- Systematic Review
- Published:
The associations between sedentary behavior and neck pain: a systematic review and meta-analysis
樱花视频 volume听25, Article听number:听453 (2025)
Abstract
Background
This study aimed to systematically evaluate the associations between sedentary behavior (SB) in daily life and the risk of neck pain (NP), and to investigate the dose-response relationships between these variables across different populations, including variations in age, sex, occupation, and lifestyle practices.
Methods
We conducted a systematic literature search of PubMed, Web of Science, Scopus, and Embase for cross-sectional, cohort and case-control studies examining the association between SB and NP risk. The National Institute of Health (NIH) quality assessment tool was utilized to evaluate study quality. Odds ratios (ORs) and relative risks (RRs) with 95% confidence intervals (CIs) were used to assess the association between SB and NP. Due to significant heterogeneity among the studies, a random-effects model was employed for the meta-analysis to obtain pooled estimates.
Results
A total of 25 studies with 43,184 participants met the eligibility criteria. Overall, the meta-analysis revealed a significant relationship between SB and NP (OR鈥=鈥1.46, 95%CI: 1.33, 1.60). Subgroup analyses revealed that the risk of NP was greater in female (OR鈥=鈥1.43, 95%CI: 1.22, 1.67) than in male (OR鈥=鈥1.13, 95%CI: 1.01, 1.27) and was greater in employees (OR鈥=鈥1.97, 95%CI: 1.70, 2.28) than in students (OR鈥=鈥1.26, 95%CI: 1.15, 1.39). Among screen-based SB, using mobile phones conferred the greatest risk of NP (OR鈥=鈥1.82, 95%CI: 1.27, 2.61), followed by using computers (OR鈥=鈥1.23, 95%CI: 1.08, 1.40), whereas watching TV was not a significant risk (OR鈥=鈥1.20, 95%CI: 0.99, 1.44). Moreover, SB鈥夆墺鈥4听h per day (h/d) increased the risk of NP (OR鈥=鈥1.60, 95%CI: 1.38, 1.87), and the risk further increased with SB鈥夆墺鈥6听h/d (OR鈥=鈥1.88, 95%CI: 1.42, 2.48). The risk of NP increased with a screen-based SB dose鈥夆墺鈥1听h/d (OR鈥=鈥1.28, 95%CI: 1.17, 1.44), 鈮モ2听h/d (OR鈥=鈥1.35, 95%CI: 1.18, 1.55), and 鈮モ4听h/d (OR鈥=鈥1.45, 95%CI: 1.26, 1.67).
Conclusion
SB is a notable risk factor for NP, with the risk escalating with longer durations of sedentary time. Targeted preventative measures, particularly for high-risk groups like female and employees, are necessary. Public health initiatives should encourage the reduction of sedentary behaviors and the promotion of physical activity to enhance neck health and alleviate the global prevalence of NP.
Background
Neck pain (NP), characterized by discomfort in the neck area, is among the most prevalent musculoskeletal disorders (MSDs). Approximately 70% of people globally experience NP at least once during their lifetime [1]. The risk of NP is increasing annually, fuelled by the rapid pace of modern society and changes in lifestyles and work habits. A report in the Lancet highlighted a significant increase of 21.9% in the years lived with disability (YLD) due to NP from 2006 to 2016 [2]. NP not only impacts the physical function, quality of life, and work efficiency of individuals but also contributes to considerable direct medical and indirect social costs. For instance, in the United States, the annual expenditure on neck and back pain is an astounding $87.6听billion, ranking behind diabetes and heart disease in terms of healthcare costs [3].
Sedentary behavior (SB), defined as activities involving low energy expenditure (鈮も1.5 METs) while seated during waking hours [4], has notably increased following lifestyle changes and the shift to online working methods since the COVID-19 pandemic in December 2019. The growing prevalence of SB has raised concerns about the associated risks of noncommunicable diseases, including cardiovascular and cerebrovascular diseases and MSDs. The annual increase in NP cases, particularly among younger populations [5], is closely linked to a significant increase in daily SB [6]. Research indicates that SB can cause various physiological changes, such as increased intervertebral disc pressure [7], reduced neck blood flow [8], imbalance in neck muscle strength [9], and diminished neck joint mobility [10], leading to the development of the NP. Despite previous studies establishing the SB as a strong predictor for NP, controversial findings remain in this area [11, 12].
