This study included 94 mobile-gaming athletes consisting of 43 professional levels (professional gamers, PG) of two top-tier gaming groups and 51 casual players (casual gamers, CG). PG participated in mobile gaming such as Mobile Legend, PUBG Mobile, and Free Fire. The PG criteria that we included are players who join certain professional esports players organizations whose main profession is as esports players, with a minimum 1 year of playing experience. Meanwhile, the CGs we included are esports players who are not members of a particular professional esports organization, with varying lengths of play.

To determine the appropriate sample size for a study, a power of 80%, a 2-sided significance level of 0.05, and a difference of a 30% incidence rate (42% and 12%) were used. The incidence rate of 42% was based on a previous study conducted by Lindberg et al. in 2020 (17). The study required a minimum of 34 patients in each group to meet the sample size requirement.

This study was approved by the ethics committee on 1st March 2023 (IRB 061/KER/FK/III/2023). This research was conducted during the off-season, a period when players are not competing. Data collection occurred from March to May 2023 for professional players and in June 2023 for casual players.

Table 1 shows the baseline information collected, including body weight, height, blood pressure, and length of play. Variables that we examined include musculoskeletal and eye problems, smoking habits, physical activity, playing duration, sleeping duration, daytime sleepiness, and physical fitness such as body mass index (BMI), body fat (BF) percentage, hand grip strength, waist circumference, and flexibility.

BMI was categorized into five groups according to the WHO Asian-BMI classification: underweight (<18.5 kg/m²), normal weight (18.5–22.9 kg/m²), overweight (23–24.9 kg/m²), obese I (25–29.9 kg/m²), and obese II (≥30 kg/m²) (18). We used Tanita Segmental Body Composition Monitor (Tanita Inner Scan BC−545N—Japan) for body fat measurement. Participants wore thin or short-sleeved clothing and stood upright while holding the handrails during the measurement process. Body fat percentage was categorized into 5 ranges: obese: >25% (men), >32% (women); overfat: 20%–25% (men), 28%–32% (women); average fitness: 15%–20% (men), 23%–28% (women); athletic fitness: 10%–15% (men), 18%–23% (women); and exceptional fitness/bodybuilder range: 3%–10% (men), 12%–18% (women) (19).

The hand grip strength test was performed by positioning the participants standing with shoulder adducted with neutral rotation, elbow in 180° extension, forearm, and wrist in a neutral position. Then, the manual dynamometer (CAMRY EH101®, China) was placed in the participant's hand. The handle of the dynamometer is adjusted if required—the base should rest on the first metacarpal (heel of palm), while the handle should rest on the middle of the four fingers. When ready the subject squeezes the dynamometer with maximum isometric effort. The duration of the maximum voluntary contraction for the handgrip test execution was 3 s. No other body movement is allowed. Participants performed the test twice, consecutively, with each hand (first the right hand and then the left hand). There was a 30-s pause between each repetition and a 1-min rest before evaluating the other limb. All participants received verbal support during the execution of the test. The best result from several trials for each hand is recorded (20, 21). We use a numerical rating system to classify the hand grip strength, with 5 denoting excellent, 4 good, 3 regular, 2 poor, and 1 very poor hand grip strength as shown in Table 2 (23).

We classified waist circumference into 2 categories: healthy and at risk, based on gender. Women are said to be at risk if their waist circumference is >88 cm and for men >102 cm, regardless of their BMI category. Waist circumference was measured using WHO guidelines (the midpoint between the lower border of the rib cage and the iliac crest) (24).

Flexibility was tested using the sit and reach (SR) test which was performed using the procedures outlined in the American College of Sports Medicine (ACSM) manual. A standard SR box was placed on the floor, by placing tape at a right angle to the 38 cm mark. The participant sat on the floor with shoes on and fully extended one leg so that the sole was flat against the end of the box. Both knees should be locked and pressed flat to the floor—the tester may assist by holding them down. The participant then extended her arms forward, placing one hand on top of the other. With palms down, she/he reached forward sling hands along the measuring scale as far as possible without bending the knee of the extended leg. The hands should remain at the same level, not one reaching further forward than the other. The subject reaches out and holds that position for at least one to two seconds while the distance is recorded (25, 26). The SR test results were divided into 5 fitness categories by age and gender as shown in Table 3.

