PREVALENCE OF LOW BACK PAIN IN CHILDREN AND ADOLESCENTS: A META-ANALYSIS
 
   

Low Back Pain in Children and Adolescents:
A Systematic Review and Meta-analysis Evaluating
the Effectiveness of Conservative Interventions

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   Eur Spine J. 2014 (Oct);   23 (10):   2046–2058 ~ FULL TEXT

Zoe A. Michaleff • Steven J. Kamper • Christopher G. Maher • Roni Evans • Carolyn Broderick • Nicholas Henschke

The George Institute for Global Health and Sydney Medical School,
The University of Sydney,
Kent Street, Sydney, 2000, Australia,
zmichaleff@georgeinstitute.org.au


PURPOSE:   To identify and evaluate the effectiveness of conservative treatment approaches used in children and adolescents to manage and prevent low back pain (LBP).

METHODS:   Five electronic databases and the reference lists of systematic reviews were searched for relevant studies. Randomised controlled trials (RCTs) were considered eligible for inclusion if they enrolled a sample of children or adolescents (<18 years old) and evaluated the effectiveness of any conservative intervention to treat or prevent LBP. Two authors independently screened search results, extracted data, assessed risk of bias using the PEDro scale, and rated the quality of evidence using the GRADE criteria.

RESULTS:   Four RCTs on intervention and eleven RCTs on prevention of LBP were included. All included studies had a high risk of bias scoring ≤7 on the PEDro scale. For the treatment of LBP, a supervised exercise program compared to no treatment improved the average pain intensity over the past month by 2.9 points (95 % CI 1.6-4.1) measured by a 0–10 scale (2 studies; n = 125). For the prevention of LBP, there was moderate quality evidence to suggest back education and promotion programs are not effective in reducing LBP prevalence in children and adolescents.

CONCLUSIONS:   While exercise interventions appear to be promising to treat LBP in children and adolescents, there is a dearth of research data relevant to paediatric populations. Future studies conducted in children and adolescents with LBP should incorporate what has been learnt from adult LBP research and be of rigorous methodological quality.

Keywords   Low back pain , Systematic review, Children, Adolescents



From the FULL TEXT Article

Introduction

Low back pain (LBP) is a common and costly condition in modern society. [1] While LBP has been comprehensively researched in adults, it is only more recently that this condition has been studied in children and adolescents. [2] Epidemiological studies have reported the prevalence of LBP to be low in children (1–6 %); however, it rises sharply in adolescents (18–51 %) to approach the prevalence in adults. [3–6] The impact of LBP on children and adolescents is significant with up to 94 % of those with pain experiencing some degree of disability. [7] The direct cost to the healthcare system was estimated at a minimum of €100 million per year in Germany alone. [8] Furthermore, it has been suggested that LBP experienced during childhood and adolescence increases the risk of LBP in adulthood [9], possibly through the development of maladaptive beliefs, behaviours, and attitudes related to the earlier pain events. [2, 5]

Similar to LBP in adults, the pathology underlying the pain in children and adolescents is not well understood and symptoms are often managed using conservative treatment approaches including exercise, massage and electrical therapies. [10] While the effectiveness of many of these conservative treatments has been evaluated for adult populations, the spine of a child and adolescent is physiologically different to the adult spine (i.e. ligamentous laxity, bone composition, muscle mass) and, therefore, potentially responds differently to various interventions, movements and loading. [11, 12] Therefore, there is reason to evaluate the efficacy of conservative interventions for LBP in this specific patient population. Current international clinical guidelines for the management of LBP are restricted to evidence from studies performed on adult populations. [13] Synthesis of the research regarding treatment for children and adolescents with LBP is necessary to appraise the available evidence and identify knowledge gaps. While some reviews have already been conducted [14, 15], all contain important methodological shortcomings. The aim of this systematic review was to identify and evaluate the effectiveness of conservative treatment approaches used to manage and prevent LBP in children and adolescents.



Methods

This systematic review was performed following the methods recommended by the Cochrane Back Review Group. [16] From the results of a sensitive search strategy, studies were included if they evaluated conservative interventions for children and adolescents with LBP or strategies to prevent LBP in children and adolescents.

      Eligibility criteria

Randomised controlled trials (RCTs) were considered for inclusion if they enrolled a sample of children or adolescents (<18 years old). The findings were split into two sections, appraising the evidence for conservative interventions to treat LBP or strategies to prevent LBP. A conservative intervention is defined as any non-invasive, non-surgical form of treatment.

For the intervention section, outcome measures could include pain, disability, global perceived effect or participation in daily activities. Data on other outcomes such as well-being or adverse effects were also considered and reported where possible. To be included in the prevention section, RCTs had to enrol children and adolescents with or without LBP and evaluate strategies to prevent the onset or development of LBP. Outcomes had to include LBP intensity or back-related disability (either prevalence thereof, or mean levels across the cohort). Studies that measured cognitions or beliefs (e.g. back beliefs, knowledge regarding risk factors), or proposed risk factors (e.g. motor control, backpack usage, lifting behaviour) as an outcome were included for descriptive purposes only.

