinically significant neck pain burden, although it may underestimate the prevalence of milder symptoms. Educational level and neck pain Higher educational level emerged as a protective factor against neck pain in this study, particularly among fourth-year students (aOR = 0.30, 95% CI: 0.14–0.66). In contrast, previous studies, including Kanchanomai et al. (2012) [ 42 ], reported an increased risk of neck pain with higher academic level (aOR = 1.62, 95% CI: 1.01–2.58), and a recent systematic review and meta-analysis by Gao et al. (2023) [ 15 ] also demonstrated a significant positive association (aOR = 2.86, 95% CI: 2.07–3.95). This discrepancy may be explained by differences in study context and exposure patterns. While prior studies primarily focused on prolonged computer use in sedentary settings, students in higher academic years in the present study, particularly those undergoing clinical training, tend to engage in more practical and patient-based activities. These activities reduce continuous tablet use, increase postural variation, and decrease sustained cervical loading, thereby lowering the risk of neck pain, consistent with ergonomic and musculoskeletal evidence [ 35 , 43 , 44 ]. However, residual confounding and the cross-sectional design should be considered when interpreting these findings. Tablet tilt angle and neck pain The present study demonstrated that tablet tilt angle is a critical ergonomic determinant of neck pain, with both 10° and 60° positions significantly increasing the risk even after adjustment for confounders. These findings suggest a non-linear (U-shaped) relationship between device positioning and neck pain. Neck pain is a strong predictor of future musculoskeletal disorders (MSDs) [ 45 ], indicating that both excessively low and high tilt angles may be associated with unfavorable biomechanical demands on the cervical spine, which may contribute to neck pain [ 30 , 35 , 46 ]. Interventional evidence suggests that improving global postural alignment through targeted interventions can significantly reduce pain and disability in individuals with nonspecific neck pain [ 47 ]. A tilt angle of 10° was associated with the highest odds of neck pain (aOR = 3.93). Rungkitlertsakul et al. (2023) investigated 20 participants performing continuous writing tasks for 40 minutes and reported that a 0° tilt angle resulted in significantly greater neck pain and higher cervical flexion compared to a 30° tilt angle. Lower tilt angles are more likely to be associated with increased neck flexion to maintain visual focus, thereby increasing gravitational loading on the cervical spine [ 48 , 49 ]. Previous biomechanical studies have demonstrated that neck flexion substantially increas
## Related Clinical Research

- [Severity-based surgical algorithm for refractory Mooren’s ulcer preserves globe integrity](https://medichelpline.com/clinical-feed/plos-one-12-evaluation-of-a-severity-based-surgical-strategy-for-refractory-mooren-s-ulcer.md)
- [Moderate-to-severe chronic spontaneous urticaria linked to higher risk of rheumatoid arthritis and](https://medichelpline.com/clinical-feed/plos-one-9-moderate-to-severe-chronic-spontaneous-urticaria-is-associated-with-increased.md)
- [Synovial inflammation, immune–stromal crosstalk and synovial fibroblast research in osteoarthritis](https://medichelpline.com/clinical-feed/frontiers-in-immunology-15-synovial-inflammation-and-immune-stromal-crosstalk-in-osteoarthritis-related.md)
- [Distinct synovial fluid B-cell activation and differentiation profiles in rheumatoid arthritis](https://medichelpline.com/clinical-feed/biorxiv-2-distinct-synovial-fluid-b-cell-differentiation-and-activation-profiles-in.md)
- [Emergency diagnosis frequency and outcomes across 13 non-cancer conditions in England: analysis of](https://medichelpline.com/clinical-feed/plos-medicine-2-frequency-and-prognostic-outcomes-of-emergency-diagnosis-in-13-non-neoplastic.md)

## Navigation
- [← Back to General Feed](https://medichelpline.com/clinical-feed/general.md)
- [← All Clinical Specialties](https://medichelpline.com/clinical-feed.md)
## Medical & Regulatory Disclaimer

> [!CAUTION]
> MedicHelpline content is structured for research, educational, and professional discovery purposes. It does not constitute individual medical advice, clinical diagnosis, or treatment recommendations.
> Always verify dosing, contraindications, and regulatory alerts against official product labeling and primary regulatory sources before clinical decision-making.