Lifetime Prevalence of Nonspecific Low Back Pain in Adolescents: A Cross-sectional Epidemiologic Survey

'It can be very complicated': A qualitative analysis of clinicians' practices and perspectives on treating adolescents with nonspecific persistent back pain

ObjectiveTo explore the practices, perspectives and beliefs of clinicians treating adolescents with nonspecific persistent back pain.DesignA qualitative descriptive study using individual, semi-structured interviews. Reflexive thematic analysis was used to code interview transcripts and generate relevant themes.SettingClinicians in any clinical setting where adolescents with nonspecific persistent back pain are treated.ParticipantsTen clinicians (eight chartered physiotherapists, one nurse and one psychologist) who currently treat or have treated adolescents with nonspecific persistent back pain.ResultsFive themes were identified which captured the practices, perspectives and beliefs of clinicians treating adolescents with nonspecific persistent back pain: (1) Multiple relationships, one priority, (2) Without buy-in, it won't work, (3) Managing pain, living life, (4) No one-size-fits-all treatment, and (5) Who you see is what you get.ConclusionsTreating an adolescent with nonspecific persistent back pain is not the same as treating an adult with the same condition. Specifically, clinicians must attend to the needs, concerns and beliefs of both adolescents and their parents, reflecting the diminished autonomy of adolescent patients. Clinicians tend to offer person-centred care to adolescents with nonspecific persistent back pain. However, they currently lack guidance on how to foster effective treatment relationships with parents and how to achieve buy-in to a modern conceptualisation of persistent back pain as a biopsychosocial phenomenon.

Does sedentary behaviour cause spinal pain in children and adolescents? A systematic review with meta-analysis

OBJECTIVE

To evaluate whether sedentary behaviour is a risk or prognostic factor for spinal pain in children and adolescents. Specifically, to estimate the (1) direction and strength of the association; (2) risk of spinal pain onset and (3) effect on spinal pain prognosis.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Electronic searches of MEDLINE, Embase, CINAHL and Web of Science up to 23 March 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Reports estimating the effect of sedentary behaviour on spinal pain in young people (≤19 years).

RESULTS

We included 129 reports, 14 were longitudinal (n = 8 433) and 115 were cross-sectional (n > 697 590). We incorporated 86 studies into meta-analyses. (1) From cross-sectional data, we found low certainty evidence of a small positive association between sedentary behaviour and spinal pain (adjusted odds ratio 1.25 (95% CI 1.17 to 1.33), k = 44, n > 92 617). (2) From longitudinal data, we found low certainty evidence of no increased risk for the onset of spinal pain due to sedentary behaviour (adjusted risk ratio 1.07 (95% CI 0.84 to 1.35), k = 4, n = 1 292). (3) No studies assessed prognosis.

CONCLUSION

Cross-sectional data suggest minimally higher odds of spinal pain for children and adolescents who engage in greater sedentary behaviours. However, longitudinal data do not support a causal relationship, indicating that sedentary behaviour does not increase the risk for onset of spinal pain. Due to the low certainty of evidence, these findings must be interpreted with caution. We found no evidence of the effect sedentary behaviour has on spinal pain prognosis in children and adolescents, highlighting a considerable gap in the literature.

The association between the site of back pain and number of painful sites with daily activities, seeking healthcare, and medication use among school adolescents

Introduction

The potential consequences of back pain (BP) are poorly described in adolescents. This study evaluated the association between BP sites (neck, thoracic and low back) and number of painful sites with missed school classes, interference in physical activities, seeking healthcare, and medication use among school adolescents.

Methods

This cross-sectional study included 350 students (5th to 9th grade) of a public school in Brazil. Information on BP site and outcomes were self-reported. Logistic regression analyses were performed.

Results

Participants reporting at least one painful site in spine were 74.9% (n = 262), with mean age of 12.73 ± 1.67 (55.7% were girls). Most of them reported pain in two sites (n = 100; 28.6%) and the most frequent pain site was neck (n = 223; 63.7%). Thoracic and low BP were associated with missing school classes, interference in physical activities, seeking healthcare, and medication use, while neck pain showed no association. The number of painful sites was associated with daily activities and healthcare with those gradients increasing with the number of painful sites.

Conclusion

Thoracic and low BP were associated with daily activities, seeking healthcare, and medication use in early adolescence.

