Adolescent Back Pain
- 1 Introduction
- 2 Epidemiology
- 3 Aetiology
- 4 Differential Diagnosis
- 4.1 Muscle-Related Pain
- 4.2 Bone-Related Pain
- 4.3 Disc-related pain
- 4.4 Other possible causes of back pain:
- 5 Diagnostic Tools and Assessment
- 6 Further Investigations
- 7 Physiotherapy Treatment
- 8 Conclusion
- 9 Outcome Measures
- 10 References
The World Health Organization describes adolescence as “young people between the ages of 10 and 19 years”. This definition is further divided into early adolescence (10-14 years old) to late adolescence (15-19 years old) by the United Nations Population Fund . Adolescent back pain has been reported to be as common as that of adult populations  and has been attributed to a number of factors such as gender , age , sitting for long periods , working at computers , school seating  and psychological factors .
There has been a high prevalence of low back pain (LBP) in adolescents demonstrated in a number of epidemiological studies . Estimates of the prevalence of back pain in children and adolescents vary greatly, ranging from 30%-70% . The study by Jeffries et al (2007) found a life time prevalence ranging from 4.7% to 74.4% for spinal or back pain and 7% to 72% for LBP. These ranges depend on the age of the participants and the methodological differences, in particular the definition of back pain used.
This level of prevalence raises concerns due to the link between LBP in adolescents and chronic LBP in adulthood. A history of symptoms has been found to be the strongest predictor of future LBP and an early onset in life linked to chronicity. It has been found that the occurrence of back pain in adolescents increases with age, in particular the years of early teens.
Growth and development of males and females is remarkably similar up to approximately the age of 10. Above the age of 10, as a result of puberty, the growth patterns of males and females deviate considerably. By at least the age of 18 or 19 years, puberty is considered to have ceased. With the potential influence of puberty related growth on the incidence of adolescent back pain  it is imperative that the range of pubertal ages are taken into consideration in epidemiological studies.
Factors associated with back pain in adolescents fall into four main categories:
- Anthropometry - Height and Weight/Body mass index
- Lifestyle factors - Physical Activity vs Sedentary Activity
- Mechanical Load - Heavy Schoolbags
- Psychological, social and behavioural factors
- Participation in sports 
Each with characteristic features as displayed in this section:
Most common causes of back pain in adolescents, as in adults, are thought to arise from within the muscles . Muscle-related pain tends to be localised to paraspinal muscles of the thoracic or lumbar area rather than over the spine itself
This type of pain is most commonly related to overuse, but there may be a history of acute injury.
Other relevent contributing factors include:
- Carrying a heavy rucksack 
- Incorrect sports equipment (e.g. improper bicycle seat positioning, lack of cushioned insoles for running) 
- Psychosocial distress, depression and anxiety
Bone-related pain tends to occur at the centre of the spine and usually exacerbated by extension (backward bending), though this finding is not specific.
Common causes of bone related back pain in adolescents include:
- Spondylolysis usually presents in early adolescence and may initially be asymptomatic, but typically manifests as aching low back pain exacerbated by hyperextension of the spine and relieved by rest.
- Spondylolysis is common in adolescent athletes with acute low back pain - accounting for 47% of cases in one orthopaedic series.
- The risk of developing Spondylolysis tends to correlate in athletes whose sport requires repetitive flexion/extension or hyperextension e.g. gymnastics, football, cricket (fast bowlers), weight lifting etc.
SpondylolisthesisSpondylolisthesis occurs when bilateral pars defects permit the vertebral body to slip anteriorly. The most common spondylolytic defects occur at the isthmus
- Spondylolysis progresses to spondylolisthesis in approximately 15 % of cases.
- Progression generally occurs during the teenage growth spurt (with minimal change after 16 years) .
- Morita et al (1995) suggests spondylolytic progression is correlated with chronicity of pain. However, Seitsalo et al 1991 argue that pain frequency has a stronger correlation to kyphotic severity (lumbosacral region).
VIDEO ANIMATION - Click here [X] (Select Spondylolithesis)
Adolescent Idiopathic Scoliosis(AIS)
Scoliosis is an abnormal lateral curvature of the spine. It can be idiopathic (unknown cause) or result from congenital spinal anomalies, muscular spasm or paralysis, infection, tumor, or other causes
- AIS is the most common form of idiopathic scoliosis, accounting for 80 - 85% of cases
- AIS is also noted as the most common spinal deformity seen by primary care physicians, pediatricians, and spinal surgeons.
