Eur J Pediatr. 2018 (Nov 21) [Epub] ~ FULL TEXT
Sarah Batley & Ellen Aartun & Eleanor Boyle & Jan Hartvigsen & Paula J. Stern & Lise Hestbæk
Canadian Memorial Chiropractic College,
6100 Leslie Street,
Toronto, M2H 3J1, Canada.
Spinal pain, back pain, and/or neck pain begins early in life and is strongly associated with spinal pain in adulthood.
Understanding the relationship between psychological and social factors and adolescent spinal pain may be important in both
the prevention and treatment of spinal pain in this age group. We aimed to determine if psychological and social factors were
associated with spinal pain in a cross-sectional study of a school-based cohort of 1279 Danish adolescents aged 11–13, who were
categorized into “any” and “substantial” spinal pain.
“Substantial spinal pain” was defined as a lifetime frequency of
“sometimes” or “often” and a pain intensity of at least two on the revised Faces Pain Scale. Logistic regression analyses,
stratified by sex, were conducted for single and all variables together. Eighty-six percent of participants reported “any spinal
pain” and 28% reported “substantial spinal pain”. Frequency of psychological and social factors was significantly higher in those
with spinal pain compared to those without. As the frequency of psychological and social factors increased, the odds of both “any
spinal pain” and “substantial spinal pain” also increased.
Conclusion: Psychological and social factors may be important determinants in adolescent spinal pain.
KEYWORDS: Adolescent; Back pain; Psychological factor; School children; Social factor; Spinal pain
CI = Confidence interval
HBSC = Health Behaviour in School-Aged Children
OR = odds ratio
rFPS = Revised Faces Pain Scale
SP = spinal pain
YSQ = Young Spine Questionnaire
SES = Socioeconomic status
From the FULL TEXT Article
Spinal pain (SP) is a major public health concern globally with
low back pain and neck pain as leading causes of years lived
with disability.  SP begins early in life and prevalence
increases rapidly during adolescence to reach adult levels by
age 18. [4, 8] Thus, SP in adolescence is very common with
some studies citing lifetime prevalence rates as high as 86%. 
The majority of this SP is mild with few consequences; however,
a smaller portion of adolescents have more persistent and
recurring pain that impacts their daily lives and well-being. 
Negative consequences of adolescent SP include absence from
school, healthcare-seeking behavior, avoidance of sports and
activities, as well as decreased quality of life. [19, 20]
SP in adolescence is strongly associated with SP in adulthood. [11, 14] The literature on SP in adult populations illustrates
that SP and psychological and social factors are strongly
related. [13, 22, 25] A few studies have shown that psychological
and social factors are also related to SP in adolescence [7, 24, 28, 31], but this is not as well established. Studies
conducted on this age group have found that higher levels of
stress, depression, negative behavior, emotional problems,
poorer overall well-being, and higher levels of peer problems
increase the odds of reporting SP. [7, 24, 28, 31]
Therefore, the primary objective of this study was to determine
if psychological and social factors are associated with SP
in a cohort of Danish adolescents aged 11–13 years.
This study was cross sectional in nature and was a secondary
analysis of baseline data collected in May and June of 2010 in
connection with the School site, Play spot, Active transport,
Club fitness, and Environment (SPACE) study. 
Setting and data collection
The SPACE study was conducted at 14 schools in the Region
of Southern Denmark. It was designed to test the effect of
optimizing the physical environment around the schools to
promote physical activity.  At baseline, the students completed
an e-survey that included questions about SP as well as
psychological and social factors. The survey was completed
under supervision of the teacher during class time.
Students at the participating schools aged 11 to 13 years (n =
1,348) were eligible for the study. Those who assented and
responded to all of the SP-related questions were included in
For the SPACE study, a letterwas sent to parents informing them
of the study and that they could withdraw their child’s participation
at any time. For more details, see the SPACE protocol. 
The Regional Ethics Committee for Southern Denmark was
advised about the study and data collection. Under Danish law,
no ethics approval was needed because the study did not include
any invasive tests or interventions. Approval was obtained from
the Danish Data Protection Agency (#2010-41-5147).
For the current study, Research Ethics Board approval was
obtained from Canadian Memorial Chiropractic College
Spinal pain (dependent variables)
The Young Spine Questionnaire (YSQ), embedded in the
SPACE e-survey , was used to assess lifetime occurrence
of SP. The YSQ was developed for 9–11-year olds and has
satisfactory feasibility, content validity, and item agreement
between questionnaire scores and interview findings. 
