Poor prognosis of child and adolescent musculoskeletal pain: a systematic literature review

Prevalence of chronic and multisite pain in adolescents and young adults with ADHD: a comparative study between clinical and general population samples (the HUNT study)

Attention-deficit/hyperactivity disorder (ADHD) and chronic pain are prevalent and associated. We examined the prevalence and distribution of chronic pain in adolescents and young adults with ADHD using 9-years longitudinal data (from T1:2009-2011 to T3:2018-2019) with three time points from a clinical health survey compared to two age-matched reference population-based samples. Mixed-effect logistic regression and binary linear regression were used to estimate the probability for chronic and multisite pain at each time point and to compare the prevalence of chronic pain with the reference populations. The prevalence of chronic and multisite pain was high in those with ADHD, especially in female young adults, with highly prevalent chronic pain at 9 years of follow-up (75.9%) compared to 45.7% in females in the reference population. The probability of having pain was only statistically significant for chronic pain in males at 3 years of follow-up (41.9%, p = 0.021). Those with ADHD were at higher risk of reporting single-site and multisite pain compared to the general population at all measurement points. Longitudinal studies should be tailored to further understand the complex sex differences of comorbid chronic pain and ADHD in adolescents, exploring predictive factors of pain assessing long-term associations with bodyweight, psychiatric comorbidities, and possible mechanisms of stimulant use effects on pain.

Self-management including exercise, education and activity modification compared to usual care for adolescents with Osgood-Schlatter (the SOGOOD trial): protocol of a randomized controlled superiority trial

BACKGROUND

Osgood-Schlatter is the most frequent growth-related injury affecting about 10% of physically active adolescents. It can cause long-term pain and limitations in sports and physical activity, with potential sequela well into adulthood. The management of Osgood-Schlatter is very heterogeneous. Recent systematic reviews have found low level evidence for surgical intervention and injection therapies, and an absence of studies on conservative management. Recently, a novel self-management approach with exercise, education, and activity modification, demonstrated favorable outcomes for adolescents with patellofemoral pain and Osgood-Schlatter in prospective cohort studies.

AIM

The aim of this trial is to assess the effectiveness of the novel self-management approach compared to usual care in improving self-reported knee-related function in sport (measured using the KOOS-child 'Sport/play' subscale) after a 5-month period.

METHODS

This trial is a pragmatic, assessor-blinded, randomized controlled trial with a two-group parallel arm design, including participants aged 10-16 years diagnosed with Osgood-Schlatter. Participants will receive 3 months of treatment, consisting of either usual care or the self-management approach including exercise, education, and activity modification, followed by 2 months of self-management. Primary endpoint is the KOOS-child 'Sport/play' score at 5 months. This protocol details the planned methods and procedures.

DISCUSSION

The novel approach has already shown promise in previous cohort studies. This trial will potentially provide much-needed level 1 evidence for the effectiveness of the self-management approach, representing a crucial step towards addressing the long-term pain and limitations associated with Osgood-Schlatter.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT05174182. Prospectively registered December 30th 2021. Date of first recruitment: January 3rd 2022. Target sample size: 130 participants.

Competences to self-manage low back pain among care-seeking adolescents from general practice - a qualitative study

BACKGROUND

There is limited knowledge about when and how adolescents with low back pain (LBP) interact with health care providers. This limits our understanding of how to best help these young patients. This study aimed to understand when and how care-seeking adolescents with LBP interact with health care providers and which health literacy competencies and strategies do they use to self-managing their LBP.

METHOD

Ten semi-structured interviews (duration 20-40 min) were conducted online among adolescents aged 15-18 with current or recent LBP (pain duration range; 9 months - 5 years). The interview guide was informed by literature on health literacy and self-management in patients. We conducted a semantic and latent thematic data analyses.

RESULTS

Three major themes emerged from the analysis: (1) Self-management, (2) Pain and Function, and (3) Communication. All adolescents were functionally limited by their pain but the main reason to consult a health care provider was an increase in pain intensity. Many were able to navigate the healthcare system, but experienced difficulties in communicating with health care providers, and many felt that they were not being taken seriously. Their first line self-management option was often over-the-counter pain medicine with limited effects. Most adolescents expressed a desire to self-manage their LBP but needed more guidance from health care providers.

