Adolescent Back Pain

Original Editor - Phil Lock, Tom Allison, Matt Deakin and Anna Mansfield as part of a University of Nottingham Project

Top Contributors - Matthew Deakin, Thomas Allison, Anna Mansfield, Phil Lock and Wanda van Niekerk  

Introduction

Back pain image.jpg

The World Health Organization describes adolescence as “young people between the ages of 10 and 19 years”[1]. 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 [2]. Adolescent back pain has been reported to be as common as that of adult populations [3][4][5] and has been attributed to a number of factors such as gender [6], age [7], sitting for long periods [8], working at computers [9], school seating [10] and psychological factors [11]




Epidemiology

There has been a high prevalence of low back pain (LBP) in adolescents demonstrated in a number of epidemiological studies [12]. Estimates of the prevalence of back pain in children and adolescents vary greatly, ranging from 30%-70% [13][14]. 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[7]. These ranges depend on the age of the participants and the methodological differences, in particular the definition of back pain used[3].


This level of prevalence raises concerns due to the link between LBP in adolescents and chronic LBP in adulthood[15]. A history of symptoms has been found to be the strongest predictor of future LBP[16] and an early onset in life linked to chronicity[17][5]. It has been found that the occurrence of back pain in adolescents increases with age, in particular the years of early teens[7].


Growth and development of males and females is remarkably similar up to approximately the age of 10[18]. Above the age of 10, as a result of puberty, the growth patterns of males and females deviate considerably[18]. By at least the age of 18 or 19 years, puberty is considered to have ceased[7]. With the potential influence of puberty related growth on the incidence of adolescent back pain [19] it is imperative that the range of pubertal ages are taken into consideration in epidemiological studies[7].

Aetiology

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[3]


Differential Diagnosis

Adolescent back pain predominantly falls into three general categories: muscular, bone-related, and discogenic[20][21]

Each with characteristic features as displayed in this section:

Muscle-related pain

Most common causes of back pain in adolescents, as in adults, are thought to arise from within the muscles [22]. Muscle-related pain tends to be localised to paraspinal muscles of the thoracic or lumbar area rather than over the spine itself[20]

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[23] [24]
  • Incorrect sports equipment (e.g. improper bicycle seat positioning, lack of cushioned insoles for running) [25]
  • Psychosocial distress, depression and anxiety[26][27]

Bone-related pain

Bone-related pain tends to occur at the centre of the spine and usually exacerbated by extension (backward bending)[20], though this finding is not specific.

Common causes of bone related back pain in adolescents include:

Spondylolysis

  • Spondylolysis = a unilateral/bilateral defect (separation) in the vertebral pars interarticularis, usually the lower lumbar vertebrae (particularly L5)[28]
  • 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[29].
  • Spondylolysis is common in adolescent athletes with acute low back pain - accounting for 47% of cases in one orthopaedic series[30].
  • 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.[25]

Spondylolisthesis

Spondylolithesis - Anterior Vertbral Translation
  • Occurs when bilateral pars defects permit the vertebral body to slip anteriorly. The most common spondylolytic defects occur at the isthmus[31] 
  • Spondylolysis progresses to spondylolisthesis in approximately 15 % of cases.[32]
  • Progression generally occurs during the teenage growth spurt (with minimal change after 16 years) [33][34].
  • Morita et al (1995)[35] suggests spondylolytic progression is correlated with chronicity of pain. However, Seitsalo et al 1991[36] 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[37]
  • AIS is also noted as the most common spinal deformity seen by primary care physicians, pediatricians, and spinal surgeons[38].
  • 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[39]


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[40]
  • 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[41]


Disc-related pain

Disc-related pain is generally exacerbated by flexion (forward bending) and may radiate[20]

Approximately 10% of persistent back pain in adolescents is disc related.[42]

Disc herniation

Nucleus pulposus migrating in postero-lateral direction

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.

