Adolescent Back Pain

Introduction

The World Health Organization describes adolescence as “young people between the ages of 10 and 19 years”Who.int. WHO | Adolescent health [Internet]. 2015 [cited 9 January 2015]. Available from: http://www.who.int/topics/adolescent_health/en/. This definition is further divided into early adolescence (10-14 years old) to late adolescence (15-19 years old) by the United Nations Population Fund Unfpa.org. UNFPA - United Nations Population Fund | State of World Population 2003 [Internet]. 2003 [cited 12 January 2015]. Available from: http://www.unfpa.org/publications/state-world-population-2003. Adolescent back pain has been reported to be as common as that of adult populations Jones G, Macfarlane G. Epidemiology of low back pain in children and adolescents. Archives of Disease in Childhood. 2005;90(3):312-316.Burton A, Clarke R, McClune T, Tillotson K. The Natural History of Low Back Pain in Adolescents. Spine. 1996;21(20):2323-2328.Harreby M, Neergaard K, Hesselsôe G, Kjer J. Are Radiologic Changes in the Thoracic and Lumbar Spine of Adolescents Risk Factors for Low Back Pain in Adults?. Spine. 1995;20(21):2298-2302. and has been attributed to a number of factors such as gender Grimmer K, Nyland L, Milanese S. Longitudinal investigation of low back pain in Australian adolescents: a five-year study. Physiother Res Int. 2006;11(3):161-172., age Jeffries L, Milanese S, Grimmer-Somers K. Epidemiology of Adolescent Spinal Pain. Spine. 2007;32(23):2630-2637., sitting for long periods Grimmer K, Williams M. Gender-age environmental associates of adolescent low back pain. Applied Ergonomics. 2000;31(4):343-360., working at computers Hakala P, Rimpela A, Saarni L, Salminen J. Frequent computer-related activities increase the risk of neck-shoulder and low back pain in adolescents. The European Journal of Public Health. 2005;16(5):536-541., school seating Troussiere B, Tesniere C, Fauconnier J, Grison J, Juvin R, Phelip X. Comparative study of two different kinds of school furniture among children. Ergonomics. 1999;42(3):516-526. and psychological factors Astfalck R, O'Sullivan P, Straker L, Smith A. A detailed characterisation of pain, disability, physical and psychological features of a small group of adolescents with non-specific chronic low back pain. Manual Therapy. 2010;15(3):240-247..


Epidemiology

There has been a high prevalence of low back pain (LBP) in adolescents demonstrated in a number of epidemiological studies Pellisé F, Balagué F, Rajmil L, Cedraschi C, Aguirre M, Fontecha C et al. Prevalence of Low Back Pain and Its Effect on Health-Related Quality of Life in Adolescents. Archives of Pediatrics & Adolescent Medicine. 2009;163(1):65.. Estimates of the prevalence of back pain in children adolescents vary greatly, ranging from 30%-70% Balagué F, Troussier B, Salminen J. Non-specific low back pain in children and adolescents: risk factors. European Spine Journal. 1999;8(6):429-438.Wedderkopp N, Leboeuf-Yde C, Andersen L, Froberg K, Hansen H. Back Pain Reporting Pattern in a Danish Population-Based Sample of Children and Adolescents. Spine. 2001;26(17):1879-1883.. The study by Jeffries et al (2007) found a life time prevalence ranging from 4.7% to 74.4% for spinal or back pain and 7% to 72% for LBP. These ranges depend on the age of the participants and the methodological differences, in particular the definition of back pain used. 

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This level of prevalence raises concerns due to the link between LBP in adolescents and chronic LBP in adulthoodHestbaek L, Leboeuf-Yde C, Kyvik K, Manniche C. The Course of Low Back Pain From Adolescence to Adulthood. Spine. 2006;31(4):468-472.. A history of symptoms has been found to be the strongest predictor of future LBPPapageorgiou A, Croft P, Thomas E, Ferry S, Jayson M, Silman A. Influence of previous pain experience on the episode incidence of low back pain: results from the South Manchester Back Pain Study. Pain. 1996;66(2-3):181-185. and an early onset in life linked to chronicityBrattberg G. The incidence of back pain and headache among Swedish school children. Qual Life Res. 1994;3(S1):S27-S31.. It has been found that the occurrence of back pain in adolescents increases with age, in particular in the years of early teens.