CONCLUSION

Adolescents with LBP seek care when pain intensifies, but they lack self-management strategies. Many adolescents want to self-manage their LBP with guidance from health care providers, but insufficient communication is a barrier for collaboration on self-management.

Associations between pain, health, and lifestyle factors in 10-year-old boys and girls from a Swedish birth cohort

BACKGROUND

Pain is common in children and its associations with various biopsychosocial factors is complex. Comprehensive pain assessments could contribute to a better understanding of pediatric pain, but these assessments are scarce in literature. The aim of this study was to examine differences in pain prevalence and pain patterns in 10-year-old boys and girls from a Swedish birth cohort and to study associations between pain, health-related quality of life and various lifestyle factors stratified by sex.

METHODS

866 children (426 boys and 440 girls) and their parents from the "Halland Health and Growth Study" participated in this cross-sectional study. Children were categorized into two pain groups, "infrequent pain" (never-monthly pain) or "frequent pain" (weekly-almost daily pain), based on a pain mannequin. Univariate logistic regression analyses, stratified by sex, were performed to study associations between frequent pain and children's self-reports of disease and disability and health-related quality of life (Kidscreen-27, five domains), and parents' reports of their child's sleep (quality and duration), physical activity time, sedentary time, and participation in organized physical activities.

RESULTS

The prevalence of frequent pain was 36.5% with no difference between boys and girls (p = 0.442). Boys with a longstanding disease or disability had higher odds of being in the frequent pain group (OR 2.167, 95% CI 1.168-4.020). Higher scores on health-related quality of life in all five domains for girls, and in two domains for boys, was associated with lower odds of being categorized into the frequent pain group. Frequent pain was associated with poor sleep quality (boys OR 2.533, 95% CI 1.243-5.162; girls OR 2.803, 95% CI 1.276-6.158) and more sedentary time (boys weekends OR 1.131, 95% CI 1.022-1.253; girls weekdays OR 1.137, 95% CI 1.032-1.253), but not with physical activity.

CONCLUSIONS

The high prevalence of frequent pain needs to be acknowledged and treated by school health-care services and the healthcare sector in order to prevent pain from influencing health and lifestyle factors negatively in children.

Applying the behavioural change wheel to guide the implementation of a biopsychosocial approach to musculoskeletal pain care

Achieving high value, biopsychosocial pain care can be complex, involving multiple stakeholders working synergistically to support the implementation of quality care. In order to empower healthcare professionals to assess, identify and analyse biopsychosocial factors contributing to musculoskeletal pain, and describe what changes are needed in the whole-of-system to navigate this complexity, we aimed to: (1) map established barriers and enablers influencing healthcare professionals' adoption of a biopsychosocial approach to musculoskeletal pain against behaviour change frameworks; and (2) identify behaviour change techniques to facilitate and support the adoption and improve pain education. A five-step process informed by the Behaviour Change Wheel (BCW) was undertaken: (i) from a recently published qualitative evidence synthesis, barriers and enablers were mapped onto the Capability Opportunity Motivation-Behaviour (COM-B) model and Theoretical Domains Framework (TDF) using "best fit" framework synthesis; (ii) relevant stakeholder groups involved in the whole-of-health were identified as audiences for potential interventions; (iii) possible intervention functions were considered based on the Affordability, Practicability, Effectiveness and Cost-effectiveness, Acceptability, Side-effects/safety, Equity criteria; (iv) a conceptual model was synthesised to understand the behavioural determinants underpinning biopsychosocial pain care; (v) behaviour change techniques (BCTs) to improve adoption were identified. Barriers and enablers mapped onto 5/6 components of the COM-B model and 12/15 domains on the TDF. Multi-stakeholder groups including healthcare professionals, educators, workplace managers, guideline developers and policymakers were identified as target audiences for behavioural interventions, specifically education, training, environmental restructuring, modelling and enablement. A framework was derived with six BCTs identified from the Behaviour Change Technique Taxonomy (version 1). Adoption of a biopsychosocial approach to musculoskeletal pain involves a complex set of behavioural determinants, relevant across multiple audiences, reflecting the importance of a whole-of-system approach to musculoskeletal health. We proposed a worked example on how to operationalise the framework and apply the BCTs. Evidence-informed strategies are recommended to empower healthcare professionals to assess, identify and analyse biopsychosocial factors, as well as targeted interventions relevant to various stakeholders. These strategies can help to strengthen a whole-of-system adoption of a biopsychosocial approach to pain care.

