Persistence and Change in Nonspecific Low Back Pain
Among Adolescents: A 3-year Prospective StudyThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Spine (Phila Pa 1976). 2004 (Nov 1); 29 (21): 2452–2457 ~ FULL TEXT
Astrid Noreng Sjolie, PhD
Department of Public Health and Primary Care,
Faculty of Medicine,
University of Bergen,
Bergen, Norway.
asjolie@hotmail.comSTUDY DESIGN: This is a 3-year prospective study of juvenile low back pain (LBP).
OBJECTIVES: To investigate persistence and change in LBP.
SUMMARY OF BACKGROUND DATA: Earlier episodes of LBP are a strong risk factor for LBP in adults, while the persistence of LBP through adolescence is not known.
METHODS: The material comprised all pupils in eighth and ninth grades (N = 105, mean age 14.7 years), living within two geographic areas in Eastern Norway in January 1997. The analyses included 88 adolescents at baseline, and 85 at follow-up. The questionnaire, which identified LBP as pain or ache in the low back during the preceding year, was answered at baseline in the classroom and at follow-up by post.
RESULTS: LBP was reported by 58% at baseline and by 39% at follow-up, and LBP provoked by manual work by 40% at baseline and 26% at follow-up. Thirty-one percent reported LBP at both occasions. LBP more than 7 days was reported by 32% at baseline, by 26% at follow-up, and by 18% at both occasions. Twenty-two percent of those reporting LBP at baseline rejected ever LBP at follow-up. Baseline reports of LBP predicted corresponding reports of LBP at follow-up: Odds ratio was 4.7 (95% confidence interval 1.7–12.7) for LBP generally, 9.1 (3.0–27.2) for LBP more than 7 days, 9.2 (2.9–28.8) for LBP provoked by manual work, and 3.8 (1.3–11.3) for LBP provoked by sitting at school.
CONCLUSION: The findings indicate a persistent, but changeable, trend in LBP from midadolescence until late adolescence. The consistency and the high rates of reports of LBP provoked by manual work and sitting imply needs for more research on the persistence of LBP, and on relevant interventions during school age.
KEYWORDS: low back pain, adolescents, persistence, change.
From the Full-Text Article:
Introduction
Unspecific low back pain (LBP) seems to increase over time in children and adolescents1 as well as in adults. [2] The prevalence of weekly LBP has increased 150% and 123% among Finnish girls and boys from 1991 until 2001. [3] In aWorld Health Organization survey, 25% and 22% of 15–year-old European girls and boys reported weekly backache. [4]
There are few prospective studies following the development and course of LBP in children and adolescents, but risk factors are reported to be increasing age, female gender, high levels of sport participation, long periods spent sitting, poor well-being, smoking, and participation in manual work. [1, 5] Former episodes of LBP are strong predictors for future LBP in adults, [6] while the studies of children and adolescents show an inconsistent pattern concerning the persistence in the reports of LBP. [5, 7] There are, however, indications that LBP in adolescence and young adulthood is associated with LBP later in adulthood. [8, 9] The persistence of LBP and of painprovoking situations in late adolescence is thus uncertain, and it is also an open and interesting question how reports of LBP provoked by manual work and sitting may predict future LBP, on the background of the high levels of physical disability due to LBP among adults. [2]
In our two former studies of a group of Norwegian adolescents, LBP was associated with poor endurance strength and stability [10] and poor well-being, but not with social class or parental LBP. [11] The aim of the present study was to investigate the persistence and change in reports of LBP among the same adolescents, and to explore whether reports of pain-provoking situations at baseline were significant predictors of later reports of LBP. It was hypothesized that both pain per se and pain provoked by manual work and sitting would predict later LBP.
Materials and Methods
Design and Implementation.
The study was an epidemiologic investigation, following a group of adolescents from 1997 until 2000. Written consent was obtained from the ethical committees, the adolescents, and the parents in 1996. The questionnaires were completed at baseline in the classrooms in the presence of a teacher and the author. As some potential means to reduce LBP was wanted by parents, teachers, and adolescents, a minor back-school based intervention was performed, comprising information to the teachers and one individual instruction session to those reporting recurrent LBP. The session emphasized consciousness of keeping a stable back during sitting and lifting [12] and strengthening extension exercises for the lumbar spine. School furniture was adjusted, mostly by elevation, according to principles of ergonomic school furniture [13] for five adolescents who reported LBP during sitting at school and dissatisfaction with the table height. The questionnaires at follow- up were sent to the adolescents’ homes and returned to the author by post.
Materials.
