Factor Analysis of Game Addiction, Playtime, and Craniovertebral Angle on Musculoskeletal Disorders among Esports Players

Introduction

Electronic sports (esports) are a form of digital sports whose main aspects are facilitated by electronic devices such as mobile phones, computers, and consoles [1,2]. The popularity of esports has grown rapidly and spread globally [3], including Indonesia, with the number of players reaching 52 million in 2021 [4]. In recent years, esports has also been increasingly recognized as an official competition, such as in the Hangzhou 2022 Asian Games, which featured eight games, which included FIFA, the Asian Games version of PUBG Mobile, Arena of Valor, Dota 2, League of Legends, Dream Three Kingdoms 2, Hearthstone, and Street Fighter V [5,6]. In addition, the gaming industry is projected to continue to experience significant growth, with market revenues estimated to reach $455.60 billion by 2024 [7]. This global trend is also reflected in the rising number of national and international esports tournaments, which attract thousands of spectators and offer prize pools of up to millions of dollars.

This global trend is also reflected in the rising number of national and international esports tournaments or events, which attract thousands of spectators and offer prize pools of up to millions of dollars [8-10]. However, behind this growing popularity, there is increasing concern about its health impacts, particularly musculoskeletal disorders such as neck and back pain, as well as psychological issues like stress and sleep disturbances, which can negatively affect players’ quality of life and career sustainability [11-13]. Previous studies have found the prevalence of pain in esports players, with the most commonly affected areas being the neck (40%), followed by fingers (38%) and head (32%). Pain was also reported in the lower back (20%) and upper back [14], as well as in the shoulder by 49.4% [15].

Musculoskeletal disorders in esports players are generally caused by activity characteristics such as long playtime, digital game addiction, and non-ideal craniovertebral angles due to poor neck posture [16,17]. Long playtime will cause increased strain on the back muscles and hips and over-compression of the intervertebral discs [18,19]. Most esports players spend 3-10 hours per day playing games, and previous studies have shown that playtime of more than 35 hours per week increases eightfold the risk of experiencing musculoskeletal symptoms such as wrist, lower back, shoulder, elbow, and finger pain [2,20].

Esports players who experience digital game addiction tend to play excessively, resulting in repetitive movements of more than 500 times per minute [21]. These activities can cause spasms and inflammation in the finger and hand muscles, increasing the risk of musculoskeletal disorders such as carpal tunnel syndrome, De-Quervain's tenosynovitis, and epicondylitis [22]. In response, the World Health Organization (WHO) included digital game addiction behavior as a gaming disorder in the International Classification of Diseases (ICD-11) in 2018 [23]. In addition, esports players often maintain unergonomic postures with non-ideal craniovertebral angles, such as bowing their heads toward the game screen, triggering a forward head posture that increases the risk of musculoskeletal disorders [24,25]. Previous studies have shown the prevalence of forward head posture in 55.6% of female and 44.4% of male mobile gamers [26], as well as in esports players in Makassar with an average craniovertebral angle of 41.59°, which, although classified as, has caused mild strain on the neck muscles [27].

Although several studies have investigated musculoskeletal disorders in esports players [2,14,28,29], research integrating the correlations between digital game addiction, playtime, and craniovertebral angle with musculoskeletal disorders remains limited. However, theoretical perspectives suggest that these three factors may be correlated with the risk of musculoskeletal disorders. Most previous studies have focused on prevalence without explaining the causal correlation between the main risk factors [9,30]. A more comprehensive understanding is needed to support the development of effective intervention strategies, both in curative and preventive contexts. Unlike previous studies, this research involves a sample of esports enthusiasts, including amateur, semi-professional, and professional players and different gaming platforms (mobile, computer, and console), which allows for a more comprehensive understanding of the variations in musculoskeletal disorders that have not been extensively explored. This study aims to analyze the correlation between digital game addiction, playtime, and craniovertebral angle and musculoskeletal disorders in esports players in Indonesia. The study is expected to be baseline for developing prevention strategies, improving player performance, improving quality of life, and extending players' careers in the competitive world of esports.

Method

Design and Participants

This article adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [31]. An observational design with a cross-sectional approach was employed to analyze the condition of esports players in Indonesia. The study aimed to analyze the correlation between digital game addiction, playtime, and craniovertebral angle (independent variables) and musculoskeletal disorders (dependent variable). Data were collected simultaneously at one point in time without intervention or follow-up with the respondents. This research was approved by the Research Health Ethics Commission (KEKP) of the Faculty of Health Sciences, Muhammadiyah University of Surakarta and received an Ethical Feasibility Letter No.625/KEPK-FIK/X/2024.

This study employed a non-probability sampling method using a convenience sampling technique to recruit esports enthusiasts who met the inclusion criteria. This technique was selected for its accessibility in reaching active esports players across various competitive levels and gaming platforms. Such an approach facilitated the collection of relevant data aligned with the study’s context and objectives [32]. In this study, the term esports enthusiast refers to individuals actively engaged in competitive gaming, categorized as follows: (1) amateur players, those who play recreationally without participating in tournaments; (2) semi-professional players, those who actively participate in esports tournaments but are not under professional contracts; and (3) professional players, those affiliated with professional esports teams, holding official contracts, and regularly competing at national or international levels. Participants were drawn from various gaming platforms, including mobile, computer, and console.