Musculoskeletal pain is not clearly associated with the risk of anterior cruciate ligament reconstruction in adolescents

Objectives

The purpose of this study was to investigate whether self-reported musculoskeletal pain (MSP) was associated with a future anterior cruciate ligament reconstruction (ACLR).

Methods

In this population-based prospective cohort study, we included 8087 participants from the adolescent part of the Trøndelag Health Study (Young-HUNT) in Norway. The exposure was self-reported MSP from the Young-HUNT3 study (2006-2008), which was categorised into two MSP load groups (high MSP and low MSP) based on frequency and number of pain sites. The outcome was ACLRs recorded in the Norwegian Knee Ligament Register between 2006 and 2019. Logistic regression was used to investigate association between MSP load and ACLR, given as ORs with 95% CIs. All tests were two-sided and p values of ≤0.05 were considered statistically significant.

Results

8087 adolescents were included. We identified a total of 99 ACLRs, with 6 ACLRs (0.9%) in adolescents who reported high MSP load and 93 ACLRs (1.3%) among those who reported low MSP load. Adolescents reporting high MSP load had 23% lower odds of an ACLR (OR 0.77, 95% CI 0.31 to 1.91) compared with adolescents with low MSP load. However, the CIs were very wide.

Conclusion

Self-reported high MSP load in adolescents was not associated with increased risk of future ACLR. Although the number of participants was high, the relatively few cases of ACLR mean that we cannot be conclusive about the presence or absence of an association.

Bio-psycho-social characteristics and impact of musculoskeletal pain in one hundred children and adolescents consulting general practice

Background

Eight percent of all child and adolescent general practice consultations are due to musculoskeletal conditions, with pain as the most frequent symptom. Despite the commonality of musculoskeletal pain, limited knowledge exists about care-seeking children and adolescents with musculoskeletal pain.

The purpose of this study was to describe characteristics of children and adolescents consulting their general practitioner with musculoskeletal pain.

Methods

This is a cross-sectional study based on baseline data from the child and adolescent musculoskeletal pain cohort study (ChiBPS), carried out in 17 Danish general practice clinics. Patients aged 8–19 years who had musculoskeletal pain when consulting their general practitioner were recruited. Participants completed a questionnaire on demographics, physical activity, pain impact, psychosocial factors, and expectations of their general practitioner. Descriptive statistics were used to summarize data. Normally distributed continuous data were described using mean and standard deviation while non-normally data were described using median and interquartile range (IQR).

Results

We included 100 participants (54% female, median age 13 [IQR: 12–16.5 years]). Frequent pain sites limiting activity were knee (56%), back (20%), ankle (19%), and neck (13%). Most participants (63%) consulted their general practitioner due to inability to use their body as usual, due to pain. Median pain duration at consultation was 5 months [IQR: 3 weeks-1 year]. More than a third were often/sometimes nervous (34%), worried or anxious (33%), and took pain medication (33%). Pain impeded ability to participate in sport activities at school (79%) and disturbed spare time activities (88%). Pain also made it difficult to concentrate for 58%, and to fall asleep for 38%. Only 38% expected a pain free long-term future.

Conclusion

This study demonstrates the bio-psycho-social impact of musculoskeletal pain in care-seeking children and adolescents. Demographics, pain characteristics, psychosocial characteristics, and physical characteristics should be included in addressing children and adolescents with musculoskeletal pain.

Trial registration

The ChiBPS study was pre-registered before participant recruitment (ClinicalTrials.gov Identifier: NCT03678922) date: 09.20.18.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01628-8.

