One of the things that some universities do to help out new researchers is have senior academics look over their grant applications before they are submitted. Recently we had a proposal for a study on back pain in adolescents assessed in this way. One of the comments was that back pain is not a problem for teenagers; it doesn’t happen very often and if it does it goes away by itself quickly anyway. It is worth noting that this feedback came from researchers outside the field of musculoskeletal pain, and seemed to be on the basis of personal experience.
This appears to be a common view, and was reflected in our study looking at how well pain reports from children match up with their parents. The answer; not very well, parents frequently reported that their child did not have pain over the past week when the child reported that they did. To dig a bit further into the issue, we collected all the systematic reviews that addressed prevalence, risk factors, prognosis, and treatment effectiveness relevant to back pain in children and adolescents. Here’s what we found.
Probably the only area with a reasonably large and coherent body of evidence relates to prevalence. The most reliable estimates are that about 18-24% of adolescents report experiencing back pain in the past month. Rates are very low up to the age of about 11 years but rise sharply from then on, and are a little higher in girls than boys.
Published prevalence estimates generally refer to report of any back pain, without reporting what impact the back pain has on the children. But there is evidence to suggest that a substantial minority are strongly impacted by their back pain. For example, back pain ranks 5 in terms of years lived with disability among 15-19 year-olds in the 2016 Global Burden of Disease study, and up to 20% of adolescents with back pain report interference with school, sporting or daily activities or seek care for their pain.
A striking feature of research into back pain paediatric populations is the tiny volume compared to that conducted in adults. While a reasonable number of risk factor studies have been published, they tell us little about what predicts or causes back pain in adolescents. In general terms, psychological variables appear the most likely risk factors, but the strength of the associations is unclear. There is no consistent evidence for the usual suspects like backpacks, posture, sedentary time and flexibility. Notably, very few of these studies are specifically designed to answer questions related to back pain in children/adolescents, the available evidence comes mostly from population surveys or cohorts set up to answer questions about general health and wellbeing.
Research investigating prognosis is practically non-existent. We could not reliably identify any factors that predict poor outcome for children with an episode of back pain.
There are a small number of studies that evaluate preventive or treatment interventions in this population. A feature of the prevention trials is that many measure the effect of interventions on knowledge or manual handling behaviours, but few measure the effect on pain. It seems educational interventions are effective for changing knowledge or behaviour, but, from what little data we have, do not impact pain. The few published treatment trials suggest that interventions that include exercise and education may be effective, but the quality of evidence is not high.
We know that about 20% of adolescents get back pain in a given month, and in all likelihood this will probably pass quickly and have no major impact for many of them. The problem is that there is no basis for predicting who needs help to recover from an episode and who does not. This is an issue because there are risks and costs associated with unnecessary contact with the medical system. Large, well-designed inception cohort studies are needed to help guide decisions about who should receive care.
If we are going to provide care for a subset of children who have back pain, we need to know more about what this care should look like. There is scant information about effective treatment protocols, delivery models, or expected effect sizes. We need good quality treatment effectiveness studies to guide best practice care. Probably it makes sense to start with simple, scalable interventions that have shown promise so far, tailored to ensure messages, activities and delivery methods are age-appropriate. Reasonable options, with some supporting evidence include education, activity advice and exercise programs.
Steve Kamper studied Physiotherapy at Sydney University and after a brief period subjecting people to his questionable clinical skills was lured/banished into the world of research. After doing his PhD at the George Institute he spent three years as a postdoc at the VU University in Amsterdam, a time packed full of patient expectations, systematic reviews, travel and cheese. He is now an Associate Professor in the School of Public Health, University of Sydney. Most of his research involves investigating MSK pain in children and adolescents, and trying to figure out where pain fits within a broader view of health. The latter is the focus of the Centre for Pain, Health and Lifestyle (https://centrephl.org) which is an initiative aimed at marrying clinical and population health perspectives to better organise services for people with pain. Outside of research he spends his time running, riding, playing football and overthinking.
Tiê completed a master’s degree in Physiotherapy at University of Sao Paulo City in 2013 and PhD at the School of Public Health, University of Sydney in 2017. Tiê has published over 45 research studies in the last 5 years. Tie is now a research fellow at Centre for Pain, Health and Lifestyle and affiliated at the University of Sydney. The overarching focus of her research is on effectiveness of treatments for chronic back pain, disabling musculoskeletal pain in children and waste in clinical research. Tiê is the co-leader of the International Collaboration for Early Career Researchers (ICECReam.org) and one of the creator of the blog “PEDrinho” to bring the best evidence indexed in the PEDro database to Portuguese speakers (~5,000 followers).
 Kamper SJ, Dissing KB, Hestbaek L. Whose pain is it anyway? Comparability of pain report from children and their parents. Chiro Man Ther 2016. 24:24.
 Kamper SJ, Yamato TP, Williams CM. The prevalence, risk factors, prognosis and treatment for back pain in children and adolescents: An overview of systematic reviews. Best Prac Res Clin Rheumatol. 2016. 30:1021-36.
 GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global Burden of Disease 2016. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet2017. 16; 390(10100): 1211–1259.
 O’Sullivan PB, Beales DJ, Smith AJ, Straker LM. Low back pain in 17 year olds has substantial impact and represents an important public health disorder: a cross-sectional study. BMC Public Health. 2012. 12(1):100
 Kamper SJ, Williams CM. Musculoskeletal pain in children and adolescents. A way forward. J Orthop Sport Phys Ther 2017. 47;702-04.