      Search methods for identification of studies

Electronic databases, including the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, PEDro, and CINAHL, were searched for potentially eligible studies from the earliest date up to 25th November 2013. Sensitive search strategies were designed to identify all studies on LBP related to children and adolescents (Appendix 1). In addition, the reference lists of included RCTs and previous systematic reviews were searched.

      Data collection and analysis

Study selection   Two authors independently reviewed all titles and abstracts identified by the electronic search to determine their potential relevance for the intervention or prevention parts of the review. Two authors also independently applied all inclusion criteria to the full text of the articles that passed the first eligibility screening. Disagreements were resolved by consensus and where necessary, by a third author.

Data extractionData extraction   Two authors independently extracted data from all eligible studies using standardised forms. Extracted data included the following: sample characteristics (participant source, mean age, gender proportions, duration of symptoms, baseline pain and disability measures); details regarding the intervention setting (e.g. tertiary pain clinic, outpatient clinic, school) and provider type; intervention characteristics (description of index and control interventions, duration and number of sessions, individual or group delivery); co-interventions; and baseline and follow-up outcome data (e.g. pain, disability/function, adverse events). Outcomes were categorised and extracted in three groups: short term (post-treatment and not longer than 3 months), intermediate term (6 months), and long term (12 months or more), according to follow-up time after randomisation.

Risk of bias assessment   The PEDro scale [17, 18] was used to evaluate the risk of bias in all eligible RCTs. Where available scores for eligible trials reported on the PEDro database were used. Otherwise, two authors independently scored the trial using the PEDro scale. All raters were previously trained and experienced in applying the PEDro scale. Disagreements were resolved by consensus.

Data analysis   The clinical homogeneity of RCTs was evaluated qualitatively based on the extracted data on population characteristics, intervention characteristics and outcomes measured. Statistical homogeneity was assessed by inspecting the I2 statistic. Suitability for pooling and selection of meta-analytic model (random or fixed effects) was determined within the comparison categories based on acceptable clinical and statistical homogeneity. Forest plots were generated to present the pooled estimates where there were two or more RCTs of sufficient clinical and statistical homogeneity.

Quality of the evidence   Grades of recommendation, assessment, development and evaluation (GRADE) profiles were used to evaluate the overall quality of the evidence and the strength of the recommendations. [19] The quality of the evidence for a specific outcome was based upon five principal factors:

(1)   methodological limitations (for example due to RCT design),

(2)   inconsistency of results,

(3)   indirectness (affecting generalisability of the findings),

(4)   imprecision (e.g. sufficient data) and

(5)   other considerations, such as reporting bias.

According to GRADE, the overall quality of evidence is considered to be high when multiple RCTs with a low risk of bias provide consistent, generalisable, and precise data for a particular outcome. The quality of the evidence was downgraded by one level for each of the factors described above that were not met. [20] Results were considered inconsistent when effect estimates were heterogeneous or only one RCT was available [21], and quality was marked down for imprecision when fewer than 400 participants were included. [22] The following definitions of quality of the evidence were applied [23]:

  • High quality: further research is very unlikely to change our confidence in the estimate of effect.

  • Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

  • Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

  • Very low quality: we are very uncertain about the estimate.



Results

Figure 1

Table 1

Table 2

Table 3 A

Table 3 B

Table 4

Table 5

Figure 2

The electronic search retrieved 2,466 articles (Figure 1). After screening, 5 articles reporting 4 RCTs were included in the intervention section (Tables 1, 2) and 12 articles reporting 11 RCTs were included in the prevention section (Tables 3, 4).

      Intervention studies

Included studies   Of the four intervention RCTs (one trial by Jones et al. reported outcomes in two articles [24, 25]) included in the review [24–28], two were conducted in the United Kingdom [24, 25, 28], one in Sweden [27], and one in South Africa. [26] Three of the four studies recruited participants from a school setting [24–26] with only one study recruiting participants who were care seeking. [27]

Sample sizes ranged from 45 to 185 participants with a mean age range from 12 to 14.8. The duration of pain at study entry was either unrestricted or unreported in all studies. Three of the studies assessed the effectiveness of supervised exercise programs: two against a no-treatment control group [24–26] and one against a self-directed exercise program. [27] One RCT assessed the effect of a seat wedge versus a no-treatment control. [28] All RCTs measured pain intensity at follow-up, while some also collected disability, quality of life and physical measures (Table 1).

