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Gait & Posture 28 (2008) 297–302

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The effect of backpack heaviness on trunk-lower extremity muscle

activities and trunk posture
Yusuf S.S.M. Al-Khabbaz a,*, Tomoaki Shimada a, Masashi Hasegawa b
a
Department of Physical Therapy, Faculty of Health Science, Kobe University, 7-10-2 Tomogaoka, Suma-ku, Kobe 654-0142, Japan
b
Department of Occupational Therapy, Kansai Sougou Rehabilitation Colleague, Awaji, Japan
Received 6 March 2007; received in revised form 30 December 2007; accepted 10 January 2008

Abstract

The purpose of the present study is to analyze trunk-lower extremity muscle activities and trunk postural changes during the carriage of
different backpacks. Nineteen male university students (21  3 years) participated in the experiment’s four standing modes: (1) unloaded
standing, (2) 10% body weight (BW) load (in the form of a backpack), (3) 15% BW load and (4) 20% BW load. Bilateral rectus abdominis,
erector spinae, vastus medialis and biceps femoris muscle activities were recorded using surface electromyography (SEMG), while trunk
inclination, side flexion and rotation were measured by using VICON 250 during all standing modes. The results showed that rectus abdominis
muscle activities increased progressively and disproportionably as the backpack load increased. As for the trunk posture, almost the same
backward inclination was adapted even with increasing backpack heaviness. Twenty percent BW backpack causes the most significant
muscular and postural changes so it should be avoided. However, it is recommended to study other backpack factors such as frequency of
usage, usage time, type of the backpack and age to come up with a complete usage recommendation.
# 2008 Elsevier B.V. All rights reserved.

Keywords: Backpack; Trunk posture; Load carriage; Electromyography; VICON

1. Introduction backpack and backpack design). Moreover, Whittfield et al.

Using backpacks is a common task in our life. Different
people carry backpacks for different purposes. Students fill
backpacks with books and stationeries, while hikers load them
with tents and supplies. Various usage of backpacks leads to a
variety in heaviness, and usage periods. Skaggs et al. [1]
reported a significant association between backpack weight
and the occurrence of back pain. Other studies stated that
carrying heavy backpacks may lead to changes in trunk
posture and eventually lower back pain (LBP) [1–4].
Researchers found out that backpacks of 10–15% of body
weight are a justified limit based on epidemiological,
physiological and biomechanical approaches [5]. However,
this percentage is specific to young children only, and lacks
consideration of other factors (distance, period of carrying a
* Corresponding author. Tel.: +81 90 6262 4495/78 795 4431;
fax: +81 78 796 4509.
E-mail address: yousif.sharaf@gmail.com (Y.S.S.M. Al-Khabbaz).
[6] stated that among adolescent students, 35% reported
prevalence of lower back musculoskeletal symptoms, even
though the mean weight of schoolbags was 11.7% (4.3) BW.
In another study, Negrini and Carabalona [7] made a
cross-sectional research on school children and indicated
that backpacks were carried on both shoulders by 94.5% of
participants for 5–15 min (48.2%) or more than 15 min
(37.3%). About 48% of the school children reported life
prevalence of back pain. 65.7% reported that carrying
backpacks causes fatigue and a significant relationship was
found between fatigue and back pain.
Other than children backpack usage researches, most
other studies have focused on specific adult backpackers
(soldiers and hikers). They usually carry much heavier loads
and for longer periods of time [8,9]. Vacheron et al. [10]
recruited 12 hikers to study carrying load effects on
movements imposed on the trunk. The researchers stated
that effective inter-segmental mobility (EISM) between S1–
L3–T12 and between L3–T12–T7 were all significantly

