Back pain in children and teenagers

How back pain influences daily activities and quality of life: Incidence of back pain related to age

Low back pain is a prevalent global musculoskeletal issue, with a lifetime prevalence ranging from 49% to 70% in adults. Traditionally associated with adults, recent field surveys indicate comparable prevalence rates in children and adolescents, challenging earlier assumptions. Non-specific low back pain, where the source cannot be identified through diagnostic imaging, accounts for about 80%-90% of cases. Studies have shown that over 80% of adolescents with low back pain exhibit no underlying pathology. The prevalence of low back pain in younger populations varies widely, influenced by study methodology, age, and pain types. Research suggests that back pain prevalence in adolescents increases with age, with a shift in attitudes considering it is not necessarily indicative of specific issues. Level of evidence: level V.

Can We Trust the Literature on Risk Factors and Triggers for Low Back Pain? A Systematic Review of a Sample of Contemporary Literature

Background

Risk factors (RFs) for the "disease" of low back pain (LBP) are probably different from the triggers of new episodes of LBP. Investigating RFs for the onset of the "disease" and the triggers of LBP is problematic if researchers fail to discern the different types of pain-free status of participants at and before baseline. There is a difference between never having had LBP and having been pain-free for a certain period only. In this review, we assessed the dependability of contemporary literature on RFs and triggers of LBP, in relation to the "disease" and the episodes, respectively.

Methods

A literature search from 2010 until 2017 was performed. Information on the definitions of LBP, potential RFs/triggers, and study design was extracted. Studies were reclassified based on the type of LBP concerning the "disease," episode, or mixed/unclear/chronic. RFs and triggers were grouped into major domains, and positive associations listed, respectively, for the "disease" and episodes.

Results

In 42 of the included 47 articles, it was not clear if the authors investigated RFs for the "disease" of LBP or triggers of new episodes. Only one study properly reported RFs for the onset of the "disease" of LBP, and four studies were deemed suitable to investigate triggers for a new episode of LBP. No study reproduced the results of other included studies.

Conclusion

Trustworthy information regarding RFs and triggers of LBP is rare in the current literature. Future research needs to use precise definitions of LBP (onset of the "disease" vs. episodes) and nominate the timing of the associated factors in relation to the types of LBP as these are two critical factors when studying causes of LBP.

Psychogenic Low-Back Pain and Hysterical Paralysis in Adolescence

STUDY DESIGN

A retrospective review.

OBJECTIVE

The purpose of this study was to investigate the clinical outcomes in adolescents diagnosed with psychogenic low-back pain and hysterical paralysis and to evaluate the efficacy of differential diagnosis methods.

SUMMARY OF BACKGROUND DATA

The incidence of low-back pain in adolescence is similar to that in adults, but the causes of low-back pain are difficult to determine in most cases. For these patients, a definitive diagnosis of psychogenic low-back pain and hysterical paralysis as well as adequate treatment are clinically important to avoid unnecessary surgical treatment.

METHODS

Eleven patients (3 males and 8 females; mean age, 16.5 years; range, 13-19 y) diagnosed with psychogenic low-back pain and hysterical paralysis were followed up for 2-10.25 years (mean, 4.67 y). Nonorganic signs were observed in almost all patients. For the purpose of excluding organic disorders, the thiopentone pain study was used in patients who complained mainly of pain, and motor evoked potentials using transcranial magnetic stimulation were measured in patients experiencing primarily muscle weakness.

RESULTS

The psychiatric diagnosis was neurosis in 9 patients, whereas it was psychosomatic disorder in 2 patients. Conservative treatment, such as physiotherapy, was performed, and at the final follow-up evaluation, outcomes were regarded as excellent in 7 patients and good in 4 patients.

CONCLUSIONS

The prognosis of psychogenic low-back pain and hysterical paralysis in adolescence is relatively good. However, it is important to understand the characteristics of psychogenic low-back pain and hysterical paralysis in childhood and young adulthood and to perform accurate diagnosis by screening for nonorganic signs and excluding organic disorders by using the thiopentone pain study and motor evoked potentials obtained using transcranial magnetic stimulation.