Growth and development of males and females is remarkably similar up to approximately the age of 10Brundtland G, Liestol K, Walloe L. Height and weight of school children and adolescent girls and boys in Oslo 1970. Acta Paediatrica. 1975;64(4):565-573.. Above the age of 10, as a result of puberty, the growth patterns of males and females deviate considerably. By at least the age of 18 or 19 years, puberty is considered to have ceased. With the potential influence of puberty related growth on the incidence of adolescent back pain Feldman D. Risk Factors for the Development of Low Back Pain in Adolescence. American Journal of Epidemiology. 2001;154(1):30-36. it is imperative that the range of pubertal ages are taken into consideration in epidemiological studies.


Aetiology

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Differential Diagnosis

Adolescent back pain predominantly falls into 3 general categories: muscular, bone-related, and discogenic Metzl JD. Back pain in the adolescent. A user-friendly guide. Adolescent Health Update 2005; 17:1..

Each with characteristic features as displayed in this section:


  • Muscle-related pain

Most back pain in adolescents, as in adults, is thought to arise from within the muscles Kim, H.J., Green, D.W., 2008. Adolescent back pain. Curr. Opin. Pediatr. 20, 37–45. doi:10.1097/MOP.0b013e3282f357fe. Muscle-related pain tends to be localised to paraspinal muscles of the thoracic or lumbar area rather than to the spine itself Metzl JD. Back pain in the adolescent. A user-friendly guide. Adolescent Health Update 2005; 17:1.. This pain is most commonly related to overuse, but there may be a history of acute injury.


The contributing factors may include:
- Carrying a heavy rucksackMacias, B.R., Murthy, G., Chambers, H., Hargens, A.R., 2008. Asymmetric loads and pain associated with backpack carrying by children. J Pediatr Orthop 28, 512–517. doi:10.1097/BPO.0b013e31817d8143Rodríguez-Oviedo, P., Ruano-Ravina, A., Pérez-Ríos, M., García, F.B., Gómez-Fernández, D., Fernández-Alonso, A., Carreira-Núñez, I., García-Pacios, P., Turiso, J., 2012. School children’s backpacks, back pain and back pathologies. Arch. Dis. Child. 97, 730–732. doi:10.1136/archdischild-2011-301253
- Incorrect sports equipment (e.g. improper bicycle seat positioning, lack of cushioned insoles for running) Baker, R.J., Patel, D., 2005. Lower back pain in the athlete: common conditions and treatment. Prim. Care 32, 201–229. doi:10.1016/j.pop.2004.11.004
- Psychosocial distress, depression and anxietyCombs, J.A., Caskey, P.M., 1997. Back pain in children and adolescents: a retrospective review of 648 patients. South. Med. J. 90, 789–792.Diepenmaat, A.C.M., van der Wal, M.F., de Vet, H.C.W., Hirasing, R.A., 2006. Neck/shoulder, low back, and arm pain in relation to computer use, physical activity, stress, and depression among Dutch adolescents. Pediatrics 117, 412–416. doi:10.1542/peds.2004-2766



  • Bone-related pain

Bone-related pain tends to occur at the centre of the spine and usually exacerbated by extension (backward bending) Metzl JD. Back pain in the adolescent. A user-friendly guide. Adolescent Health Update 2005; 17:1., though this finding is not specific.

Common causes of bone related back pain amongst adolescents:


Spondylolysis and Isthmic Spondylolisthesis


Spondylolysis - is a unilateral/bilateral defect (separation) in the vertebral pars interarticularis (usually the lower lumbar vertebrae - particularly L5). Morita, T., Ikata, T., Katoh, S., Miyake, R., 1995. Lumbar spondylolysis in children and adolescents. J Bone Joint Surg Br 77, 620–625.
Spondylolysis usually presents in early adolescence. It may be asymptomatic initially, but typically manifests as aching low back pain exacerbated by hyperextension of the spine and relieved by rest Kim, H.J., Green, D.W., 2008. Adolescent back pain. Curr. Opin. Pediatr. 20, 37–45. doi:10.1097/MOP.0b013e3282f357fe.

