Rehabilitation of back pain in the pediatric population: a mixed studies systematic review

Hainan Yu; Danielle Southerst; Jessica J. Wong; Leslie Verville; Gaelan Connell; Lauren Ead; Silvano Mior; Lise Hestbaek; Michael Swain; Ginny Brunton; Heather M. Shearer; Efrosini Papaconstantinou; Daphne To; Darrin Germann; Katie Pohlman; Christine Cedraschi; Carol Cancelliere

doi:10.1186/s12998-024-00538-z

Table 2

Research questions, population, intervention, comparison, outcome and study type

Included Excluded
Research question 1: What is the effectiveness and safety of rehabilitation interventions for improving pain, functioning, and health outcomes in children and adolescents with back pain?

Population Children and adolescents with low back pain, thoracic spine pain, mechanical back pain, lumbago, lumbar sprain or strain, back sprain or strain, lumbopelvic pain, lumbar radiculopathy, lumbar disc herniation, lumbar spondylolysis, sacroiliac syndrome or sciatica in any duration
(1) Back pain attributed to major structural or systemic pathology (e.g., fracture, infection, tumour, osteoporosis, inflammatory arthritides, cauda equina syndrome, neuromuscular disease, myelopathy and scoliosis)
(2) Back pain attributed to a non-spine-related condition that might refer pain to the chest wall (e.g., heart, lung or esophagus conditions)

Intervention Rehabilitation interventions including pharmacological, non-pharmacological, and psychological interventions delivered by various healthcare providers including, but not limited to, general practitioners, nurses, physiotherapists, chiropractors, occupational therapists, psychologists and registered massage therapists Surgical interventions, and interventions solely conducted at the societal level, such as barrier removal initiatives (e.g., fitting a ramp to a public building)

Comparison Other conservative interventions, placebo or sham, wait list, standard care, and no intervention or intervention of interest as an addition to active comparison interventions where the attributable effect of the comparison interventions can be isolated

Outcome
1. Outcomes related to body functions and structures to describe a child’s impairment: e.g., pain intensity, frequency, duration; range of motion; psychological outcomes such as depression and anxiety
Examples of outcome measures: NRS, VAS, Faces Pain Scale—Revised;(Hicks et al., 2001, Michaleff et al., 2017) goniometer, Revised Child Anxiety and Depression Scale,(Chorpita et al., 2000) State-Trait Anxiety Inventory for Children,(Spielberger 1973) PROMIS Pediatric Self Report Scale
2. Outcomes related to activities and participation to describe a child’s functional status and involvement in life situations: e.g., disability, communication, mobility, interpersonal interactions, preferences, self-care, learning, applying knowledge, return to activities/school
Examples of outcome measures: Modified Oswestry Low Back Pain Disability Questionnaire,(Fairbank et al., 1980) KIDSCREEN-52,(Ravens-Sieberer et al., 2008) Pediatric Quality of Life Inventory(Varni et al., 2001)
3. Adverse events: any unfavourable sign, symptom, or disease temporarily associated with the treatment, whether or not caused by the treatment.(Pohlman et al., 2014) We will also consider indirect harms, where the use of an intervention delays a diagnosis or treatment, and such delay holds a potential harm.(Zorzela et al., 2014)

Study design
Randomized controlled trials
Cohort studies
Case–control studies
Mixed methods studies (quantitative component)

Research question 2: What are the patients’, caregivers’ and providers’ experiences, preferences, expectations and valued outcomes regarding rehabilitation interventions for back pain?

Outcome Experiences, preferences, expectations, valued outcomes
Study design
Qualitative studies (e.g., phenomenology, grounded theory, ethnography, action research, descriptive qualitative studies)
Mixed-methods studies (qualitative component)

Research question 3: What is the cost-effectiveness of rehabilitation interventions for improving pain, functioning, and health outcomes in children and adolescents with back pain?