Credibility, readability and content analysis of treatment recommendations for adolescents with nonspecific back pain published on consumer websites

BACKGROUND

Parents may seek out health information online when their adolescent has nonspecific back pain to better understand treatment options. Such information directed towards consumers has not been previously analysed.

METHODS

A descriptive cross-sectional content analysis was performed to describe the treatments recommended on consumer websites for nonspecific back pain in adolescents. The credibility and readability of the websites were also assessed. Systematic Google searches were completed in five countries, and relevant content from eligible web pages was analysed. An a priori codebook with 34 treatment-related codes was developed. Nine additional codes were inductively created during analysis. Credibility was assessed using the JAMA benchmark. Readability was assessed via the Flesch Kincaid Grade Level.

RESULTS

Of 245 web pages, 48 were deemed eligible and analysed. Of 43 treatment codes, 37 were present in at least one web page. The five most frequently identified codes were See the doctor/get a diagnosis (found on 85% of web pages), Ergonomics/posture/biomechanics (52%), Reassurance (48%), Physiotherapy (48%) and Non-prescription pharmaceuticals/supplements (46%). Only 21% of the web pages met all four JAMA benchmark criteria, and 15% cited at least one recent or high-quality source. The median Flesch Kincaid Grade Level score was 9.0 (range 3.5-12.9).

CONCLUSIONS

Parents of adolescents with nonspecific back pain may find that treatment recommendations published online are numerous and varied, with visits to the doctor encouraged. The credibility scores of these web pages are generally low, while the median reading level may be too high for the general population.

SIGNIFICANCE STATEMENT

This analysis reveals that public-facing websites with recommendations for treating adolescent nonspecific back pain do not cite the most recent, high-quality research. Although web pages correctly encourage physical activity and exercise over surgery and prescription medications, they do not reflect the psychologically informed or interdisciplinary care emphasized in recently published treatment recommendations. Clinicians must be aware that caregivers of their adolescent patients with nonspecific back pain may be exposed to online messages that encourage them to keep seeking a diagnosis.

The Impact of Physical Activity on Adolescent Low Back Pain: A Systematic Review

Background: The relationship between physical activity and low back pain (LBP) in adolescents is complex, with conflicting evidence on whether activity is protective or a risk factor. The COVID-19 pandemic has introduced new challenges, increasing sedentary behaviors among adolescents. This systematic review updates the evidence on the association between physical activity and LBP in this population, focusing on the impact of the pandemic. Methods: A systematic search of PubMed, Cochrane Library, Web of Science, Medline, and SCOPUS identified observational studies published between January 2011 and December 2023. This review focused on adolescents aged 10 to 19 years, examining the effects of various physical activity levels and types on LBP incidence. Quality assessment was conducted using the ROBINS-I tool. Results: Twelve studies were included, with a total of 78,850 adolescents. The findings suggest a U-shaped relationship between physical activity and LBP, where low and high activity levels increase LBP risk, while moderate activity appears protective. The pandemic exacerbated LBP prevalence, likely due to increased sedentary behavior. Gender differences were noted, with females more likely to report LBP, particularly related to sports participation. Conclusions: Moderate physical activity may protect against LBP in adolescents, whereas both inactivity and excessive activity heighten risk. The pandemic's impact highlights the need for balanced physical activity to prevent LBP. Further research should explore the long-term effects of these changes.

myoActivation®, a Structured Assessment and Therapeutic Process for Adolescents With Myofascial Dysfunction and Chronic Low Back Pain: A Case Series