0966-6362/$ – see front matter # 2008 Elsevier B.V. All rights reserved.
doi:10.1016/j.gaitpost.2008.01.002
298 Y.S.S.M. Al-Khabbaz et al. / Gait & Posture 28 (2008) 297–302
different between empty and loaded backpack stances. Goh
et al. [9] compared the change in lumbosacral trunk forces
under different backpack loads in 10 infantry soldiers.
Results showed significant increase in peak lumbosacral
forces as backpack load increases (26.7% and 64% with 15%
and 30% BW backpack loading, respectively).
Although some researchers studied the effect of external
load on the human body, it is a very wide field and requires
more explanations. Steele et al. [11] made a systematic
literature review to emphasize the research evidence
regarding load carriage related postural changes in young
people. They found that only seven papers met their
required level of evidence, concluding that no current
standardized approach is available to study the load-
induced postural changes in young people. Moreover, fewer
papers were found in adult subjects, and – for the
researchers’ knowledge – there are no previous studies to
examine changes in trunk and lower extremities during
loaded standing posture. The present study is the first
research to study changes in trunk-lower extremity muscle
activities and trunk posture during carrying different
backpack loads. The purpose of the present study is to
analyze trunk-lower extremity muscle activities and trunk
postural changes during carrying backpacks. 10%, 15% and
20% body weight (BW) load backpacks were used to
emphasize if muscular and postural measurements differed
from the unloaded standing, and so to recommend suitable
backpack weight limitations. In this study, bilateral rectus
abdominis, erector spinae, vastus medialis, and biceps
femoris muscle activities were recorded by surface
electromyography (SMEG), while biomechanical analysis
was performed to measure trunk inclination, rotation, and
side flexion using a VICON 250. Muscular and postural
changes due to the carrying of a backpack were compared to
those of the unloaded standing position. It was hypothesized
that changes in backpack heaviness would lead to different
muscular and postural reactions.
2. Methodology
2.1. Participants
The experiment approval was obtained from the
university’s board. Nineteen male university students of
age 21 (3 years) participated in this study. All subjects
gave their written consent to participate before starting any
research activity. Two subjects were excluded due to
reporting chronic low back pain (LBP) for more than 6
months which fits the research exclusion criteria. The
exclusion criteria also included recent injury, postural
deformities, spine surgery, history of low back pain and
major surgery during the last 6 months. Except the
excluded subjects, all subjects were healthy with normal
body mass (height: 170  4 cm, weight: 59.7  5 kg, BMI:
20.7  1.17).
2.2. Experiment design
Each subject was asked to stand in four modes: (1)
unloaded standing, (2) 10% BW load, (3) 15% BW load and
(4) 20% BW load. Unloaded standing served as a reference
to compare muscle activity and trunk postural changes
between the three different load modes. The load was
applied in the form of a regular non-framed backpack. The
same backpack was used during all loaded standing modes
for all subjects. The backpack was filled with sand weights
to weigh 10%, 15% or 20% BW of each subject depending
on the loaded standing mode.
During each standing mode, the subjects stood erect with
extended knees and head facing forward. To keep the
subjects focus on facing forward, the subjects were asked to
keep looking at a piece of towel at eye level placed four
meters away. Each subject did all standing modes in one
session (Fig. 1).
2.3. Data collection
Data collection took place over eight trials, two trials per
standing mode. During each trial, trunk-lower extremity
muscle activities were recorded by SEMG, while trunk
postural changes were collected by VICON motion analysis
system. SEMG and VICON data was collected during 5 s
and 30 frames respectively, beginning after 10 s initial
standing mode. All trials were followed by a 1 min rest to
avoid accumulative fatigue.
2.3.1. Surface electromyography (SEMG)
SEMG was utilized to study changes in trunk and lower
extremity muscle activities [12–16]. Bilateral SEMG
activities of erector spinae (trunk extensor), rectus abdo-
Fig. 1. Side view of a subject carrying backpack (VICON reflective markers
are attached).
 Y.S.S.M. Al-Khabbaz et al. / Gait & Posture 28 (2008) 297–302
minis (trunk flexor), vastus medialis (knee extensor) and
biceps femoris (knee flexor) were recorded during all
standing modes.
Rectus abdominis fiber orientation was approximated at
the level of the anterior superior iliac spine, 2 cm lateral to
the midline. Erector spinae muscle sites were determined at
the level of the L4–L5 interspace, 2 cm lateral to the midline
[17]. Eighty percent on the line between the anterior superior
iliac spine and medial knee joint space in front of anterior
border of the medial ligament was the electrode site for the
vastus medialis, while 50% on the line between the ischial
tuberosity at the lateral condyle of the tibia was for the
biceps femoris [18].
Before attaching surface electrodes, electrode sites were
cleaned with alcohol and shaved with disposable shavers.
After that, the skin was abraded by soft sand paper then
again cleaned with alcohol to ensure decreasing skin
impedance to lower than 5 V. Ag/AgCl pre-amplified
disposable surface electrodes (Blue sensor M, Ambu,
Denmark) were used to record EMG data. Blue sensor
EMG electrodes were self adhesive with conductive wet gel,
and had a 13.2 mm2 sensor area.
Data was sampled at 1000 Hz and amplified by an eight-
channel digital EMG system (Noraxon, MyoSystemTM
1400A, USA). Myoresearch XP Master EditionTM was used
to process EMG raw data (rectification, smoothing, ECG
reduction and maximum voluntary contraction (MVC)
normalization). To normalize EMG data, MVC was
performed for all examined muscles [19–21]. MVC records
were taken in two trials. Each trial lasted for 5 s and was
followed by 2 min rest to avoid muscle fatigue. All vocal
commands and encouragements were done by a tape
recorder.
2.3.2. Trunk posture
Changes in trunk inclination, side flexion and rotation
were studied using VICON 250 motion analysis system
(Oxford Metrics Group, Oxford, UK). VICON 250’s five
camera system can localize reflective markers in three
dimensional co-ordinal spaces. VICON Cameras have
300,000 pixel resolution and sample frames at 60 Hz [22–
24]. VICON reflective skin markers are 25 mm in diameter
and placed on certain bony markers externally. Reflective
markers placed on each subject’s sacrum, bilaterally on
acromion process, elbow lateral epicondyle, radius styloid
process, one third on the line between the anterior superior
iliac spine and the femur greater trochanter, knee joint lateral
aspect, calcaneus and forefoot. Diff Gait and Wave Eyes
software programs were used to analyze VICON 250’s
collected raw data.
3. Statistical analysis
All muscle activities (bilateral erector spinae, rectus
abdominis, biceps femoris and vastus medialis) were
299
normalized and expressed as an MVC percentage. On the
other hand, to elucidate changes in trunk posture,
unloaded standing data served as a reference of 08 (the
difference between unloaded standing and it self).
Changes in trunk posture were expressed as the difference
between 10%, 15% and 20% BW load modes and
unloaded standing.
Mean and standard deviation of the eight muscles
recorded activities and trunk postural changes were
calculated for all standing modes. Repeated ANOVA
procedure was used to compare MVC normalized muscle
activities and trunk postural changes during all standing
modes. To identify the main significant effect, a Post-Hoc
Tukey Kramer test was utilized to get the specific
mean differences. Results were considered significant at
P < 0.05.
4. Results
4.1. Surface electromyography
Average electromyography muscles activities are illu-
strated in Fig. 2. Bilateral erector spinae showed no
significant changes in muscle activity. Average right
erector spinae muscle activities were 16.17%, 15.96%,
16.85% and 16.78%, while average left erector spinae
muscle activity were 17.5%, 18.05%, 18.71% and 19%
during unloaded standing, 10%, 15% and 20% BW load
modes respectively. On the other side, bilateral rectus
abdominis showed significant changes between each mode
(P < 0.05). Average right rectus abdominis muscle
activities were 3.1%, 3.98%, 5.37% and 6.84%, while
average left rectus abdominis muscle activities were
2.96%, 3.41%, 4.58% and 5.42% during unloaded
standing, 10%, 15% and 20% BW load modes, respectively
(P < 0.05). It was also revealed that the right rectus
abdominis showed more activity than the left rectus
abdominis during all standing modes.
No significant changes were found during the different
standing modes in vastus medialis and biceps femoris
bilaterally.
4.2. Trunk posture
Changes in trunk posture are demonstrated in Fig. 3.
The positive degree means forward inclination, right side
flexion and right rotation, while negative degree means
backward inclination, left side flexion and left rotation.
Results clarify that with a change in carriage only trunk
inclination showed significant changes (P < 0.05). Trunk
inclined backward 3.378, 3.028 and 3.908 during
10%, 15% and 20% BW load respectively (P < 0.05).
Trunk rotation and side flexion remained almost the
same during load modes and no significant changes were
found.
300 Y.S.S.M. Al-Khabbaz et al. / Gait & Posture 28 (2008) 297–302