The YSQ assesses the three spinal regions, neck, mid back,
and low back, separately. For lifetime prevalence of pain, the
participant was asked: “Have you ever had pain in your (specific
region listed)?” with the response categories of “often”,
“sometimes”, “once or twice”, and “never”. The participants
who responded at least “once or twice” were asked to assess
their worst pain ever using the revised Faces Pain Scale
(rFPS). This scale is based on six faces that illustrate progressively
worsening pain and can be scored from 0, representing
no pain, to 5, representing worst imaginable pain. The rFPS
has been found to be valid and appropriate for use in assessing
pain intensity in children over the age of 4. 
The three spinal pain regions were collapsed into one category
indicating SP in any region. A previous study on this
population found that there was a high overlap of pain between
the three spinal regions.  “Any SP” was defined as any
frequency of SP above “never” regardless of intensity level.
“Substantial SP” was defined as a frequency of “sometimes”
or “often” in at least one spinal region with a corresponding
pain intensity of at least 2 on the rFPS. Stallknecht et al. previously
used this method of defining SP from the YSQ. 
Psychological and social factors (independent variables)
Data on psychological and social factors was collected using
questions from the Health Behaviour in School-Aged
Children: World Health Organization Collaboration Cross-
National Survey (HBSC)  that was embedded in the
SPACE e-survey.  The HBSC questions are subject to
validation studies and piloting at national and international
levels.  The four-item psychological subscale has been
found to have good internal validity, convergent validity,
and discriminant validity. 
For each of the psychological variables, the questionnaire asks
them: “In the past six months, how often have you been feeling
low/bad mood/nervousness/difficulty sleeping?”. The response
categories were “every day”, “more than once a week”, “almost
every week”, “almost every month”, and “rarely or never”.
The social variables related to loneliness and pupil acceptance
and the questions were: “Do you feel lonely?” with the
response options: “no”/“sometimes”/“often”/“very often”,
and “Other pupils accept me as I am?” with the response
options: “Strongly agree”/“agree”/“neither agree nor
Other variables of interest
Age, socioeconomic status (SES), smoking, and alcohol were
identified as covariates. Low SES has been shown to be associated
with poorer overall health and there is high-quality evidence
from a recent systematic review to suggest that low SES
is a risk factor for developing musculoskeletal pain in adolescents.  Low SES is also associated with higher levels of
mental health problems.  SES was based on the father’s
occupation at follow-up 2 years later and coded according to
the Danish Occupational Social Class Measure.  SES was
classified as high, middle, or low based on these ratings.
Smoking has been shown to increase the odds of reporting
LBP, and alcohol consumption has been found to be positively
associated with current LBP in adolescents and young adults. [12, 15, 23] Smoking and alcohol consumption have also been
identified as risk factors for mental health problems in adolescents. [3, 5] A participant was considered to smoke if they
reported smoking at least once every week and to drink if they
reported drinking alcohol at least once every month.
Descriptive statistics were used to present the study cohort in
terms of psychological and social factors aswell as SP. Results
are presented as frequencies and percentages.
We constructed multiple logistic regression models to determine
the association between the psychological and social
variables and the two outcomes. The models were adjusted for
age and SES, but due to rather small proportions of children
smoking and drinking, these variables were not included (n =
6 and n = 86, respectively). We also checked if any interactions
existed between the psychological and social variables.
All regression analyses were stratified by sex. Adjusted odds
ratios (OR) with 95% confidence intervals (CI) were reported.
To determine if there was an independent relationship between
the psychological and social variables and the two outcomes,
an exploratory factor analysis was first conducted for
each of the constructs to determine if they would load onto the
same factor, because a scoring system to estimate a combined
score has not been created previously.
The psychological variables loaded onto the same factor;
therefore, a scoring system was developed where a value of
“0” to “4” was assigned to the response categories (“0” = never/
rarely, “1” = almost every month, “2” = almost every week, “3 = more than once per week, and “4” = almost every day). The
values were summed across the four variables to reach a composite
psychological score that could range from “0” to “16”.
There was no linear relationship between the composite psychological
score and the two outcomes, and we therefore categorized
the score into three categories: (1) no psychological
complaints (value of 0), (2) low composite psychological score
(value of 1 to 4), and (3) high composite psychological score
(value of 5 to 16). A one-factor solution for the social variables
could not be found. The regression analyses described above
were repeated for the composite psychological score.