Lumbar injuries of the pediatric population

Primary musculoskeletal etiologies, such as stress fractures, strains, facet arthropathy, and sacroiliac joint dysfunction, are more common causes of pediatric pain than systemic diseases, both in the office setting and the emergency room. Systemic features, young age, and atypical pain should clue physicians to causes other than a primary musculoskeletal cause and prompt an intensive search for other conditions.

Spinal manual therapy interventions for pediatric patients: a systematic review

OBJECTIVE

Although much has been written about the efficacy of manual therapy interventions for adults with headaches or spinal pain, little research has focused on the use of these interventions in pediatric patients. The purpose of this systematic review was to evaluate the evidence for spinal manual therapy (SMT) interventions in patients 4-17 years old with headaches and/or mechanical spinal pain.

METHODS

A search for relevant studies published in the past 15 years was conducted on MEDLINE, CINAHL, Cochrane Central Register of Randomized Control Trials, PEDro, PubMed, and Sports Discus. Only English language articles were reviewed. Studies had to include at least one outcome measure for pain, function, or quality of life. Studies evaluating post-operative interventions, or those in which the interventions were directed at influencing excessive spinal curvatures, were excluded. Case reports and studies that did not limit analysis of the results to the pediatric population were also excluded.

RESULTS

Two randomized control trials and two studies offering lower levels of evidence were identified in the literature search. The latter studies were prospective cohort studies. The four studies were evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

DISCUSSION

There are very little data in the literature to support or refute the use of SMT interventions in pediatric patients. Further research is required to establish a strong evidence-based foundation for use of these interventions in children.

What is adolescent low back pain? Current definitions used to define the adolescent with low back pain

Adolescent low back pain (ALBP) is a common form of adolescent morbidity which remains poorly understood. When attempting a meta-analysis of observational studies into ALBP, in an effort to better understand associated risk factors, it is important that the studies involved are homogenic, particularly in terms of the dependent and independent variables. Our preliminary reading highlighted the potential for lack of homogeneity in descriptors used for ALBP. This review identified 39 studies of ALBP prevalence which fulfilled the inclusion criteria, ie, English language, involving adolescents (aged 10 to 19 years), pain localized to lumbar region, and not involving specific subgroups such as athletes and dancers. Descriptions for ALBP used in the literature were categorized into three categories: general ALBP, chronic/recurrent ALBP, and severe/disabling ALBP. Whilst the comparison of period prevalence rates for each category suggest that the three represent different forms of ALBP, it remains unclear whether they represented different stages on a continuum, or represent separate entities. The optimal period prevalence for ALBP recollection depends on the category of ALBP. For general ALBP the optimal period prevalence appears to be up to 12 months, with average lifetime prevalence rates similar to 1-year prevalence rates, suggesting an influence of memory decay on pain recall.

Ependymoma as a cause of low back pain in a young healthy athlete

Young athletes with exercise-associated, acute low back pain are likely to be symptomatic from musculoskeletal trauma. Those who experience more insidious pain or pain not associated with physical activity must be assessed for infectious, inflammatory, or mass lesions. We present an adolescent athlete who was suspected of an overuse syndrome as the cause for low back pain. The case illustrates the potential hazard of such a presumptive diagnosis. The patient was found to have a myxopapillary ependymoma of the lumbar spine. This case emphasizes the importance of follow-up care.