Three in Every 10 School-aged Children in Brazil Report Back Pain in Any Given Year: 12-Month Prospective Cohort Study of Prevalence, Incidence, and Prognosis

OBJECTIVE

To estimate the prevalence, incidence, and prognosis of back pain in children and adolescents.

DESIGN

Prospective cohort study.

METHODS

We followed children and adolescents between the ages of 8 and 18 years with and without back pain over 12 months (3, 6, and 12 months) from public and private schools. At baseline, parents (or guardians) answered questionnaires including sociodemographic characteristics and perception of sleep quality of their children and adolescents. Children and adolescents answered questionnaires including sociodemographic characteristics, presence of back pain, pain intensity, quality of life, and psychosomatic symptoms. At follow-up, children and adolescents answered questions about the presence of back pain.

RESULTS

Six hundred fifteen children and adolescents were included, 163 of whom had back pain and 452 of whom had no back pain at baseline. The mean age of participants was 11.6 years (SD = 2.5), and the majority were female (n = 362; 59%). The 1-month prevalence of back pain was 26% (95% confidence interval: 23%-30%). The incidence rate of back pain was 35% (31%-40%) over 12 months. Of the 163 participants who had back pain at baseline, 83% had recovered by 12 months. Of those who recovered within 6 months, 31% had a recurrence of back pain at the 12-month follow-up.

CONCLUSION

Two to 3 in every 10 children and adolescents reported back pain in the last month. New cases of back pain were reported by 3-4 in every 10 children and adolescents for a period of 12 months. Nearly all children recover within 12 months, but recurrence seems to be common. J Orthop Sports Phys Ther 2022;52(8):554-562. Epub: 19 June 2022. doi:10.2519/jospt.2022.10819.

Laboured reading and musculoskeletal pain in school children - the role of lifestyle behaviour and eye wear: a cross-sectional study

Background

Lifestyle behaviour in children and adolescents has become increasingly sedentary and occupied with digital work. Concurrently, there has been an increase in the prevalence of headache, neck- and low back pain, which are leading causes of disability globally. Extensive near work and use of digital devices are demanding for both the visual system and the upper body head-stabilizing musculature. Uncorrected vision problems are present in up to 40% of Nordic school children, and a lack of corrective eye wear may cause eyestrain, musculoskeletal pain and headache. The aim of this study was to investigate associations between laboured reading, musculoskeletal pain, uncorrected vision, and lifestyle behaviours in children and adolescents.

Methods

This was a cross-sectional study with a total of 192 Norwegian school children aged 10–11 and 15–16 years. As a part of a school vision testing program, the children completed an online questionnaire about general and ocular health, socioeconomic status, academic ambition, near work and related symptoms, upper body musculoskeletal pain, and physical and outdoor activities.

Results

The 15–16-year-olds had a more indoor, sedentary, digital-based lifestyle with higher academic demands, compared with the 10–11-year-olds. Concurrently, reading became more laboured and upper body musculoskeletal pain increased with age. Girls reported more symptoms, higher academic ambitions, and more time spent on schoolwork and reading, compared with boys. Non-compliance in wearing prescribed eye wear (glasses or contact lenses), increased use of near digital devices, and experiencing visual stress (glare) were positively associated with laboured reading and upper body musculoskeletal pain.

Conclusions

A screen-based lifestyle with high academic demands challenges the ability to sustain long hours of static, intensive near work. Extensive near work tires the visual system and upper body musculature and provokes laboured reading and musculoskeletal pain symptoms. This study emphasizes the importance of regular eye examinations in school children, and the need to raise awareness among children, parents, and school- and health personnel about the importance of optimal vision and visual environment for academic performance and health.

Screen time and health issues in Chinese school-aged children and adolescents: a systematic review and meta-analysis

Backgrounds

Many literature reviews summarized relationships between screen time and child health, but they only included a few studies conducted in Chinese children and adolescents. The potential influence of screen time may vary by social context. The current systematic review and meta-analysis aimed to evaluate relationships between screen time and health issues among Chinese school-aged children and adolescents.