Spondylolysis is common in adolescent athletes with acute low back pain - accounting for 47% of cases in one orthopaedic series Micheli, L.J., Wood, R., 1995. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med 149, 15–18.. The risk of developing Spondylolysis tends to correlate in athletes whose sport requires repetitive flexion/extension or hyperextension Baker, R.J., Patel, D., 2005. Lower back pain in the athlete: common conditions and treatment. Prim. Care 32, 201–229. doi:10.1016/j.pop.2004.11.004


Spondylolisthesis - occurs when bilateral defects permit the vertebral body to slip anteriorly - the most common spondylolytic defects occur at the isthmus Ginsburg, null, Bassett, null, 1997. Back Pain in Children and Adolescents: Evaluation and Differential Diagnosis. J Am Acad Orthop Surg 5, 67–78.. Spondylolysis progresses to spondylolisthesis in approximately 15 % of casesFredrickson, B.E., Baker, D., McHolick, W.J., Yuan, H.A., Lubicky, J.P., 1984. The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am 66, 699–707.. Progression generally occurs during the teenage growth spurt, with minimal change after 16 years of ageLonstein, J.E., 1999. Spondylolisthesis in children. Cause, natural history, and management. Spine 24, 2640–2648.Motley, G., Nyland, J., Jacobs, J., Caborn, D.N.M., 1998. The Pars Interarticularis Stress Reaction, Spondylolysis, and Spondylolisthesis Progression. J Athl Train 33, 351–358. Morita et al (1995)Morita, T., Ikata, T., Katoh, S., Miyake, R., 1995. Lumbar spondylolysis in children and adolescents. J Bone Joint Surg Br 77, 620–625. suggest progression to spondylolisthesis is correlated with persistent pain…ADD SOMETHING ON!!!


Adolescent Idiopathic Scoliosis


Scoliosis — Scoliosis is an abnormal lateral curvature of the spine. It can be idiopathic or result from congenital spinal anomalies, muscular spasm or paralysis, infection, tumour, or other causes (REFERENCE)
Idiopathic scoliosis is scoliosis for which there is no definite aetiology.
Adolescent idiopathic scoliosis (AIS) is the most common form of idiopathic scoliosis, accounting for 80 to 85% of casesNegrini, S., Aulisa, A.G., Aulisa, L., Circo, A.B., Mauroy, J.C. de, Durmala, J., Grivas, T.B., Knott, P., Kotwicki, T., Maruyama, T., Minozzi, S., O’Brien, J.P., Papadopoulos, D., Rigo, M., Rivard, C.H., Romano, M., Wynne, J.H., Villagrasa, M., Weiss, H.-R., Zaina, F., 2012. 2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis 7, 3. doi:10.1186/1748-7161-7-3. AIS is also noted as the most common spinal deformity seen by primary care physicians, paediatricians, and spinal surgeonsAltaf, F., Gibson, A., Dannawi, Z., Noordeen, H., 2013. Adolescent idiopathic scoliosis. BMJ 346, f2508–f2508. doi:10.1136/bmj.f2508.The prevalence of AIS with a Cobb angle ≥10º is approximately 3 %. However, only 10% of adolescents with AIS require treatment. Males and females are affected equally. Though, the risk of curve progression and therefore the need for later treatment is 10 x higher in females Miller, N.H., 1999. Cause and natural history of adolescent idiopathic scoliosis. Orthop. Clin. North Am. 30, 343–352, vii..