The widespread adoption of electronic devices, such as televisions, mobile phones, and computers, driven by advancements in modern science and technology, has drastically changed contemporary lifestyles. The design of office furniture has also undergone significant innovations. However, the influence of these changes on the relationship between SB and NP remains unclear. To consolidate existing research and settle ongoing debates, our study meticulously explored the nexus between various types of SB and NP. Furthermore, we assessed the dose鈥抮esponse relationships between these variables in diverse populations, taking into account varying age, sex, occupation, and lifestyle practices.
Methods
Following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review and meta-analysis on the relationship between SB and NP, which has been registered on the PROSPERO (PROSPERO CRD42023476732).
Search strategy
In this study, we searched the PubMed, Web of Science, Embase, and Scopus databases. Two reviewers (YCM, YQX) independently conducted searches across all four databases, with the search timeframe spanning from the inception of the databases to October 10, 2023. The search keywords encompassed a range of terms related to NP and SB. For NP, the keywords included neck pain, neck ache, cervical pain, cervicalgia, cervicodynia, cervical spondylosis, cervical spondylopathy, and cervical spondylotic. For SB, the keywords were sedentary, sitting time, prolonged sitting, stationary, seated, and motionless.
Outcome and exposure
NP was defined as the outcome measure. The assessment of NP varied among studies, with some employing self-reported questionnaires (such as the Nordic musculoskeletal questionnaire or musculoskeletal disorders questionnaire), while others utilized medical diagnoses. The timeframe for measuring pain also exhibited diversity, spanning from the past week to one year.
SB was established as the exposure factor, which included any seated activity during waking hours that involved low energy expenditure (鈮も1.5 METs). This encompassed both general SB (e.g., sitting during work or leisure activities) and screen-based SB (e.g., using mobile phones, computers, or watching TV). The duration and frequency of SB were recorded and analyzed based on self-reported data furnished by the participants in each study.
Selection criteria
The inclusion criteria were as follows: (1) Peer-reviewed original articles published in English-language scholarly journals. (2) Empirical studies focusing on SB and NP, where NP is the outcome measure and SB is the exposure factor. (3) Studies including cross-sectional, cohort and case-control designs. (4) Included studies must provide effect size values of odds ratios (ORs) or relative risks (RRs) along with their 95% confidence intervals (CIs) for the relationship between SB and NP.
The exclusion criteria were as follows: (1) Unpublished documents, theses, conference abstracts, reviews, literature reviews, books, and case reports. (2) Studies involving special populations, such as professional athletes or individuals with disabilities. (3) Research involving participants with other chronic diseases, such as cardiovascular diseases, diabetes, chronic respiratory diseases, and other conditions that may interfere with the relationship between SB and NP. (4) Literature that does not provide valid data or sufficient information for analysis.
Study selection
Two researchers (YCM, YQX) independently screened titles, abstracts, and full texts using EndNote 20.0 (Clarivate Analytics, Pennsylvania, USA) and Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA) to identify studies that satisfied the inclusion criteria. In cases of disagreement, a third researcher (FW) was involved to make the final judgement.
Data extraction
After the papers were independently selected, the following information was extracted from each eligible study: the first author鈥檚 name, publication date, geographical region, sample size, sample characteristics (including sex, age, and occupation), exposure factors (types and duration of SB), outcome measures (NP within one year or less), measurement tools, and study results.
Quality assessment
The quality of the included studies was rigorously evaluated by two independent reviewers (YCM, YQX) using two distinct quality assessment tools provided by the National Institutes of Health (NIH) (available at ). For observational cohort and cross-sectional studies, the reviewers applied the 鈥淨uality Assessment Tool for Observational Cohort and Cross-Sectional Studies,鈥 which includes 14 questions designed to assess various aspects of the research. These aspects include the clarity of research aims, specification of the study population, participation rates, consistency in participant selection, justification of sample size, temporal sequence of exposure and outcome, validity of exposure measurement, control for confounding variables, completeness of follow-up (for cohort studies), comparability of exposed and unexposed groups (for cohort studies or comparison groups in cross-sectional studies), outcome assessment, handling of missing data, result reporting, and the appropriateness of statistical methods, among others. For case-control studies, the 鈥淨uality Assessment of Case-Control Studies鈥 tool, consisting of 12 targeted questions, was employed. This tool focuses on key areas such as the clarity of research questions, definition of study populations, justification of sample size, selection of controls (including whether they are appropriately matched), case definition, random selection of participants (when applicable), use of concurrent controls, temporal relationship of exposure (ensuring that exposure preceded the outcome), validity of exposure assessment, blinding of evaluators (if applicable), adjustment for confounding, and the application of appropriate statistical analysis methods. Following these evaluations, the studies were categorized into three quality levels: good, fair, or poor. In cases of disagreement between reviewers, a third reviewer (FW) was consulted to resolve the discrepancies.