The research population consisted of esports enthusiasts in Indonesia. Since the population size was unknown, the sample size was calculated using the Lemeshow formula, with a 5% margin of error and a proportion of 31.3% [32], which represents the most commonly reported site of musculoskeletal pain -the back region- among esports athletes. As a result, a minimum sample of 329 respondents was obtained. The forms were distributed in eight provinces: Central Java, East Java, West Java, North Borneo, East Borneo, Bengkulu, Jambi, and Lampung. A total of 415 esports players were willing to fill out the research questionnaire. After data screening, 338 respondents who fit the inclusion criteria were included. Inclusion Criteria: 1) 16-30 years old; 2) male and female gender; 3) status as an esports enthusiast, defined as an individual actively engaged in competitive gaming activities, whether recreationally or in formal tournaments, across various levels of participation (amateur, semi-professional, professional) and platforms (mobile, computer, or console); 4) actively practicing or playing video games every day for more than six months; 5) and willing to be a respondent. Exclusion Criteria: 1) have a history of previous musculoskeletal injuries such as scoliosis, herniated nucleus pulposus, entrapment of vertebral nerves, and fractures of fingers, wrist, hand, elbow, shoulder, or back within the past six months; 2) medical disorders such as neurological disorders and autoimmune diseases.

To minimize potential biases and confounding variables related to musculoskeletal disorders, exclusion criteria were established based on medical conditions that directly affect the musculoskeletal system. Musculoskeletal symptoms were assessed using a questionnaire that specifically evaluated complaints experienced during, after, or as a result of gaming within the past 12 months, thereby reducing the influence of temporary health conditions or unrelated physical activities. The questionnaire also collected data on occupation and education level to identify potential involvement in physically demanding activities outside of esports. Although a convenience sampling technique was employed, efforts were made to include a diverse range of respondents across different levels of participation and gaming platforms to enhance representativeness and reduce selection bias. To ensure data accuracy, the researcher provided assistance during questionnaire completion when needed and used an Indonesian-language instrument to improve clarity and comprehension.

Procedure

Prior to the current study, a trial was carried out on 10 respondents to ensure that the research instrument could be understood correctly and aligned with the research objectives. The research was conducted through virtual and in-person meetings from October to December 2024 using a virtual form platform. Digital game addiction and playtime data were collected online through the form. Craniovertebral angle measurements were taken offline to ensure the accuracy of the photographs. If offline measurement was not possible, participants were asked to upload photos online according to the guidelines and examples provided in the form. Inappropriate photos were reviewed, and participants were contacted for correction. The data were not included in the analysis if there was no response.

Measurement of musculoskeletal disorders and correlated factors in esports Players

Musculoskeletal disorders were measured using the Indonesian version of the Nordic Musculoskeletal Questionnaire (NMQ), which has validity between 0.501-0.823 and reliability (α = 0.78) [33] by adding the context of gaming to the question: “Have you ever felt aches, pains, or discomfort in any of the following body parts in the past 12 months: upper neck, lower neck, back, waist, buttocks, shoulders, upper arms, elbows, forearms, wrists, hands, pelvis, thighs, knees, lower legs, or ankles?” The level of impairment in each body part was rated using a scale: 1 (no impairment), 2 (mild), 3 (moderate), and 4 (severe). The cumulative impairment scores were then categorized into four risk levels: 28-49 as (low risk), 50-70 as (moderate risk), 71-91 as (high risk), and 92-112 as (very high risk). In this study, video game addiction is defined as a form of behavioral addiction characterized by a compulsive or repetitive urge to engage in excessive gaming, thereby impairing an individual’s social, emotional, or academic functioning [34]. To identify the level of addiction among participants, the Indonesian version of the Video Game Addiction Test (VAT) was used. This instrument consists of 14 statements rated on a 5-point Likert scale (0 = never to 4 = very often) and has demonstrated strong validity and reliability (KMO = 0.861; Cronbach’s α = 0.846; factor loading = 0.344-0.747) [35]. Scores were classified as follows: 0-14 = Normal (non-problematic), 15-28 = Mild (possibly unproductive gaming habit), 29-42 = Moderate (some degree of addiction), and 43-56 = Severe (significant gaming addiction) [36]. Playtime was measured based on the duration of play in hours/day and classified as low (<3 hours/day), medium (3-7 hours/day), and long (>7 hours/day) [37]. The craniovertebral angle was determined by measuring the angle made between the horizontal line drawn from the cervical spinous process 7 to the ear tragus [38], using the Kinovea application (ICC 0.920-0.995) and marking the cervical spinous process seven and the ear tragus. Classification of craniovertebral angle (normal ≥ 50°), (mild group 45.5°-49.9°), (moderate-to-severe group < 45.5°) [39].

Statistical analysis

The research data were processed using the IBM SPSS Statistics 24 application through several stages of testing. First, samples were checked for normality of distribution using the Kolmogorov-Smirnov method. Based on the normality test results, the data showed a non-normal distribution (p < 0.05), so the analysis was carried out using non-parametric methods. The testing stages included (1) univariate analysis to describe data characteristics, (2) bivariate analysis using Spearman's rank correlation test to evaluate the relationship between independent and dependent variables, and (3) multivariate analysis using an ordinal regression analysis to examine the correlation between independent variables and the ordinal-scaled dependent variable. The validity of the analysis results was tested using statistical indicators such as correlation coefficient, p-value, and pseudo R-squared to ensure model consistency and accuracy.