Statistical significance was set at a p value of less than 0.05
(p < 0.05) for all analyses.
All statistical analyses were carried out in Stata 15.0
(StataCorp, College Station, Texas, USA).
In this sample of Danish adolescents, the odds of reporting
“any SP” or “substantial SP” were greatly increased with
higher frequencies of psychological factors with ORs ranging
from 2 to 13. Participants reporting “any SP” or “substantial
SP” reported significantly higher frequencies of all four psychological
factors than those without SP. Furthermore,
reporting multiple psychological factors with higher frequencies,
indicated by a higher composite psychological score,
resulted in an increased OR of reporting SP.
Recently, Stallknecht et al. found that Danish adolescents
aged 10–14 reporting medium and high values of stress had
an increased OR of reporting SP compared to those reporting
no stress.  Adolescents who reported poorer general wellbeing
also had increased odds for reporting SP compared to
those who reported better well-being.  Similarly, in Dutch
adolescents aged 12–16, stress and depressive symptoms were
found to be associated with neck pain/shoulder pain and low
back pain.  Two British studies assessed emotional factors in
British adolescents aged 11–14 using the Strengths and
Difficulties Questionnaire and both found that participants
reporting high levels of “negative” behavior were significantly
more likely to report low back pain. [24, 31] Another British
study found that children aged 11–14 who reported higher
levels of psychosocial difficulties were more likely to develop
LBP compared to their peers. 
Previous studies have shown inconsistent evidence for the
effect of sleep quantity on back pain onset in adolescents. 
There is moderate evidence of no higher risk of poor sleep
quality with back pain onset.  There is moderate quality
evidence that boys with daytime tiredness are not at higher risk
of back pain, but this evidence is inconsistent in girls. 
Recent reviews have shown that there is a reciprocal relationship
between sleep and pain and that sleep impairments are a
stronger predictor of pain than pain is of sleep impairments. 
In our study, those reporting “any SP” or “substantial SP”
reported significantly higher levels of loneliness and lower
levels of pupil acceptance than those without SP. When the
social variables were both included in an analysis together
with SP, associations were still positive, but the estimates were
lower and most of them not statistically significant. These
findings are similar to a study by Watson et al. where
participants reporting high levels of pupil problems had a
small but significant OR for reporting LBP compared to those
reporting low levels of pupil problems. 
When the composite psychological score and social variables
were included in the same analysis, all the estimates
were reduced. This indicates that loneliness and psychological
scores are likely interdependent and thus lower the effect of
one another when included in the same model.
There are several strengths in this study including the high
participation rate (95%). The sample is also representative of the
Danish population, increasing the generalizability of the study.
The HBSC questionnaire is subjected to validation and piloting
at national and international level  and the YSQ was developed
and tested for this age group.  This study also provides
information on two definitions of SP, which allows us to comment
on the association between the frequency of psychological
and social factors and the severity of reported SP.
However, this study also has some limitations. Due to the
cross-sectional nature, neither causation nor direction of
association can be determined. The 95% CI for some associations
are quite wide, and thus, results should be interpreted with
caution. Due to missing SES data, a substantial number of participants
were excluded from the adjusted analyses. These participants
reported significantly higher frequencies of low mood,
nervousness, loneliness, and pupil acceptance. Thus, their exclusion
from the adjusted analyses have likely resulted in an
underestimation of the reported ORs. Finally, the composite
psychological scoring has not undergone a validation process.
There was a high prevalence of psychological and social
factors among adolescents in this study cohort. Previous studies
have shown that depression, stress, anxiety, sleeping difficulties,
and loneliness can all result in negative health-related
consequences, including SP. With SP causing such a high
level of disability in the population, and SP beginning early
in life, it is important to understand the factors associated with
the development and perpetuation of SP in adolescents. A
better understanding of these factors is likely to lead to better
preventative measures as well as more comprehensive intervention
strategies in adolescents with SP.
This study indicated that psychological and social factors
are associated with SP in adolescents with a higher frequency
of these reported factors resulting in higher odds
of reporting SP, especially “substantial SP”. Psychological
factors appear to be more strongly related to SP than the
social variables. Together, this reinforces the importance of
understanding psychological and social factors in adolescents
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