Adolescent Low Back Pain
Low back pain is the leading cause of years lived with disability in the world. While rare below 10 years of age, LBP emerges during adolescence and prevalence rates increase until plateauing in early adulthood.
The Perth based Raine Cohort Study identified at 14 years, 30% of girls and 26% of boys reported LBP in the past month and 11% reported chronic (>3 months) LBP. At 17 through to 22 years, Raine Study participants reporting LBP over the past month, significantly increased from 32% to 45%. Additionally, for those reporting chronic LBP, comorbid pain problems such as neck pain and headache are frequently reported. At 17 years, 20% of adolescents with chronic LBP report negative impacts such as modifying physical and daily life activities, along with taking time off school or work. The burden of LBP can begin young for some.
Specific Adolescent Lumbar Pathology
While LBP is common in adolescents, serious pathologies such as malignancy, inflammatory disorders and infection are rare (less than 1%) and can be initially screened via thorough questioning. Where LBP is disabling and associated with clear trauma, screening for fracture is warranted. While serious pathology is rare, MRI findings such as disc degeneration is present in 30% of adolescents at 13 years and in the vast majority of cases should be considered normal. Disc herniation with associated leg pain (sciatica) is very rare with rates estimated to be 0.2 to 0.6% of presentations.
Adolescent LBP Without Related Pathology
The majority of adolescents with LBP have no clear pathology explaining their LBP. The absence of clear pathology can lead to adolescent LBP being labelled with what can appear clinically appealing labels such as hypermobility syndromes, postural syndromes or muscle imbalances. In Raine Study participants, generalized joint hypermobility at 14 years was prevalent, particularly in girls irrespective of LBP. Additionally there was no relationship between joint hypermobility and chronic musculoskeletal pain or LBP at 17 years. A recent systematic review concluded there is no evidence for an increased risk of LBP in adolescents with scoliosis. Sitting in a slumped position at 14 years only demonstrated a weak relationship with LBP at 17 years. A standing posture study at 14 years of age found standing with a hyperlordotic posture was related to an increased risk of previous and current LBP and was associated with higher BMI scores. At 14 years back muscle endurance was not related to LBP. However in rowers and those with moderate disabling LBP, lower back muscle endurance was observed. At 14 years there was an association with schoolbag carriage and spinal pain. Perceived load, duration of carriage and mode of transport to school were factors. However, actively getting to school by walking or riding appeared to offset the risk. These factors that historically are thought to be involved in LBP are only weak predictors.
Multidimensional factors related to Adolescent LBP
Current evidence suggests there is a significant role of lifestyle factors in chronic musculoskeletal pain including physical activity levels, dietary factors, smoking and poor sleep. Psychological factors have been associated with LBP. At 14 years of age poorer mental health (anxiety, depression, aggressive behavior) was associated with neck and back pain. Have a primary carer with LBP and environmental stresses, such as significant life stress events, also play a role in the development of LBP.
What to do?
Adolescent LBP is common. Once serious causes of LBP are excluded, LBP treatment requires a flexible and multidimensional approach to assessment and management. When disability is significant early intervention involving a wholistic approach is supported by current evidence. Helpful messages regarding LBP include;
- LBP is rarely serious, and the back is strong
- LBP has many influences including activity, sleep, mood, posture, stress and fitness
- Maintaining a healthy spine involves being physical active and conditioned to play sports or carry a heavy school bag
- There is no ideal posture and you best posture is your next posture. Moving and varying your posture is helpful.
If you have significant LBP, our Physiotherapists have the experience and skills to get you back on track. More information on LBP care can be found here, at Pain Health or by reading the reference for this newsletter .
1.O’Sullivan, P., et al., Understanding Adolescent Low Back Pain From a Multidimensional Perspective: Implications for Management. Journal of Orthopaedic & Sports Physical Therapy, 2017. 47(10): p. 741-751.