Risk of bias   The four RCTs all met between 4 and 6 criteria on the PEDro scale (Table 5). Three [26–28] reported concealed allocation and none reported an intention-to-treat analysis. Due to the nature of the interventions and the self-reported outcomes, blinding of patients, providers or assessors was not possible in any of the studies. Based on these considerations, risk of bias in all studies was considered moderate.

Effectiveness of the interventions   In two RCTs (n = 125), there was a pooled mean benefit of 2.9 points on a 0–10 pain scale for average pain over the past month (95 % CI 1.6–4.1) of a supervised exercise program over no treatment (Figure 2). [24–26] One study [26] also reported that this benefit was maintained at 6–month follow-up. There was no difference between groups in terms of current pain at either follow-up. Sufficient data were not available to enable pooling of other outcomes.

Ahlqwist et al. [27] reported no difference in terms of pain intensity between a supervised and a home exercise program. Candy et al. [28] reported a statistically significant difference in short-term pain intensity in favour of a seat wedge group over no treatment.

Two RCTs measured function as an outcome; Jones et al. [24, 25] reported a reduction in absences from physical activity in favour of supervised exercise [MD (95 % CI): -1.0 (-1.65, -0.35) p<0.01], and Ahlqwist et al. [27] found no difference between supervised or home exercise on the Roland–Morris Disability Questionnaire [MD (95 % CI): -0.8 (-2.3, 0.7) p = 0.29] (Table 2).

Secondary outcomes such as physical impairment measures (i.e. range of motion, muscle strength and endurance, flexibility) and self-reported quality of life were inconsistently measured across studies (Supplementary Table 1). No studies reported adverse events associated with the interventions; however, one study [27] reported that some participants had to temporarily stop exercising due to pain.

Quality of the evidence—GRADE ratings   There is a moderate quality evidence (downgraded due to imprecision) that in the short term, supervised exercise programs are effective in reducing average back pain over the past month in children compared to no treatment. There is low quality evidence (imprecision, inconsistency) that there is no effect on LBP of supervised versus unsupervised exercise programs.

There is very low quality evidence (imprecision, inconsistency, limitations in design) that a foam seat wedge reduces LBP intensity compared to no intervention; that supervised exercise programs are effective in reducing absences from physical activities, compared to no treatment; and that supervised exercise programs are not effective in reducing disability compared to home exercise programs.


      Prevention studies

Included studies   Of the 11 prevention RCTs (reported in 12 articles) included in the review [29–40], three each were conducted in Belgium [30, 31, 34, 35], the USA [29, 32, 39], and Spain [33, 36, 40], and one each in Sweden [37] and Brazil. [38] All included studies recruited participants from a school setting. The sample sizes ranged from 17 to 603 and all participants were students attending the schools chosen for inclusion in the various studies (Table 3). The mean participant age was 9–11 years across the studies at the time of randomisation. The majority of the studies identified in this section assessed outcomes such as back care beliefs and knowledge about posture and ergonomics, and cognitive factors such as fear avoidance and self-efficacy. Several studies also observed postural, manual handling or backpack wearing behaviour and recorded this as an outcome (Supplementary Table 2). No studies reported adverse events associated with the interventions.

Since the focus of this part of the review was on prevention of LBP, further discussion of the results is centred on those studies that reported LBP prevalence or intensity at follow-up assessment. Only four [30, 31, 34, 35, 37] of the included prevention studies reported the effectiveness of the interventions in terms of LBP prevalence. Three studies assessed the effect of an educational and back care promotion program versus no intervention [30, 31, 34, 35], and one study assessed the effect of providing ergonomically designed school desks against conventional furniture. [37]

Table 6

Risk of bias   All of the four studies met 4 or 5 criteria on the PEDro scale (Table 6). None of the studies reported concealed allocation and none reported an intention-to-treat analysis. Due to the nature of the interventions and the self-reported outcomes, blinding of patients, providers or assessors was not possible in any of the prevention studies. Based on these considerations, risk of bias was considered to be moderate.

Effectiveness of the prevention interventions   Studies by Geldhof et al. [34, 35], Cardon et al. [30] and Dolphens et al. [31] all reported no short- or long-term effect on LBP prevalence of education and back care promotion programs when compared to no treatment. Linton et al. [37] reported a large effect of ergonomically designed furniture with a LBP prevalence post-intervention of 38 % in the intervention group and 66 % in the group that used conventional furniture. It is noted that around 50 % of the students reported back pain prior to the intervention, a high figure for this age group.

Quality of the evidence—GRADE ratings   There is moderate quality evidence (downgraded due to limitations in design) that back-related education and promotion programs are not effective in reducing LBP prevalence in children. There is very low quality evidence (imprecision, inconsistency, limitations in design) that ergonomically designed furniture reduces LBP prevalence compared to conventional furniture.



