Abstract
Emerging data suggest that back pain in adolescents is responsible for a substantial disability burden and consumes considerable healthcare services. Of further concern is the fact that back pain during this period of life may have health implications in adulthood. Given this, understanding the epidemiology and clinical evidence base relevant to clinicians and researchers in the field of musculoskeletal health is crucial. This chapter provides an overview and synthesis of systematic reviews that address important questions related to back pain in children and adolescents:
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What is the prevalence of back pain in children and adolescents?
- •
What are the risk factors?
- •
What is the clinical course and what are the prognostic factors?
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Which are the most effective preventative interventions and clinical treatments?
Introduction
While the enormous disability burden of back pain in adults is well documented , the consequences of the condition in children are not so well acknowledged. Yet there is a good reason for concern about the effect of back pain in children and adolescents worldwide. In 2015, back and neck pain ranks 9th in years lived with disability in 10- to 14-year-olds and 4th in 15- to 19-year-olds (GBD data viz), in the latter case ahead of much higher high profile ‘non-communicable’ conditions such as cancer and anxiety disorders. In contrast to a perception that back pain in children is generally transient and trivial in terms of impact on individuals, evidence suggests that prevalence is high , and a substantial minority of children who report back pain are significantly impaired by their pain. A large number of children seek care for their back pain , miss school or work , or miss out on sport and physical activities .
Unsurprisingly, the high prevalence and care-seeking translate into a substantial financial burden for society. A study in the US estimated the annual cost of chronic pain in adolescents aged 10–17 years, of which musculoskeletal pain comprised the largest proportion, was $19.5 billion . A large survey in Germany estimated a minimum figure for direct costs for the treatment of people under the age of 25 with back disorders of €100 million per year . Although data documenting the costs associated with children’s back pain are sparse, they appear to be substantial, meaning investigation into prevention and treatment is worthwhile from an economic perspective.
Of further concern are the links between back pain and lifestyle-related risk factors, including smoking , alcohol and substance use and overweight . The question of whether the relationships between back pain and these indicators of poor health are causal in one direction or in another direction has not been answered, but the links are of concern nonetheless. This evidence suggests that back pain may play a part in a picture of overall poor health and adverse health risk in adolescents. The concern is that just as health-related behaviours track from adolescence into adulthood , so will the experience of back pain and its associated disability burden.
Studies that examine the nature of back pain across the life-course point to the importance of understanding the condition as it presents in childhood. Epidemiological studies conducted in adult populations characterise back pain as a recurrent condition , and the most consistent risk factor for an episode of back pain is having had a previous episode . In the few longer-term cohort studies conducted, the presence of long-term back pain in adolescents appears to increase the risk of chronic pain in adulthood . On the basis of these considerations, it follows that exploring back pain at the time of its earliest presentation may be of value.
The conception of back pain in children and adolescents has undergone a large change on the past 15–20 years. Report of back pain in childhood was previously considered rare and a sign of serious underlying pathology, in fact several clinical practice guidelines include ‘age under 20 years’ as a red flag for back pain assessment . However, more recent studies have indicated that the condition is common, and it is usually not possible to diagnose a specific patho-anatomical cause for the pain . While popular clinical and media explanations portray back pain as a consequence of biomechanical or ergonomic influences, implicating backpacks, computer/device use and posture, research increasingly identifies a range of psychological and social risk factors as well . To further advance the understanding of paediatric back pain, it is clear that a broader view of the influencing factors and management approaches is required. Drawing on paradigms such as the biopsychosocial model used in the adult field to frame understanding of paediatric back pain, particularly chronic pain, may be a useful initial step .
The aim of this article was to present a ‘state-of-the-art’ for back pain research in children, as represented by systematic reviews relevant to various aspects of the condition. The findings of published systematic reviews that addressed the questions below were synthesised to summarise the current understanding and identify gaps in knowledge.
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What is the prevalence of back pain in children?
- •
What are the risk factors?
- •
What is the clinical course, and what are the prognostic factors?
- •
Which are the most effective preventative interventions and clinical treatments?
Methods
MEDLINE, Embase and the Cochrane Database of Systematic Reviews were searched in January 2017 for systematic reviews that relate to the above questions. Search terms for back pain and paediatric studies were taken from two recent Cochrane systematic reviews . These were combined with the Ovid filter for review articles (see Appendix 1 for search strategy).
Search results were screened, and full text copies were retrieved for those not clearly ineligible on the basis of title or abstract. The process was repeated with full text articles, and decisions were made regarding eligibility. Hand searches were conducted of the reference lists of all included reviews and records of the author team.