Physical activity and low-back pain in schoolchildren

Design of the experiment is to study the cross-sectional sample with retrospective information. The objective is to identify the types of physical activity associated with the decreased occurrence of low-back pain (LBP) in schoolchildren. Physical activity may be hypothesized to possess a potential for LBP prevention. The possible connection between LBP and specific sports activities is however sparsely documented. A total of 546, 15- to 16-year-old schoolchildren filled a questionnaire on current physical activities and LBP occurrence and severity. In multiple logistic regressions, the association of LBP with exposure variables was corrected for body height and weight (data from school health service files) and for anthropometric and school furniture parameters. More than half of the children reported pain or discomfort in the low-back region during the preceding 3 months, and 1/4 experienced a decreased functioning or need of care because of LBP. LBP correlated with physical inactivity, e.g. time spent on homework and hours watching TV or video, and with a series of sports activities, e.g. jogging, handball playing and gymnastics. Among sports activities, only swimming and the number of hours per week participating in soccer were associated with a decreased LBP prevalence. With the exception of swimming and soccer, the types of sport reported by this schoolchild population do not offer themselves for consideration as tools for LBP prevention. Based on the associations found with indicators of physical inactivity, attempts to motivate the children to increase their general physical activity level should be considered for trial.

Low back pain in 15- to 16-year-old children in relation to school furniture and carrying of the school bag

STUDY DESIGN

Cross-sectional sample with longitudinal information.

OBJECTIVE

To estimate the relationship between the occurrence of low back pain (LBP) and various types of school furniture and anthropometric dimensions in schoolchildren, and physical loading by school bag carrying.

SUMMARY OF BACKGROUND DATA

Some types of school furniture may be hypothesized to prevent or cause LBP. Despite strong opinions in the public debate about a possible relationship between use of various types of school furniture and LBP, scientific research on this matter is sparse.

METHODS

Five hundred forty-six schoolchildren aged 14 to 17 years answered a questionnaire about sitting positions during school hours and the presence and severity of LBP. Furthermore, the anthropometric dimensions and the weight of the school bags were measured. The types and dimensions of the school furniture were described and measured. In multivariate analyses was adjusted for physical activity and other possible risk factors.

RESULTS

More than half of the adolescents experienced LBP during the preceding 3 months, and 24.2% reported reduced daily function or care seeking because of LBP. LBP occurrence was not associated with the types or dimensions of the school furniture or body dimensions, but was positively associated with carrying the school bag on 1 shoulder [OR: 2.06 (1.29-3.31)].

CONCLUSION

The present study does not support the hypothesis of different types of school furniture being a causative or preventing factor for LBP. Carrying the school bag in an asymmetric manner may play a role.

Is active participation in specific sport activities linked with back pain?

A cross-sectional survey of 439 children/adolescents aged 12-13, living in Odense, Denmark, in the year 2001. To investigate (1) if there is any difference in back pain reporting among those practising specific sports as compared with non-performers and (2) if there is an association between specific kinds of sports and self-reported back problems. Back pain is a common complaint in young people and physical inactivity is generally thought to contribute to this. However, some specific sport activities may be detrimental or beneficial to the spine. Information was collected through a semi-structured interview, a physical examination, and a questionnaire. Associations for back pain, low back pain, mid back pain and neck pain in the preceding month were investigated in relation to specific sports. Associations were controlled for body mass index, puberty stage and sex. There was no association between back problems and the practising of sports in general. However, some sports were either positively or negatively associated with back pain. Taking into account the relatively small subgroups and multiple testing, some sports seem to be potentially harmful or beneficial. These sports should be investigated in proper longitudinal study designs, in relation to their effects on back problems in the young.

[Risk factors for back pain in children and adolescents]

Factors that have led to the increasing prevalence of back pain amongst children and adolescents living in industrialized nations are mostly unknown. The following literature review was aimed at determining the risk factors for back pain amongst children and adolescents. We searched both PUBMED and MEDLINE between the years 1985 and 2003 for the keywords "children or adolescents" and "back pain". Only data published in original articles were used. The risk for suffering back pain is influenced by physical, behavioural, emotional and social factors. The effects of physical activity, sitting, muscle status, weight of schoolbags, exercise, television and computer use, as well as age and gender on the development of back pain in children and adolescents were examined. Associations between continuous or recurring back pain and psychosocial factors (lifestyle, emotional factors, social relationships) could be demonstrated. There was no relationship between changes of the spine seen by radiological tests and the development of chronic back pain. Longitudinal epidemiological studies are urgently needed to delineate the risk factors for the development as well as the natural history of chronic back pain in the young.