Senior Musculoskeletal Physiotherapist
Curtin University WA 2002
Cumberland College of Health Sciences NSW 1988
Rob Waller is a Musculoskeletal Physiotherapist, with over 25 years experience. He is passionate about restoring function following injury and for people with complex musculoskeletal presentations, particularly spinal and shoulder pain. He is also a lecturer at Curtin University teaching on the Postgraduate Clinical Masters program and is currently completing a PhD investigating pain characteristics in young adults using data from the Raine Study Birth Cohort. (http://www.rainestudy.org.au). Other research interests include spinal pain and translation of evidence to practice.
Low Back Pain (LBP) and Cognitive Functional Therapy (CFT)
WHAT IS COGNITIVE FUNCTIONAL THERAPY (CFT)?
CFT provides a patient centered targeted approach to management of LBP based on a thorough examination. This classification based management approach for LBP considers many domains including: lower back movement and postures, psychological factors, social factors, workplace factors, comorbidities (e.g. diabetes, obesity), pain processing mechanisms: influenced by genetics and life experiences, sleep and lifestyle factors and their relative contributions to an individual’s LBP. CFT challenges thoughts and behaviours in a functionally specific and graduated manner.
It differs from Cognitive Behavioural Therapy (CBT) as changes in beliefs, thoughts and emotions can be realized by the patient when they experience an improvement in symptoms as they move which may challenge previous beliefs, experiences and knowledge about their condition. In a recent study CFT when compared with a manual therapy and exercise group showed clinically and statistically significant large effect sizes across multiple dimensions. The group receiving CFT was 3x less likely to take time off work in the 12 months following treatment1.
As physiotherapists, in a practical sense, it means we are considering both mechanical and non-mechanical aspects of a person’s disorder. By managing patients in this way we are helping them better understand their pain and to move and function in a way that does not perpetuate their pain. By involving the patients in the problem solving and goal setting the longer term prognosis is improved. Essentially this puts patients back in the “driving seat” for directing the course of their rehabilitation and Sarah and I are both excited about the results we are seeing implementing our improved skills so far….
Low back pain (LBP) is very common and is currently the leading cause of disability worldwide3. Only a very small proportion of people with LBP have serious pathology, such as vertebral fracture, cancer, infection or underlying inflammatory disorder, causing their pain2. Unfortunately using a scan to help diagnose LBP is not reliable because MRI abnormalities are as common in those with LBP as in those without. A common recommendation across all high quality LBP guidelines is routine imaging is discouraged unless serious pathology or specific disease is suspected e.g. if surgery is being considered or there has been a limited response to conservative care. There is no evidence that routine imaging improves LBP outcomes. Over time there has been a significant increase in LBP expenditure without any change in associated levels of disability.
Key positive messages supported by current best evidence regarding LBP include:
- The causes of LBP are rarely serious
- LBP has a good prognosis
- Stay active and resume normal activity as soon as reasonable
- Bed rest is specifically not advised
- The back is a strong structure
- Pain does not equal harm
Key management principles for LBP include:
- Diagnosing LBP via thorough questioning and physical examination
- Limited use of imaging
- Advice about what’s contributing to LBP and an understanding of what’s contributing to the pain experience
- Strategies to self-manage pain including physical activity
- Treatment and exercise specific to the problem
- Medication when required but not as the primary management
The key message here is the clear majority of people with LBP, including leg pain (sciatica), will have a good outcome with evidence based, non-surgical care. Cognitive Functional Therapy is an emerging approach to deliver high quality care considering the complexity of factors that can be relevant to a patient’s lower back condition. At Central Bassendean Physiotherapy we pride ourselves on our accurate diagnosis and evidence based, contemporary management of LBP. We are happy to have a further discussion on the material presented here.
You can BOOK HERE or Call us to make an appointment at 9279 7411
- Vibe Fersum, K, O’Sullivan P, Skouen J, et al. Efficacy of classification based cognitive functional therapy in patients with non-specific chronic low back pain- A randomised control trial. Eur J Pain 2013;17;916-28
- Almeda M, Saragiotto B, Richards B, et al. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018;208(6):272-275.
- Clark S, Horton R. Low back pain: a major global challenge. The Lancet 2018;391(10137):2302.