Results

The following flowchart provides a visual representation of the respondent eligibility assessment for this study as a guide to conducting statistical analysis of subjects who have completed the stages of the study, as shown in Figure 1.

Figure 1. Flow Chart Diagram for Research Sampling.

Descriptive analysis based on Table 1 indicates that the majority of respondents were aged 21-25 years (51.5%, n = 174), with an average Body Mass Index (BMI) of 22.07. Most were amateur (recreational) esports players (69.5%, n = 235), had been engaged in esports for ≥5 years (52.4%, n = 177), and predominantly used mobile devices (79.3%, n = 268). In terms of gender, male respondents constituted the majority (69.5%, n = 235), while females accounted for 30.5% (n = 103). Regarding digital game addiction, 26.3% (n = 89) were classified as normal, 55.6% (n = 188) as mild, 17.8% (n = 60) as moderate, and 0.3% (n = 1) as heavy, based on the Video Game Addiction Test (VAT) scores. For playtime, most respondents reported playing less than 3 hours per day (68.3%, n = 231), followed by 3-7 hours/day (28.7%, n = 97), and more than 7 hours/day (3%, n = 10), with an average playtime of approximately 3 hours/day. In terms of posture, 55.9% (n = 189) of respondents had craniovertebral angles within the normal category (≥50°). Most participants reported low-risk levels of musculoskeletal disorders (89.6%, n = 303).

Table 1. Demographic characteristics and playing patterns of Indonesian esports players.

Based on Table 2, the body part that experiences the most musculoskeletal disorders in e-sport players in Indonesia is back (65.1%), followed by the lower back (55%), upper neck (54.7%), right hand (48.8%), right wrist (47.3%), lower neck (46.2%), and buttocks (36.1%). The average musculoskeletal disorder was in the mild category based on the Nordic Musculoskeletal Questionnaire (NMQ) assessment.

Table 2. The degree of musculoskeletal disorders in specific areas was assessed using the 4-point Nordic Musculoskeletal Questionnaire (NMQ) (nil 1, mild 2, moderate 3, severe 4).

Based on Table 3, the Spearman correlation test results show that digital game addiction (p = 0.00), playtime (p = 0.00), and craniovertebral angle (CVA) (p = 0.00) have a significant correlation with musculoskeletal disorders in Indonesian’s esports players. The r value shows that digital game addiction (r = 0.503) and playtime (r = 0.405) have a strong correlation, while the craniovertebral angle (r = -0.378) has a moderate correlation with musculoskeletal disorders [40]. The results of the ordinal regression analysis indicated that digital game addiction, playtime, and craniovertebral angle (CVA) showed significant correlations with musculoskeletal disorders (p = 0.000) in Indonesian esports players. Collectively, these three variables explained 32.7% of the variance in musculoskeletal disorders. The remaining 67.3% may be attributed to other factors not examined in this study. Among these, digital game addiction had the strongest correlation (p = 0.000), followed by craniovertebral angle (p = 0.001) and playtime (p = 0.038).

Table 3. Correlation and ordinal regression analysis of musculoskeletal disorders with digital game addiction, duration of gameplay, and craniovertebral angle.

These results indicate that high levels of game addiction, prolonged playtime, and craniovertebral angles suggestive of a forward head posture show a positive correlation with an increased risk of musculoskeletal disorders, particularly in the upper body regions. These findings emphasize the importance of concrete preventive measures, such as postural education, early ergonomic interventions, and raising awareness among esports players to mitigate the risk of musculoskeletal disorders.

Discussion

The findings of this study indicate that digital game addiction, playtime duration, and craniovertebral angle, reflecting a tendency toward forward head posture, show significant correlations with musculoskeletal disorders among esports players in Indonesia. Digital game addiction and playtime demonstrated strong positive correlations with musculoskeletal disorders, while a smaller craniovertebral angle, indicating forward head posture, demonstrated a moderate negative correlation [40]. Data analysis revealed that higher levels of addiction and longer playtime, along with a smaller craniovertebral angle, were associated with increased musculoskeletal disorder risk. Although this study focused on a limited set of variables, the results highlight their theoretical relevance in understanding the risk of musculoskeletal disorders. It is also important to consider that other theoretically relevant factors, such as physical activity level, stress, sleep quality, sedentary behavior, and seating ergonomics, were not included in this study and warrant further investigation [13,41,42].

Several factors not analyzed in this study are both theoretically and empirically relevant. Ndongo et al. [43] reported that poor sleep quality is associated with increased pain sensitivity (hyperalgesia) and impaired muscle recovery. Yadegaripour et al. [44] highlighted that the use of non-ergonomic equipment, such as chairs without lumbar support or monitors positioned too low, can lead to excessive tension in the back and neck muscles. Lack of physical activity outside gaming sessions has also been linked to reduced muscle endurance and flexibility, increasing the risk of injury due to prolonged static postures [45]. Additionally, Kha et al. [42] found that individuals with sedentary behavior tend to experience a higher prevalence of musculoskeletal disorders across various body regions. Theoretically, this may be explained by reduced blood flow to muscles and increased static muscle tension resulting from extended periods of sitting or lying down with low energy expenditure (<1.5 METs) [46]. Most musculoskeletal disorders in this study occurred in the back region, with a prevalence of 65.1%. Similar results were also found by Sinatra [5], who reported a prevalence of musculoskeletal disorders in the back of 66.7%. The findings of Lindberg et al. [30] also identified the back as the main complaint but with a prevalence of 31.3%. This difference in prevalence indicates the presence of complex risk factors, mainly due to the variety of playing devices, namely computers, consoles, and mobile devices, with the latter dominating at 79.3%. Meanwhile, Lindberg et al. [30] focused on computer-based devices, which may explain this difference, as computer use tends to involve static sitting positions with ergonomic adjustments, such as screens, chairs, and tables [47]. In contrast, mobile device use more often involves a slouched posture, excessive pressure on the hands, and additional strain on the neck [48].