Outcome
Direct costs: resources consumed or saved by an intervention
Indirect costs: productivity gains or losses (e.g., time consumed or freed by the intervention)
Economic health outcomes: QALY, ICER, NMB
Intangible: e.g., pain or suffering saved or brought on by an intervention

Study design Full economic evaluations (trial- and model-based): cost-effectiveness, cost-utility, cost–benefit, cost-consequences

ICER incremental cost-effectiveness ratio,
NMB measure of net monetary benefit,
NRS Numerical Rating Scale,
PROMIS Patient-Reported Outcomes Measurement Information System,
QALY quality adjusted life years,
VAS Visual Analogue Scale

	Included	Excluded
Research question 1: What is the effectiveness and safety of rehabilitation interventions for improving pain, functioning, and health outcomes in children and adolescents with back pain?

Population	Children and adolescents with low back pain, thoracic spine pain, mechanical back pain, lumbago, lumbar sprain or strain, back sprain or strain, lumbopelvic pain, lumbar radiculopathy, lumbar disc herniation, lumbar spondylolysis, sacroiliac syndrome or sciatica in any duration	(1) Back pain attributed to major structural or systemic pathology (e.g., fracture, infection, tumour, osteoporosis, inflammatory arthritides, cauda equina syndrome, neuromuscular disease, myelopathy and scoliosis) (2) Back pain attributed to a non-spine-related condition that might refer pain to the chest wall (e.g., heart, lung or esophagus conditions)

Intervention	Rehabilitation interventions including pharmacological, non-pharmacological, and psychological interventions delivered by various healthcare providers including, but not limited to, general practitioners, nurses, physiotherapists, chiropractors, occupational therapists, psychologists and registered massage therapists	Surgical interventions, and interventions solely conducted at the societal level, such as barrier removal initiatives (e.g., fitting a ramp to a public building)

Comparison	Other conservative interventions, placebo or sham, wait list, standard care, and no intervention or intervention of interest as an addition to active comparison interventions where the attributable effect of the comparison interventions can be isolated

Outcome	1. Outcomes related to body functions and structures to describe a child’s impairment: e.g., pain intensity, frequency, duration; range of motion; psychological outcomes such as depression and anxiety Examples of outcome measures: NRS, VAS, Faces Pain Scale—Revised;(Hicks et al., 2001, Michaleff et al., 2017) goniometer, Revised Child Anxiety and Depression Scale,(Chorpita et al., 2000) State-Trait Anxiety Inventory for Children,(Spielberger 1973) PROMIS Pediatric Self Report Scale 2. Outcomes related to activities and participation to describe a child’s functional status and involvement in life situations: e.g., disability, communication, mobility, interpersonal interactions, preferences, self-care, learning, applying knowledge, return to activities/school Examples of outcome measures: Modified Oswestry Low Back Pain Disability Questionnaire,(Fairbank et al., 1980) KIDSCREEN-52,(Ravens-Sieberer et al., 2008) Pediatric Quality of Life Inventory(Varni et al., 2001) 3. Adverse events: any unfavourable sign, symptom, or disease temporarily associated with the treatment, whether or not caused by the treatment.(Pohlman et al., 2014) We will also consider indirect harms, where the use of an intervention delays a diagnosis or treatment, and such delay holds a potential harm.(Zorzela et al., 2014)

Study design	Randomized controlled trials Cohort studies Case–control studies Mixed methods studies (quantitative component)

Research question 2: What are the patients’, caregivers’ and providers’ experiences, preferences, expectations and valued outcomes regarding rehabilitation interventions for back pain?

Outcome	Experiences, preferences, expectations, valued outcomes
Study design	Qualitative studies (e.g., phenomenology, grounded theory, ethnography, action research, descriptive qualitative studies) Mixed-methods studies (qualitative component)

Research question 3: What is the cost-effectiveness of rehabilitation interventions for improving pain, functioning, and health outcomes in children and adolescents with back pain?

Outcome	Direct costs: resources consumed or saved by an intervention Indirect costs: productivity gains or losses (e.g., time consumed or freed by the intervention) Economic health outcomes: QALY, ICER, NMB Intangible: e.g., pain or suffering saved or brought on by an intervention

Study design	Full economic evaluations (trial- and model-based): cost-effectiveness, cost-utility, cost–benefit, cost-consequences