The inclusion criteria was all schoolchildren in eighth and ninth grades in two geographic areas in Eastern Norway in January 1997, and their parents. One of the areas was an urban municipality, Rendalen, where the total population was 2300 inhabitants, and the relevant students numbered 44. The other area was a nearby rural region, Hanstad in Elverum municipality. The total population in Hanstad region was 2100, and the relevant students numbered 61. All participants belonged to the only junior secondary school in their areas, respectively. The exclusion criterion was serious disease that could interfere with physical performance or LBP; none was excluded. At baseline, 38 girls and 50 boys participated, making the response rate 84%. Mean (standard deviation) age was 14.7 (0.7) years, and the range was 14.1 to 16.1 years. The follow-up was performed 3 years later. Two nonresponders were boys who confirmed and rejected LBP, respectively, at baseline. Another boy reported serious LBP in the follow-up period, due to a bicycle crash during a competition. The data concerning these three boys were omitted from the study.
Data Collection.
LBP was measured by a slightly adjusted Nordic questionnaire, designed, and validated for schoolchildren [14] (Salminen JJ, personal communication 1996). The questionnaire, displayed previously, [10] included a drawing of the back and defined LBP as pain, ache, or discomfort in the lower back during the preceding year, not related to trauma or menstrual pain. The questions comprised duration of LBP from daily to lifetime occurrence, consequences of LBP, such as intake of pain relievers and visits to health professionals, and different situations provoking LBP, such as sitting at school, using television/computer or working manually. Additional questions treated frequency, time use, and types of physical activity, well-being, and satisfaction with school furniture. The questionnaire at follow-up also included open questions concerning the adolescents’ own opinions of causes of potential improvement of LBP.
Social class was measured as parental occupations. Eightyseven percent of the fathers and 91% of the mothers informed of their occupations and their LBP in a questionnaire sent by post in 1996. The occupations were registered in seven categories [15] according to the parent with the highest level.
Data Analyses.
Social class was condensed into three levels as follows.Lower class: skilled or unskilled manual worker, farmer.
Middle class: service occupations, skilled health worker, elementary school teacher, office clerk.
Upper class: business-owner, executive, university-educated specialist, professional.The level of significance was set to P ≤ 0.05. Univariate analyses of the categorical data included comparisons between baseline and follow-up data, using McNemar’s test (McN) and two-tailed t tests, binary logistic regression analyses, and ordinal regression analyses, in which baseline data were compared with ordinal data at follow-up. The interpretation of the odds ratio is the same as in binary logistic regression analyses. The ordinal levels ranged LBP during the preceding year as follows: 1, no LBP; 2, LBP 1 to 30 days; 3, LBP 31 days to daily. The multivariate analyses were performed by multiple ordinal logistic regression analyses, including gender and social class as covariates. Significant findings were marked with bold types in the tables. The program Minitab, version 13.1, was used in the analyses.
Results
Plain Comparisons Between Baseline and Follow-up
Table 1 The distribution of the duration, consequences, and situations provoking LBP at baseline and at follow-up is described in Table 1. The most frequently reported painprovoking situations were performance of manual work, followed by sitting at school during examination days, sitting during ordinary school days, and performance of leisure physical activity. Manual work and sitting at school provoked pain among 69% and 47% of those reporting LBP at baseline, and among 67% and 55% at follow-up, respectively. Corresponding figures for those reporting LBP more than 7 days were 70% and 63% at baseline, and 70% and 68% at follow-up, respectively. Forty-three percent of those who reported LBP provoked by sitting at school at baseline also reported LBP provoked by using television/computer, and 35% of those reporting LBP provoked by sitting at school at baseline also reported LBP provoked by leisure physical activity.
Baseline and follow-up reports of LBP were associated for the whole group (McN: P = 0.007) and for girls (McN: P = 0.009), and there was a tendency to an association for boys (McN: P = 0.1). Thirty-one percent of the whole group reported LBP at both occasions, and 53% of those who reported LBP at baseline still reported LBP at follow-up. Among girls and boys, 59% and 45%, respectively, of those who reported LBP at baseline still reported LBP at follow-up.
Table 2 In Table 2, the recollection of ever LBP at follow-up is displayed according to the baseline reports of LBP during the preceding year. Rejecting answers to the question of ever LBP at follow-up were given by 22% of those reporting LBP during the preceding year at baseline, and by 11% of those reporting LBP more than 7 days at baseline. All those who had been treated or used painkiller due to LBP at baseline answered confirmatory to the question of ever LBP at follow-up. Three of those still reported LBP at follow-up, and two of them had used painkiller due to LBP during the preceding year at follow- up. Four of the five adolescents whose school tables were adjusted at baseline still reported LBP at follow-up.