Data analysis
Stata 15.0 software was used for the statistical analysis in this study. The OR/RR and their corresponding 95% CIs were calculated, with significance determined by the Z test. Heterogeneity among the included studies was analysed using the Q test and I2 statistic. Significant heterogeneity was indicated by P鈥<鈥0.05 and I2鈥>鈥50%, for which case a random-effects model was utilized; otherwise, a fixed-effects model was applied [13]. Sensitivity analysis was also conducted to test the stability of the results. Subgroup analyses based on factors such as sex, occupation, type of SB, and duration of SB were used to investigate the impact of the study characteristics on the outcome variables and to identify sources of heterogeneity. Egger鈥檚 test was used to assess publication bias. If publication bias was present, then a nonparametric trim-and-fill method was used to adjust the effect size.
Results
Literature search
After searching the PubMed, Web of Science, Scopus, and Embase databases, 2492 records were identified, and duplicate publications were removed. After screening the titles, abstracts, and full texts, 25 studies were found to satisfy the inclusion criteria and were included in the meta-analysis. The PRISMA flow diagram illustrating this selection process is presented in Fig.听1.
Study characteristics
The 25 studies included in our research comprised 22 cross-sectional studies, two cohort studies and one case-control study, with a total sample size of 43,184 participants, 41.4% of whom were female. The research spanned 13 countries, including Belgium, Brazil, China, Ethiopia, Finland, India, Iran, Malaysia, Netherlands, Portugal, South Africa, Sweden and the Tunisia. Sixteen of these studies focused on general SB, whereas nine studies specifically examined screen-based SB, which included the use of mobile phones, televisions and computers. All the data regarding SB in these studies were obtained through self-reports. The participants in 10 of the studies were students and working professionals in 15 studies. Detailed information on all the included studies can be found in Table听1.
Quality appraisal
The NIH quality assessment tool was employed to evaluate the literature. Among the 24 studies included in the systematic review, which comprised 2 cohort studies and 22 cross-sectional studies, 18 were rated as good quality, 6 were rated as fair quality, and 1 case-control study was also rated as good quality. The methodological quality of the included studies is summarized in Supplementary Table S2, which provides detailed scores for each dimension of assessment. The main reasons for the fair quality rating of some cross-sectional studies were inadequate participation rates (below 50%), lack of sample size justification or power analysis, issues with the timing of exposure and outcome measurements, insufficient timeframes to establish associations, and a lack of blinding of outcome assessors to participants鈥 exposure status.
Associations of SB with NP
The 25 studies included in this research used NP occurrence as the outcome measure and reported the relationship between SB and the risk of NP. Figure听2 displays the results of the meta-analysis. High heterogeneity was found among the included studies (I2鈥=鈥78.7%, P鈥<鈥0.001), leading to the use of a random-effects model for the combined results. The meta-analysis revealed a significant association between SB and NP (OR鈥=鈥1.46, [1.33, 1.60], P鈥&濒迟;鈥0.001).
Publication bias among the 25 included studies was assessed using Egger鈥檚 test. A funnel plot was constructed with the log OR values of each study plotted against their standard error (Fig.听3). The distribution of studies largely exhibited a funnel shape, and Egger鈥檚 test revealed no significant publication bias (t鈥=鈥1.56, P鈥=鈥0.125).
Subgroup analysis
In this study, subgroup analyses were conducted based on various factors, including SB type, sex, occupation, type of screen-based SB, dose of SB, and dose of screen-based SB. The results of these subgroup analyses are presented in Table听2.