Methods

Peer-reviewed articles written in Chinese and English were retrieved from CNKI, Wanfang, PubMed, Embase, and Web of Science from inception to June 2020. The Downs & Black checklist was applied to assess study quality. Meta analyses used random effect models and mixed effects model to calculate pooled adjusted odds ratios and 95% confidence intervals. Heterogeneity, sensitivity, and publication bias were assessed using Q and I² statistics, “one-study removed” analysis, the funnel plot, trim and fill analysis, and classical fail-safe N, respectively.

Results

In total, we identified 252 articles reporting 268 studies with unique samples. These studies investigated relationships between screen time and health issues of adiposity, myopia, psycho-behavioral problems, poor academic performance, cardiometabolic disease risks, sleep disorder, poor physical fitness, musculoskeletal injury, sub-health, and miscellaneous issues of height and pubertal growth, injury, sick leave, and respiratory symptoms. Proportions of studies reporting positive relationships with screen time were lowest in adiposity (50.6%) and higher in myopia (59.2%) and psycho-behavioral problems (81.8%). Other health issues were examined in 10 or less studies, all of which had more than half showing positive relationships. The pooled odds ratio from 19 studies comparing health risks with the screen time cutoff of 2 hours per day was 1.40 (95% CI: 1.31 to 1.50, I² = 85.9%). The pooled effect size was 1.29 (95% CI: 1.20 to 1.39) after trimming 7 studies for publication bias adjustments.

Conclusions

Findings exclusively generated from Chinese school-aged children and adolescents resonate those mainly from western countries. Evidence suggests that higher levels of screen time are related with greater risks of various health issues, although the relationships appear to be weak and intertwined with other confounding factors. Future studies need to investigate health-specific dose effects and mechanisms of screen time.

Supplementary information

The online version contains supplementary material available at 10.1186/s12889-022-13155-3.

Risk factors and risk profiles for neck pain in young adults: Prospective analyses from adolescence to young adulthood-The North-Trøndelag Health Study

The objective was to investigate risk factors and risk profiles associated with neck pain in young adults using longitudinal data from the North-Trøndelag Health Study (HUNT). Risk factors were collected from adolescents (13-19 years of age), and neck pain was measured 11 years later. The sample was divided into two: Sample I included all participants (n = 1433), and Sample II (n = 832) included only participants who reported no neck/shoulder pain in adolescence. In multiple regression analyses in Sample I, female sex (OR = 1.9, 95% CI [1.3-2.9]), low physical activity level (OR = 1.6, 95% CI [1.0-2.5]), loneliness (OR = 2.0, 95% CI [1.2-3.5]), headache/migraine (OR = 1.7, 95% CI [1.2-2.6]), back pain (OR = 1.5, 95% CI [1.0-2.4]) and neck/shoulder pain (OR = 2.0, 95% [CI 1.3-3.0]) were associated with neck pain at the 11-year follow-up. Those with a risk profile including all these risk factors had the highest probability of neck pain of 67% in girls and 50% in boys. In Sample II, multiple regression analyses revealed that female sex (OR = 2.2, 95% CI [1.3-3.7]) and perceived low family income (OR = 2.4, 95% CI [1.1-5.1]) were associated with neck pain at the 11-year follow-up. Girls and boys with a perceived low family income had a 29% and 17% higher probability of neck pain than adolescents with a perceived high family income. The risk profiles in both samples showed that co-occurrence of risk factors, such as headache/migraine, neck/shoulder pain, back pain, low physical activity level, loneliness, and perceived low family income cumulatively increased the probability of neck pain in young adulthood. These results underline the importance of taking a broad perspective when studying, treating, and preventing neck pain in adolescents.

A widening gap between boys and girls in musculoskeletal complaints, while growing up from age 11 to age 20 - the PIAMA birth Cohort study

INTRODUCTION

The adolescent years represent a key period for the development of musculoskeletal complaints (MSC) and the differences between boys and girls. We evaluated the prevalence and course of MSC and factors associated with MSC while growing up from age 11 to age 20.