The results of this study are in line with previous theories and findings that digital game addiction, playtime, and craniovertebral angle have a significant correlation with musculoskeletal disorders in esports players. Ahmed et al. [49] reported that digital game addiction on mobile increased the risk of musculoskeletal discomfort two to three times higher for neck pain (OR 2.84, 95% CI 1.49-5.36; p = <0.001), upper back (OR 3.75, 95% CI 1.97-7.12; p = <0.001), elbow (OR 1.78, 95% CI 0.93-3.40; p = 0.083), and wrist (OR 3.38, 95% CI 1.34-8.50; p = 0.010) and hand (OR 2.14, 95% CI 1.00-4.57; p = 0.049). In addition, the results of the research by Heidarimoghadam et al. [50] also showed similar results that social network addiction and digital game addiction could increase the risk of neck disorders with (OR 2.45, 95% CI 1.65, 3.6) and (0.58 ROC). Another thing is also supported by the theoretical aspect that digital game addiction will create impaired control over the game and can result in musculoskeletal disorders due to overuse, spasms, and inflammation in the muscles [22,51].

Consistency of findings was also seen in the playtime factor. Based on a systematic review conducted by Tholl et al. [17], 11 out of 16 studies showed a negative impact on the musculoskeletal system due to excessive playtime (> 3 hours/day), with odds ratios (OR) ranging from 1.3 to 5.2 for the risk of developing disorders. Previous studies have also reported a significant correlation between computer and mobile device use and neck pain (p<0.05) [51], as well as a significant association between playtime and musculoskeletal disorders (OR = 8.0; 95% CI 1.4-44.6; p = 0.018) [2]. Theoretically, this finding is supported by the mechanism that esports players with long playtime tend to experience muscle fatigue in the trunk area. This fatigue weakens the spinal support function, increasing compression on ligaments and intervertebral discs, ultimately leading to musculoskeletal pain and discomfort [14].

Previous research showed that a non-ideal forward craniovertebral angle or forward head posture correlated with neck pain levels of 0.323, although the study focused on a group of university students [52]. Similar results were also reported by Mahmoud et al. [25] through a systematic review and meta-analysis of eight studies, which showed a significant negative correlation between non-ideal craniovertebral angle and neck musculoskeletal pain (r = -0.55; 95% CI = -0.69 to -0.36) and disability (r = -0.42; 95% CI = -0.54 to -0.28). However, these results were based on a sample of adults in general, not esports players. Static positions maintained during prolonged gaming sessions may cause craniovertebral angle changes and affect the activation patterns of the sternocleidomastoid and upper trapezius muscles. This muscle activation imbalance can lead to discomfort and pain [53].

This study fundamentally differs from previous research as it involves a sample of esports enthusiasts across various categories, amateur, semi-professional, and professional. Additionally, it includes a diverse range of gaming platforms, such as mobile phones, computers, and consoles. In contrast, most prior studies have focused primarily on professional esports players [14,28], whereas investigating non-professional players is also essential to understand the potential health impacts of gaming habits outside structured environments [54]. Some relevant studies have examined specific devices [15,30], particular game genres [55], or player populations with distinct characteristics and behaviors [51]. These differences may influence ergonomic behaviors among esports players of different levels. Professional players are generally better trained and more aware of ergonomic posture and equipment use due to performance demands and guidance from coaches or teams [56,57]. On the other hand, amateur players may have less awareness of optimal posture and are more prone to musculoskeletal disorders due to non-ergonomic gaming habits [13]. These factors may also explain variations in digital game addiction levels, playtime duration, craniovertebral angles, and the prevalence of musculoskeletal disorders observed in this study.

• The findings of this study have practical relevance in the fields of physiotherapy and esports health. Health promotion strategies focused on playing posture ergonomics and playtime management can be developed as preventive measures to reduce the risk of musculoskeletal disorders in esports players [12]. Physiotherapists play a key role in designing stretching and muscle-strengthening programs, particularly for the back, neck, hands, and wrists, and in conducting periodic evaluations of the craniovertebral angle to detect early postural risks. Personalized interventions, such as posture correction, core strengthening exercises, and pain management strategies, may enhance players’ performance and quality of life [58].

• These findings also pave the way for future research, including intervention and longitudinal studies to assess the effectiveness of corrective exercises, digital ergonomic education, and long-term monitoring of musculoskeletal symptoms in the context of esports. Consequently, the scientific evidence generated can strengthen the role of physiotherapy in sustainable strategies for musculoskeletal disorder prevention among esports players. Furthermore, these results highlight the need for health policy development within the esports industry, including the use of ergonomic devices and the implementation of regular physical training programs. Education on proper posture and ideal gaming duration is particularly relevant for amateur players to prevent musculoskeletal issues in the future.