SB type
In the subgroup analysis for general SB, considerable heterogeneity was found (16 studies, n鈥=鈥34647, I2鈥=鈥75.6%). The pooled ORs determined by a random effects model indicated a significant association between general SB and NP (OR鈥=鈥1.77, [1.53, 2.05], P鈥&濒迟;鈥0.001). A pooled analysis of 11 studies (n鈥=鈥15423, I2鈥=鈥76.9%) assessing screen-based SB as a predictor for NP also revealed a significant association (OR鈥=鈥1.27 [1.14, 1.42], P鈥&濒迟;鈥0.001).
Sex
In the male subgroup, relatively low heterogeneity was observed (four studies, n鈥=鈥4213, I2鈥=鈥42.7%). The odds of NP were marginally significantly associated with SB (OR鈥=鈥1.13 [1.01, 1.27], P鈥<鈥0.05). In contrast, the results for the female subgroup (six studies, n鈥=鈥6337, I2鈥=鈥81.4%) were significant (OR鈥=鈥1.43 [1.22, 1.67], P鈥&濒迟;鈥0.001).
Occupation
The occupation-based subgroup analysis of the 25 studies categorized the study populations into student (10 studies, n鈥=鈥15295, I2鈥=鈥73.8%) and employee groups (15 studies, n鈥=鈥27889, I2鈥=鈥58.6%). Both the student (OR鈥=鈥1.26, [1.15, 1.39], P鈥<鈥0.001) and employee (OR鈥=鈥1.97, [1.70, 2.28], P鈥<鈥0.001) groups were shown to have an increased risk of NP. These results indicate that SB is a risk factor for NP in students and employees and that the risk of NP due to SB is greater in employees than in students.
Screen-based SB type
Screen-based SB was divided into three subgroups: watching TV (four studies, n鈥=鈥9349, I2鈥=鈥65.0%), using mobile phones (two studies, n鈥=鈥1273, I2鈥=鈥0.0%), and using computers (nine studies, n鈥=鈥14627, I2鈥=鈥84.8%). Subgroup analyses according to screen-based SB type yielded interesting results, as for watching TV, the odds of NP were marginally nonsignificantly associated with watching TV (OR鈥=鈥1.20, [0.99, 1.44], P鈥>鈥0.05). The results for using mobile phones (OR鈥=鈥1.82, [1.27, 2.61], P鈥<鈥0.001) and using computers were significant (OR鈥=鈥1.23, [1.08, 1.40], P鈥&濒迟;鈥0.01).
General SB dose
Based on the duration of SB, the studies were divided into two groups: those engaging in SB for 鈮モ4听h per day (h/d) (10 studies, n鈥=鈥13496, I2鈥=鈥63.8%) and those engaging in SB for 鈮モ6听h/d (five studies, n鈥=鈥9902, I2鈥=鈥66.5%). Subgroup analyses indicated that an SB dose of 鈮モ4听h/d significantly increased the risk of NP (OR鈥=鈥1.60, [1.38, 1.87], P鈥&濒迟;鈥0.001). When the SB dose increased to 6听h/d, the risk of NP increased further (OR鈥=鈥1.88, [1.42, 2.48], P鈥&濒迟;鈥0.001).
Screen-based SB dose
The studies were categorized into three groups based on the duration of screen-based SB: 鈮1听h/d (10 studies, n鈥=鈥13496, I2鈥=鈥63.8%), 鈮モ2听h/d (seven studies, n鈥=鈥10968, I2鈥=鈥70.7%), and 鈮モ4听h/d (five studies, n鈥=鈥9062, I2鈥=鈥0.00%). In the 鈮モ1听h/d group, a significant association was observed between SB and NP risk (OR鈥=鈥1.28, [1.17, 1.44], P鈥&濒迟;鈥0.001). As the dose increased, the risk of NP increased in the 鈮モ2听h/d group (OR鈥=鈥1.35, [1.18, 1.55], P鈥<鈥0.001) and the 鈮モ4听h/d group (OR鈥=鈥1.45, [1.26, 1.67], P鈥&濒迟;鈥0.001).