We also asked participants about their physical activity level using the IPAQ (International Physical Activity Questionnaire). We divided physical activity levels into high, moderate, and low. A participant who scores a high level on the IPAQ engages in at least a moderate-intensity activity for one hour or more every day. Those who score a moderate level engage in at least 30 min a day of moderate-intensity activity on most days. Those who did not fit into the high and moderate categories were grouped into low-level physical activity (28). Moderate-intensity activity is a physical activity that allows a person to talk while doing activities but not sing, examples are walking briskly (3 miles per hour or faster, but not race-walking), water aerobics, bicycling slower than 10 miles per hour on primarily flat or level terrain without hills, tennis (doubles), ballroom dancing, and general gardening. Above moderate-intensity activity, there is vigorous-intensity activity. When doing vigorous-intensity activity, a person cannot speak more than a few words without pausing for a breath. Examples of vigorous intensity-activity are race walking, jogging, or running; swimming laps; tennis (singles); aerobic dancing; bicycling 10 miles per hour or faster that may include hills; jumping rope; etc (29).

Questionnaires were given to the patient to assess the self-reported musculoskeletal and eye problems. The participants were also given a body diagram, which was presented in the questionnaire. They were required to fill out the Nordic musculoskeletal questionnaire and eye problems in Indonesian (30). The eye problems that we asked about in the questionnaire are blurred vision while viewing the computer, blurred vision when looking into the distance after computer work, difficulty or slowness in refocusing eyes from one distance to another, irritated or burning eyes, dry eyes, eyestrain, headache, tired eyes, sensitivity to bright lights, and eye discomfort (31).

A descriptive analysis was carried out to assess the demographic information, the health profile, the injury characteristics, the number of self-reported eye complaints, and the MSK problems of the participants. The relationships between MSK problems with physical fitness and physical activity were analyzed using a Chi-square correlation test. We utilized the chi-square test to evaluate the association between categorical variables within our dataset, specifically comparing two non-paired groups. This choice of test was made due to the non-paired nature of the data being compared. The factors we analyze from physical fitness are body mass index (BMI), body fat percentage (BF), waist circumference, hand grip strength, and flexibility. We further examined the association between musculoskeletal complaints and demographic factors such as age and gender, alongside exploring the interrelation among physical fitness variables and physical activity. The different incidences of those variables among PGs and CGs were evaluated using the same test. If the chi-squared data assumption was violated, the likelihood ratio was used. All analyses maintained a significance level of p < 0.05. SPSS 27.0 software (IBM, Armonk, NY, USA) was employed for all statistical analyses.

Our data revealed that two-thirds of players experienced MSK complaints, with the most common complaints being pain in the neck, shoulder, hand, and wrist. This correlated with previous research indicating that gamers also experience MSK pain and overuse injuries in the neck, back, shoulder, hand, and wrist (1, 2, 17, 32). Several factors may influence the mechanism of injury in esports players, including poor posture and ergonomics, prolonged static sitting, repetitive upper extremity movements, and lifestyle variables such as physical inactivity (2, 12, 17, 32). Clinically, prolonged use of mobile phones or gaming devices correlates with neck, shoulder, and upper limb pain (1) and also significantly worse spinal posture, mobility, and stability due to prolonged periods of forward flexion head posture (13). Prolonged sitting can trigger abnormal postures that activate the neck and back muscles, leading to muscle strain and fatigue. Weakened muscles are less able to support spinal function, contributing to increased mechanical pressure on intervertebral discs and ligaments, resulting in musculoskeletal pain and discomfort (1). Therefore, in the current study, discomfort was the predominant complaint experienced by most of the players (36.9%) followed by fatigue (24.6%). There is no statistically significant difference in MSK complaints was observed between the PG and CG groups. We also did not observe any correlation between MSK complaints and physical fitness or physical activity among esports players. This finding could potentially be attributed to the relatively brief career span of esports players, typically pursued by individuals in their twenties. Unlike many traditional sports, where athletes may continue competing into their early thirties, esports players often have shorter careers, with approximately one in five professional esports players discontinuing their careers after just two years (33). This trend is driven by the reliance of esports players on their capacity to swiftly and accurately respond to complex visual stimuli, a skill that is believed to decline after the age of 24 (34).

The majority of players (76.6%) in the present study report low levels of physical activity. There is a significant disparity in physical activity levels between PG and CG, with PG exhibiting notably lower activity levels compared to their casual counterparts (p = 0.001). This is similar to the previous study by DiFrancisco-Donoghue et al. which surveyed 65 collegiate varsity esports players, this study found that the average esports player practices between 5.5 and up to 10 h per day before competitions, 40% of players reported no physical activity outside of gaming, and 15% reported sitting for 3 or more hours without getting up to take a break (2). Another study by Bayrakdar et al. found that average esports players spend 9.3 ± 1.1 h for practice and have poor physical activity levels, recording only 6,646 ± 3,400 steps according to Tudor-Locke & Bassett physical activity level determination criteria (35). Furthermore, it is noteworthy that the guidelines for adult physical activity prescribed by both the American Heart Association and the American College of Sports Medicine are consistent, advocating for a minimum of 150 min of moderate exercise per week, complemented by strength training sessions on 2 or more days per week (36). The majority of our participants failed to meet these recommended activity levels. This aligns with prior research indicating that esports players exhibit significantly lower levels of physical activity than the recommended minimums, with an average frequency of only 1.7 ± 1.9 days per week and a duration of 39.5 ± 40.4 min per day (32, 37).