Disc herniation is a common disorder among adults with degenerated intervertebral discs with a life time occurrence as high as 40%[43]. However, its occurrence in adolescence is much less frequent at 3-8%[44] as adolescents tend to have a healthier lumbar spine.[45][46]

Risk factors for disc herniation include: [13][47]   

  • Acute trauma 
  • Scheuermann’s disease 
  • Family history of disc herniation
  • Obesity 
  • Sporting activities e.g. weight lifting, wrestling, gymnastics, and collision sports

Other possible causes of back pain:

Tumor

Osteoid Osteoma - CT Imaging
  • Back pain caused by a spinal tumor is a rare occurrence[48] 
  • The most common tumor that presents with back pain in adolescents is Osteoid Osteoma[49], 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[50]


Infection

  • 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)

Inflammatory Arthritis

  • 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 [51]

Diagnostic Tools and Assessment

Overview 

Past studies have suggested that children with low back pain likely suffer from serious spinal pathologies, such as infections and tumors. [52][53] [54] 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.[55][56] 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. [57][21]

Subjective History

The subjective history should include:[58][59]

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
Family history 
Orthopedic, Neurologic, Rheumatic diseases (Ankylosing Spondylitis, Reactive Arthritis, Psoriasis, Inflammatory Bowel Disease). Family History of Back Pain. 

Physical Examination

The physical examination should include: [59] [21][58]

Observations

  • 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


Palpation

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:

Neurological Exam

Should the patient history suggest potential neurological involvement the following tests should be performed:

  • Dermatomes
Lower limb dermatomes
  • Myotomes
L2 Hip Flexion
L3 Knee Extension
L4 Ankle Dorsiflexion
L5 Great Toe Extension
S1 Ankle Plantarflexion/ Eversion
S2 Knee Extension


  • 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

Special tests

Special tests should always be considered an integral part of a much larger examination process. [58]

Below are some examples of special tests that can assist in the diagnosis of a back pain patient:


Red Flags

The “red flags” of back pain are important historical and physical features that point to potentially dangerous conditions. [60] Identification of a red flag in both the subjective history and physical examination warrants close attention and further diagnostic testing. [61]


Spinal "red flags" and their causes include:


 Spinal Red Flags

Potential Causes

Duration > 6 weeks

Tumor, Infection, Rheumatologic disorders

Age < 18 years old

Congenital defect, Tumor, Infection, Spondylolysis, Spondylolysthesis

Major trauma

 Fracture

Cancer

 Tumor

Fever, Chills, night sweats

 Tumor, Infection

Weight loss

 Tumor, Infection

Drug use

 Infection

Night pain

 Tumor, Infection

Unremitting pain, even when in supine

 Tumor, Infection, Abdominal aortic aneurysm,  Nephrolithiasis

Pain worsened by coughing, sitting

 Herniated disc

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

Saddle anaesthesia

Cauda equina syndrome, spinal chord compression

Severe or rapidly progressing neurological deficit

Cauda equina syndrome, spinal chord compression

Yellow Flags

There have been associations demonstrated between adolescent LBP and various psychosocial factors including:[11]

  •  Depressive symptoms and perceived stress[27]
  •  Poor wellbeing[62]
  •  Negative affect[63]
  •  Hyperactivity[64]
  •  Emotional and conduct problems[64][65]


In addition, stressful experiences in childhood have been associated with an increased risk of chronic LBP (CLBP) in later life[66]. 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[67].
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[3].

Further Investigations

Overview

When a thorough subjective history and physical examination are not sufficient to rule out an organic cause of back pain, imaging is performed.[57][21]

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),[68][69][70][71][72][73] there is limited evidence regarding which of these imaging techniques should be used as an initial screening tool to evaluate adolescent low back pain.[57]


Imaging


Radiographs

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. [69][70][57][21]

Anteroposterior radiograph of the chest

Bone Scan

Bone scans help to identify areas of increased osteoblast activity and can help to localise areas of bone injury not immediately apparent on radiographs.[57][21]

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.[68][70][72]


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). [71][73][21]

MRI herniated disk


Investigations

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.[21]

Evidence

Auerbach et al., (2008)[57] 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:


Imaging

NPV Sensitivity

Radiograph

0.68                           0.38                                  

SPECT

0.75 0.56

MRI

0.79 0.65

Radiography + SPECT + decrease hamstring length

0.87 0.90

Radiography + MRI + decrease hamstring length

0.90 0.90

Radiography + SPECT + pain on hyperextension

0.98 0.98

Radiography + MRI + pain on hyperextension

1 1


  • 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.

