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  • Writer's pictureDaniel Selin

Back pain among children and adolescents

Updated: Apr 13, 2023

Children's back pain, stress fracture, vertebral displacement, scoliosis, osteopathy, herniated disc, youth overuse injuries, pain, arthritis, physiotherapy, treatment, spondylolysis, growing pains.

Back pain is common among children and adolescents and can result from many different factors. The majority of cases involve non-specific back pain, which does not have an apparent tissue injury as its underlying cause, but is rather provoked by biomechanical factors. Several external factors influence the occurrence of back pain, such as age, gender, activity level, computer use, hobbies, sitting in school, and psychological factors.

 

Epidemiology

Estimates of the prevalence of back pain in children and adolescents vary greatly from study to study, ranging from 30% to 70%. This large variability is due to differences in the age of the participants, the methodology used in the studies, and, above all, the definition of back pain used in the studies. Back pain in children typically occurs after the age of 13. Before this age, it occurs only rarely.


Moderately high prevalence should raise concern because there appears to be a link between back pain in youth and chronic back pain in adulthood. Previous back problems have been found to be the strongest predictor of future back pain, and back pain that starts at an early age is associated with the chronicity of back pain. However, back pain in young people is often dismissed as growing pains or attributed to a weak or poor back inherited from the family. For this reason, the cause of back pain is often not investigated, and the pain and resulting dysfunction may go untreated for too long. Muscle and bone growth itself is not a painful process, and genetics is never the only reason for back pain.


Functional factors are often behind back pain in children and adolescents, such as poor back control, excessive sitting, overloading, immobility, muscle tightness, or muscle imbalances and tension caused by uneven growth. Nutrition and insufficient sleep have also been found to contribute to the onset of back pain. Lack of sleep can sensitize the body's pain pathways, making pain more easily felt, stronger, and more likely to spread over a wider area.


In addition, psychosocial factors, such as stress and anxiety, can increase and maintain perceived back pain. School pressures and social worries often act as factors that exacerbate and maintain back pain.


Although less common, structural changes in the back can also underlie back pain in children and adolescents. These include stress fractures and vertebral displacement or changes to the bone, growth plates, and intervertebral discs. The most typical of these are spondylolysis and spondylolisthesis, which are discussed below.


Structural changes in the back occur significantly more frequently in active children than in those who do not engage in physical activity. Changes occur either from a single, severe event or as a result of repeated, smaller events that overload the structures in the back. Often, there is an underlying genetic predisposition that increases the likelihood of these changes.

 

Differentiation

Back pain in young people is primarily divided into three main groups: soft tissue pain, bone related backpain, and discogenic pain. Each group differs from the other and has its own characteristics.


Soft tissue pain

Soft tissue pain refers to pain that originates in either the muscles, muscle tendons, or fascial structures. Soft tissue pain is the most common cause of back pain in both adults and children. Pain related to muscles is usually localized to the paraspinal muscles of the thoracic or lumbar spine, and not the spine itself. Tendon-related pain is located near the muscle-tendon junction, and pain due to fascial structures can be felt almost anywhere in the body.

Typically, the underlying cause of soft tissue pain is overuse or inadequate recovery, but acute injury or trauma can also be a cause. Poorly fitting equipment or shoes can also contribute to the prevalence of soft tissue back pain. On the other hand, psychosocial factors such as stress, depression, or anxiety can also contribute to the development of this type of back pain.

 

Bone related backpain

The symptoms of bone-related back pain usually worsen with exertion and the pain is localized in the spine. Straightening the back or tapping the spine can provoke pain, and rest can help alleviate it. The most common causes of bone-related back pain in young people are bone overload conditions related to strain (strain osteopathy), stress fractures, and vertebral slippage.


Stress-related osteopathies and stress fractures

Stress osteopathy and stress fractures can be roughly divided into two groups: stress changes and fractures due to bone dysfunction, and stress changes and fractures due to overuse. Fractures due to bone dysfunction may not involve overuse at all, but changes in bone arise from this osteoporotic structure. In this case, the bone does not need to be subjected to increased loads to break, as its endurance is already insufficient. Stress fractures due to overuse, on the other hand, occur from excessive load, even though the bone itself is physiologically normal. Changes due to overuse are much more common than those due to bone dysfunction.