Discussion
This study utilized a meta-analysis, systematically and quantitatively amalgamated and evaluated the results of multiple independent studies on the risk of NP associated with various types of SB across different populations. This study provides significant evidence that SB is an important risk factor for NP. The meta-subgroup analysis further scrutinized the impact of different types and doses of SB on the risk of NP occurrence in diverse groups, yielding the following findings: (1) Various forms of SB (general SB, using mobile phones, and using computers) are risk factors for NP. (2) SB escalates the risk of NP across all demographics (sex: male, female; occupations: students, employees). The risk of NP due to SB is more pronounced in female than in male and greater in employees than in students. (3) Compared with not engaging in SB, an SB duration of 4听h/d increases the risk of NP by 45%. With prolonged screen-based SB, the risk of NP further intensifies; for SB durations exceeding 6听h/d, the risk of NP is nearly 88% greater than that for non-SB individuals.
Previous studies have largely confined their focus to a narrow segment of the population or a single type of SB, neglecting a holistic examination of various SB, diverse demographic traits, and the duration or intensity of such behaviors. For instance, Tehrani鈥檚 research [37] predominantly examined adult populations, whereas Mahdavi鈥檚 study [8] zeroed in on neck pain risk factors specifically among school-aged children and adolescents. Consequently, these studies exhibit constraints in terms of the breadth of their sample selection and the depth of their variable analysis.
In the modern era, owing to innovations in electronic information technology and the ubiquitous use of electronic devices, such as televisions, computers, tablets, and mobile phones, a shift in work and leisure activities has been observed, inevitably leading to an increase in SB. Most individuals, while typing on computers or browsing on mobile phones or tablets, tend to adopt postures involving bending the neck and slouching the shoulders [38]. As the duration of screen-based SB increases, these habits can compromise the normal biomechanical structure of the neck. The muscles in the neck and upper back, particularly the sternocleidomastoid, trapezius, and erector spinae muscles, remain tense for extended periods, disrupting the balance of their length and tension [39, 40]. This condition can precipitate various musculoskeletal issues, especially in the neck region.
Dianat [12] reported that watching TV for more than 12听h a week or using computers for more than 4听h a week did not increase the risk of NP. Conversely, Minghelli [20] discovered that using mobile phones for more than 10听h a week significantly increased the risk of NP. Our study aligns with these findings, indicating that screen-based SB is a crucial risk factor for NP, with prolonged use of mobile phones posing the greatest risk. This finding might be attributed to the amount of time spent on mobile phones and the neck posture maintained during their use. Watching TV was not identified as a risk factor for NP, possibly because of the ergonomic aspects of seating and viewing [41], along with the specific SB dosage and demographics of the studied population. Additionally, the specific SB dosage and demographics of the studied population, such as the frequency and duration of TV viewing, may also contribute to these varying risk levels.
Some studies have shown that females are more prone to experiencing NP than males are [42, 43], while others have found no significant sex-based difference in NP prevalence. Our study supports the notion that female face a heightened risk of NP associated with SB. This disparity in our findings may stem from a multitude of factors, encompassing behavioral patterns, biogenetic predispositions, ergonomic considerations, and psychological influences [5, 44, 45]. Unlike prior research, which largely concentrated on describing overall prevalence or general correlations, our study offers a more detailed insight through a meta-analysis and subgroup examinations, delving into the sex-specific risks of NP linked to various types and durations of SB. This nuanced exploration provides robust support for the observation that SB poses a particularly elevated risk of NP in female. These sex-specific nuances underscore the importance of developing tailored preventive and management strategies for NP, taking into account the distinct risk profiles of both male and female.
During adolescence, a period characterized by the middle to late stages of growth and development, the body鈥檚 organs and functions largely mature, and the skeletal muscles stabilize or grow slowly [46]. SB is often inevitable among adolescent students given the nature of their academic commitments. Studies have shown that SB can lead to posture abnormalities, chronic muscle strain, and other musculoskeletal issues in adolescents [7, 47]. Our study also revealed that SB is a strong predictor of NP in adolescents. However, the risk of NP due to SB in employees is still significantly greater than that in adolescents. This finding may be related to the inclusion of studies involving high-risk occupational groups for NP, such as electronics factory employees [14] and sewing machine operators [26]. In contrast to adolescents whose NP due to SB is often short-term and easily overlooked, employees tend to face long-term impacts of NP. This difference highlights the need for targeted interventions in different age groups, considering the specific risks and lifestyle factors associated with each group. For adolescents, interventions might focus more on education about appropriate posture and regular movement breaks, whereas for employees, especially in high-risk occupations, ergonomic adjustments and workplace interventions could be more beneficial.