Physiotherapy Treatment

Overview

  • Treatment of LBP in adults has been investigated extensively[74]. Evidence has shown that physiotherapy treatment with exercise, backschool and manual therapy are effective in reducing pain and functional limitations in adults [75][76].
  • 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. [77]
  • Investigation and practice of therapeutic treatments for children and adolescents with back pain is more recent than with adults [74]
  • 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[74]
  • However, there is a dearth of good quality research data in the adolescent population[78]

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 [74]
  • The best prevention of back pain is early detection[79]
  • 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[80]

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:[81]

Teenage-students-with-backpack-100103396.jpg
  • 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.[81]


Treatment

It has been concluded that physiotherapy treatments are effective in treating adolescents with LBP[74]. Some of the suggested treatments are outlined below:

Back education

Theoretical or practical education involving:

  • Acquisition of knowledge
  • Posture training habits
  • Body awareness training

Posture2.jpg

Exercise 

  • Stretching
  • Strengthening
  • Breathing
  • Posture correction exercises
  • Balance exercises
  • Functional exercises
  • Relaxation
  • Coordination
  • 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.[82][82]


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[83]:


Knee to chest stretch

a) 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.




b) 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.




c) Progressive exercises imposing a higher challenge on the lumbar stabilisers and more strength related activities, for instance horizontal side support on feet.





Manual therapy

Central PA mobilisation to the lumbar spine


  • Mobilisation
  • Manipulation
  • Massage



See Manual Therapy Techniques For The Lumbar Spine

Therapeutic physical conditioning 

A teenager enjoying keeping active


This is general fitness and includes any general cardiovascular exercise, for example[74]:

  • Walking
  • Running
  • Swimming
  • Cycling





Evidence

  • This meta analysis[74], 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.


Other

  • There is a need to
    Smiling-teenagers-007.jpg
     incorporate care and exercise into physical education curricula in schools[83][84].
  • 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[85].
  • 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[77][80]
  • Return to sport should be a gradual process once the pain has resolved and the athlete has regained full strength[77][80]
  • 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[86]

For more inormation regarding young athletes and LBP click here.

Conclusion

  • 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[74]
  • 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[78],.

Outcome measures

There are many different outcome measures that may be used by physiotherapists in their treatment of adolescents with back pain.

These include:

  • 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
  • Function
  • Self efficacy
  • Return to sport
  • Return to study/work