The frequency and associated factors of low back pain among a younger population in Turkey

STUDY DESIGN

Open design cross-sectional questionnaire.

OBJECTIVES

The aims of this study are to determine the frequency of low back pains in the younger population and the factors that have an influence on this frequency.

SUMMARY OF BACKGROUND DATA

Low back pain is one of the most important social problems that causes injuries in the younger population. Low back pain frequency is around 30% among adolescents, and 88% of those with low back pain experiences in adolescence have low back pain in later years. Therefore, identifying and, if possible, preventing the associated factors in adolescence and young adulthood is essential for the solution of this social problem.

METHODS

A total of 1,552 students from a total of 8,000 who had come from all parts of Turkey for university registration accepted to participate in the study and were given a questionnaire about low back pain experiences, disability, and possible associated factors.

RESULTS

Low back pain frequency was found to be 40.9%. This rate increases with age. Abandonment of moderate level physical activity and traumas such as slipping on ice and falling down the stairs were identified as associated factors.

CONCLUSIONS

Regular physical activity and the prevention of falls might be ways for decreasing the frequency of low back pain experiences among the youth and significantly influencing the frequency of low back pain in adult population.

Children and adolescents with low back pain: a descriptive study of physical examination and outcome measurement

STUDY DESIGN

A retrospective, cohort study of children and adolescents with low back pain (LBP) referred to physical therapy.

OBJECTIVES

To describe the clinical presentation, examination findings, and classification of children and adolescent patients with LBP, and to explore the concurrent validity of the Oswestry questionnaire as a disability measure in this group.

BACKGROUND

Little information is available regarding the clinical presentation, physical examination findings, and outcome assessment in children and adolescents with LOP.

METHODS AND MEASURES

Charts were reviewed for historical, diagnostic, physical examination,and outcome information. Diagnoses given by the referring physicians were recorded. A treatment-based classification was made for each subject. Descriptive statistics were calculated for all variables. The validity of the Oswestry questionnaire was examined.

RESULTS

The children and adolescents included in this study represented 5% (n = 25) of all cases of LOP referred to physical therapy. A greater percentage of patients had difficulty with extension than with flexion range of motion (ROM). Initial pain scores were lower if a specific pathology was present (P = .001). Initial pain and Oswestry scores were poorly correlated (r = 0.16). Forty-four percent (n = 11) of patients scored under the floor value of 12% on the Oswestry.

CONCLUSION

The referral rate of children and adolescents with LBP seems to be low. Compared to adults, children and adolescents appear more likely to have a specific diagnosis given to them by their physician. The physical examination findings appear to indicate that spinal stabilization approaches may be beneficial for many patients. The Oswestry questionnaire may not be a valid tool for documenting changes in disability in these patients. Further research is needed on the conservative management of children and adolescents with LBP.

Can passive prone extensions of the back prevent back problems? A randomized, controlled intervention trial of 314 military conscripts

SUMMARY OF BACKGROUND DATA

Back schools may be effective in treating back problems, but there is conflicting evidence of the effect on prevention.

OBJECTIVES

To investigate if passive prone extensions of the back can prevent back problems.

STUDY DESIGN

Prospective, randomized controlled intervention trial.

METHODS

In total, 314 male conscripts were randomized into two groups. After randomization, 65 conscripts dropped out for administrative reasons, leaving 249 conscripts to participate fully in the study. Data were collected through questionnaires at the start of military duty and after 10 months. All conscripts in the intervention group had one 40-minute theoretical lesson on back problems and ergonomics and had to perform passive prone extensions of the back daily during the rest of their military duty. The control group had no intervention. Outcome variables were as follows: 1) number of persons with self-reported back problems during the last 3 weeks; 2) number of persons with self-reported back problems during the last year; and 3) number of persons who reported having consulted the regiment medical physician with back problems during their military service.