- The prevalence of adolescents with a spinal curvature or Cobb angle ≥10º is approximately 3 %.
- AIS has equal prevalence in males and females,though, the risk of curve progression and therefore the need for later treatment is 10 x higher in females
- Only 1 in 10 adolescents with idiopathic scoliosis require treatment though
Scheuermann’s Disease / Juvenile Kyphosis
- Sheuermann's Disease is the abnormal growth (Osteochondrosis) typically of the thoracolumbar region of the spine leading to increasing spinal curvature
- It may be associated with spondylosis
- Scheuermann’s is the most common cause of structural kyphosis in adolescents with a prevalence of 1-8% and often accompanied with poor posture and backache
Disc herniation is a common disorder among adults with degenerated intervertebral discs with a life time occurrence as high as 40%. However, its occurrence in adolescence is much less frequent at 3-8% as adolescents tend to have a healthier lumbar spine.
Vertebral bodies are separated by intervertebral discs, (to provide support and mobility). The intervertebral disc is composed of 2 Layers:
- Tough, ligamentous outer annulus
- Gelatinous inner nucleus pulposus.
A combination of intervertebral pressure and degeneration of the ligamentous fibres can lead to a tear in the annulus - allowing herniation of the nucleus pulposus.
- Acute trauma
- Scheuermann’s disease
- Family history of disc herniation
- Sporting activities e.g. weight lifting, wrestling, gymnastics, and collision sports
Other possible causes of back pain:
- Back pain caused by a spinal tumor is a rare occurrence
- The most common tumor that presents with back pain in adolescents is Osteoid Osteoma, a benign tumor characterized by nocturnal pain and prompt relief with NSAID's, although these features are variable.
- Only 10 to 20% of osteoid osteomas are localised to the spine
- Infectious causes of back pain in adolescents include vertebral osteomyelitis, sacroiliac joint infection, epidural abscess, and nonspinal infections (eg, paraspinous muscle abscess, endocarditis, and myalgia (muscle pain) associated with viral illness)
- A limited number of systemic inflammatory conditions affect the spine and manifest as back pain
- Conditions include ankylosing spondylitis, psoriatic arthritis and reactive arthritis.
- The hallmark of inflammatory disease is morning stiffness
- Some patients experience aching nocturnal pain that makes it uncomfortable to turn over in bed but severe back pain is unusual 
Differential Diagnosis of Back Pain in Children and Adolescents
|Presentation||Possible diagnosis||Associated symptoms|
|Night time pain||Tumor, infection||Fever, malaise, weight loss|
|Pain with fever or other generalized symptoms||Tumor, infection||Night time pain|
|Acute pain||Herniated disk, slipped apophysis, spondylolysis
|Radicular pain, positive straight leg raising test result
Other injuries, neurologic loss
Muscle tenderness without radiation
|Chronic pain||Scheuermann's kyphosis
Morning stiffness, sacroiliac joint tenderness
|Pain with spinal forward flexion||Herniated disk, slipped apophysis||Radicular pain, positive straight leg raising test result|
|Pain with spinal extension||Spondylolysis, spondylolisthesis, lesion or injury in the pedicle or lamina (posterior arch)||Hamstring tightness|
|Pain with recent-onset scoliosis||Tumor, infection, herniated disk, syrinx
|Fever, malaise, weight loss, positive straight leg raising test result
Symptoms most common in patients 15 years and older
|Other||Pyelonephritis, sickle cell crisis||Abnormal urinalysis findings, dysuria, fever, other bone pain, history of sickle cell disease|
Diagnostic Tools and Assessment
Past studies have suggested that children with low back pain likely suffer from serious spinal pathologies, such as infections and tumors.   These studies provided the evidence for the extensive diagnostic workup of pediatric low back pain practiced today.