Among the 49 adolescents who reported LBP at baseline, 23 did not report LBP at follow-up. Four of those 23 informed that they believed training was the main reason for the improvement, another four that knowledge of ergonomic principles like sitting and lifting with straight back had improved their back health. Two adolescents reported cessation of pain-inducing physical activity as a reason for improvement, and another two reported both training and cessation of pain-inducing physical activity as reasons. Nine of the 49 reporting LBP had received treatment during the preceding year, of whom six still reported LBP at follow-up.
Among the 36 adolescents who reported no LBP at baseline, 29 reported no LBP at follow-up. Five of the 29 reported that training and/or ergonomic principles had helped them to recover from episodes of LBP during the follow-up period. Three had received treatment in the period; two of those reported no LBP at follow-up. One third of those reporting LBP more than 7 days at follow- up had changed their activity due to LBP during the preceding year.
There were significant associations between baseline and follow-up reports of LBP provoked by manual work for the whole group (McN: P = 0.02) and for girls (McN: P = 0.02), but not for boys (McN: P = 0.7). Twenty-six percent of the whole group reported LBP provoked by manual work at both occasions, and 50% of those who reported LBP provoked by manual work at baseline still reported the same LBP at follow-up. The corresponding figures were 48% and 55% for girls and boys, respectively. Eleven percent reported LBP provoked by sitting at school at both occasions. Thirty-one percent (12 boys and 14 girls) reported LBP provoked by either manual work or sitting at school at follow-up.
Associations by Regression Analyses
Table 3
Table 4 In Table 3, the univariate associations between the various corresponding reports of LBP at baseline and at follow- up are displayed as odds ratios (OR) by binary logistic regression analyses:
Baseline reports of LBP ever, LBP during the preceding year, LBP more than 7 days, LBP provoked by manual work, and by sitting at school predicted corresponding reports at follow-up; the strongest correspondences were found for LBP more than 7 days and LBP provoked by manual work.
Table 4 displays associations between various reports of LBP at baseline and LBP at follow-up in univariate and multiple ordinal regression analyses, adjusting for gender and social class:
Associations were found between LBP at follow-up and baseline reports of LBP. The strongest baseline predictors in univariate and multiple analyses were LBP more than 7 days (OR = 8.0 and 11.7, respectively), LBP provoked by manual work (OR = 5.2 and 7.1, respectively), and LBP provoked by sitting at school (OR = 5.8 and 6.2, respectively). No associations were found between baseline reports of LBP provoked by use of television and computer or leisure physical activity and LBP at follow-up.
Other Findings
Answers to the open questions concerning painprovoking situations were various forward-leaning positions both during sitting and leisure physical activity; none mentioned carrying the school bag, either at baseline or at follow-up. LBP at baseline was associated in multivariate analyses with female gender, seldom physical activity, much time spent using television or computer, and a perception of poor well-being. The frequency of weekly manual work was 60% at baseline and 56% at follow-up, and quite similarly reported by both genders at both occasions. The frequency of regular leisure physical activity three times weekly or more was 65% at baseline and 39% at follow-up. Mean reported time spent weekly on television or computer was 16 hours at baseline and 15 hours at follow-up. Approximately half of the group was classified in the lower social class, and one fourth in the middle and upper social class, respectively.
Discussion
The main findings of the study were that baseline reports of LBP were strongly associated with future LBP among adolescents. The 1-year prevalence of LBP both at baseline and at follow-up was high, even if a reduction was measured. Although girls reported LBP more frequently than boys, the pattern and hierarchy of pain-provoking situations was similar among the genders. The strength of the predictions of baseline reports of LBP more than 7 days, LBP provoked by manual work and by sitting at school for future LBP was amazing. It is a possibility that those who report LBP provoked by manual work and sitting at school at age 15 and 18 may experience problems also later when performing manual work and prolonged sitting, and thus contribute to the steadily growing high rates of disability due to LBP among adults. [2] Scandinavian studies indicate that juvenile LBP is a strong predictor of LBP 20 to 25 years later. [8, 9] In a British population-based study of adults, 78% of those reporting chronic pain at baseline still reported chronic pain 4 years later. [16]
Sitting at school predicted future LBP, in contrast to LBP provoked by use of television or computer. One explanation may be that it is possible to vary positions at home during use of television and computer. The correspondence between LBP provoked by sitting at school and during using television/computer indicates that the sitting position per se is a problem for some of the students, but not for others. Another reason for the difference might be that the use of television/computer was initiated by free choice, and thus possibly associated with more positive attitudes and emotions than the compulsory sitting at school; there is a large amount of evidence that LBP in young people is associated with poor wellbeing. 1 The combination of television and computer in the question may also disguise potential associations between LBP and the two different situations of using television and computer.