Studies were included if it was a systematic review published in a peer-reviewed journal, included people 18 years old or under (or reported separately on this age group), reported on non-specific back pain. Studies were excluded if they reported on back pain due to cancer, systemic, infectious or inflammatory disease, fracture, acute neurological condition, included subjects post-surgery, reported on patients with scoliosis or thoracic pain.
Quality of the included studies was rated using the AMSTAR instrument , and the quality rating was used in the data synthesis process to inform the conclusions of this review. Data relevant to the research questions were extracted from the included systematic reviews. Because of methodological and clinical heterogeneity, meta-analysis was not possible; therefore, the extracted data were synthesised qualitatively using the AMSTAR ratings to give greater weight to the findings from higher quality reviews.
Methods
MEDLINE, Embase and the Cochrane Database of Systematic Reviews were searched in January 2017 for systematic reviews that relate to the above questions. Search terms for back pain and paediatric studies were taken from two recent Cochrane systematic reviews . These were combined with the Ovid filter for review articles (see Appendix 1 for search strategy).
Search results were screened, and full text copies were retrieved for those not clearly ineligible on the basis of title or abstract. The process was repeated with full text articles, and decisions were made regarding eligibility. Hand searches were conducted of the reference lists of all included reviews and records of the author team.
Studies were included if it was a systematic review published in a peer-reviewed journal, included people 18 years old or under (or reported separately on this age group), reported on non-specific back pain. Studies were excluded if they reported on back pain due to cancer, systemic, infectious or inflammatory disease, fracture, acute neurological condition, included subjects post-surgery, reported on patients with scoliosis or thoracic pain.
Quality of the included studies was rated using the AMSTAR instrument , and the quality rating was used in the data synthesis process to inform the conclusions of this review. Data relevant to the research questions were extracted from the included systematic reviews. Because of methodological and clinical heterogeneity, meta-analysis was not possible; therefore, the extracted data were synthesised qualitatively using the AMSTAR ratings to give greater weight to the findings from higher quality reviews.
Results
Included studies
Electronic searches identified 1887 articles, and hand searches identified further two records. After screening titles and abstracts, the full text of 63 articles were retrieved; of these, 27 studies were eligible. The results from these systematic reviews provided the source data for this paper (see Fig. 1 ). Most of the articles excluded at the full-text stage were not eligible because they were not systematic reviews.
The systematic reviews included between 5 and 63 primary studies; inclusion criteria and number of participants varied widely depending on the study question, for example population-based studies assessing prevalence and risk factors included total participant numbers >100,000 , and reviews of treatment studies included total numbers in the hundreds . Most studies focused on participants above the age of 10 years, which means that the findings presented here are most applicable to adolescents, rather than to younger children. Selected characteristics of the included systematic reviews are presented in Table 1 .
| Included studies | Number of included studies | Type of included studies | Number of participants | Age in years | Inclusion criteria |
|---|---|---|---|---|---|
| Prevalence | |||||
| Balague 1999 | 17 | 15 x-sect 2 longit | NR | NR | NR |
| Calvo-Munoz 2013b | 59 | 52 x-sect 7 longit | 125,483 | mean 13.6 range 9–18.4 |
|
| Duggleby 1997 | 11 | 11 x-sect | NR | NR | NR |
| Hoy 2012 | NR | NR | NR | NR |
|
| Jeffries 2007 | 55 | 43 x-sect 12 longit | NR | range 4–19 |
|
| King 2011 | 32 | NR | NR | range 0–18 | NR |
| Louw 2007 | 27 | 23 x-sect 4 retrosp | 31,690 | range 11–19 |
|
| Smith 2007 | 15 | NR | NR | NR |
|
| Hill 2009 | 35 | 23 x-sect 10 longit 1 retrosp 1 x-sect & longit | 39,635 | range 6–17 |
|
| Risk Factors | |||||
| Cardon 2004 | risk: 44 intervention: 5 | NR | NR | NR |
|
| Dockrell 2013 | 18 | 18 x-sect | NR | range 6–18 |
|
| Hill 2010 | 5 | 5 longit | 2706 | range 4–14 |
|
| Huguet 2016 | 36 | 21 longit | 40,404 | range 0–18 |
|
| Lardon 2014 | 5 Studies | 3 x-sect 2 longit | 8034 | range 11–17 |
|
| Lardon 2015 | 8 | 6 x-sect 1 longit 1 retrosp, | NR | NR |
|
| Lauchlan 2005 | 17 | NR | NR | NR |
|
| Lindstrom-Hazel 2009 | 63 | NR | NR | NR | NR |
| Morton 2014 | 11 | NR | NR | range 14–23 |
|
| Paulis 2014 | 40 | 33 x-sect 7 longit | 1,109,055 | range 2–19 |
|
| Shiri 2010 | 40 | 27 x-sect 13 longit | 362,579 (incl. meta-analysis) | range 11–79 |
|
| Sitthiporn 2011 | 17 | 12 x-sect 5 longit | NR | NR |
|
| Trevelyan 2006 | NR | NR | NR | range 11–14 | NR |
| Balague 1999, Calvo-Munz 2013b, Duggleby 1997, King 2011, Louw 2007, Smith 2007 | Described above | ||||
| Course/Prognosis | |||||
| Huguet 2016, Lindstrom-Hazel 2009 | Described above | ||||
| Prevention and Treatment | |||||
| Calvo-Munoz 2012 | 23 | NR | 4423 | mean 11.3 |
|
| Calvo-Munoz 2013a | 8 | 3 RCTs 3 non-RCTs 1 longit 1 case series | 334 | mean 14.1 range 11–18 |
|
| Hestbaek 2010 | 4 | 2 RCTs 2 longit | NR | NR |
|
| Michaleff 2014 | 15 | 15 RCTs prevention: 11 treatment:4 | 3064 intervention: 364 prevention: 2700 | Mean ∼11.8 |
|
| Cardon 2004, Morton 2014, Steele 2006 | Described above | ||||
We defined thresholds for total AMSTAR scores to designate low (0–3), moderate (4–6) and high (7–11) quality reviews. The quality of the included studies was mixed; 11 reviews were low quality, seven moderate and nine scored high quality ( Table 2 ). Sixteen of the included reviews were published in 2010 or later.