However, recent epidemiological evidence has indicated pediatric low back pain may be much more prevalent than previously perceived and often mechanical in nature. As a result a far greater emphasis is being placed on conducting a thorough subjective history and physical examination, before performing costly and often inconclusive diagnostic tests. 
|Type of Symptoms||What to specifically look for|
|Description of the pain characteristics||Location, Type, Onset, Duration, Change with Activity or Rest, Aggravating and Easing Factors, 24 hour pattern, Night Pain|
|Trauma||Acute Macrotrauma, Repetitive Microtrauma, Athletic Activities, Recent/Remote|
|Mechanical symptoms||Worse during or after activity|
|Inflammatory symptoms||Morning stiffness, How long? Better with movement?|
|Systemic symptoms||Fever, Night Sweats, Weight Loss|
|Neurological symptoms||Radiculopathy, Weakness, Bowel or Bladder Dysfunction|
|Gait||Foot Drop, Abnormal Patterns of Movement|
|Current level of function||Activities, Hobbies, What can they still do?|
|Psychosocial factors||Lifestyle, Interference with School, Backpack Weight, Emotional Significance/ Depression|
|Previous Injury/Treatment||A history of previous Injury or Surgery, Treatment with Immunosuppressive Agents, Scoliosis, Osteoporosis, Malignancy, Neurological disorder, or Chronic Inflammatory Joint Disease|
||Orthopedic, Neurologic, Rheumatic diseases (Ankylosing Spondylitis, Reactive Arthritis, Psoriasis, Inflammatory Bowel Disease). Family History of Back Pain.|
- Posture, pelvis heights, lower limb alignment, foot arches, skin markings are observed with the patient standing
- Lower limb lengths and alignment can be assessed in supine or sitting position
Range of Movement
Reproduction of symptoms, quality of movement and resistance should be observed.
- Active movements of the spine (flexion = 40°-60°, extension = 20°-35°, lateral flexion = 15°-20°and rotation = 3°-18°) should be tested in a standing position with the pelvis/iliac crest stabilized
- Passive physiological intervertebral movements (PPIVM’s) of the spine can be performed in side lying/ supine/ sitting to assess the range of movement at each segment of the spine
- Passive accessory intervertebral movements (PAIVM’s) can be performed in supine/ prone as required
Resisted Isometric Movements
The following resisted movements should be performed with the spine in a neutral position
- Flexion, extension, lateral flexion and rotation
- Painful movements should be performed last
Provided neutral testing is normal further testing can be performed:
- Dynamic abdominal endurance
- Dynamic extensor endurance
- Double straight leg lowering
The point of tenderness should be correlated with the underlying bone or soft tissue anatomy (e.g. spinous processes, facet joints, paraspinal muscles, sacroiliac joints, gluteal muscles, posterior superior iliac spines, posterior iliac crest, ischial tuberosities and greater trochanters).
Peripheral Joint Scanning
The following joints should be quickly scanned to rule out any contributing pathology, and any deviation from the normal should lead to a more detailed examination of the joint:
Should the patient history suggest potential neurological involvement the following tests should be performed:
|L5||Great Toe Extension|
|S1||Ankle Plantarflexion/ Eversion|
- Sensation of the lower leg in major dermatomes
- Deep tendon reflex tests e.g. Patellar (L2, 3, 4), Achilles (S1)
- Pathologic reflexes e.g. Babinski test
- Hot/Cold, Sharp/ Blunt
Below are some examples of special tests that can assist in the diagnosis of a back pain patient:
- Straight leg raise
- Trendelenberg Test
- Adams Test
- Schober and Modified Schober
- Thomas Test
- FABER or Patrick's Test
The “red flags” of back pain are important historical and physical features that point to potentially dangerous conditions.  Identification of a red flag in both the subjective history and physical examination warrants close attention and further diagnostic testing. 
Spinal "red flags" and their causes include:
|Spinal Red Flags||
Duration > 6 weeks
Tumor, Infection, Rheumatologic disorders
Age < 18 years old
Congenital defect, Tumor, Infection, Spondylolysis, Spondylolysthesis
Fever, Chills, night sweats
Unremitting pain, even when in supine
Tumor, Infection, Abdominal aortic aneurysm, Nephrolithiasis
Pain worsened by coughing, sitting
Pain radiating below knee
Herniated disc, Nerve root compression below L3 nerve root
Fecal and urinary incontinence, Sexual dysfunction
Cauda equina syndrome, spinal chord compression
Cauda equina syndrome, spinal chord compression
Severe or rapidly progressing neurological deficit
Cauda equina syndrome, spinal chord compression
By definition, teenagers with back pain fulfil one of these red flags as they are under 20 years old, requiring a high index of suspicion.