Scheuermann’s Disease / Juvenile Kyphosis


Scheuermann’s Disease — is the abnormal growth (osteochondrosis), typically of the thoracolumbar spine leading to increasing spinal curvatureCassas, K.J., Cassettari-Wayhs, A., 2006. Childhood and adolescent sports-related overuse injuries. Am Fam Physician 73, 1014–1022.. It may be associated with spondylosis Ogilvie, J.W., Sherman, J., 1987. Spondylolysis in Scheuermann’s disease. Spine 12, 251–253., Scheuermann’s is the most common cause of structural kyphosis in adolescents Lowe, T.G 2007. Scheuermann's kyphosis. Neurosurg Clin N Am 18(2):305-15. and often accompanied with poor posture and backache.Emedicine.medscape.com, (2015). Scheuermann Disease. [online] Available at: http://emedicine.medscape.com/article/311959-overview [Accessed 14 Jan. 2015].

  • Disc-related pain

Disc-related pain is generally exacerbated by flexion (forward bending) and may radiate Metzl JD. Back pain in the adolescent. A user-friendly guide. Adolescent Health Update 2005; 17:1.. Approximately 10% of persistent back pain in adolescents is disc relatedMicheli, L.J., Wood, R., 1995. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med 149, 15–18..


Disc herniation — vertebral bodies are separated by intervertebral discs, (to provide support and mobility). The intervertebral disc is composed of a tough, ligamentous outer annulus and a gelatinous inner nucleus pulposus. The combination of intervertebral pressure and degeneration of the ligamentous fibres can lead to a tear in the annulus, allowing herniation of the nucleus pulposus.


Disc herniation is a common disorder among adults with degenerated intervertebral discs. However, its occurrence in adolescence is much less frequent mostly as adolescents tend to have a healthier lumbar spine Dang, L. and Liu, Z. 2009. A review of current treatment for lumbar disc herniation in children and adolescents. European Spine Journal, 19(2), pp.205-214.. Herniation of the nucleus pulposus is much less common in children and adolescents than in adults Haidar, R., Saad, S., Khoury, N. and Musharrafieh, U. (2010). Practical approach to the child presenting with back pain. European Journal of Pediatrics, 170(2), pp.149-156. 

Risk factors for disc herniation includeDePalma, M.J., Bhargava, A., 2006. Nonspondylolytic etiologies of lumbar pain in the young athlete. Curr Sports Med Rep 5, 44–49.Balagu, F., Troussier, B. and Salminen, J. 1999. Non-specific low back pain in children and adolescents: risk factors. European Spine Journal, 8(6), pp.429-438.: 
- Acute trauma 
- Scheuermann’s disease 
- Family history of disc herniation
- Obesity  
- Sporting activities e.g. weight lifting, wrestling, gymnastics, and collision sports

TUMOURS
Osteoid Osteoma — Back pain caused by a spinal tumour is a rare occurrence. The most common tumour that presents with back pain in adolescents is osteoid osteoma Greenspan A, Jundt G, Remagen W. 2006. Differential diagnosis in orthopaedic oncology. Lippincott Williams &amp; Wilkins., a benign tumour characterized by nocturnal pain and prompt relief with NSAIDs, although these features are variable. Only 10 to 20% of osteoid osteomas are localised to the spine.Cohen, M.D., Harrington, T.M., Ginsburg, W.W., 1983. Osteoid osteoma: 95 cases and a review of the literature. Semin. Arthritis Rheum. 12, 265–281.


Treatment

Treatment of LBP in adults has been investigated extensively (Calvo). Evidence has shown that physiotherapy treatment with exercise, back school and manual therapy are effective in reducing pain and functional limitations in adults (Heymans et al and Aure). A study looking at low back pain in adolescent athletes suggested that despite undergoing pubescent changes into adulthood, adolescents cannot be treated like young adults. Therefore, treatment of adolescents can be difficult and must be approached differently, with good understanding of spinal development (De Luigi).


Investigation and practice of therapeutic treatments for children and adolescents with back pain is more recent than with adults (Calvo-Muñoz). Treatments used include back education, exercise, manual therapy and therapeutic conditioning. These interventions are primarily aimed at decreasing the prevalence, and lessening the intensity of LBP and disability (Calvo-Muñoz).