Fig. 2. EMG activities of the trunk and lower extremity muscles during the different standing modes.

5. Discussion
5.1. Trunk muscle EMG activities
Rectus abdominis EMG activities increased significantly
with the increase of backpack heaviness. This increase can
be explained bio-mechanically as Goh et al. [9] reported.
According to them, carrying a backpack shifts the centre of
gravity (COG) backward and causes extra extension
moment. As a result, both side’s rectus abdominis will
contract more to counter balance this extra extension
moment which was manifested as an increase in EMG
record during loaded standing modes. It was also noticed
that rectus abdominis EMG activity increase differs as the
heaviness of backpack changes. However, the EMG
increases are not of the same proportion as in the increase
of backpack heaviness. With 10% and 15% BW load, rectus
abdominis EMG had a 35% and 105% increase on the right
side and a 20% and 65% on the left side respectively.
Maximum increases were 157% on the right side and 110%
on left side during carrying 20% BW backpack. It is also
interesting to note that the increase in EMG activity on the
right side was always higher than left side during all load
modes. Similar results were reported by Motmans et al. [17]
who studied trunk EMG activity during carrying various
types of school bags. They reported 54% and 99% increase
on the left and right rectus abdominis respectively during
carrying 15% BW backpack. However, there is no logical
explanation for this unique phenomenon. It is assumed that
both left and right rectus abdominis are not the trunk’s main
stabilizers and not adapted to the new posture. This may lead
to rough imbalance muscle activation between the left and
right side.
Motmans et al. [17] also reported decrease in erector
spinae activities during the carriage of 15% BW backpack.
However, in the current study, erector spinae remained the