• This study has a notable strength in its participant diversity, involving 338 esports enthusiasts across varying levels of competence (amateur, semi-professional, and professional) and using various gaming platforms, including mobile phones, computers, and consoles. This diversity reflects the real-world conditions of esports players and provides valuable cross-group perspectives. Furthermore, this study helps fill a gap in the existing literature by exploring the correlation between digital game addiction, playtime, and craniovertebral angle with musculoskeletal disorders, an area that has rarely been investigated comprehensively. These findings provide a broader initial understanding of potential risk factors for musculoskeletal disorders among esports players. The results are relevant for developing multidimensional intervention strategies in esports health, particularly in preventing musculoskeletal injuries among Indonesian esports players.

Limitations and Recommendations

The main limitation of this study is the imbalance in sample proportions, with most respondents coming from the amateur player group and mobile device users. This imbalance may be attributed to the use of a convenience sampling technique, which, although effective in providing access to participants from various levels and platforms, does not ensure an even distribution of the sample. This condition may influence the interpretation of results and limit the generalizability of the findings to the broader esports player population. Different device types, such as mobile, computer, and console, lead to varied playing postures, and the dominance of mobile users in this study may restrict the diversity of postural patterns represented. Moreover, this study did not account for potential confounding factors, including neck muscle strength and endurance, or the duration of screen exposure for non-gaming activities such as academic or occupational tasks, which may be correlated with the occurrence of musculoskeletal complaints.

Given the findings and limitations of the present study, future research is advised to employ a stratified random sampling method to ensure a more proportionate representation of respondents based on esports participation levels (amateur, semi-professional, professional) and types of gaming devices (mobile, computer, console). This approach is expected to yield broader and more generalizable insights into gameplay patterns, training intensity, and musculoskeletal injury risks. Subsequent studies should further investigate the correlations and differences across various levels of esports engagement and device types by examining the interaction between digital gaming addiction, gameplay duration, and craniovertebral angle. Additional factors, such as psychosocial conditions, physical activity levels, and rest patterns based on game genre, may also be correlated with musculoskeletal disorders and should be considered. Moreover, potential confounding variables, including neck muscle strength and endurance, as well as screen exposure from non-gaming digital activities such as studying or entertainment, should be carefully controlled. Longitudinal study designs are highly recommended to assess the long-term biomechanical and postural consequences associated with prolonged use of different gaming devices.

Conclusions

This study demonstrates that digital game addiction, playtime, and craniovertebral angle have significant correlations with musculoskeletal disorders among esports players. These findings align with the study’s objective of exploring the correlations between these three variables and musculoskeletal disorders. Although the results suggest potential roles for these factors, it is important to note that the findings are correlational and cannot be interpreted as causal relationships due to the cross-sectional nature of the study design. Additionally, musculoskeletal disorders in esports players are likely multifactorial, with correlating factors such as prolonged static postures, extensive use of mobile devices, and limited ergonomics education, particularly among amateur players. Other factors, including psychological stress, physical activity habits, and the type of gaming device used, should also be considered in future research.

These findings also emphasize the importance of ergonomics education, playtime regulation, and postural awareness in preventing musculoskeletal disorders. Physiotherapists play a vital role in maintaining player health by providing practical advice, such as encouraging regular stretching, avoiding prolonged forward head posture, and limiting daily gaming time, while also conducting postural assessments and delivering evidence-based preventive interventions. Coaches or team staff can support these efforts by organizing ergonomic training and developing balanced practice schedules. These recommendations are relevant for both healthcare providers and the broader esports industry in fostering healthier and more sustainable gaming environments.

References

1. Wattanapisit A, Wattanapisit S, Wongsiri S. Public health perspectives on esports. Public Health Rep [Internet]. 2020;135(3):295-8. doi: https://doi.org/10.1177/0033354920912718

2. Ekefjärd S, Piussi R, Hamrin Senorski E. Physical symptoms among professional gamers within esports, a survey study. BMC Sports Sci Med Rehabil [Internet]. 2024;16(1):18. doi: https://doi.org/10.1186/s13102-024-00810-y

3. Cantrell WA, Cantrell C, Cruickshank J, Schwartz D, Aaron D, Belle J, et al. Esports. In: Krabak BJ, Brooks A, editors. The youth athlete [Internet]. Amsterdam: Elsevier; 2023. p. 761-767. doi: https://doi.org/10.1016/B978-0-323-99992-2.00030-X

4. Akbar R, Hendrastomo G. Dinamika dalam relasi sosial tim UNY esport. Jurnal Perspektif: Jurnal Kajian Sosiologi dan Pendidikan [Internet]. 2024;7(2):331-40. doi: https://doi.org/10.24036/perspektif.v7i2.970

5. Sinatra F, Rochmania A. Gangguan kesehatan pada atlet e sport Jatim divisi Mobile Legends. Jurnal Prestasi Olahraga [Internet]. 2022;5(6):90-7. Available from: https://ejournal.unesa.ac.id/index.php/jurnal-prestasi-olahraga/article/view/48520

6. Venkat R. Asian Games 2022: Esports to make debut; FIFA, PUBG, Dota 2 among eight medal events [Internet]. Lausanne: International Olympic Committee; c2025 [updated 2021 Sep 9; cited 2024 Jun 30]; [about 4 screens]. Available from: https://olympics.com/en/news/fifa-pubg-dota-2-esports-medal-events-asian-games-2022