Introduction Myofascial dysfunction is a significant, but often unrecognized, contributor to chronic low back pain (CLBP). myoActivation is an innovative method that utilizes a structured assessment and therapeutic process to recognize and manage myofascial dysfunction and pain. Since 2017, the British Columbia Children's Hospital Complex Pain Service has used myoActivation as a tool in the interdisciplinary care of adolescents with chronic pain. This case series explores the journey to discharge of patients in whom myoActivation was incorporated as part of their CLBP management. Methods We retrospectively reviewed clinical records of adolescents reporting CLBP who underwent myoActivation between August 2022 and January 2023 and had subsequently been discharged. Information obtained for analysis included preclinical information (medical/injury/pain history, previous investigations, diagnoses, therapies, and quality of life indicators); clinic recommendations, assessment findings, management strategies, and specifics of the myoActivation process; and reported changes at discharge (quality-of-life measures and medication use). Results Eight cases were reviewed: all female, with a median age (range) of 16.5 (15.7-19.5) years. Before admission, patients had experienced chronic pain for a median duration of 4.3 (1-8) years, had self-reported average pain intensity of 7.5 (4-9) on the 0-10 numeric pain scale, with poor quality-of-life impacts including sleep disturbance (8/8, 100%), school absence (8/8, 100%), and low mood (6/8, 75%). Patients attended three (2-5) myoActivation sessions over two (1-10) weeks. The overall duration of their interdisciplinary care was 12 (7-25) months. At discharge, there were improvements in pain (7/8, 88%), physical functioning (5/8, 63%), sleep (6/8, 75%), school attendance (5/8, 63%), and mood (4/6, 67%) and reduced prescription and over-the-counter medication use in most cases. Conclusion This case series suggests that myoActivation may be a useful clinical tool in the assessment and management of adolescents with myofascial dysfunction and CLBP. Prospective longitudinal research is required to establish evidence that confirms the clinical efficacy of myoActivation within interdisciplinary care.

Severity of slouched posture during smartphone use is associated with the musculoskeletal discomfort, daily usage, and school year among adolescents

Real-time measurement of the craniovertebral, thoracic kyphosis, and lumbar lordosis angles during natural and smartphone usage postures in sitting were analysed in a cohort of 560 adolescents using independent t-tests and Spearman's correlations between their reported musculoskeletal symptoms, daily device use and school year. Students with musculoskeletal symptoms (mean difference: 4.1-9.4°, p < .001) and in secondary schools (mean difference: 13.6-29.4°, p < .001) had a greater forward-head posture quantified by craniovertebral angle in both postures. Loss of lumbar lordosis was found in students spending ≥2 h/day on electronic devices (mean difference: 3.2°, p = .029) and those with musculoskeletal symptoms (mean difference: 5.4°, p = .001). Secondary school students exhibited a greater thoracic kyphosis when using smartphones (mean difference: 3.3°, p = .003). Findings suggest the urgent need for early and proactive intervention targeted to minimise the risk of developing musculoskeletal disorders related to intense device use for young adolescents.Practitioner Summary: Adolescents: (1) in higher school year had increased forward-head posture (FHP) and thoracic kyphosis; (2) with musculoskeletal symptoms had increased FHP and loss of lumbar lordosis, and; (3) with extended device use had a loss of lumbar lordosis. Early intervention targeting young adolescents promoting optimal posture and habit of device use is warranted.

Association between untreated low back pain and injury proneness and confounding role of behavioral-health difficulties among younger adolescents: a population-based study

PURPOSE

Low back pain (LPB) is mostly left untreated (LBP_untreated) and may increase the injury risk due to associated behavioral-health difficulties (BHDs) among adolescents. This study assessed the association between LBP_untreated (vs. treated LBP (LBP_treated)) and injuries and the mediating role of BHDs among younger adolescents (10-16 years).

METHODS

This population-based study compared 328 adolescents with LBP_untreated (mean age = 13.7 ± 1.3) with 291 with LBP_treated (mean age = 13.3 ± 1.2) from north-eastern France. They completed a questionnaire collecting, at school-year end, socioeconomic features, LBP_treated/LBP_untreated, BHDs (alcohol/tobacco use, excessive screen-time, poor social support, poor physical health, depressive symptoms, and pain limiting activities), and injuries during the current school-year. Data were analyzed using multinomial logistic regression models and Kaplan-Meier estimates.

RESULTS

The proportion of subjects without alcohol/tobacco use or depressive symptoms decreased with time more quickly since age 10 among the adolescents with LBP_untreated than among those with LBP_treated. Hence, most LBP early started and the subjects with LBP_untreated had a higher risk of single injury (sex-age-class-level-socioeconomic-features-adjusted relative risk ratio RR = 1.63, p < 0.05, vs. LBP_treated) and a much higher risk of ≥ 2 injuries (RR = 2.60, p < 0.001). BHDs played a strong mediating role in the association between LBP_untreated and ≥ 2 injuries (contribution = 48%) but a modest mediating role in that between LBP_untreated and single injury (contribution = 10%) (pseudo R² = 7.6%).

CONCLUSION

LBP_untreated is common and associated with injuries partly due to BHDs (which may alter physical/mental capabilities, risk perception/awareness, and vigilance) among younger adolescents. Our results may inform healthcare providers that they can detect/treat LBP and BHDs to prevent their aggravation and injuries.