In this study, the majority of players (59.6%) reported sleeping for 6–7 h per night. These findings parallel those of a study on South Korean esports players, which noted delayed sleep patterns, extended wake times, and a nightly sleep duration of less than 7 h (38). The prevalence of late-night gaming among esports players may contribute to their irregular and abnormal sleep schedules. Sleep deprivation can impact esports performance similarly to traditional sports, as sleep plays a critical role in fundamental cognitive functions such as processing speed, attention, and working memory, all of which are vital for esports success. Inadequate sleep not only compromises performance but also undermines physical health and recovery from injuries. Moreover, it heightens the likelihood of resorting to performance-enhancing substances or excessive caffeine consumption, potentially exacerbating the health consequences associated with insufficient sleep (32). Conversely, 49% of participants in our study reported no daytime sleepiness. This disparity may stem from variances in individual tolerance levels to drowsiness, as suggested by experts.

Our data indicate that 51% of players do not smoke, whereas only 44% of players are smokers, resulting in a slight difference between these two habits. This aligns with a study conducted by Arslan et al., which investigated the esports community at a university in Turkey. The study reported that a notable proportion of esports players, comprising 37.9%, were smokers (39). The rising incidence of smoking among esports players represents a significant concern and exacerbates predisposing factors for stroke (40).

Common eye problems experienced by computer and mobile users can broadly be categorized into two types: (a) dry eye that causes irritation, headaches, and light sensitivity; and (b) visual accommodation problems, such as near-focal blurred vision and difficulty with refocusing (32). In our study, eye fatigue emerged as the most common eye problem (n = 50) in Figure 8, followed by distance vision blur (n = 46), blurry vision during screen viewing, photophobia (both n = 40), and accommodative dysfunction (n = 30). This aligns with a previous study by DiFrancisco-Donoghue et al. which concludes that ocular fatigue was the most reported non-musculoskeletal health issue among collegiate esports participants (56%) (2). All esports players reported at least one ocular problem, with the majority reporting multiple complaints. A study by Schary et al. suggests that prolonged visual attention, inconsistent sleep schedules, and excessive computer screen blue light exposure can cause generalized eyestrain and abnormal sleep patterns. It is imperative to implement preventive measures by undergoing regular eye tests, utilizing appropriate glasses, avoiding dry eyes, and taking breaks between games (32).

Mobile esports players are susceptible to musculoskeletal (MSK) issues due to ergonomic challenges associated with their playing positions. Typically, players adopt a head-down posture while looking at the screen, hold the mobile device with a bent wrist, and engage in repetitive thumb movements involving twisting or pushing (47). These actions can lead to an imbalance between agonist and antagonist muscles, increasing the risk of muscle injury as discussed in the preceding section (2). Prolonged durations of gameplay and increased flexion of the neck further heighten susceptibility to neck, shoulder, and upper limb pain (48, 49). Additionally, repetitive thumb and finger movements during gaming can result in tendinopathy due to the pushing and twisting motions involved (50).

Musculoskeletal disorders in e-sports players can be reduced by improving posture and work environment. Players need to pay attention to the height and distance of the screen, the grip and hand position, and the use of an arm or backrest (51). The optimal viewing distance for a mobile device is at least 35 cm. However, larger screens, such as those resembling a personal computer (PC), necessitate a proportionally greater viewing distance (52). When using a PC, the center of the monitor should be 5 to 6 inches below the straight vision line at a distance of 20 to 28 inches away. Room light must be adjusted to limit glare. Esports players must be educated to do exercises to prevent eye fatigue such as near-far focusing, palming, and the “20-20-20 rule” that instructs players to look 20 feet away for 20 s every 20 min (12, 53, 54). To reduce neck and back pain, players must regularly do core exercises such as back extensions, rhomboids, balance training, active and passive stretching (54–56). For mobile device usage, to mitigate the risk of neck and shoulder discomfort, it is recommended to engage in stretching exercises targeting the pectoral muscles, upper trapezius, rhomboid muscles, and levator scapulae (57). Adjusting the position of the arms and hands is also important to prevent upper extremity injuries (54).