Stress osteopathy and stress fractures appear to be rapidly increasing in children and young people who often engage in physical activity. For example, gymnasts and wrestlers experience back pain twice as often as children who do not engage in sports. In this case, the cause of pain is often a loosening of the vertebral arch, with the first symptoms being back pain and stiffness.


Stress osteopathy is a precursor to stress fractures, in which bone softening and swelling can be detected. These changes are also seen in asymptomatic children and young people and require at least an MRI to verify, as there is no fracture line yet, and therefore cannot be seen on X-rays. On X-rays, stress fractures often appear several weeks after the onset of stress pain, so a basic image taken too early can easily provide false information.


A fracture due to overuse can occur in any bone, depending on the repeated compression, tensile stress, shock, or muscle-induced bending caused by the sport. As the bone repeatedly bends, the mineral content increases on its concave side, while osteoclasts (bone-resorbing cells) become more active on its convex side. If this continues, microscopic fractures occur in the bone, accelerating bone metabolism and causing local swelling and stress pain. A stress fracture occurs when these microscopic fractures combine into a continuous fracture line with prolonged stress.


Spondylosis

Spondylolysis, or a stress fracture in the pars interarticularis, is a condition where there are stress-related changes or fractures in the posterior arch of a vertebra. It is most commonly seen in children aged 12-16 years who participate in sports that involve repeated hyperextension and rotation of the spine, such as gymnastics, figure skating, soccer, or hockey. Boys are more commonly affected than girls. The fractures most often occur in the lowest or second lowest lumbar vertebrae, which are the segments that bear the most load during these movements. The initial symptoms of spondylolysis are local back pain and stiffness during activity, which is relieved by rest. As the condition progresses, the pain often worsens and becomes more widespread, and its duration increases. Untreated or advanced spondylolysis can lead to vertebral slippage or spondylolisthesis.


Spondylolisthesis

Spondylolisthesis is the next stage after spondylolysis, where a vertebra slips forward relative to the vertebra below it. This can be due to a bilateral fracture in the pars interarticularis, either as a result of trauma or repetitive loading. The slippage can also be visible as a bony prominence in the spinous process. The symptoms and clinical findings are similar to those of spondylolysis. Spondylolysis progresses to spondylolisthesis in about 15% of cases, and this often occurs during the adolescent growth spurt when the spine is exposed to the greatest amount of stress.


Scoliosis

Scoliosis is an abnormal lateral curvature or rotation of the spine. It can be idiopathic, meaning that the underlying cause is unknown, or it can be due to congenital spinal abnormalities, infection, or tumor. Idiopathic scoliosis is the most common type, accounting for more than 80% of cases. It is the most common spinal deformity seen by primary care physicians, pediatricians, and spine surgeons. Idiopathic scoliosis affects boys and girls equally, but the risk of curve progression and the need for later treatment is much higher in girls than in boys. However, only about one in ten young people with idiopathic scoliosis require treatment. Treatment is based on a combination of exercise, manual therapy, and possible bracing.


Scheuermann's disease

Scheuermann's disease is a growth disorder of the vertebrae that leads to an increase in the curvature of the spine. In Scheuermann's disease, the growth of the anterior part of the vertebrae slows down, while the posterior part continues to grow, resulting in a wedge-shaped vertebra and an increase in the kyphotic curve of the spine. The changes are typically seen in the thoracic spine or at the junction of the thoracic and lumbar spine.

Scheuermann's disease is the most common cause of structural kyphosis in young people and is often associated with poor posture, spinal stiffness, and back pain. It is more common in boys than in girls and often begins in adolescence.

 

Dicogenic pain

Pain related to intervertebral discs typically worsens when the back is bent forward and often involves pain or numbness radiating down the leg. Inter-vertebral disc related back pain is relatively uncommon among young people.


In a herniated disc, the inner mass of the disc moves backwards, pushing towards the wall of the disc and potentially compressing nerve root openings, which can cause nerve root irritation or compression. This typically results in a radiating pain sensation down the same side of the leg. Herniated discs are a common condition in adults whose intervertebral discs have degenerated, with a lifetime prevalence of up to 40%. However, the prevalence is significantly lower among young people, which is thought to be due to fewer degenerative changes in the discs.