- Age <20 years (especially prepubertal)
- Sudden onset of severe back pain
- Duration >4 weeks
- Thoracic spine pain
- Night pain or wakes patient from sleep
- Unremitting pain, even when supine
- Fever, chills, night sweats
- Unexplained weight loss
- Immunocompromise or HIV
- Previous malignancy
- Corticosteroid use
- Recent trauma
- Progressive neurological deficit
- Bladder or bowel dysfunction
- Saddle anaesthesia
- Disturbed gait or limp
- Vertebral tenderness or deformity
There have been associations demonstrated between adolescent LBP and various psychosocial factors including:
- Depressive symptoms and perceived stress
- Poor wellbeing
- Negative affect
- Emotional and conduct problems
In addition, stressful experiences in childhood have been associated with an increased risk of chronic LBP (CLBP) in later life. Catastrophizing and a family history of chronic pain have both been shown to be associated with a greater level of disability in adolescents with CLBP.
In summary there is good evidence that adolescents with LBP are more likely to report negative psychosocial experiences and there is some evidence to support the hypothesis that such negative experiences predict those at high risk of onset.
Despite multiple studies examining the diagnostic accuracy of magnetic resonance imaging (MRI), single photon emission computer tomography (SPECT) and plain film radiography in diagnosing specific conditions (e.g. spondylolysis, spondylolisthesis, disc herniation), there is limited evidence regarding which of these imaging techniques should be used as an initial screening tool to evaluate adolescent low back pain.
When clinical findings do not sufficiently rule out an organic cause of back pain in children, plain film radiography of the lumbar spine (anteroposterior, lateral and oblique views) is the most common diagnostic test. 
SPECT(Single Photon Emission Computed Tomography)
It is recommended for imaging the spine in patients who have negative radiographs and no neurological findings. SPECT is especially useful in diagnosing stress fractures and spondylolysis.
Magnetic Resonance Imaging (MRI)
MRI allows for increased soft tissue contrast allowing more detailed evaluation of the spinal cord and surrounding structures. MRI is useful in the diagnosis of back pain with neurological findings (e.g. disc herniation, nerve root compression/ irritation). 
Laboratory tests are necessary in evaluating patients with back pain and a high suspicion of infection or systemic disease. HLA-B27 and rheumatoid factor are useful in diagnosing inflammatory conditions. Blood and joint cultures should be performed if infection is suspected.
Auerbach et al., (2008) performed a retrospective cohort study on 100 children (mean age = 13.5). All subjects received radiographs, MRI’s and SPECT scans. The negative predictive values (NPV) and sensitivity of each test was explored on an individual basis and also in tandem with each other and findings from the physical examination. The results of the study are summarised below:
Radiography + SPECT + decrease hamstring length
Radiography + MRI + decrease hamstring length
Radiography + SPECT + pain on hyperextension
Radiography + MRI + pain on hyperextension
In all cases MRI had the highest NPV and sensitivity. It was most effective when combined with a radiograph and pain on hyperextension.
- However MRI has a considerably increased cost compared to all other imaging techniques.
- The study found that for subjects with duration of symptoms of < 6 weeks, SPECT was 100% predictive of mechanical back pain.
- For patients with duration > 6 weeks MRI was the most effective diagnostic tool but was dependent on the hyperextension test being positive.
- Treatment of LBP in adults has been investigated extensively. Evidence has shown that physiotherapy treatment with exercise, backschool and manual therapy are effective in reducing pain and functional limitations in adults .
- A study looking at low back pain in adolescent athletes suggested that despite undergoing pubescent changes into adulthood, adolescents cannot be treated like young adults. Therefore, treatment of adolescents can be difficult and must be approached differently, with a good understanding of spinal development. 
- Investigation and practice of therapeutic treatments for children and adolescents with back pain is more recent than with adults 
- Suggested treatments include back education, exercise, manual therapy and therapeutic conditioning.
- These interventions are primarily aimed at decreasing the prevalence, and lessening the intensity of LBP and disability
- However, there is a dearth of good quality research data in the adolescent population
Prevention of LBP
- Preventative treatments have been carried out over the last 3 decades, including physical therapy exercises, postural hygiene and the promotion of physical activity 
- The best prevention of back pain is early detection
- Preventative measures can include ‘proper technique’ e.g. in lifting sports and limiting excessive lumbar lordosis, plus participating in core-strengthening exercises and stretches for tight hamstrings and hip flexors which also may help reduce the risk of low back pain
School Backpacks and LBP
Some literature suggests that backpacks carried by schoolchildren can cause back pain if they are to heavy or if the weight is carried unevenly.