7. Williams A, Baxter G, Hainey T, Boyle E. Design of a serious game to teach esports concepts and career pathways. European Conference on Games Based Learning [Internet]. 2024;18(1):855-62. doi: https://doi.org/10.34190/ecgbl.18.1.2705

8. Gasparetto T, Safronov A. Streaming demand for esports: Analysis of Counter-strike: Global offensive. Convergence [Internet]. 2023;29(5):1369-88. doi: https://doi.org/10.1177/13548565231187359

9. Sand Hansen F, Lyngs M, Dyg Hyllested Lauridsen M, Lund Straszek C. Musculoskeletal health in esport: a cross-sectional comparison of musculoskeletal pain among young Danish esports players and handball players. German Journal of Exercise and Sport Research [Internet]. 2024. doi: https://doi.org/10.1007/s12662-024-00948-4

10. Hattingh W, Berg LVD, Bevan-Dye AL. The “why” behind generation Y amateur gamers’ ongoing esports gameplay intentions. International Journal of Sports Marketing & Sponsorship [Internet]. 2024;25(1):67-87. doi: https://doi.org/10.1108/ijsms-04-2023-0064

11. Clements AJ, Paul RW, Lencer AJ, Seigerman DA, Erickson BJ, Bishop ME. Analysis of musculoskeletal injuries among collegiate varsity electronic sports athletes. Cureus [Internet]. 2022;14(11):e31487. doi: https://doi.org/10.7759/cureus.31487

12. Khan MA, Chaikumarn M. Musculoskeletal disorders, perceived stress, and ergonomic risk factors among smartphone esports athletes: a cross-sectional study. Journal of Musculoskeletal Surgery and Research [Internet]. 2024;8(3):247-55. Available from: https://doi.org/10.25259/jmsr_113_2024

13. Saefullah R, Yohandoko SLO, Lianingsih N. Injury prevention strategy training in esports players: a holistic approach to physical and mental health. International Journal of Ethno-sciences and Education Research [Internet]. 2024;4(3):96-100. doi: https://doi.org/10.46336/ijeer.v4i3.711

14. Lam WK, Liu RT, Chen B, Huang XZ, Yi J, Wong DWC. Health risks and musculoskeletal problems of elite mobile esports players: a cross-sectional descriptive study. Sports Med Open [Internet]. 2022;8(1):1-9. doi: https://doi.org/10.1186/s40798-022-00458-3

15. Monma T, Matsui T, Koyama S, Ueno H, Kagesawa J, Oba C, et al. Physical complaints and their relationships to esports activities among Japanese esports players: a cross-sectional study. medRxiv [Internet]. 2023;2023.11.14.23298495. doi: https://doi.org/10.1101/2023.11.14.23298495

16. Andriawan W, Rahman F. Risk factors for neck functional ability in esports players. Jurnal Pendidikan Jasmani dan Olahraga [Internet]. 2024;9(1):66-74. doi: https://doi.org/10.17509/jpjo.v9i1.67946

17. Tholl C, Bickmann P, Wechsler K, Froböse I, Grieben C. Musculoskeletal disorders in video gamers - a systematic review. BMC Musculoskelet Disord [Internet]. 2022;23(1):1-16. doi: https://doi.org/10.1186/s12891-022-05614-0

18. Mbada C, Olaogun M, Oladeji O, Omole J, Ogundele A. Biomechanical effect of sitting postures on sitting load and feet weight in apparently healthy individuals. Nigerian Journal of Health Sciences [Internet]. 2016;16(1):15. doi: https://doi.org/10.4103/1596-4078.190030

19. Mondal M, Sarkar B, Alam S, Das S, Malik K, Kumar P, et al. Prevalence of piriformis tightness in healthy sedentary individuals: a cross-sectional study. Int J Health Sci Res [Internet]. 2017;7(7):134-42. Available from: https://www.ijhsr.org/IJHSR_Vol.7_Issue.7_July2017/IJHSR_Abstract.020.html

20. DiFrancisco-Donoghue J, Werner WG, Douris PC, Zwibel H. Esports players, got muscle? competitive video game players’ physical activity, body fat, bone mineral content, and muscle mass in comparison to matched controls. J Sport Health Sci [Internet]. 2022;11(6):725-30. doi: https://doi.org/10.1016/j.jshs.2020.07.006

21. Harianda D, Lupiya PAG. Manajemen kesehatan atlet e-sports. Cermin Dunia Kedokteran [Internet]. 2023;50(8):447-50. doi: https://doi.org/10.55175/cdk.v50i8.668

22. Zwibel H, DiFrancisco-Donoghue J, DeFeo A, Yao S. An osteopathic physician’s approach to the esports athlete. J Am Osteopath Assoc [Internet]. 2019;119(11):756-62. doi: https://doi.org/10.7556/jaoa.2019.125

23. World Health Organization [Internet]. Geneva: WHO; c2025. Addictive behaviours: gaming disorder; 2020 Oct 22 [cited 2024 Jun 30]; [about 3 screens]. Available from: Available from: https://www.who.int/news-room/questions-and-answers/item/addictive-behaviours-gaming-disorder

24. Güloğlu S, Yalçın Ü. The effect of smartphone addiction on neck pain and disability in university students. Kafkas J Med Sci [Internet]. 2021;11(2):225-30. doi: https://doi.org/10.5505/kjms.2021.75057

25. Mahmoud NF, Hassan KA, Abdelmajeed SF, Moustafa IM, Silva AG. The relationship between forward head posture and neck pain: a systematic review and meta-analysis. Curr Rev Musculoskelet Med [Internet]. 2019;12(4):562-77. doi: https://doi.org/10.1007/s12178-019-09594-y