Preventative treatments have been carried out over the last 3 decades, including physical therapy exercises, postural hygiene and the promotion of physical activity (Calvo-Muñoz). According to Curtis and d’Hemecourt (2007) the best prevention of back pain is early detection. Preventative measures can include ‘proper technique’ e.g. in lifting sports and limiting excessive lumbar lordosis, plus participating in core-strengthening exercises and stretches for tight hamstrings and hip flexors which also may help reduce the risk of low back pain (Purcell).


Some literature suggests that back packs carried by schoolchildren can cause back pain if they are to heavy or if the weight is carried unevenly. (?NHSCHOICES) According to this group-randomised control trial the following should be advised to prevent LBP:

  • Load the minimum weight possible
  • Carry a school backpack on two shoulders
  • Correct the belief that school backpack weight does not affect the back
  • Using a locker at school

(Vidal, 2013)

The study found that children were able to learn healthy backpack habits. However, this study was in primary school aged children rather than secondary, therefore results may not be generalisable for an adolescent population.


It has been concluded that physiotherapy treatments seem to be effective in adolescents with LBP (Calvo-Muñoz).


Suggested treatments for the rehabilitation of adolescents with back pain include:

  1. Back education (theoretical or practical)- acquisition of knowledge, posture training habits, body awareness training
  2. Exercise- including stretching, strengthening, breathing, posture correction, balance exercises, functional exercises, warm-up, relaxation, coordination, stabilisation.

    

A study which evaluated the efficacy of an exercise program for recurrent non-specific back pain in adolescents, concluding that an exercise was an effective short-term treatment strategy, incorporated the following forms of exercise:



    a) Pain relieving exercises which encourage motion of the lumbar spine to reduce joint stiffness such as the ‘cat stretch’ and flexibility exercises for the hip and knee, such as knees to chest and knees to the side

    

b)Reconditioning exercises aiming to provide muscle endurance of lumbar stabilisers and help encourage appropriate motor control of muscle recruitment such as ‘superman’ single leg extension holds in ?4 point kneeling.

    

c) Progressive exercises imposing a higher challenge on the lumbar stabilisers and more strength related activities, for instance horizontal side support on feet.

  3. Manual therapy- mobilisation, manipulation, massage
  4. Therapeutic physical conditioning- walking, running, swimming, cycling.

(Calvo-Muñoz).


A meta analysis in 2013 examined the differential effectiveness of physiotherapy treatment for LBP in children and adolescents aiming to determine whether the treatments were beneficial for pain and disability among other outcome variables. Prior to this analysis, there was no solid evidence to suggest which treatment was most effective for adolescents with back pain.

All the treatment outcome measures reached a statistically significant effect magnitude and showed a clinically relevant improvement of symptoms. The most effective combination treatment was therapeutic physical conditioning (ie general fitness) and manual therapy. However, there was limited details of what the treatments actually involved.


Intensity and duration of treatment

The study found that the average:

  • number of weeks of treatment was 12
  • time a week spent engaging in treatment was 1 hour


Quality of the study
The meta-analysis itself has good methodological quality, however, there was a low number of applicable studies with only 8 articles met the selection criteria. There was also a lack of control groups and methodological quality of the studies was poor. This prevents definite conclusions being drawn. Furthermore, no evidence was provided regarding the duration of the beneficial effects, or details of follow up.


According to Jones et al, 2007 and Cardon et al 2007, there is a need to incorporate back care and exercise into physical education curricula in schools.

Interestingly, an RCT by Ahlqwist (2008) found that an active physiotherapy program improved adolescent experience of back pain regardless of whether the program consisted of supervised exercises by a physiotherapist.

Conclusion


Outcome measures

There are many different outcome measures that may be used by physiotherapists in their treatment of adolescents with back pain.

  • Pain e.g. VAS, Painometer (a smartphone app to assess pain intensity)
  • Disability e.g. Modified Oswestry Disability Questionnaire, Roland & Morris Disability Questionnaire
  • Flexibility eg Back-saver sit and reach
  • Endurance
  • Mental health
  • Quality of life e.g. Child Health Questionnaire Child Form 87
  • Function
  • Self efficacy
  • Return to sport
  • Return to study/work




Further research


References




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