According to this group-randomised control trial (RCT) the following should be advised to prevent LBP:
- Load the minimum weight possible
- Carry a school backpack on two shoulders
- Correct the belief that school backpack weight does not affect the back
- Using a locker at school
The study found that children were able to learn healthy backpack habits. However, this study was in primary school aged children rather than secondary, therefore results may not be relevant for an adolescent population.
It has been concluded that physiotherapy treatments are effective in treating adolescents with LBP. Some of the suggested treatments are outlined below:
Theoretical or practical education involving:
- Acquisition of knowledge
- Posture training habits
- Body awareness training
- Posture correction exercises
- Balance exercises
- Functional exercises
- Stabilisation- stabilisation, or ‘core stability’, exercises defined as: facilitation of deep muscles of the spine (primarily transversus abdominis or multifidus) at low level, integrated into exercise, progressing into functional activity.
A study which evaluated the efficacy of an exercise program for recurrent non-specific back pain in adolescents, concluding that an exercise was an effective short-term treatment strategy, incorporated the following forms of exercise:
- Pain relieving exercises which encourage motion of the lumbar spine to reduce joint stiffness such as the ‘cat stretch’ and flexibility exercises for the hip and knee, such as knees to chest and knees to the side.
- Reconditioning exercises aiming to provide muscle endurance of lumbar stabilisers and help encourage appropriate motor control of muscle recruitment such as ‘superman’ single leg extension holds in 4 point kneeling.
- Progressive exercises imposing a higher challenge on the lumbar stabilisers and more strength related activities, for instance horizontal side support on feet.
Therapeutic Physical Conditioning
This is general fitness and includes any general cardiovascular exercise, for example:
- This meta analysis, in 2013, examined the differential effectiveness of physiotherapy treatment for LBP in children and adolescents aiming to determine whether the treatments were beneficial for pain and disability among other outcome variables, and which most most effective.
- Prior to this analysis, there was no solid evidence to suggest which treatment was most effective for adolescents with back pain.
- All the treatment outcome measures reached a statistically significant effect magnitude and showed a clinically relevant improvement of symptoms.
- The most effective combination treatment was therapeutic physical conditioning (ie general fitness) and manual therapy.
- However, there was limited details of what the treatments actually involved.
Intensity and Duration of Treatment
The study found that the average:
- Number of weeks of treatment was 12
- Time per week spent engaging in treatment was 1 hour
Quality of the Study
The meta-analysis itself has good methodological quality, however, there was a low number of applicable studies with only 8 articles met the selection criteria. There was also a lack of control groups and methodological quality of the studies were poor. This prevents definite conclusions being drawn. Furthermore, no evidence was provided regarding the duration of the beneficial effects, or details of follow up.
- There is a need to incorporate care and exercise into physical education curricula in schools.
- Interestingly, an RCT found that an active physiotherapy programme improved adolescent experience of back pain regardless of whether the programme consisted of supervised exercises by a physiotherapist.
- When treating adolecsents it is important to remember that they are different to adults, and therefore factors such as growth, age and boredom should be taken into account.
- Treatment of adolescent athletes, as well as helping alleviate current symptoms, should address flexibility and muscle imbalance to prevent future injuries
- Return to sport should be a gradual process once the pain has resolved and the athlete has regained full strength
- There is little literature regarding the prognosis of back pain in adolescents. However, an observational study found that adolescents with LBP due to sports participation experienced less improvement in disability than non participants, which may indicate a worse prognosis for sports participants
For more inormation regarding young athletes and LBP click here.
In conclusion, there are many suggested physiotherapy treatments for adolescents with back pain. Most of these are similar to those suggested for adults with back pain. Research suggests a combincation of general fitness excerise and manual therapy are the most effective physiotherapy treatments for adolescents with back pain. Due to there being a dearth in good quality research, there is a big need for more research to be carried out. 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,.
There are many different outcome measures that may be used by physiotherapists in their treatment of adolescents with back pain.
- Pain e.g. visual analogue scale (VAS), Painometer (a smartphone app to assess pain intensity)
- Disability e.g. Modified Oswestry Disability Questionnaire, Roland & Morris Disability Questionnaire
- Flexibility eg Back-saver sit and reach
- Endurance e.g. number of sit ups, squats etc
- Mental health eg Beck Youth Inventories
- Quality of life e.g. Child Health Questionnaire Child Form 87
- Self efficacy
- Return to sport
- Return to study/work
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