The 2020 World Health Organization guidelines on physical activity (PA) and SB emphasize [48] the need for children and adolescents to limit their SB, particularly screen time for entertainment purposes. For adults, the guidelines recommend increasing PA to replace SB time, but they fail to specify a particular dose of SB. To date, no literature has reported the dose鈥抮esponse relationship between SB and the risk of NP. The present study, by collating and analysing previous research, investigated the relationship between SB and NP in terms of dosage. The findings revealed that a daily duration of general SB exceeding 4听h increases the risk of NP by 60%. The risk of NP further increases when the general SB exceeds 6听h/d. In addition, our study segmented screen-based SB into different doses (鈮モ1听h/d, 鈮 2听h/d, and 鈮モ4听h/d) and revealed that all three doses are strong predictors of NP risk, with the risk increasing with increasing dosage. This approach provides data support for developing effective SB-based strategies to mitigate the risk of NP.
Finally, NP is a condition resulting from multiple risk factors. In the context of the modern era, the inevitable increase in necessary daily SB time because of work and study demands calls for appropriate prevention strategies that consider cognitive, behavioral, and psychological factors. Numerous studies have proven that increasing daily PA can effectively reduce the risk of various noncommunicable diseases caused by SB. The WHO guidelines on PA and SB also emphasize the importance of at least one hour of moderate to vigorous PA daily for children and adolescents. Therefore, increasing the daily PA concentration is recommended as a preventive measure against NP.
Limitations
This study has several limitations that should be acknowledged. First, the included studies may have varied in their definitions and measurements of SB, which could introduce heterogeneity and potentially affect the pooled results. Second, although we attempted to conduct subgroup analyses based on various factors, the limited number of studies in some subgroups may have reduced the statistical power and reliability of these findings. Third, the majority of the studies included in this meta-analysis were observational, which limits our ability to establish causal relationships between SB and the outcomes of interest. Fourth, we were unable to account for all potential confounding factors, such as physical activity levels, dietary habits, and genetic predisposition, which may have influenced the association between SB and health outcomes. Additionally, the studies included in our meta-analysis did not provide sufficient information to conduct a subgroup analysis on leisure time SB versus work (or school) time SB, which is an important distinction that could provide further insights into the relationship between SB and neck pain. Finally, the generalizability of our findings may be limited to the populations and settings studied in the included articles, and may not necessarily apply to other populations or contexts. Therefore, caution should be exercised in interpreting and applying these results.
Conclusions
The findings of this study unequivocally point to SB as a notable risk factor for NP. Across a spectrum of studies and demographically diverse populations, a consistent correlation has been established between SB and an elevated risk of NP. This association persists whether the SB is general or screen-based, with activities involving mobile phones and computers emerging as particularly problematic. Notably, the risk of NP was observed to intensify with longer durations of SB, underscoring the critical importance of minimizing sedentary time to diminish the likelihood of NP. Furthermore, our research highlights the necessity for targeted preventative measures, especially for high-risk groups like female and employees, who demonstrated heightened vulnerability to NP because of SB. In conclusion, this study emphasizes the urgent need for public health initiatives that encourage the reduction of sedentary behaviors and the promotion of physical activity, ultimately to enhance neck health and alleviate the worldwide prevalence of NP.
Data availability
All extracted data used in this review has been reported in the text, figures and tables.
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Funding
Humanities and Social Sciences Project of the Ministry of Education (23YJC890027); Fundamental Research Funds for the Central Universities (2023SKPYTY02); Educational Reform and Research Funding Project for Undergraduate Education at China University of Mining and Technology-Beijing (J24ZX03); Funding for Undergraduate Innovative Training Projects at China University of Mining and Technology-Beijing (202416005).
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YCM conducted literature search. YCM, YQX and SJY evaluated the study articles and made decisions on inclusion and exclusion of the articles. YCM, FW and YYD performed statistical analyses. All authors were involved in the manuscript development and its revision. All authors read and approved the final manuscript.
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Meng, Y., Xue, Y., Yang, S. et al. The associations between sedentary behavior and neck pain: a systematic review and meta-analysis. 樱花视频 25, 453 (2025). https://doi.org/10.1186/s12889-025-21685-9
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DOI: https://doi.org/10.1186/s12889-025-21685-9