References

  1. Who.int. WHO | Adolescent health [Internet]. 2015 [cited 9 January 2015]. Available from: http://www.who.int/topics/adolescent_health/en/
  2. Unfpa.org. UNFPA - United Nations Population Fund | State of World Population 2003 [Internet]. 2003 [cited 12 January 2015]. Available from: http://www.unfpa.org/publications/state-world-population-2003
  3. 3.0 3.1 3.2 3.3 Jones G, Macfarlane G. Epidemiology of low back pain in children and adolescents. Archives of Disease in Childhood. 2005;90(3):312-316.
  4. Burton A, Clarke R, McClune T, Tillotson K. The Natural History of Low Back Pain in Adolescents. Spine. 1996;21(20):2323-2328.
  5. 5.0 5.1 Harreby M, Neergaard K, Hesselsôe G, Kjer J. Are Radiologic Changes in the Thoracic and Lumbar Spine of Adolescents Risk Factors for Low Back Pain in Adults?. Spine. 1995;20(21):2298-2302.
  6. Grimmer K, Nyland L, Milanese S. Longitudinal investigation of low back pain in Australian adolescents: a five-year study. Physiother Res Int. 2006;11(3):161-172.
  7. 7.0 7.1 7.2 7.3 7.4 Jeffries L, Milanese S, Grimmer-Somers K. Epidemiology of Adolescent Spinal Pain. Spine. 2007;32(23):2630-2637.
  8. Grimmer K, Williams M. Gender-age environmental associates of adolescent low back pain. Applied Ergonomics. 2000;31(4):343-360.
  9. Hakala P, Rimpela A, Saarni L, Salminen J. Frequent computer-related activities increase the risk of neck-shoulder and low back pain in adolescents. The European Journal of Public Health. 2005;16(5):536-541.
  10. Troussiere B, Tesniere C, Fauconnier J, Grison J, Juvin R, Phelip X. Comparative study of two different kinds of school furniture among children. Ergonomics. 1999;42(3):516-526.
  11. 11.0 11.1 Astfalck R, O'Sullivan P, Straker L, Smith A. A detailed characterisation of pain, disability, physical and psychological features of a small group of adolescents with non-specific chronic low back pain. Manual Therapy. 2010;15(3):240-247.
  12. Pellisé F, Balagué F, Rajmil L, Cedraschi C, Aguirre M, Fontecha C et al. Prevalence of Low Back Pain and Its Effect on Health-Related Quality of Life in Adolescents. Archives of Pediatrics & Adolescent Medicine. 2009;163(1):65.
  13. 13.0 13.1 Balagué F, Troussier B, Salminen J. Non-specific low back pain in children and adolescents: risk factors. European Spine Journal. 1999;8(6):429-438.
  14. Wedderkopp N, Leboeuf-Yde C, Andersen L, Froberg K, Hansen H. Back Pain Reporting Pattern in a Danish Population-Based Sample of Children and Adolescents. Spine. 2001;26(17):1879-1883.
  15. Hestbaek L, Leboeuf-Yde C, Kyvik K, Manniche C. The Course of Low Back Pain From Adolescence to Adulthood. Spine. 2006;31(4):468-472.
  16. Papageorgiou A, Croft P, Thomas E, Ferry S, Jayson M, Silman A. Influence of previous pain experience on the episode incidence of low back pain: results from the South Manchester Back Pain Study. Pain. 1996;66(2-3):181-185.
  17. Brattberg G. The incidence of back pain and headache among Swedish school children. Qual Life Res. 1994;3(S1):S27-S31.
  18. 18.0 18.1 Brundtland G, Liestol K, Walloe L. Height and weight of school children and adolescent girls and boys in Oslo 1970. Acta Paediatrica. 1975;64(4):565-573.
  19. Feldman D. Risk Factors for the Development of Low Back Pain in Adolescence. American Journal of Epidemiology. 2001;154(1):30-36.
  20. 20.0 20.1 20.2 20.3 Metzl J. Adolescent Health Update. Back pain in the adolescent. A user-friendly guide. 2nd ed. 2005.