Describing the nonsurgical, nonpharmacological interventions offered to adolescents with persistent back pain in randomized trials: A scoping review

BACKGROUND AND OBJECTIVES

Persistent nonspecific back pain is now established as a biopsychosocial phenomenon that can be meaningfully affected by individuals' cognitions, emotions, lifestyle factors and family and social relationships. Recent guidelines for the treatment of adolescents with persistent nonspecific back pain, as well as those for youth with mixed chronic pain, strongly recommend interdisciplinary care in which adolescents receive treatment for both mind and body. The objective of this scoping review was to examine the interventions evaluated in randomized trials for adolescents with persistent back pain to determine whether they correspond to these guidelines and to reveal future research priorities.

DATABASES AND DATA TREATMENT

The review protocol was registered in March 2022. We followed the PRISMA guidelines for scoping reviews. Twelve electronic databases were searched for relevant study reports. Data were charted on study characteristics, participant characteristics and intervention details using the Template for Intervention Description and Replication (TIDieR) checklist.

RESULTS

The search yielded 1952 records, of which eight reports representing seven randomized trials were eligible. The most common interventions were exercise therapy (n = 6) and back education (n = 4). Five studies employed multiple intervention components, but none was multidisciplinary. Studies primarily targeted posture or biomechanical factors. One study included an intervention addressing participants' fears and beliefs about pain.

CONCLUSIONS

Randomized trials for adolescents with persistent back pain have primarily relied upon an outdated, biomechanical explanation of persisting pain. Future randomized trials should align with current treatment recommendations and measure outcomes across multiple biopsychosocial domains.

SIGNIFICANCE

This scoping review describes in detail the interventions included in randomized trials for adolescents with persistent, nonspecific back pain. The review is important because it reveals discrepancies between those interventions and the interventions recommended for this population.

Risk Factors for Disabling and Nondisabling Neck Pain in a Large Cohort of Adolescents

OBJECTIVES

Neck pain is extremely common and represents a substantial economic burden to our society. We aimed to investigate risk factors for nondisabling and disabling neck pain in a large cohort of Italian adolescents with a cross-sectional study.

DESIGN

Six thousand two hundred eighty-one students (14-19 yrs old) answered an online questionnaire, investigating the following: anthropometric data, lifestyle-related items, neck pain frequency and intensity, need for medical examination, and several risk factors. Students who had to give up social activities because of neck complaints constituted the disabling neck pain group.

RESULTS

Our findings revealed that sex, age, sports practice, hours of sleep, and family history were risk factors ( P < 0.001) for neck pain in our cohort. Moreover, disabling neck pain group experienced neck pain more frequently ( P < 0.001) and with higher levels of pain ( P < 0.001) compared with the nondisabling group. The number of hours of sleep was the only risk factor that showed a trend to differ comparing the disabling neck pain group with the nondisabling neck pain one ( P = 0.057).

CONCLUSIONS

Different risk factors for neck pain were detected in a very large cohort of adolescents. This study may pave the way for future prospective studies and for the development of preventive strategies for neck pain in adolescents.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Identify different risk factors for neck pain in adolescents; (2) Determine the differences between adolescents with nondisabling neck pain and disabling neck pain; and (3) Recognize that most risk factors for disabling neck pain are still unknown, but insufficient sleep quantity could potentially contribute to the development of this condition.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Back Pain without Disease or Substantial Injury in Children and Adolescents: A Twin Family Study Investigating Genetic Influence and Associations

This twin family study first aimed to investigate the evidence for genetic factors predicting the risk of lifetime prevalence of non-specific low back pain of at least three months duration (LBP (life)) and one-month current prevalence of thoracolumbar back pain (TLBP (current)) using a study of children, adolescents, and their first-degree relatives. Secondly, the study aimed to identify associations between pain in the back with pain in other regions and also with other conditions of interest. Randomly selected families (n = 2479) with child or adolescent twin pairs and their biological parents and first siblings were approached by Twins Research Australia. There were 651 complete twin pairs aged 6-20 years (response 26%). Casewise concordance, correlation, and odds ratios were compared for monozygous (MZ) and dizygous (DZ) pairs to enable inference about the potential existence of genetic vulnerability. Multivariable random effects logistic regression was used to estimate associations between LBP (life) or TLBP (current) as an outcome with the potentially relevant condition as predictors. The MZ pairs were more similar than the DZ pairs for each of the back pain conditions (all p values < 0.02). Both back pain conditions were associated with pain in multiple sites and with primary pain and other conditions using the combined twin and sibling sample (n = 1382). Data were consistent with the existence of genetic influences on the pain measures under the equal environments assumption of the classic twin model and associations with both categories of back pain were consistent with primary pain conditions and syndromes of childhood and adolescence which has research and clinical implications.