26. Ali M, Ashraf N, Khan S, Zahid A, Naeem M, Rehman A, et al. Incidence of forward head posture in mobile gamers: cross sectional study. Pakistan Journal of Medical & Health Sciences [Internet]. 2022;16(4):766-8. doi: https://doi.org/10.53350/pjmhs22164766

27. Sa’Bantoro AF, Irianto I, Hasyar ARA. Hubungan Forward Head Posture dengan Kejadian Nyeri Otot Upper Trapezius pada Atlet Esports di kota Makassar. Jurnal Fisioterapi dan Rehabilitasi [Internet]. 2023;8(1):72-7. doi: https://doi.org/10.33660/jfrwhs.v8i1.324

28. Lam WK, Chen B, Liu RT, Cheung JCW, Wong DWC. Spine posture, mobility, and stability of top mobile esports athletes: a case series. Biology (Basel) [Internet]. 2022;11(5):1-11. Available from: https://doi.org/10.3390/biology11050737

29. Muttaqqin Z, Rahman F. Kontribusi status ergonomi terhadap keterbatasan fungsional neck pada esports player. Jurnal Riset Kesehatan Poltekkes Depkes Bandung [Internet]. 2025;17(1):175-88. doi: https://doi.org/10.34011/juriskesbdg.v17i1.2800

30. Lindberg L, Nielsen SB, Damgaard M, Sloth OR, Rathleff MS, Straszek CL. Musculoskeletal pain is common in competitive gaming: a cross-sectional study among Danish esports athletes. BMJ Open Sport & Exercise Medicine [Internet]. 2020;6(1):e000799. doi: https://doi.org/10.1136/bmjsem-2020-000799

31. Cuschieri S. The STROBE guidelines. Saudi Journal of Anaesthesia [Internet]. 2019;13(Suppl 1): S31-4. doi: https://doi.org/10.4103/sja.SJA_543_18

32. Andrade C. The inconvenient truth about convenience and purposive samples. Indian J Psychol Med [Internet]. 2021;43(1):86-8. doi: https://doi.org/10.1177/0253717620977000

33. Ramdan IM, Duma K, Setyowati DL. Reliability and validity test of the Indonesian version of the Nordic Musculoskeletal Questionnaire (NMQ) to Measure Musculoskeletal Disorders (MSD) in Traditional Women Weavers. GMHC [Internet]. 2019;7(2):123-30. doi: https://doi.org/10.29313/gmhc.v7i2.4132

34. Yue Y. Effects of video game addiction on mental health. Lecture Notes in Education Psychology and Public Media [Internet]. 2024;33(1):137-44. doi: https://doi.org/10.54254/2753-7048/33/20231573

35. Permata A, Ismaningsih I. Aplikasi neuromuscular taping pada kondisi carpal tunnel syndrom untuk mengurangi nyeri. Jurnal Ilmiah Fisioterapi [Internet]. 2020;3(1):12-7. doi: https://doi.org/10.36341/jif.v3i1.1226

36. Darwesh A, Almalhan SBA, Bameshan SBM, Alghamdi ABA, Alamari MBH, Qurban W. Impact of Prolonged use of Video Gaming on Grip and Pinch Strength in Young Adult. Global Journal of Human-Social Science [Internet]. 2023;23(H8):29-41. doi: https://doi.org/10.34257/GJHSSHVOL23IS8PG29

37. Manita YA, Rahayu CD, Setyawati A, Alviana F, Purnamasari I. Hubungan durasi bermain game online dengan kualitas tidur pada remaja dalam tinjauan q.s arrum:23. Jurnal Ilmiah Kesehatan [Internet]. 2023;13(2)47-55. Available from: https://ojs.unsiq.ac.id/index.php/jik/article/view/5897

38. Cote R, Vietas C, Kolakowski M, Lombardo K, Prete J, Dashottar A. Inter and intra-rater reliability of measuring photometric craniovertebral angle using a cloud-based video communication platform. Int J Telerehabil [Internet]. 2021;13(1):e6346. doi: https://doi.org/10.5195/ijt.2021.6346

39. Heidary Z, Pirayeh N, Mehravar M, Yazdi MJS. Evaluating the stability limits between individuals with mild and moderate-to-severe grades of forward head posture. Middle East Journal of Rehabilitation and Health Studies [Internet]. 2024;11(4):e144970. doi: https://doi.org/10.5812/mejrh-144970

40. Akoglu H. User’s guide to correlation coefficients. Turk J Emerg Med [Internet]. 2018;18(3):91-3. doi: https://doi.org/10.1016/j.tjem.2018.08.001

41. Kamijantono H, Sebayang MM, Lesmana A. Risk factors and ergonomic influence on musculoskeletal disorders in the work environment. JLMH [Internet]. 2024;5(3):660-70. doi: https://doi.org/10.37899/journallamedihealtico.v5i3.1413

42. Kha MS, Kibria MG, Hossain F, Ferdous J, Shihab HM. Exploring the prevalence, risk factors and association with physical activity of musculoskeletal disorders among patients attending a tertiary teaching hospital in Gazipur Bangladesh: a cross-sectional study. CeMec Journal [Internet]. 2024;7(1):47-56. doi: https://doi.org/10.3329/cemecj.v7i1.70942