 

Tumors

While tumors can also be the underlying cause of young people's back pain, they are extremely rare. The typical symptom of an intradural tumor in the spine is back pain radiating down to the legs, which makes standing and walking difficult. If the symptom is severe, it is often observed that the child leans forward or supports both thighs with their hands while standing. The most common tumors that cause back pain in young people are osteoid osteoma and eosinophilic granuloma, both of which are benign.


Osteoid osteoma is a slowly growing bone lesion that usually occurs in the posterior structures of the spine. The typical symptom is back pain that occurs when going to bed at night, and it responds exceptionally well to anti-inflammatory medication. The characteristic symptoms of eosinophilic granuloma are back pain and difficulty walking.

 

Infections

Infections are among the possible causes of back pain in young people, with conditions such as spinal osteomyelitis, sacroiliac joint infection, epidural abscess, and non-spinal infections being some examples. In addition to back pain, symptoms of spinal infections may include difficulty walking or limping. While fever is a common symptom of these infections, its absence does not rule out the possibility of infection. Neurological deficits typically do not have time to develop, although they are also possible.

 

Inflammation of the joints

Inflammation of the joints affecting the spine can also be a cause of back pain, but these are rare. The most common inflammations affecting the spine in children and young adults are ankylosing spondylitis, psoriatic arthritis, and reactive arthritis.


The hallmark of an inflammatory disease is intense morning stiffness and pain that is worse in the morning or at night and improves with movement. Some patients experience nighttime pain, which makes turning in bed uncomfortable, but severe back pain is rare. Pain in the back may switch sides and symptoms may also occur in other areas of the body besides the back.

 

Physical therapy

Physical therapy for children and adolescents with back pain is always individually tailored, taking into account the underlying condition and related factors. However, we can roughly outline what physiotherapy for children and adolescents with back pain may involve.


Extensive research has been conducted on treating back pain in adults, and evidence has shown that physiotherapy that includes exercise, therapeutic training, back school, and manual therapy is effective in reducing pain and functional limitations.


In contrast, the research on treatment of back pain in children and adolescents is not as profound as the research for treatment of back pain in adults is, so information obtained from adult treatment is also applied to children. However, children and adolescents cannot always be treated using the same principles as adults since spinal development stages, added pressure from growth spurts, and external factors must be taken into account.


Despite these differences, many of the same methods used for adults are also used for children and adolescents, but the amounts and intensities differ. Physiotherapy typically involves a combination of the following methods: guidance and counseling, modification of exercise, manual therapy, and therapeutic training. The primary goals of physiotherapy are to reduce the intensity and frequency of back pain and to improve functionality and capacity.

Studies have shown that physiotherapy treatments are effective in treating back pain in young people, but there is still limited research on this population.

 

Self care

  1. Encourage physical activity: Regular physical activity, such as walking, swimming, or biking, can help strengthen the muscles that support the back and improve flexibility, which can alleviate back pain.

  2. Ensure proper posture: Encourage your child to sit and stand up straight with shoulders back and chin tucked in. Discourage slouching or hunching over electronic devices.

  3. Limit screen time: Excessive screen time can lead to poor posture, which can contribute to back pain. Encourage your child to take frequent breaks and engage in other activities that promote movement.

  4. Provide proper backpacks: Make sure your child's backpack is the appropriate size and weight, and encourage them to use both straps to evenly distribute the weight.

  5. Support good sleeping habits: Make sure your child's mattress is supportive and comfortable. Encourage them to sleep on their side with a pillow between their knees to help maintain spinal alignment.

  6. Manage stress: Stress can contribute to muscle tension and back pain. Encourage your child to engage in relaxation techniques, such as deep breathing, yoga, or meditation.

  7. Seek medical advice: If your child's back pain persists or is severe, it's important to seek medical advice from a healthcare professional as a physical therapist.

 

Summary

In summary, physiotherapy for back pain in children and adolescents consists of similar methods as for adults with back pain. A combination of rehabilitative exercises and manual therapy appears to be the most effective way to alleviate back pain and improve functionality in both children and adults.

Selected treatment methods should always be tailored to the individual, taking into account background factors and the patient's goals. Individualization appears to be key to achieving the best possible outcome in this case as well. Therefore, if a child or adolescent is experiencing back pain, it is important to contact a physiotherapist or doctor who is knowledgeable in pediatric musculoskeletal disorders if the pain doesn't subside on its own in about a week.




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