Residents of Mountainous Areas Have a Higher Low Back Pain Prevalence Than Flat Areas of Chongqing, China: A Cross-Sectional Study

Background and Purpose

Epidemiological studies on low back pain in residents living in mountainous areas are scarce. The study was aimed at investigating the prevalence and associated factors of low back pain in Chongqing, relatively impoverished mountainous areas of China.

Materials and Methods

This was a cross-sectional study conducted at selected community or village health service centers in Chongqing over a 2-month period (May 2021 to June 2021), which included adults of Chongqing aged >18 years with or without low back pain (N=1820) chosen by stratified, cluster-sampling. Associated factors of low back pain including sociodemographic characteristics, lifestyle, and occupational features were collected, along with medical history, Oswestry Disability Questionnaire (ODI), and Numerical Rating Scale (NRS) of patients with low back pain, and carried out for at least 20 minutes per respondent. Univariate and multivariate logistic regression models were utilized for statistical analysis.

Results

Overall, 30.5% of 1704 respondents presented with low back pain, with 26.3% living in flat areas and 35.6% in mountainous areas. The associated factors of low back pain were mountainous area residence (OR 1.4, 95% CI 1.1-1.8), advanced age (OR 1.8, 95% CI 1.3-2.5 for those aged 45-59 years, OR 2.3, 95% CI 1.6-3.4 for those aged 60-74 years, and OR 2.1, 95% CI 1.2-3.6 for those aged ≥75 years), married or remarried (OR 1.9, 95% CI 1.1-3.2), divorced or widowed (OR 2.7, 95% CI 14-5.4), moderate labor intensity (OR 1.4, 95% CI 1.1-1.8), frequent stoop (OR 1.6, 95% CI 1.1-2.4), and depressed mood (OR 1.6, 95% CI 1.2-2.1). Residents in the mountainous areas had a higher score on Oswestry Disability Questionnaire (8.3 [SD 6.3] vs 6.2 [SD 4.3]) than those in flat areas.

Conclusion

Mountainous areas in Chongqing had higher prevalence of low back pain as 35.6%, compared with 26.3% in flat areas, with more severe dysfunction in low back pain patients. Multifactorial analysis found that the factors associated with low back pain in Chongqing residents included mountain residence, labor intensity, stoop, psychological factors and frequency of exercise.

Association Between Family History of Surgically Treated Low Back Pain and Adolescent Low Back Pain

STUDY DESIGN

Cross-sectional.

OBJECTIVE

To study the associations between a family history of surgically treated low back pain (LBP) and adolescent LBP.

SUMMARY OF BACKGROUND DATA

A family history of LBP is related to adolescent LBP, but whether a family history of back surgery is relevant to adolescent LBP is not known.

METHODS

A subpopulation of the Northern Finland Birth Cohort 1986 was contacted when they were aged between 18 and 19years. The postal questionnaire asked the participants to report their LBP and a relative's (mother, father, sibling) LBP and back surgery, and to provide data on potential covariates. The association between a family history of LBP ("no family history of LBP," "family history of LBP but no surgery," and "family history of LBP and surgery") and adolescent LBP (no LBP, occasional LBP, and frequent LBP) were evaluated using logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (CIs), adjusted for sex, smoking, and psychological distress.

RESULTS

Of the 1374 adolescents in the study, 33% reported occasional LBP and 9% frequent LBP. Both the "family history of LBP but no surgery" and "family history of LBP and surgery" categories were associated with frequent LBP (adjusted OR [aOR] 2.09, 95% CI 1.38-3.16; aOR 2.23, 95% CI 1.02-4.90, respectively). Occasional LBP was associated with the "family history of LBP and surgery" category. A subgroup analysis of adolescents with a family history of LBP found no statistically significant associations between family history of back surgery and adolescent LBP.

CONCLUSION

Our findings suggest that adolescents who report a family history of LBP have higher odds of frequent LBP irrespectively of a family history of back surgery.Level of evidence: 4.