43. Ndongo JM, Bika Lele EC, Moussa Ahmet HM, Guessogo WR, Wiliam MB, Guyot J, et al. Poor quality of sleep and musculoskeletal pains among highly trained and elite athletes in Senegal. BMC Sports Sci Med Rehabil [Internet]. 2024;16(1):54. doi: https://doi.org/10.1186/s13102-023-00705-4

44. Yadegaripour M, Hadadnezhad M, Abbasi A, Eftekhari F, Samani A. The effect of adjusting screen height and keyboard placement on neck and back discomfort, posture, and muscle activities during laptop work. International Journal of Human-Computer Interaction [Internet]. 2021;37(5):459-69. doi: https://doi.org/10.1080/10447318.2020.1825204

45. Chaves TO, Balassiano DH, Araújo CGS. Influência do hábito de exercício na infância e adolescência na flexibilidade de adultos sedentários. Rev Bras Med Esporte [Internet]. 2016;22(4):256-60. doi: https://doi.org/10.1590/1517-869220162204159118

46. Pinto AJ, Bergouignan A, Dempsey PC, Roschel H, Owen N, Gualano B, et al. Physiology of sedentary behavior. Physiol Rev [Internet]. 2023;103(4):2561-622. doi: https://doi.org/10.1152/physrev.00022.2022

47. Thaper R, Gibson MJ, Mykoniatis K, Sesek R. The role of smart hand held devices - smartphones/iPads/tablets/smartwatches in causing musculoskeletal disorders: a systematic literature review. International Journal of Industrial Ergonomics [Internet]. 2023;97:103497. doi: https://doi.org/10.1016/j.ergon.2023.103497

48. Dhale T, Verma P, Dhande S, Bandre P, Kumar P. A Review on the risk of musculoskeletal disorder in humans originating from excessive use of smartphone. In: 2024 Second International Conference on Intelligent Cyber Physical Systems and Internet of Things (ICoICI) [Internet]; 2024 Aug 28 - 30. College of Engineering and Technology. Coimbatore: IEEE; 2024. p. 1432-6. doi: https://doi.org/10.1109/ICoICI62503.2024.10696192

49. Ahmed S, Samuel AJ, Mishra A, Rahman M, Islam A, Rashaduzzaman, et al. Mobile game addiction and its association with musculoskeletal pain among students: A cross-sectional study. PLoS One [Internet]. 2024;19(8):e0308674. Available from: https://doi.org/10.1371/journal.pone.0308674

50. Heidarimoghadam R, Mortezapour A, Ghasemi F, Ghaffari ME, Babamiri M, Razie M, et al. Musculoskeletal Consequences in Cyber-Addicted Students - is It really a matter of health? A ROC curve analysis for prioritizing risk factors. J Res Health Sci [Internet]. 2020;20(2): e00475. doi: https://doi.org/10.34172/jrhs.2020.10

51. Cankurtaran F, Menevşe Ö, Namlı A, Kızıltoprak HŞ, Altay S, Duran M, et al. The impact of digital game addiction on musculoskeletal system of secondary school children. Niger J Clin Pract [Internet]. 2022;25(2):153-9. doi: https://doi.org/10.4103/njcp.njcp_177_20

52. Wibisono IS, Soesanto, Azam M . The effect of neck pain on craniovertebral angle due to the use of smartphone as a learning media for physiotherapy students in Widya Husada University Semarang. JKF [Internet]. 2022;4(2):284-9. doi: https://doi.org/10.35451/jkf.v4i2.1089

53. Çobanoğlu G, Demirkan MY, Ecemiş ZB, Atalay Güzel N. Forward head posture and its effect on muscle activation. Gazi Sağlık Bil [Internet]. 2024;9(1):85-93. doi: https://doi.org/10.52881/gsbdergi.1376080

54. Cyma-Wejchenig M, Maciaszek J, Ciążyńska J, Stemplewski R. The Level of physical activity, e-game-specific reaction time, and self-evaluated health and injuries’ occurrence in non-professional esports players. Electronics [Internet]. 2024;13(12):2328. doi: https://doi.org/10.3390/electronics13122328

55. Arthamevia SM, Bachtiar F, Prabowo E, Purnamadyawati P. Hubungan antara durasi penggunaan smartphone dan keluhan nyeri leher pada tim e-sport mobile legend. Jurnal Fisioterapi Terapan Indonesia [Internet]. 2022;1(2). doi: https://doi.org/10.7454/jfti.v1i2.1037

56. Baena-Riera A, Carrani LM, Piedra A, Peña J. Exercise recommendations for e-athletes: guidelines to prevent injuries and health issues. Journal of Electronic Gaming and Esports [Internet]. 2023;1(1):jege.2023-0003. doi: https://doi.org/10.1123/jege.2023-0003

57. Emara AK, Ng MK, Cruickshank JA, Kampert MW, Piuzzi NS, Schaffer JL, et al. Gamer’s health guide: optimizing performance, recognizing hazards, and promoting wellness in esports. Curr Sports Med Rep [Internet]. 2020;19(12):537-45. doi: https://doi.org/10.1249/JSR.0000000000000787

58. Alshuweihi HH, Al-Sharman A, Abdelbasset WK. A narrative review on the role of physiotherapy in musculoskeletal disorders. Fizjoterapia Polska [Internet]. 2024;24(3):367-72. doi: https://doi.org/10.56984/8zg020ak7n