RESULTS

In an intention-to-treat analysis, significantly fewer persons in the intervention group versus those in the control group reported back problems during the last year (33% versus 51%), and the number needed to prevent was 6. Significantly fewer persons in the intervention group versus those in the control group consulted the regiment infirmary (9% versus 25%), and the number needed to prevent was 6.

CONCLUSION

It may be possible to reduce the prevalence rate of back problems and the use of health care services during military service, at a low cost, using passive prone extensions of the back motivated by a back school approach, including the theory of the disc as a pain generator and ergonomic instructions.

Back pain reporting pattern in a Danish population-based sample of children and adolescents

STUDY DESIGN

A cross-sectional survey of 806 pupils in Odense, Denmark was performed. This survey included children and adolescents ages 8 to 10 and 14 to 16 years obtained through two-stage cluster sampling from schools stratified according to school type, location, and socioeconomic character of the uptake area.

OBJECTIVES

To establish the 1-month prevalence of neck, middle back, and low back pain and the consequences this disorder may have in relation to age and gender.

SUMMARY OF BACKGROUND DATA

The differences in definitions of back pain and the variety of age groups included in previous studies make it difficult to draw clear conclusions about the onset of pain for various spinal regions in the young.

METHODS

Information on back pain within the preceding month, obtained through a standardized interview of 481 children and 325 adolescents, was categorized according to area of pain, age, and gender. The consequences of back pain also were studied.

RESULTS

The 1-month prevalence of back pain was 39%. Thoracic pain is most common in childhood, whereas thoracic pain and lumbar pain are equally common in adolescence. Neck pain and pain in more than one area of the spine are rare in both age groups. No gender differences were found. Of those who had back pain, 38% also reported some type of consequence, usually either visits to a medical physician or diminished physical activities.

CONCLUSIONS

For clinical and research purposes, neck pain, middle back pain, and low back pain in childhood should be regarded as three specific entities. In future research the data for different age groups should be reported separately.

Lumbar disc herniation in a 27-month-old child. Case report

The occurrence of disc herniation is rare in children. A 27-month-old child fell from his cradle and developed, in the following 2 weeks, irritability, low-back pain, and difficulty in walking. On physical examination a compensatory gait, paravertebral muscle spasm, and a restricted right straight-leg raising test were demonstrated. Plain x-ray films revealed a narrowed L4-5 intervertebral space. Magnetic resonance imaging of the lumbosacral spine demonstrated decreased signal in the L4-5 disc, with posterior disc protrusion. At surgery, blood infiltrating the subperiosteal plane was observed. Via a left hemilaminectomy and under microscopic magnification, the left L-5 nerve root was found to be intact, and on the right side significant nerve root compression was identified. During dissection an accidental dural tear occurred. A right L-4 hemilaminectomy was performed, and the disc fragments were removed until a complete nerve root decompression was obtained and the dura was repaired. The child recovered uneventfully and was asymptomatic 7 years postsurgery. This child is one of the youngest patients with a herniated disc reported in the world literature. The authors discuss the diagnostic difficulties and management of this entity in children.

Back pain in children who present to the emergency department

The purpose of this study was to identify the causes and epidemiology of back pain in children who present to the emergency department. All children who presented to an urban pediatric emergency department (ED) during a 1-year period with the chief complaint of back pain were examined and evaluated with a uniform questionnaire. This was completed at the time of the ED visit in 48%, and within 48 hours in 52%. During a 1-year period, 225 children with a complaint of back pain were evaluated. The mean age was 11.9 +/- 4 years and 60% were female. Onset was acute (< or = 2 days) in 59%, and chronic (> or = 4 weeks) in only 11.6%. Pain awakened children from sleep in 47%, and caused 52% to miss school or work. The most common diagnoses were direct trauma (25%), muscle strain (24%), sickle cell crises (13%), idiopathic (13%), urinary tract infection (5%), and viral syndrome (4%). Radiographs of the back were rarely helpful. About 5% required hospital admission; one half of these were attributed to sickle cell crises. We conclude that back pain is an uncommon reason for children to present to an emergency department. When present, pediatric back pain is most often musculoskeletal, associated with an acute infectious illness or a traumatic event. Although the etiology is rarely serious, back pain often affects the daily activities of symptomatic children.