Discussion

Four RCTs were included in the treatment section and eleven RCTs in the prevention section of this systematic review that evaluated the effectiveness of conservative approaches to treat or prevent LBP in children and adolescents. There is moderate quality evidence to suggest that a supervised exercise intervention has a large effect on average monthly pain scores in children and adolescents compared to no treatment. There is very low quality evidence supporting the use of a foam seat wedge for the treatment of LBP in children. For the prevention of LBP, there is moderate quality evidence to suggest that back-related education and back care promotion programs are not effective in preventing LBP in children and adolescents. There is also very low quality evidence supporting the use of ergonomically designed furniture over conventional furniture. There are conflicting results for the treatment and prevention of LBP when considering measures beyond pain and disability, e.g. physical measures in intervention studies and observed behaviour, physical measures, and knowledge tests in prevention studies.

The findings of this review are somewhat consistent with previous systematic reviews that report on the effectiveness of treatment and prevention interventions for LBP in children and adolescents. [14, 15] The strengths of this systematic review and meta-analysis are that it was conducted in accordance with the methods recommended by the Cochrane Back Review Group [16], focused on clinically meaningful outcome measures of pain and disability, and used a sensitive search strategy, which limits the likelihood any relevant studies have been missed. Only RCTs were eligible for inclusion in this review as this methodology provides the most reliable form of evidence when evaluating treatment effectiveness. The methodological quality of included studies was assessed using the PEDro scale, a rigorously developed [41] and evaluated risk of bias tool that is both valid and reliable; [17, 18] and the strength of recommendations reported in accordance with GRADE guidelines. At last, only studies that demonstrated sufficient clinical and statistical homogeneity were pooled in the meta-analysis.

The limitations of this review include the small number of primary treatment and prevention studies and large heterogeneity between studies that prevented the pooling of results in the meta-analysis for all but one comparison. The inability to pool results means that the findings of this review are based on individual studies; as such it is not possible for robust conclusions to be made. Newly conducted, high quality research is likely to have a large influence on our understanding of the effectiveness of interventions to treat and prevent LBP in children and adolescents. Future studies need to carefully consider the methodological issues known to influence internal and external validity. The issue of generalisability is of particular relevance in this field given that study participants are often recruited from schools, as opposed to from care providers. This choice of sampling frame has unknown implications for the estimate of treatment effectiveness. [42] Furthermore, limitations in the reporting of studies included in the intervention section of this review (e.g. no study reported the duration of pain at study entry) negatively impact on the generalisability and applicability of the results.

Compared to adult populations, the effectiveness of exercise treatment programs in children appears to have a greater effect on pain; however, a similar effect on function. Hayden et al. [43] found no difference in short-term pain relief or function between exercise therapy and no treatment for adults with acute LBP and insufficient evidence for the use of exercise in the sub-acute phase. For adults with chronic LBP, exercise therapy appears to be minimally effective at decreasing pain (7.29 points on a 0–100 scale) and improving function (2.50 points on a 0–100). [43] Our review found a large mean benefit for a supervised exercise program over no treatment for average pain over the last month (2.9 points on a 0–10 pain scale for average pain over the past month). Despite the observed effect on average pain, there was no effect on the current pain or function, so this discrepancy reduces our confidence in the effect reported. As mentioned above, the robustness of the comparison between children and adults is compromised due to included studies not reporting the duration of low back pain symptoms experienced by the children enrolled. In keeping with the findings of the current review, the use of education and back care promotion programs has not been recommended to prevent the onset of LBP in adult populations [13] and there is no robust evidence to support the use of ergonomic furniture.

This review has a number of important implications for clinical practice and future research in the area of child and adolescent LBP. Low back pain research conducted in children and adolescents is an emerging area when compared to the volume of research that has been conducted in adult populations. The four intervention RCTs included in this review can be compared to the several hundred conducted in adult populations. [13] This situation provides a unique opportunity to reflect and learn from the work that has been done in adult populations and apply this knowledge and skill to a new population. [44] In particular, there is a need for large, high quality RCTs to guide clinicians treating children and adolescents with LBP and inform the development of evidence-based health promotion programs targeting the prevention of spinal pain.

There is a need to use psychometrically sound, clinically meaningful and standardised outcome measures for pain, function, health care utilisation and physical activity, as this will increase the clinical applicability of the research and facilitate the pooling of RCT results. [44] The infancy of this research area provides an opportunity to use alternative research methods (e.g. qualitative methods) to identify outcomes that are most important to patients and their family caregivers and highlights the need for detailed and systematic data collection including duration of LBP and adverse events.

At last, while the prevention of LBP could prove to be a major advance in musculoskeletal research there is a need to improve our understanding of the causative mechanisms of LBP to facilitate the development and evaluation of targeted treatment and prevention interventions.


Conflict of interest

None of the authors involved in the preparation of this manuscript have any potential, perceived or real conflict to disclose.



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