METHODS

Questionnaire-based data at age 11 (n = 2,638), age 14 (n = 2,517), age 17 (n = 2,094) and at age 20 (n = 2,206) from the ongoing Prevention and Incidence of Asthma and Mite Allergy (PIAMA) birth cohort were analyzed. MSC refers to pain of lower back, upper- and/or lower extremities. A multivariable logistic regression analysis was used to evaluate a number of factors in relation to persistent pain (pain reported at three out of four measurements).

RESULTS

Prevalence of MSC increased from 14.2% at age 11 to 22.1% at age 20 for boys, and from 17.4% at age 11 to 37.9% at age 20 for girls. Persistent pain was found among 5.1% of the boys and 16.5% of the girls. Being bullied, sleeping problems and tiredness during the day were significantly associated with persistent pain, in both boys and girls, while the latter two were more prevalent among girls. Self-reported (sports-) accidents, and among girls also early onset of puberty, were also significantly associated with persistent pain, but lifestyle factors, such as physical activity and smoking, were not.

CONCLUSION

The prevalence of MSC increases during adolescence, with a widening gap between boys and girls. The factors associated with MSC are similar in boys and girls, though the prevalence of some of these differ by sex.

SIGNIFICANCE

Measuring a group of youngsters 4 times between age 11 and 20 shows an increase in the percentage reporting musculoskeletal complaints (MSC) with a widening gap between girls and boys, with more pain among girls. Boys and girls do hardly differ with respect to factors associated with MSC, being mainly psychosocial factors and (sports) accidents.

The Adolescent Knee Pain (AK-Pain) prognostic tool: protocol for a prospective cohort study

Background: One in three children and adolescents experience knee pain. Approximately one in two adolescents with knee pain will continue to experience pain even five years later and have low quality of life. The general practitioner (GP) is the first point of contact for children and adolescents with knee pain in Denmark. There is a variety of treatments being delivered in general practice, despite similar symptoms and patients' characteristics. This suggests a need to support the GPs in identifying those at high risk of a poor outcome early on, in order to better allocate resources. The aim of this study is to develop a user-friendly prognostic tool to support GPs' management of children and adolescents' knee pain. Methods: A preliminary set of items in the prognostic tool were identified using systematic reviews and meta-analysis of individual participant data. Following feedback from GPs and children and adolescents on the content and understanding, the tool was piloted and implemented in general practice. A cohort of approximately 300 children and adolescents (age 8-19 years old) is being recruited from general practices (recruitment period, July 2019 - June 2020). Clinically meaningful risk groups (e.g. low/medium/high) for the recurrence/persistence of knee pain (at 3 and 6 months) will be identified. Discussion: If successful, this prognostic tool will allow GPs to gain insights into the likely prognosis of adolescents with knee pain and subsequently provide the first building blocks towards stratified care, where treatments will be matched to the patients' prognostic profile. This has the potential to improve the recovery of children and adolescents from knee pain, to improve the allocation of resources in primary care, and to avoid the decline in physical activity and potential associated health and social consequences due to adolescent knee pain. Registration: Registered with ClinicalTrials.gov on 24 June 2019 (ID NCT03995771).

Low back pain rehabilitation in 2020: new frontiers and old limits of our understanding

Low back pain (LBP) is the most common musculoskeletal condition affecting the quality of life of individuals, especially if persistent. Over the decades, a lot of work has been done in an attempt to reduce the negative impact of back pain, and help patients recover and maintain a better quality of life. New insights are coming from different fields of research, with a lot of work being done in searching for the etiology of LBP, describing the different phenotypes of symptomatic spines, and identifying factors involved in the persistence of the disease. Nevertheless, still a lot remains to be done to fully understand the problem of back pain and its causes. Even today, there appears to be a wide gap between basic science and applied rehabilitation research on LBP. The first is still searching in many different ways for the "holy grail" of the pain generator and providing very interesting results with particular relevance to surgical, drug-related and other biological approaches, while the second is pragmatically focusing on modifiable factors that may influence back pain outcomes. Yet, personalized, effective spine care has not been fully realized. While we recognize the potential of basic science advances, there is an immediate need for more translational rehabilitation research, as well as studies focused on the effectiveness of rehabilitation approaches.