| Included Studies | Total Score | Item 1 A priori design provided? | Item 2 Duplicate study selection and data extraction? | Item 3 Literature search performed? | Item 4 Status of publication used as an inclusion criterion? | Item 5 List of studies (included and excluded) provided? | Item 6 Characteristics of the included studies provided? | Item 7 Scientific quality of the included studies assessed and documented? | Item 8 Scientific quality of the included studies used appropriately in formulating conclusions? | Item 9 The methods used combine the findings of studies appropriate? | Item 10 The likelihood of publication bias assessed? | Item 11 Conflict of interest stated? |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Balague 1999 | 0 | – | – | – | – | – | – | – | – | – | – | – |
| Calvo-Munoz 2012 | 9 | – | + | + | + | – | + | + | + | + | + | + |
| Calvo-Munoz 2013a | 9 | – | + | + | + | – | + | + | + | + | + | + |
| Calvo-Munoz 2013b | 9 | – | + | + | + | – | + | + | + | + | + | + |
| Cardon 2004 | 2 | – | – | + | – | – | + | – | – | – | – | – |
| Dockrell 2013 | 2 | – | – | + | – | – | + | – | – | – | – | – |
| Duggleby 1997 | 0 | – | – | – | – | – | – | – | – | – | – | – |
| Hestbeak 2010 | 3 | – | + | + | – | – | + | – | – | – | – | – |
| Hill 2009 | 4 | – | – | + | – | – | + | + | + | – | – | – |
| Hill 2010 | 3 | – | – | + | – | – | + | + | – | – | – | – |
| Hoy 2012 | 4 | – | – | + | – | – | – | + | + | + | – | – |
| Huguet 2016 | 8 | + | + | + | – | – | + | + | + | + | – | + |
| Jeffries 2007 | 3 | – | – | + | – | – | + | – | – | – | – | + |
| King 2011 | 7 | + | + | + | – | – | + | + | + | – | – | + |
| Lardon 2014 | 6 | – | – | + | – | + | + | + | + | – | – | + |
| Lardon 2015 | 5 | + | – | + | – | – | + | + | – | + | – | – |
| Lauchlan 2005 | 1 | – | – | + | – | – | – | – | – | – | – | – |
| Lindstrom-Hazel 2009 | 2 | – | – | + | – | – | + | – | – | – | – | – |
| Louw 2007 | 4 | – | – | + | – | – | + | + | + | – | – | – |
| Michaleff 2014 | 7 | – | + | + | – | – | + | + | + | + | – | + |
| Morton 2014 | 5 | – | – | + | – | – | + | + | + | + | – | – |
| Paulis 2014 | 8 | – | + | + | – | – | + | + | + | + | + | + |
| Shiri 2010 | 7 | – | – | + | – | + | + | + | – | + | + | + |
| Sitthiporn 2011 | 6 | – | – | + | – | – | + | + | + | + | – | + |
| Smith 2007 | 0 | – | – | – | – | – | – | – | – | – | – | – |
| Steele 2006 | 8 | + | + | + | + | + | + | + | + | – | – | – |
| Trevelyan 2006 | 2 | – | – | + | – | – | – | – | – | – | – | + |
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Behaviour change and self-management interventions in persistent low back pain
Causal mechanisms in the clinical course and treatment of back pain
Developing implementation science to improve the translation of research to address low back pain: A critical review
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