  21. 21.0 21.1 21.2 21.3 21.4 21.5 21.6 21.7 Houghton K. Review for the generalist: evaluation of low back pain in children and adolescents. Pediatric Rheumatology. 2010;8(1):28.
  22. Kim H, Green D. Adolescent back pain. Current Opinion in Pediatrics. 2008;20(1):37-45.
  23. Macias B, Murthy G, Chambers H, Hargens A. Asymmetric Loads and Pain Associated With Backpack Carrying by Children. Journal of Pediatric Orthopaedics. 2008;28(5):512-517.
  24. Rodriguez-Oviedo P, Ruano-Ravina A, Perez-Rios M, Garcia F, Gomez-Fernandez D, Fernandez-Alonso A et al. School children's backpacks, back pain and back pathologies. Archives of Disease in Childhood. 2012;97(8):730-732.
  25. 25.0 25.1 Baker R, Patel D. Lower Back Pain in the Athlete: Common Conditions and Treatment. Primary Care: Clinics in Office Practice. 2005;32(1):201-229.
  26. COMBS J, CASKEY P. Back Pain in Children and Adolescents. Southern Medical Journal. 1997;90(8):789-792.
  27. 27.0 27.1 Diepenmaat A. Neck/Shoulder, Low Back, and Arm Pain in Relation to Computer Use, Physical Activity, Stress, and Depression Among Dutch Adolescents. PEDIATRICS. 2006;117(2):412-416.
  28. Standaert C. Spondylolysis: a critical review. British Journal of Sports Medicine. 2000;34(6):415-422.
  29. Kim H, Green D. Adolescent back pain. Current Opinion in Pediatrics. 2008;20(1):37-45.
  30. Micheli LJ, Wood, R. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med. 1995 Jan;149(1):15-8
  31. Orthoinfo.aaos.org. Adult Spondylolisthesis in the Low Back-OrthoInfo - AAOS [Internet]. 2015 [cited 15 January 2015]. Available from: http://orthoinfo.aaos.org/topic.cfm?topic=A00588
  32. Beutler W, Fredrickson B, Murtland A, Sweeney C, Grant W, Baker D. The Natural History of Spondylolysis and Spondylolisthesis. Spine. 2003;28(10):1027-1035.
  33. Lonstein J. Spondylolisthesis in Children. Spine. 1999;24(24):2640.
  34. Motley G, Nyland J, Jacobs J, Caborn D. The Pars Interarticularis Stress Reaction, Spondylolysis, and Spondylolisthesis Progression. Journal of Athletic Training. 1998;33:351-358.
  35. MORITA T, IKATA T, KATOH S, MIYAKE R. Lumbar Spondylolysis in children and Adolescents. Bone and Joint Surgery. 1995;77:620-625.
  36. SEITSALO S, STERMAN K, HYVRINEN H, TALLROTH K, SCHLENZKA D, POUSSA M. Progression of Spondylolisthesis in Children and Adolescents. Spine. 1991;16(4):417-421.
  37. 0. Negrini S, Aulisa A, Aulisa L, Circo A, de Mauroy J, Durmala J et al. 2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis. 2012;7(1):3.
  38. 11. Altaf F, Gibson A, Dannawi Z, Noordeen H. Adolescent idiopathic scoliosis. BMJ. 2013;346(apr30 1):f2508-f2508.
  39. Miller N. CAUSE AND NATURAL HISTORY OF ADOLESCENT IDIOPATHIC SCOLIOSIS. Orthopedic Clinics of North America. 1999;30(3):343-352.
  40. 13. OGILVIE J, SHERMAN J. Spondylolysis in Scheuermannʼs Disease. Spine. 1987;12(3):251-253.
  41. Lowe T. Scheuermann's Kyphosis. Neurosurgery Clinics of North America. 2007;18(2):305-315.
  42. Micheli L. Back Pain in Young Athletes. Archives of Pediatrics; Adolescent Medicine. 1995;149(1):15.
  43. Frymoyer JW, Pope MH, Clements JH, Wilder DG, MacPherson B, Ashikaga T. Risk factors in low-back pain. An epidemiological survey. J Bone Joint Surg Am. 1983;65:213–218
  44. Kumar R, Kumar V, Das N, Behari S, Mahapatra A. Adolescent lumbar disc disease: findings and outcome. Childs Nerv Syst. 2007;23(11):1295-1299.
  45. Dang L, Liu Z. A review of current treatment for lumbar disc herniation in children and adolescents. European Spine Journal. 2009;19(2):205-214.