Epidemiology of juvenile low back pain: a review

Studies show that the cumulative prevalence of low back pain (LBP) in juveniles was close to 30%. The majority of the LBP was mild. Of those with LBP approximately 8% sought medical treatment. Chronic or recurrent LBP averaged 8.1% of the adolescent populations studied. The cumulative prevalence of LBP increased with age. One study showed a cumulative prevalence of LBP of over 70% by age 15. A potential link between the adolescent growth spurt and the increased prevalence of LBP was proposed. Asynchronous bone growth resulting in skeletal malalignment was proposed as a possible cause of LBP. Immaturity of the vertebral bony structures was thought to increase the risk of pars defects. Correlations between anthropometric measurements of height and weight were inconclusive. The role of decreased muscle flexibility in LBP was also inconclusive. Some researchers found a correlation between age, gender, height and LBP. Disc degeneration and spondylolytic symptoms were also noted as sources of LBP. However, not all cases of disc degeneration (DD) or spondylolysis were symptomatic of LBP. It was noted that the prevalence of DD was rare in adolescents. Disc protrusions were more common in LBP groups than in non-LBP groups, and females with LBP had more disc protrusions than males with LBP. Risk factors for spondylolysis and spondylolisthesis included genetics, the growth spurt, repetitive stresses and sports participation. Within competitive sports, age and training more than 15 hours/week correlated with the incidence of spondylolytic changes. Participation in sports as a risk factor for LBP was reported. A familial tendency for LBP was noted in one study in which the child had an increased incidence of reported LBP if one or both parents had a history of LBP.

Difficulties in diagnosing intrinsic spinal cord tumours

Thirteen children with intrinsic spinal cord tumours were seen between 1984 and 1995. In only one was this the presumptive diagnosis at referral, despite a high incidence of characteristic features. Eight had presented to their local paediatrician, four to local orthopaedic teams, and one to a general surgeon. Eleven had back pain. Eleven had either spinal curvature or change in gait. The interval between onset of symptoms and diagnosis ranged from one week to six years, with a mean of 17.5 months. In nine children symptoms had been present for four or more months. In nine, unrewarding investigations had been carried out. This paper highlights typical presenting features of these tumours and how earlier diagnosis can be achieved.

An assessment of lower back pain in young adults: implications for college health education

A convenience sample of 243 undergraduates completed a 36-item questionnaire on their knowledge about back care and exercise patterns before they attended lectures and a workshop on back mechanics. At the workshop, the students were individually evaluated for posture, hamstring flexibility, hip flexor flexibility, back and abdominal strength, and lifting technique. Twenty-nine percent of the students reported that they experienced no back pain; 71% experienced lower back pain 1 to 5 days a week. The majority were neglectful of their posture, lifting and carrying techniques, and scored fair-to-poor on the hamstring flexibility test, possibly foreshadowing back problems in later life. The majority of respondents were unsure of what exercises to do for back care. Within the subgroup of students who claimed they were knowledgeable about exercise, more than 50% were performing ineffective and potentially harmful exercises. The results underscored the potential worth of health education on back care offered through didactic instruction and experiential workshops.

Childhood back pain: diagnostic evaluation of an unusual case

Low back pain is uncommon in children. The case of a 5-year-old boy presenting with back pain that proved to be caused by a metastatic primitive neuroectodermal tumor is presented and the evaluation of such patients is discussed.