The 1–year prevalence of LBP at baseline of 58% corresponds to 51% in Danish 13– to 16–year-old adolescents [17] but is lower than French data of 83%. [18] The high frequency corresponds to 1–month prevalence reports of 24% among 11– to 14–year-old children in a recent British survey, [19] and 20% and 12% among 14–year-old Finnish girls and boys. [20] The high reports of LBP provoked by manual work and sitting at school are in agreement with reports of disability and pain during sitting at school among 94% and 53%, respectively, of schoolchildren reporting LBP in the British survey, [19] and one conclusion in a review that sitting is the main aggravating factor for LBP among children and adolescents. [1]
The strong association between LBP at baseline and at follow-up corresponds to findings of an OR of 7.4 (95% CI, 4.3–11.4) for persistence of substantial LBP in Feldman’s 1-year prospective study, [5] and the findings in a prospective Finnish study, showing a consistent pattern in recurrent LBP among adolescents 15 years old at baseline and 18 years old at follow-up. [21] However, the lack of recollection of former LBP at follow-up among 22% of those reporting LBP at baseline indicates that juvenile LBP also includes minor episodes that are forgotten and probably have no associations with future low back function. The finding is in correspondence with another Norwegian study, which showed a persistent pattern in neck pain, but not in LBP in a follow-up study after 9 to 12 years in 16-year-old adolescents at baseline. [22]
Similar results were found in a British 4–year prospective study, in which poor associations were found between LBP reports of children 11 years old at baseline and at followup. [7] Although lifetime prevalence rose from 12% at age 11 to 50% at age 15 in the British study, reports of LBP showed an inconsistent pattern, and episodes at baseline were often forgotten later. [7] Similar findings were made in a recent Belgian 2–year prospective study of 9– and 11–year-old schoolchildren at baseline. [23] The age differences in the material may account largely for the difference; the persistence of LBP may be less in younger children, and there is also a possibility that the reports may be less accurate among children of younger age. The longer time interval in the British study may also cause some difference.
The lower 1–year prevalence of LBP at follow-up compared with baseline contrasts the common trend that age is an independent risk factor for LBP in children and adolescents [1] but corresponds to the decline of LBP in Feldman’s 1–year prospective study. [5] One reason may be the different collection methods of data at baseline and at follow-up in our study, as the presence of the researcher during the baseline examination may have induced higher reports of LBP than at follow-up, where there was no personal contact. This interpretation is supported by the fact that 11% of those reporting LBP more than 7 days at baseline did not recollect to have experienced LBP at follow-up. However, good agreements have been found between use of questionnaire and interview concerning juvenile LBP. [24]
Other possibilities may be indicated by the answers given by 13 adolescents regarding potential recovery from LBP, suggesting that some of the lower prevalence at follow-up may be due to training and use of ergonomic principles. Several studies have shown a protective effect concerning LBP among schoolchildren by back-school interventions, including use of elevated school furniture. [25–28] A minor McKenzie-inspired regimen including instructions of exercises, back school, and taping of the low back reduced the risk of developing LBP during military service in a randomized Danish study. [29]
The small sample is a limitation of the present study and implies careful interpretations and a danger that true associations may not be uncovered. The similarities with other studies concerning rates and covariates of LBP indicate, however, that the sample still may have some general relevance. The use of the well-known questionnaire and the high follow-up rate strengthen the study further. By using ordinal regression analyses, data are better used. Our results need to be confirmed in further studies, using larger and representative material.
Conclusion
Our findings indicate that reports of LBP in midadolescence are strong predictors of future LBP in late adolescence, although half of those reporting LBP at baseline did not report LBP at follow-up and one fourth had forgotten minor previous episodes. The data confirm the general trend that LBP, often provoked by manual work and prolonged sitting, is common, and the results indicate a consistent, but changeable, pattern of juvenile LBP. Future research should study the significance of reports of LBP provoked by manual work and sitting during adolescence for future LBP and disability in adulthood.
Key Points
A prospective study of adolescents, 14 to 15 years of age at baseline, was performed to investigate the persistence and change in reports of low back pain (LBP) over a 3-year period.
LBP during the preceding year was reported by 58% at baseline and 39% at follow-up, LBP more than 7 days by 32% and 26%, respectively, and LBP provoked by manual work by 40% and 26%, respectively.
Strong associations were found between corresponding reports of LBP at baseline and at followup: Odds ratio (95% confidence interval) was 4.7 (1.7–12.7) for LBP, 9.1 (3.0 –27.2) for LBP more than 7 days, and 9.2 (2.9 –28.8) for LBP provoked by manual work.
Twenty-two percent of those reporting LBP at baseline rejected ever having experienced LBP at follow-up. The findings indicate a persistent, but changeable pattern in juvenile LBP.
Acknowledgements
The author thanks Professor A.E. Ljunggren at the University of Bergen, Norway, for constructive discussions, and the participating adolescents for twice allowing me some access into their lives.
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