  46. 18. Haidar R, Ghanem I, Saad S, Uthman I. Lumbar disc herniation in young children. Acta Paediatrica. 2009;.
  47. DePalma M, Bhargava A. Nonspondylolytic Etiologies of Lumbar Pain in the Young Athlete. Current Sports Medicine Reports. 2006;5(1):44-49.
  48. Spine-health. Potential Causes of Back Pain in Children and Teens [Internet]. 2015 [cited 14 January 2015]. Available from: http://www.spine-health.com/conditions/lower-back-pain/potential-causes-back-pain-children-and-teens
  49. Greenspan A, Jundt G, Remagen W, Greenspan A. Differential diagnosis in orthopaedic oncology. Philadelphia: Lippincott Williams & Wilkins; 2007.
  50. Cohen M, Harrington T, Ginsburg W. Osteoid osteoma: 95 cases and a review of the literature. Seminars in Arthritis and Rheumatism. 1983;12(3):265-281.
  51. Knott D. Ankylosing Spondylitis AS. Inflamed spine information. Patient | Patient.co.uk [Internet]. Patient.co.uk. 2015 [cited 17 January 2015]. Available from: http://www.patient.co.uk/doctor/ankylosing-spondylitis
  52. Turner P, Green J, Galasko C. Back Pain in Childhood. Spine. 1989;14:812-814.
  53. Weinstein S. The Pediatric Spine: Principles and Practice. 2nd ed. Philadelphia: Lippincott, Williams and Wilkins; 2001.
  54. Bradford D, Hensinger R. The Paediatric Spine. New York: Thieme Publishing Group; 1985.
  55. Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatrics. 2013;13(1):14.
  56. Smith D, Leggat P. Back Pain in the Young: A Review of Studies Conducted Among School Children and University Students. CPR. 2007;3(1):69-77.
  57. 57.0 57.1 57.2 57.3 57.4 57.5 Auerbach J, Ahn J, Zgonis M, Reddy S, Ecker M, Flynn J. Streamlining the Evaluation of Low Back Pain in Children. Clin Orthop Relat Res. 2008;466(8):1971-1977.
  58. 58.0 58.1 58.2 Magee D. Orthopedic physical assessment. St. Louis, Mo.: Saunders Elsevier; 2006.
  59. 59.0 59.1 Chou R. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine. 2007;147(7):478.
  60. Downie A, Williams C, Henschke N, Hancock M, Ostelo R, de Vet H et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013;347(dec11 1):f7095-f7095.
  61. Greenhalgh S, Selfe J. A qualitative investigation of Red Flags for serious spinal pathology. Physiotherapy. 2009;95(3):223-226.
  62. Sjolie N. Psychosocial correlates of low-back pain in adolescents. European Spine Journal. 2002;11(6):582-588.
  63. Staes F, Stappaerts K, Lesaffre E, Vertommen H. Low back pain in Flemish adolescents and the role of perceived social support and effect on the perception of back pain. Acta Paediatrica. 2003;92(4):444-451.
  64. 64.0 64.1 Jones G, Watson K, Silman A, Symmons D, Macfarlane G. Predictors of Low Back Pain in British Schoolchildren: A Population-Based Prospective Cohort Study. PEDIATRICS. 2003;111(4):822-828.
  65. Watson K, Papageorgiou A, Jones G, Taylor S, Symmons D, Silman A et al. Low back pain in schoolchildren: the role of mechanical and psychosocial factors. Archives of Disease in Childhood. 2003;88(1):12-17.
  66. Kopec J, Sayre E. Stressful Experiences in Childhood and Chronic Back Pain in the General Population. The Clinical Journal of Pain. 2005;21(6):478-483.
  67. Lynch A, Kashikar-Zuck S, Goldschneider K, Jones B. Psychosocial Risks for Disability in Children With Chronic Back Pain. The Journal of Pain. 2006;7(4):244-251.
  68. 68.0 68.1 Ralston S, Weir M. Suspecting Lumbar Spondylolysis in Adolescent Low Back Pain. Clinical Pediatrics. 1998;37(5):287-293.