Fig. 3. Changes in trunk posture during the different load modes.

 Y.S.S.M. Al-Khabbaz et al. / Gait & Posture 28 (2008) 297–302
same with no significant changes during all standing modes.
The steadiness of erector trunk activation was explained by
O’Sullivan et al. [25] who stated that erector spinae muscles
play a role in the trunk postural stabilizing during standing
posture. The erector spinae were active to stabilize the trunk
from change due to external load effect.
5.2. Lower extremity EMG activities
Both vastus medialis and biceps femoris showed no
significant changes in EMG activities during load modes.
This lack of change suggests that external load (backpack)
has a neglectable effect on lower extremity muscles. It also
explains why in the 77% of musculoskeletal symptoms
prevalence related to wearing schoolbag only 5.7% were in
the knees or lower leg as shown by Whittfield et al. [6]. Most
prevalent symptoms were in the neck (44%), shoulders
(57.9%), upper back (36.7%) and lower back (35%).
5.3. Trunk posture
During load modes (10%, 15% and 20% BW load), the
trunk posture showed significant backward inclination. The
backpack extension moment caused the trunk to change into
backward inclination. In other words, even though the rectus
abdominis activities increased to counter balance the
extension moment, there was still a change in posture. It
was noticed that changes in trunk inclination were not
strongly progressive, and almost the same change was found
with change of backpack load (10% BW = 3.378, 15%
BW = 3.028 and 20% BW = 3.908). This similarity in
backward inclination changes and the progressive increase
in rectus abdominis EMG indicate that the rectus abdominis
counter balance reaction deficit was not because of lack of
muscle power. It seems that the trunk is changing into a new
compensated posture as a reaction to the external load.
About 38 of backward inclination can be considered a small
change but prolonged carriage time might lead to
progressive changes. Hong and Cheung [26] indicated that
postural discomfort and muscular pain maybe caused by
trunk prolonged postural strain.
5.4. Implications
As mentioned in the results, carrying a backpack leads to
changes in trunk posture and muscle activity. These
biomechanical changes may lead to musculoskeletal
symptoms in the trunk area. Therefore, it will be useful
to use this research data to help in producing backpack risk
preventative measures. The heaviness of backpack effect is
one factor, and other factor such as frequency of usage,
usage time, type of the backpack, age and previous/current
musculoskeletal symptoms should be measured too. By
studying all factors influencing the effect of carrying
backpacks on the human body, a valid preventive measure
can be assembled.
301
5.5. Limitations and recommendations
The limitations of this study are the sample size and sex.
It is recommended to apply the same study on bigger
samples, both male and female.
Even though trunk rotation and side flexion showed no
significant changes, different results may appear during
walking. Therefore, it is recommended to study the effect of
carrying a backpack on human gait generally and trunk
specifically. Both trunk and lower extremity muscles need to
be investigated too to have a better understanding of
muscular changes. In another point of view, the current study
was applied on normal subjects. The difference between a
normal subject and a musculoskeletal symptomatic patient’s
reactions to carrying a backpack should be studied.
6. Conclusion
In summary, rectus abdominis muscle activities increased
progressively and disproportionably as the backpack
heaviness increased. No significant changes occurred to
erector spinae, vastus medialis or biceps femoris. As for the
trunk posture, almost the same backward inclination was
adapted even with increasing backpack heaviness. A 20%
BW backpack causes the most significant muscular and
postural changes so it should be avoided. However, it is
recommended to study other backpack factors to come up
with a complete usage recommendation.
Acknowledgments
This study was conducted as a partial fulfillment of the
requirement of the Master of Health Science from Kobe
University Graduate School of Medicine, Japan. The main
Author would like to acknowledge Professor Shigenori
Miyamoto support and guidance, and also Kansai Sougou
Rehabilitation University staffs and students for their great
help and cooperation.
Conflict of interest
None.
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