  69. 69.0 69.1 Roberts F, Kishore P, Cunningham M. Routine oblique radiography of the pediatric lumbar spine: is it necessary?. American Journal of Roentgenology. 1978;131(2):297-298.
  70. 70.0 70.1 70.2 Ryan P, Evans P, Gibson T, Fogelman I. Chronic low back pain: comparison of bone SPECT with radiography and CT. Radiology. 1992;182(3):849-854.
  71. 71.0 71.1 Cohen E, Stuecker R. Magnetic resonance imaging in diagnosis and follow-up of impending spondylolysis in children and adolescents: early treatment may prevent pars defects. Journal of Pediatric Orthopaedics B. 2005;14(2):63-67.
  72. 72.0 72.1 Feldman D, Hedden D, Wright J. The Use of Bone Scan to Investigate Back Pain in Children and Adolescents. Journal of Pediatric Orthopaedics. 2000;20(6):790-795.
  73. 73.0 73.1 Goda Y, Sakai T, Sakamaki T, Takata Y, Higashino K, Sairyo K. Analysis of MRI signal changes in the adjacent pedicle of adolescent patients with fresh lumbar spondylolysis. European Spine Journal. 2014;23(9):1892-1895.
  74. 74.0 74.1 74.2 74.3 74.4 74.5 74.6 74.7 Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Physical therapy treatments for low back pain in children and adolescents: a meta-analysis. BMC Musculoskeletal Disorders. 2013;14(1):55. (LoE: 1A)
  75. Heymans M, van Tulder M, Esmail R, Bombardier C, Koes B. Back Schools for Nonspecific Low Back Pain. Spine. 2005;30(19):2153-2163. (LoE: 1A)
  76. Aure O, Hoel Nilsen J, Vasseljen O. Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain. Spine. 2003;28(6):525-531. (LoE:1B)
  77. 77.0 77.1 77.2 De Luigi A. Low Back Pain in the Adolescent Athlete. Physical Medicine and Rehabilitation Clinics of North America. 2014;25(4):763-788. (LoE:A)
  78. 78.0 78.1 Michaleff Z, Kamper S, Maher C, Evans R, Broderick C, Henschke N. Low back pain in children and adolescents: a systematic review and meta-analysis evaluating the effectiveness of conservative interventions. European Spine Journal. 2014;23(10):2046-2058. (LoE:1A)
  79. Curtis C, d’ Hemecourt P. Diagnosis and management of back pain in adolescents. Adolesc Med State Art Rev. 2007 May;18(1):140–64, x. (LoE: 5)
  80. 80.0 80.1 80.2 Purcell L, Micheli L. Low Back Pain in Young Athletes. Sports Health: A Multidisciplinary Approach. 2009;1(3):212-222. (LoE:B)
  81. 81.0 81.1 Vidal J, Borràs P, Ponseti F, Cantallops J, Ortega F, Palou P. Effects of a postural education program on school backpack habits related to low back pain in children. European Spine Journal. 2012;22(4):782-787. (LoE: 1B)
  82. 82.0 82.1 Kordi R, Rostami M. Low back pain in children and adolescents: an algorithmic clinical approach. Iranian journal of pediatrics. 2011 Sep;21(3):259.
  83. 83.0 83.1 Jones M, Stratton G, Reilly T, Unnithan V. Recurrent non-specific low-back pain in adolescents: the role of exercise. Ergonomics. 2007;50(10):1680-1688. (LoE: 1B)
  84. Cardon G, de Clercq D, Geldhof E, Verstraete S, de Bourdeaudhuij I. Back education in elementary schoolchildren: the effects of adding a physical activity promotion program to a back care program. European Spine Journal. 2006;16(1):125-133. (LoE: 2B)
  85. Ahlqwist A, Hagman M, Kjellby-Wendt G, Beckung E. Physical Therapy Treatment of Back Complaints on Children and Adolescents. Spine. 2008;33(20):E721-E727. (LoE: 1B)
  86. Fritz J, Clifford S. Low Back Pain in Adolescents: A Comparison of Clinical Outcomes in Sports Participants and Nonparticipants. Journal of Athletic Training. 2010;45(1):61-66. (LoE: 3B)